Every finding on record at Elderwood at Burlington

Based on interview and record review, the facility failed to ensure that 1 of 3 sampled residents (Resident #2) remained as free from fall-related accidents as possible by failing to ensure that direct care staff properly use an assistive device and prevent an avoidable accident from occurring. Findings include:A facility policy titled, Safe Patient Handling Program, last modified on 1/16/20, states All employees responsible for resident movement shall attend a Safe Patient Handling Training Program and demonstrate competency in resident transfers, lifts and positioning /repositioning of residents. A full-body mechanical lift will be used by those residents who have no weight-bearing abilities and/or other indicated medical conditions.Two (2) or more caregivers must be present.A review of the facility fall investigation revealed that Resident # 2 sustained a witnessed fall from the mechanical lift on 6/19/26. A statement from the supervising Registered Nurse reveals that LNA #1 and the Support Aide were present in the room at the time of the fall. A review of a provider's progress note dated 6/19/26 indicates that Resident #2 is being evaluated following a fall from a Hoyer lift during a transfer from a chair to a bed by two staff members. The nurse reports that the resident is experiencing pain in the right upper extremity and bilateral hips and that Resident #2 also sustained a head strike.Per interview on 6/24/26 at 12:13 PM, Resident #4 stated s/he was in the room when the fall from the lift occurred. S/he stated that an LNA (Licensed Nursing Assistant) and the person who can bring things like water and towels attempted to move his/her roommate (Resident #2) from the chair to the bed using a lift machine, and that they dropped him/her on the floor. S/he reported that the LNAs often transfer using the mechanical lift with only one person. Per the medical record, Resident #4 has a BIMS of 15 (Brief Interview for Mental Status) (A tool used to assess cognitive status), suggesting that s/he is cognitively intact.A facility job description titled Support Aide, last revised on 1/25, section Essential Job Functions, does not include transferring residents with mechanical lifts. Per interview with LNA #1 on 6/24/26 at 1:50 PM, she revealed she had asked the Support Aide to assist her with transferring Resident #2; she did not know the Support Aide was unable to help her transfer the resident using the mechanical lift.On 6/24/26 at 1:58 PM, an interview with the Support Aide revealed that she occasionally assists the Licensed Nursing Assistants (LNAs) with Hoyer lift transfers. She explained that she was not sure how Resident #2 fell because she wasn't looking at her, as she was not there to help, but she was just watching as another person. She stated that she has not received any training from the facility on how to transfer or assist in transferring a resident and knows now that she isn't supposed to assist with transfers. Employee education records for LNA #1 and the Support Aide do not include competencies evaluating the use of a mechanical lift. For more information, see F726.Per interview with the facility Educator on 6/26/26 at 4:01 PM, she stated that the role of the Support Aide does not include transferring residents or assisting with transfers, especially with the use of a mechanical lift or any form of personal care. All direct care staff are required to complete specific training and undergo an annual competency assessment to operate a mechanical lift. The lift requires two trained staff; she confirmed that LNA #1 had no evidence of having completed the mechanical lift competencies.

Based on employee file review, record review, and interviews, the facility failed to ensure that direct care staff had the specific competencies, and skill sets necessary to meet residents' needs related to the use of a mechanical lift for 1 of 4 sampled Licensed Nursing Assistant (LNA) [LNA#1]. Findings include: A review of the facility fall investigation revealed that Resident # 2 sustained a witnessed fall from the mechanical lift on 6/19/26. A statement from the supervising Registered Nurse reveals that LNA #1 and the Support Aide were present in the room at the time of the fall. A review of a provider's progress note dated 6/19/26 indicates that Resident #2 is being evaluated following a fall from a Hoyer lift during a transfer from a chair to a bed by two staff members. The nurse reports that the resident is experiencing pain in the right upper extremity and bilateral hips, and reports that Resident # suffered a head strike as well. See F689 for more information.A review of the Facility Assessment, last updated 11/11/25, reveals that the residents who reside in the facility have various care needs, such as catheter care, transfer assistance with a mechanical Hoyer lift, dressing, toileting, and bathing assistance. The assessment describes a service offered as Mobility and fall/fall with injury prevention, which includes transfers, ambulation, and restorative nursing. The facility assessment indicates that staff will be trained and evaluated for competencies related to assistance with lifts. A review of 4 LNA training files confirmed that one file (LNA #1) lacks documented training or competency for operating a mechanical Hoyer lift.On 6/24/26, at 1:58 PM, an interview with the Support Aide revealed that she occasionally assists the Licensed Nursing Assistants (LNAs) with Hoyer lift transfers. She stated that she has not received any training from the facility on how to transfer or assist in transferring a resident.Per interview with the facility Educator on 6/26/26 at 4:01 PM, she stated that the role of the Support Aide does not include transferring residents or assisting with transfers, especially with the use of a mechanical lift or any form of personal care. All direct care staff are required to complete specific training and undergo an annual competency assessment to operate a mechanical lift. The lift requires two trained staff; she confirmed that LNA #1 had no evidence of having completed the mechanical lift competencies and the Support Aide does not receive training on any type of transfer or mechanical lifts.

Based on observation, interview, and record review, the facility failed to communication and coordination between the staff with all departments special dietary for 1 of 1 sampled residents (Resident #1). Findings include:Per record review, Resident #1 has diagnoses that include diabetes type 2, disorders of phosphorus metabolism, stage 5 chronic kidney disease, and is on a Monday, Wednesday, Friday schedule for dialysis. Per review of Resident #1 medical record, s/he had dialysis nutrition labs dated 6/12/26 that revealed a Phosphorus level at 7.8 and a note requesting to encourage the resident to avoid ice cream. Per record review Resident #1, they have been partaking in dairy products since the recommendation from dialysis was sent to the facility on 6/12/26, to encourage the resident to not eat ice cream. The resident was noted to have eaten ice cream, yogurt, and milk since 6/12/26. Resident's orders or care plan do not reflect the recommendation. Per interview on 6/30/26 with the Unit Manager at 2:50 PM, verbalized that when a resident returns from dialysis they have a dialysis book they take with them for any new orders or recommendations. She verbalized that staff would then communicate any dietary changes thru their Diet Order and Communication slip. This could be used for new diet orders, recommendations, or short-term diet adjustments such as nothing by mouth (NPO). Also stated that the nurses and dietary staff at dialysis at times communicate with them via a call or email. Per interview on 6/30/26 with Dietary Manager at 3:13 PM, he was not able to locate a Diet Order or Communication slip for Resident #1 for the month of June. Per interview on 6/30/26 with the Dietary Tech at 3:15 PM, when shown the Dialysis Nutrition Labs from 6/12/26 with the Phosphorus levels at 7.8 and the comment noted with it requesting to encourage the resident to avoid ice cream. The Dietary Tech verbalized that she did not know about this and that this was not communicated to her. She stated that if she or the Dietary Manager had seen the recommendation, they would have put it in the system. She confirmed that it was not in the system and that it should have been in the system.

Based on observation, interview and record review the facility failed to provide quality care to 1 of 3 sampled residents (Resident #3) related to skin assessment, and non-pressure wound care. Findings include:1.) Resident #3 is a long term resident of the facility with diagnoses including lymphedema (swelling caused by fluid build up), chronic venous insufficiency (veins in the legs do not work well resulting in blood buildup), diabetes, chronic pain, depression and anxiety. Per interview with Resident #3 on 6/24/2026 at 10:45 AM, s/he stated that his/her legs have been unwrapped for days. S/he reported that the bandages were removed earlier in the week before his/her shower and that they have not been replaced. S/he voiced concern about the open areas on his/her legs and stated they hurt a lot. Per observation of Resident #3's lower legs at the time of his/her interview, legs were open to air, both lower extremities were reddened, a dime sized blister could be seen on the inner aspect of his/her lower leg, and 2 open areas of skin on both of his/her shins. Per review of Resident #3's physician orders there is an order for knee high compression to bilateral lower extremities with kerlix, coban, and tubigrip (all are types of bandages used in wound care).Per review of the facility's skin assessment policy, the resident's physician orders and the resident's care plan on 7/1/2026, systemic skin assessments are to be conducted weekly and as needed. According to Resident #3's medical record his/her last skin assessment was performed on 6/12/2026.Per interview with a Licensed Practical Nurse (LPN) on 6/24/2026 at 12:30 PM, she stated that she was the nurse who removed the bandages from Resident #3's lower legs on Monday 6/22/2026. She observed that Resident #3's lower legs were swollen with a blister on his/her left leg and skin breakdown on both lower legs. She stated that she was unsure if this was a change in condition so reported it to leadership several times over the next 2 days with a request that a skin assessment be completed before rebandaging. The LPN reported the following:6/22/2026 - the nurse noted the condition of Resident #3's legs and reported her findings to the day shift supervisor.6/22/2026 - the nurse noted that Resident #3's skin assessment had not been completed and reported her findings to the night shift supervisor. 6/23/2026 - the nurse noted that Resident #3's skin assessment had not been completed, and his/her legs were not bandaged. She reported her findings to an Assistant Director of Nursing (ADON)/unit manager, wound care nurse and the facility's nurse educator.6/24/2026 - the nurse noted that Resident #3's skin assessment had not been completed, and his/her legs were not bandaged. She reported her findings to the Director of Nursing (DON).Per interview with the Unit Manager on 6/24/2026 at 2:15 PM, she stated that they were waiting for orders from the wound care team. She confirmed that a skin assessment had not been completed since 6/12/2026, and should have been based on facility policy, the resident's physician orders, and care plan. She confirmed that an assessment should have taken place after the nurse's report of alteration in the resident's skin integrity. Per interview with the Director of Nursing (DON) and a wound care nurse on 6/24/2026 at 2:40 PM, the DON reported that they were in the process of doing a skin assessment on Resident #3 and getting new orders for wound care. She confirmed that the last skin assessment was completed on 6/12/2026 (12 days previous) and that a skin assessment should have been completed on Resident #3 weekly and after the staff nurse reported her findings.

Based on interview and record review, the facility failed to complete a performance review of every nurse aide at least once every 12 months or provide regular in-service education based on the outcome of these reviews for 4 of 4 sampled employee files. Findings include: A review of 4 employee files indicated that Licensed Nursing Assistant (LNA) #1 was hired on 10/1/2024, LNA #2 with a hire date of 7/18/2023, LNA # 3 with a hire date of 7/24/2025, and LNA #4 with a hire date of 12/17/2018 did not have evidence of performance reviews for 2025 in their employee files.Per the interview with the Administrator on 3/25/26 at 2:40 PM, she confirmed that the 2025 employee reviews had not been completed.

Based on observation and interview, the facility failed to ensure expired medications were stored or disposed of properly for 3 of 3 units. This is a repeat deficiency for this facility, with violations cited during the previous two recertification surveys dated 4/2/25 and 1/11/24. Findings include:Per review of the facilities policy titled Medications Administration Methods dated 1/25/24, it states that medication expiration dates are checked prior to administration. Per observation and interview on 3/24/26 at 10:30 AM, the [NAME] medication room had seven cases, 69 packs of nystatin oral suspension packs 500,000 units/5ml (a medication used to treat fungal infections), that had expired in 2025. A nurse confirmed this medication was expired.Per observation and interview on 3/24/26 at 11:12 AM of a medication treatment cart on the [NAME] Unit, a medication called Benzonatate 100 mg tablets (a medication used to help alleviate coughing) expired on 10/31/25 along with Aspirin 325mg (a medication used to make the blood thinner) with an expiration date of 1/26. A nurse confirmed these medications were expired.Per observation and interview on 3/24/26 at 11:31 AM in the [NAME] medication room, a medication called Ipratropium bromide and albuterol sulfate inhalation solution .5mg/3mg (a medication to help open the airways) expired on 12/25. A nurse confirmed this medication had expired.

Based on observation, interview, and record review, the facility failed to ensure that residents who require dialysis (A life-sustaining medical treatment that filters waste, toxins, and excess fluids from the blood when the kidneys have failed.) receive services consistent with professional standards of practice for one of two residents (Resident #112). Findings include:Per review of the facility policy and procedure titled Dialysis- Care of Resident Receiving Off Site Dialysis, revised on 7/6/18, it revealed that vital signs, including weights, should be performed as ordered by the provider.Per record review, Resident #112 was admitted to the facility on [DATE] with diagnosis that include end stage renal (kidney) disease, anemia (low red blood cells) in chronic kidney disease, chronic diastolic heart failure (CHF), and pulmonary edema (fluid in lungs). The Resident has a central catheter (a soft plastic tube, tunneled under the skin and placed in a vein in the neck, chest, or groin, which enters a central vein that leads to the heart). Review of Resident #112's care plan reveals a focus area of I require hemodialysis r/t End Stage Renal Disease with the intervention of monitoring for vital signs as needed, initiated on 3/7/26. An additional focus area is Resident #112s Respiratory Status which states I have a potential for alteration in respiratory status r/t CHF, fluid overload, Shortness of Breath with an intervention of monitor vital signs/pulse oximetry as needed/ordered, initiated on 3/7/26.Per review of the dialysis binder for Resident #112, there are two dialysis center communication record forms that are missing various information, like the patient identifier, the Resident's weight, how much fluid was removed, and the dialysis centers recommendations.Per interview on 3/25/26 at 2:39 PM with the nurse supervisor, she reported that the dialysis communication binder goes to dialysis and that it isn't always filled out. She confirmed that the patient identifier should be filled out, any recommendations from dialysis, pre and post vitals, weights, how much fluid they took off, and the date of treatment.Per observation on 3/25/26 at approximately 4:25 PM, there were no clamps observed in Resident #112's room.Per interview on 3/25/26 at 4:30 PM, the Unit Manager confirmed that Resident #112 should have clamps in the room for use in case of an emergency, and that there were not any in the room. The Unit Manager then went to get clamps from the medication room but could not find them. The Unit Manager then found the clamps in the Clean Utility room and stated that he would make sure the clamps go in Resident #112's room.Per interview on 3/25/26 at 4:51 PM, the Unit Manager confirmed that Resident #112 has a central line, not a shunt per the treatment plan. The Unit Manager also confirmed that the care plan should indicate central line.

Based on staff interview and record review, the facility failed to assure that a PASARR (Pre-admission Screening and Resident Review) was conducted for 1 applicable resident (Resident #20), who was admitted with a 30-day exemption and has exceeded the expected 30-day stay. Findings include:Per record review, Resident #20 had a PASARR Level 1 exception form signed and dated by a physician on 4/15/2025 that stated, If the individual is found to meet the conditions of this exemption, the individual may be admitted to a nursing facility without further screening. Hospital Discharge for Short-Stays (30 days or less) less) Is this individual being admitted to a nursing facility directly following an acute hospitalization for treatment of a condition that he/she was hospitalized for? (The attending physician must certify by signing below, before admission, that the individual is likely to require less than 30 days in the nursing facility to qualify for this exemption.)If it is later decided the individual will exceed the 30 days, another Level 1 form screening for serious mental illness (SMI) and intellectual/developmental disability (IDD/DD) and/or a related condition (RC) must be completed by the admitting nursing home and submitted to the Department of Mental Health. Please be sure to send completed copies of this form to the hospital of record, nursing facility, and individual/legal guardian(s). There is no evidence in Resident #20's medical record that a Level 1 PASARR was completed prior to admission and there is no evidence of further screening after the 30 days exemption. Resident #20 has diagnoses including but not limited to, Post Traumatic Stress Disorder, Unspecified, Adjustment Disorder with Mixed Anxiety and Depressed Mood, and insomnia. Per interview on 3/24/26 at approximately 3:10 PM, the Director of Nursing confirmed that the PASARR screening had not been updated since the initial 30-day period and the resident still resides in the facility.

Based on interview and record review, the facility failed to follow the providers' orders in administering a medication for one of eight residents (Resident #64).Per record review, Resident #64 has the medical diagnosis of cellulitis of left lower limb, Methicillin Resistant Staphylococcus Aureus infection (MRSA), and pain in their left leg. On 2/19/26, a telehealth provider created a treatment plan including Start linezolid 600 mg BID for five days to cover for MRSA. A second progress note on 2/24/26 by a provider identified that the Resident had been prescribed linezolid on 2/19/26 and that they could not see that it was ever obtained or administered.Per interview on 3/25/26 at 4:05 PM with the infection preventionist (IP) nurse, she provided a text message with the provider that asked if Resident #64 had been given the linezolid per the telehealth orders and indicated that linezolid would have been a good choice. When asked who enters the orders for telehealth providers, she stated that typically it's whoever calls the telehealth provider, but the telehealth provider or the nurse can do it.Per interview on 3/25/26 at 5:01 PM with the infection preventionist (IP) nurse, she confirmed that they don't have a policy specific to nurses putting in orders.Per interview on 3/25/26 at 5:11 PM with the infection preventionist (IP) nurse and the Unit Manager (UM), the UM confirmed that the order was not transcribed over and that it wasn't given to the Resident #64 as ordered. [NAME] & amp; [NAME]. 2023. Lippincott Nursing Procedures - 9th Ed. Philadelphia. [NAME] & [NAME].

Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety for 1 applicable unit. Findings include:Per observation of the kitchenette #1 refrigerator on the [NAME] unit on 3/23/26 at 11:21 AM there was a can of Redi-whip that expired on 3/16/26. There were (2) 32-ounce bottles of milk that expired on 3/19/26. In the freezer there were three packs of two donuts with no label or date. An interview was conducted with the Kitchen Manager on 3/23/26 at approximately 11:30 AM. The Kitchen Manager confirmed the items in the fridge were expired stating, I'll throw these [items] away. He confirmed that the packs of donuts had no label or date on them stating, I don't know what these are from.Per review of the facility's Dietary, Food and Supply Orders-Storage policy [last revised 10/26/18] it states, 1. Food and non-food items are removed from storage areas by kitchen personnel, as needed on a per meal basis. 2. Before use, all items are checked for spoilage. 3. If a food is partially used, the item is labeled with name and date and covered before being put back in storage.

Based on observation, interview, and record review the facility failed to implement appropriate infection control practices during medication administration via tube feed for one sampled resident (Resident #14). This is a repeat deficiency for this facility, with violations cited during the previous two recertification surveys dated 4/2/25 and 1/11/24. Findings include:1. Medication administration via a tube feed was observed on 3/25/26 at approximately 8:45 AM for Resident #14 by LPN#2. Per observation, Resident #14 had an Enhanced Barrier Precautions sign outside of their room. Per record review, Resident #14 has an order stating Precautions: Maintain barrier precautions r/t [related to] hx [history] of MRSA [Methicillin-resistant Staphylococcus aureaus, a bacterium that is resistant to many antibiotics], PEG [Percutaneous Endoscopic Gastrostomy] tube use.Per observation, LPN#2 did not don PPE [Personal Protective Equipment] prior to going into the room.Per review of the facility's Transmission Based Precaution Levels (Type of Infectious Condition, Techniques and Documentation) SNF policy [last revised 6/6/24] it states, Enhanced Barrier Precautions: Enhanced barrier precautions involve gown and glove use during high contact resident activities for residents known to be colonized or infected with an MDRO [Multidrug-Resistant Organism, an organism resistant to many antibiotics] as well of those who at increased risk of MDRO acquisition.An interview was conducted with LPN#2 on 3/25/26 at 8:55 AM. She confirmed she did not put on PPE prior to entering the resident's room to administer medications via a PEG tube. She stated, I'm not sure if we need to wear PPE [for tube feeding]. She confirmed tube feeding is on the EBP sign stating, We'll have to look into that.An interview was conducted with the Infection preventionist on 3/25/26 at 9:22 AM. The Infection Preventionist confirmed that PPE should be worn for EBP residents with a PEG tube.

Based on record review and interviews, the facility failed to document for 1 of 6 residents (Resident #124) whether the resident was offered, educated, and received or declined the influenza and pneumococcal vaccinations. Findings include:Per record review on 03/25/2026, Resident #124 was admitted on [DATE], and no documentation was located in the electronic medical record (EMR) to indicate the resident, or their representative had been educated, offered, and received or declined vaccinations. The Immunizations Report generated from the EMR indicates Resident #124's influenza status is historical, but lacks documentation of the immunization. The report doesn't indicate whether the resident received the pneumococcal vaccination. Per interview on 3/25/2026 at approximately 11:39 AM, the Infection Preventionist was asked to provide the Vaccination Review: Consent/Declination SNF Resident Form for Resident #124. Per interview on 3/25/2026 at approximately 4:05 PM, the Infection Preventionist confirmed documentation of offering, educating, and either receiving or declining the influenza and pneumococcal vaccinations were not available. Review of the facility policy titled, Influenza Immunization (Residents) Policy, last modified 6/2025, notes: Annually.Prior to administration, residents and/or responsible parties will be educated regarding the risks and benefits of the influenza vaccine. The policy further states, the resident Influenza Vaccination Consent/Declination form will then be completed, and once consent is obtained, the vaccination may be ordered and administered. Review of facility policy titled Pneumococcal Vaccination (Resident), last modified August 2023, states: Documentation of immunization will be placed in the individual's record at the facility. If a resident is not immunized, the reason will be documented.

Based on interview and record review the facility failed to include documentation in the electronic medical record (EMR) for 1 of 6 residents (Resident #124) whether the resident was offered, educated, received, or declined the COVID-19 vaccinations.Findings include: Per record review on 03/25/2026, Resident #124 was admitted on [DATE], and no documentation was located in the EMR to indicate the resident or their representative had been educated, offered, received, or declined the COVID-19 vaccinations. The Immunizations Report generated from the EMR indicates Resident #124's COVID-19 status is historical with a date of receiving it on 12/5/24, however it lacks documentation of the immunizations. Per interview on 03/25/2026 at approximately 11:39 AM, The Infection Preventionist was asked to produce the Vaccination Review: Consent/Declination SNF Resident Form for Resident #124. Per interview on 3/25/2026 at approximately 4:05 PM, the Infection Preventionist confirmed documentation of offering, educating, and either receiving or declining the COVID-19 vaccinations were not available. Review of the policy entitled COVID-19 Policy (Resident), Last Modified 9/2025 notes: For residents who decline to be vaccinated for COVID-19, the facility will obtain a written affirmation for signature indicating that the resident was offered and declined the opportunity for the facility to arrange for a COVID-19 vaccination .Vaccination fact sheets will be made available to residents and resident representatives prior to administration. Informed consent either written or verbal will be obtained from all individuals being vaccinated.

Based on staff interviews and record reviews, the facility failed to ensure that 10 of 10 residents sampled (#1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) were free from misappropriation of 6 different types of controlled medications identified by the facility audit. Findings include:Per review of the facility's reported investigation, a concern was raised on 12/15/25 regarding documentation of resident #1 receiving an as-needed (prn) medication. The assigned medication nurse reported that resident #1 hadn't received the medication for 3 months, which they confirmed with the resident. The facility conducted audits of all Control Medication logbooks (record-keeping systems used by facilities to track the inventory, administration, and disposal of controlled substances) and the medication administration records of residents who were to receive these medications. It was found that on 2 separate occasions, for ten different residents (#1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) in the facility and on two units, a Licensed Practical Nurse (LPN) had not followed the procedure for administering medications as evidenced by two logbooks having entries overwritten, out-of-sequence entries, and potentially fraudulent entries all with the removal and not administered medications. These medications included pain medications: Oxycodone, Tramadol, Morphine, Percocet, and Butalbital/Acetaminophen/Caffeine. During the process of conducting the facility's internal investigation, the facility found irregularities with the Controlled Medication logbook, which included, per the facility, falsified sign-outs, forged staff signatures, altered dates, and removals without corresponding MAR (medication administration record) documentation. Nursing staff handwriting samples were obtained to compare with the logbooks. Upon conclusion, the facility investigation verified the LPN's alleged medication diversion. Per interview with Administrator on 1/14/26 at approximately 12:00 PM, she stated that the handwriting sample provided by the suspected LPN was compared to documentation in the logbook, and it was determined that she had made the entries in the logbook. The Administrator confirmed the LPN was involved in ten incidents of removing medications that are believed not to have been administered to the prescribed residents. The Administrator confirmed that there was a failure to protect residents from the suspected LPN's misappropriation of medications at the facility, and confirmed the LPN doesn't hold an active [NAME] nursing license (see citation F659 for additional information). Per interview on 1/14/26 at 1:00 PM with one of the nurses who initiated the report, she confirmed that when completing a change of shift count of the controlled medications, she noted a resident's count of a prn medication had drastically changed in one day since her previous shift, and she noticed her documentation had been altered. She reported her concerns to the Director of Nursing (DON) and began reviewing the logbook for discrepancies by comparing its entries with the individual residents' MARs, which identified additional errors. She stated the medication count in the logbook was correct, but the altered documentation in the logbook indicated an issue that needed to be reported. Per interview on 1/15/26 at 11:26 AM with the former Director of Nursing (DON), who resigned on 1/13/26, she confirmed receiving a report on 12/15/25 regarding an issue with the logbooks for two of six medication carts. One of the Assistant Directors of Nursing (ADON) informed her that there was something wonky, something weird with the logbooks after a nurse assigned to one of the medication carts noticed that a PRN medication had been used for a resident who hadn't taken the medication for an extended period. Upon review of the logbooks, it was found that the count numbers weren't off, but the signatures didn't match the staff who had worked the past couple of shifts, and the dates were out of sequence for signing out the identified medications. On 12/15/25, the DON had the staff assigned to the medication carts meet with her and provide a sample of their writing. The suspected LPN was visibly shaky during the interview and, while providing the writing sample, questioned which numbers she should write on the paper. The DON stated that after the meeting with the suspected LPN, the LPN didn't return to her assigned unit immediately. When the LPN returned to the unit, she completed a change-of-shift count with the oncoming nursing staff. The DON stated she quickly went to the medication cart and reviewed the logbook, which revealed handwriting matching the entries believed to be fraudulent. The LPN was brought to the office for further questioning, and the DON states the LPN didn't actually deny it, and was placed on administrative leave pending further investigation. The DON confirmed that the incident has been reported to the [NAME] Police Department, and an investigation is in progress with the Office of Professional Regulations.

Based on interview and record review, the facility failed to ensure that 1 of 5 nursing staff had an active [NAME] license to practice. Findings include:A review of credentials for a Licensed Practical Nurse (LPN) investigation for misappropriation of medications (see citation F602 for additional information) revealed that the LPN lacked an active [NAME] license to practice. The nurse's multistate compact license (a license with the authority to practice in multiple member states), which permitted practice in [NAME], had expired on [DATE]. A request for an updated license was made to the Administrator on [DATE] at 12:00 PM, and nursys.com (the national nurse licensure and disciplinary database) was used to search for it. The search confirmed the LPN's license was only active in North Carolina, a single-state license, and was no longer valid for [NAME]. The Administrator stated, I asked her to fix this. She was asked who she was referring to, and she stated she had spoken to the LPN by phone regarding the LPN's active single-state LPN license for North Carolina, rather than a multistate compact license that previously included [NAME]. Per the administrator, the LPN had clicked the wrong button during renewal. Review of the nurse's timecard showed that after the multistate compact license expired, the individual worked 11 shifts from [DATE] to [DATE], with 6 shifts administering medications as an LPN. During an interview on [DATE] at 2:00 PM with the Administrator, she stated that the facility has had a vacant Human Resources position and that a spreadsheet hadn't been updated with staff's license expiration dates. She continued by saying that an audit of all licensed staff, dated [DATE], was completed, and that it was determined the suspected LPN was the only staff member noted to have an expired [NAME] license. The Administrator stated the expected process is for staff to renew their licenses to practice in [NAME], and if this task isn't completed, they will not work at the facility until they have an active license. The Administrator confirmed that the LPN had worked a total of 11 shifts during the period without a valid [NAME] license. The LPN Team Leader job description for the employee, last revised 1/2025, requires credentials as a Licensed Practical Nurse with a current state license in good standing for the state of employment. An essential job function listed is administering medications and treatments. Per interview on [DATE] at 11:26 AM with the former Director of Nursing (DON), who resigned on [DATE], she revealed that during a review of the suspected LPN's personnel file, the facility identified that the LPN's [NAME] nursing license had expired, which is needed for the LPN position. The DON stated that the Administrator had taken on the task of researching the expired license.

Based on record review and staff interviews, the facility failed to implement a system to ensure nursing staff members administering medications maintain ongoing qualifications for 1 of 5 nursing staff sampled. Findings include:Per the facility's reported investigation, a concern was raised on [DATE] when the oncoming shift medication nurse reported that a resident hadn't received an as-needed (prn) medication for 3 months, a claim the nurse confirmed with the resident. The facility conducted audits of all Control Medication logbooks (record-keeping systems used by facilities to track the inventory, administration, and disposal of controlled substances) and the medication administration records of residents who were to receive these medications. It was found that on 2 separate occasions, for ten different residents in the facility and on two units, a Licensed Practical Nurse (LPN) had not followed the procedure for administrating medications as evidence identified by the facility as irregularities with the logbook, which included, per the facility, falsified sign-outs, forged staff signatures, altered dates, and removals without corresponding MAR (medication administration record) documentation. The medications suspected of being taken and not administered to the prescribed residents were pain medications: Oxycodone, Tramadol, Morphine, Percocet, and Butalbital/Acetaminophen/Caffeine. During the facility investigation on [DATE], it was revealed that the LPN suspected of failing to follow medication administration procedures had an expired nursing license in [NAME]. Per interview with the Administrator on [DATE] at approximately 12:00 PM, confirmed the LPN was working without a current [NAME] State license. The facility policy titled Controlled Substances Inventory Policy/Storage, last modified [DATE], states that the change of shift controlled substance count procedure process is, The oncoming licensed nurse . will count remaining doses of each medication and the outgoing licensed nurse.will verify the amount. Per facility policy titled Medications Administration Methods, last modified [DATE], states A Licensed Nurse.per state regulations will be responsible for passing medications according to techniques and procedures that meet current practice standards and are in compliance with State Codes, Rules and Regulations and other applicable state and federal laws. The facility policy titled Nursing Documentation Standards, last modified [DATE], states Corrections must be made by the original author: .Handwritten records: draw one line through the error, write omit, initial, and date. During an interview on [DATE] at 1:38 PM with the Administrator, she confirmed that the LPN had been assigned the task of medication administration without the required [NAME] nursing license and had fraudulently removed controlled medications by failing to follow procedures for administering and documenting accurately in the logbooks per facility policies. Per interview on [DATE] at 11:26 AM with the former Director of Nursing (DON), who resigned on [DATE], she revealed that during a review of the suspected LPN's personnel file, the facility identified that the LPN's [NAME] nursing license had expired, which is needed for the LPN position. The DON stated that the Administrator had taken on the task of researching the expired license. See citations F602 and F659 for additional information.

Based on interview and record review, the facility failed to send written documentation to resident and resident representative about transfers to outside facilities for one of three sampled residents (Resident #1). The facility also failed to send transfer records to the Long-Term Care Ombudsman for three of three sampled residents (Residents #1, #2, and #3). Findings include: Per record review, Resident #1 was transferred to an outside facility on 10/3/25 for geriatric psychiatric care. Resident #2 was transferred to the hospital on [DATE]. Resident #3 was transferred to the hospital on [DATE]. Per record review of the transfer notices for Resident #1, #2, and #3, the bottom of the document states, Copy sent to Office of the State Long-Term Care Ombudsman on . This left blank for all three notices of transfer forms. There was no record of any information being sent to the residents' representatives.Per review of the facility's Discharge Planning, Death and Notice of Discharge/Transfer policy [last revised 7/6/23] states, Following notification of an emergency discharge or planned transfer/discharge, the Director of Social Services/designee sends to the responsible party the notice of transfer form documenting the reason for transfer/discharge. A copy is kept on file in the social services department. the facility will send a copy of the notice to a representative of the office of the state long term care ombudsman with every transfer or discharge.An interview was conducted with the Long-Term Care Ombudsman on 12/10/25 at 11:00 AM. The ombudsman confirmed that he was not sent any transfer notices for Residents#1, #2, or #3.An interview was conducted with the DON (Director of Nursing) on 12/10/25 at 11:27 AM. She confirmed Resident #1's Representative was not sent any transfer information in writing. At 12:20 PM, the DON confirmed written notice of transfers were not sent to the family representative for Resident #2 and #3. She confirmed notices of transfers were not sent in writing to the Long-Term Care Ombudsman stating, This is a process we still need to work on.

Per interview and record review the facility's failed to prevent significant medication errors for one of four residents [Resident #1] sampled. Findings include:Per review of Resident #1's medical record, s/he had major diagnoses of Type II Diabetes, Alzheimer's Disease with late onset, Schizoaffective Disorder [a mental illness where the person experiences symptoms of both schizophrenia and a mood disorder], and anxiety. Resident #1 has a BIMS [Brief Interview of Mental Status] score of 4 as of 6/27/25. A BIMS score of 4 indicates Resident #1 was cognitively impaired. Per record review of the Resident #1's July 2025 MAR [Medication Administration Record] a medication order on the MAR states, Lisinopril [a medication used to treat high blood pressure] tablet 40 mg [milligrams] Give one tablet buy mouth in the morning for hypertension. Hold for SBP [systolic blood pressure] <100 [under 100] mmHg [millimeters of mercury] and notify provider. The MAR shows that the medication was ordered on 6/27/25.Per record review of Resident #1's nurse progress note written on 7/20/25 at 7:00 AM states, Resident found on the floor by CNA [Certified Nursing Assistant] sitting with [his/her] buttocks, with legs and arms extended. This writer assessed the resident, [s/he] is alert and oriented times 3, upper and lower extremities ROM [range of motion] OK [okay], no pain, no bruises at time of fall. [His/Her] head had no bumps. [S/he] said that [s/he] didn't hit [his/her] head [s/he] hit [his/her] buttocks. A nursing note at 7/20/25 at 11:50 AM states, Resident noted to have hypotensive during routine vitals at 7:22 AM BP [blood pressure] 77/45 at 9:18 AM 89/54 at 11:27 [AM]: 77/45. APN [Advanced Practice Nurse] orders resident to be transferred to ED [Emergency Department].Per record review of a physician order note dated 7/20/25 at 5:50 AM states, Assess pain per protocol, Fall precautions per facility protocol, Monitor with neurochecks [a neurological assessment] per facility protocol. Notify a clinician of any change in condition [sic] cbc [complete blood count], cmp [comprehensive metabolic panel]. Give 8 ounces of broth followed by 200 mL [milliliters] of fluid. Recheck BP [blood pressure] in 2 hours, notify provider if SBP < 100 mm hg [systolic blood pressure under 100 millimeters of mercury] Hold am [morning] lisinopril dose today [sic] Ice to back of head x 15 minutes [every fifteen minutes] as tolerated.Per record review of a physician order dated 7/20/25 at 10:15 AM states, Transfer to Emergency Department establish IV [intravenous access]/ give 500ml [milliliters] of 0.9 NS [normal saline] provide via NC [nasal cannula] or simple mask PRN [as needed] spo2 95-99% [Oxygen saturation 95-99%].Per record review of the facility's Medication Error Reporting Policy [last modified 7/6/18] states, The Medication Error Report is completed by a licensed nurse, and will be categorized and defined as follows:.2. Omission or wrong drug:.Medication given without order: Dose given to resident without physician's order.Note: A significant medication error means one that causes the resident discomfort or jeopardizes his/her life or safety.Per record review of Resident #1's MAR, Lisinopril was administered by Licensed Nurse #1 during the 7:00 AM to 10:00 AM medication pass. The blood pressure at the time of the Lisinopril administration was documented in the MAR as 89/54 mmHg [millimeters of mercury]. The systolic blood pressure recorded was too low to have Lisinopril administered as the systolic blood pressure needed to be over 100 mmHg [millimeters of mercury]. There was no documentation on the July 2025 MAR showing that normal saline via IV was administered to Resident #1.An interview was conducted with the DON [Director of Nursing} on 8/11/25 at 11:45. The DON confirmed that the MAR was documented as the medication administered with the blood pressure of 89/54 mmHg [millimeters of mercury]. She stated, I'm doing a med [medication] error report with the nurse who signed off the medication. The DON confirmed the blood pressure of the resident decreased to 77/45 mmHg at 11:27 AM and 11:56 AM. She confirmed Resident #1 was never administered normal saline or IV access prior to going to the hospital.Works Cited:Schizoaffective Disorder. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/schizoaffective-disorder/symptoms-causes/syc-20354504. Accessed 8/12/25.

Per interview and record review, the facility failed to ensure one of four residents (Resident #2) was free from chemical restraints by prescribing an as needed psychotropic medication with no stop date of 14 days. Findings include:Per review of Resident #2's medical record, Resident #2 has major diagnoses of vascular dementia [a form of dementia associated with impaired reasoning, planning, judgment, and memory caused by brain damage from impaired blood flow to your brain], Stage 2 chronic kidney disease, and COPD [Chronic Obstructive Pulmonary Disease]. Resident #2 had a BIMS [Brief Interview of Mental Status] score of 9 as of 7/17/25. A BIMS score of 9 indicates that Resident #2 is cognitively impaired. Per record review of a physician order dated 7/23/25 states, Lorazepam tablet 0.5 mg [milligram]: Give one tablet by mouth every 6 hours as needed for itching and anxiety. There was no documented stop date of 14 days on this order. Resident #2 was administered the Lorazepam 8 times from 7/23/25 to 8/11/25.An interview was conducted with the DON [Director of Nursing] on 8/11/25 at 11:45 AM. The DON confirmed that the order for Lorazepam did not include a stop date of 14 days. Works CitedVascular Dementia. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/vascular-dementia/symptoms-causes /syc-20378793. Accessed 8/12/25.

Based on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 resident [Resident #1] of 3 sampled residents. Findings include: Per interview with the State Surveyor on 5/12/25 at 10:30 AM and per review of the State Surveyor's written report, Resident #1 reported to the Surveyor allegations of employee misconduct and possible abuse involving Resident #1's roommate and a Licensed Nursing Assistant on 2/18/25. The Surveyor reported the allegations of abuse and misconduct to both the facility's former Administrator [FADM] and Assistant Director of Nursing [ADON] on the same date, 2/18/25. Additionally, the Surveyor reported the allegations of abuse and misconduct to Adult Protective Services. An interview was conducted on 5/12/25 at 11:47 AM with the facility's current Administrator [ADM] and Director of Nursing [DON]. The ADM and DON confirmed that Adult Protective Services arrived at the facility 7 days after the incident on 2/26/25 to investigate the allegations, and it was on 2/26/25 that the facility then initially reported the allegations to the required State Survey Agency. An interview was conducted via phone with the Assistant Director of Nursing [ADON] on 5/12/25 at 12:40 PM. The ADON stated that an investigation into Resident #1's allegations was done by the former ADM who was no longer at facility. The current ADM, DON, and ADON confirmed there was no documentation of an investigation being conducted or allegations reported as required to the State Survey Agency, prior to the arrival of Adult Protective Services 7 days after the incident. The ADON was offered the opportunity to forward any new evidence if any was uncovered by the facility, but none was received as of 5/22/25.

Based on record review and interview, the facility failed to provide safe and effective skin and wound care consistent with facility policy and professional standards of practice for preventing and treating existing pressure ulcers for 7 of 37 sampled residents (Residents #50, #7, #1, #99, #43, #21, and #107), resulting in new or worsening pressure ulcers for all 7 residents. Findings include: Facility policy titled Pressure Ulcer, Pressure Injury & Other Skin Conditions: Initial Assessment, Care Planning, Ongoing Evaluation and Management (HAM, [NAME], SS, WAV, WMS [facility name initails]) SNF, last revised on 2/27/2023 reveals the following under procedures: Care Plan Development & Implementation: a baseline care plan will be developed by the IDT [interdisciplinary team] within 48 hours of admission identifying appropriate interventions to stabilize, reduce or remove underlying risk factors to prevent or treat skin conditions. The individualized care plan will be reviewed and revised as needed to meet the skin care needs of the resident based on assessment and risk factors. Medical providers are part of the IDT and will discuss, review, monitor and assess the progress of ulcers, pressure injuries or other skin conditions during routine visits and when necessary. Ongoing assessment of existing pressure ulcers, pressure injuries & other skin conditions will be conducted weekly by facility staff and/or a consultant who specialized in wound management. Progress, treatment, and care plan interventions are reviewed at that time and will be documented in the medical record. Wound consultant progress notes will be scanned into the medical record and may be used as the source document to meet the requirement of a weekly assessment. The assessment will include characteristics of the wound and surrounding tissue such as but not limited to presence of epithelial or granulation tissue, measurements, stage, presence of exudates, necrotic tissue such as eschar or slough and evidence of erythema or swelling around the wound. Staging of a pressure ulcer or pressure injury will be conducted according to professional standards of practice. Documentation also includes signs and symptoms of pain and intervention for pain related to the wound or treatment. Appendix F: Wound Care & Skin Product Formulary Guide, dated 2/19/2020, reveals the following formulary products for MASD: Thera Calazinc Body Sheild Cream (zinc product) and [NAME] Med Skin Protectant (aluminum hydroxide product); guidelines for use, Apply QS [every shift] & PRN [as needed] or as directed by MD order; considerations, Nurse to apply. 1. Per record review, Resident #50 was admitted to the facility on [DATE] for rehabilitation services following a below-knee amputation (BKA) with diagnoses that include diabetes, osteomyelitis (bone infection), hypertension, and severe kidney disease. A 11/20/23 form titled Braden Scale for Predicting Skin Ulcers, a tool used to identify the level of risk a resident has for developing pressure ulcers, reveals that Resident #50 is at risk. Review of an initial wound assessment dated [DATE] reveals that Resident #50 has an abrasion on his/her lower left leg 2.5 cm x 0.2 cm. There are 3 other skin conditions identified on this assessment: MASD (Moisture-associated skin damage, which can contribute to the formation of a pressure injury since the tissue has been compromised) on the groin, MASD on the coccyx, and a surgical incision on the right knee. There is no documentation of the size of these conditions. A second wound assessment dated [DATE] reveals that Resident #50 has a left lower leg abrasion that is 2.5 x 0.2 cm; a groin MASD that is marked healed; a coccyx MASD, 1 x 0.5 cm; and a right knee surgical incision, 16 x 0.1 cm. A third wound assessment dated [DATE] reveals that Resident #50 has groin MASD, no measurement; coccyx MASD, no measurement; and no assessments of abrasion or surgical incision from the previous assessment. Record review reveals that Resident #50 did not have a baseline care plan within 48 hours of admission related to his/her risk for impaired skin or for the skin conditions present on admission. The following care plan focus was created 25 days after admission SKIN INTEGRITY: I am at risk for impaired skin integrity related to 5 (or more) medications, Activity Intolerance, Deconditioning, Diabetes, Hx [history] of Pressure Ulcers, Immobility, Incontinence, Overall Physical Condition, initiated on 12/15/23. It does not address the actual condition of Resident #50's skin. Apply/administer treatments and barrier creams, as ordered, created 12/15/23. Per review of physician order and the medication and treatment administration records, Resident #50 does not have physician orders for any wound treatment or barrier creams and there is no evidence in their medical record that any wound treatment or barrier creams were provided. Per review of a 12/21/23 transfer form, Resident #50 was transferred to the emergency roiagnom on [DATE]. Review of a 12/21/23 hospital admission note reveals on physical exam Resident #50 has a purplish/erythematous (redness of the skin) ulcer per imaging, and has a wound consult planned related to Resident #50's sacral pressure wound. The note includes a small photograph of Resident #50's sacrum and coccyx area that is approximately 6 inches by 4 inches and dark purplish red. It is difficult to determine if the area is open based on just the photo. Review of a 12/22/2023 hospital wound care note reveals the following, Healing fungal rash notes to sacrum extending down bilateral buttocks. Superficial ulceration to left buttock and left coccyx, etiology likely moisture and friction. Linear, full thickness wound in gluteal cleft. Difficult to determine primary etiology as linear distribution tends to be due to moisture and friction however wound is located directly over coccyx so could likely have a pressure component. All wounds present on admission. Per interview on 12/26/23 at approximately 8:30 AM, the Unit Manager stated that it is very difficult to get a sense of the current status of the skin and current wounds with the skin assessment form that is used in the EMR (electronic medical record). S/He was unable to find any wound care orders for Resident #50 and confirmed that Resident #50 did not have a baseline care plan for skin and should have. 2. Per record review, Resident #1 has diagnoses that include diabetes, end stage renal disease requiring dialysis, malnutrition, and a history of pressure ulcers. A 7/10/23 MDS (Minimum Data Set; a comprehensive assessment used as a care-planning tool) assessment reveals that Resident #1 is at risk for developing pressure ulcers. Review of an 8/29/23 wound assessment reveals that Resident #1 has a stage 3 pressure left heel pressure ulcer that measures 3.9 cm length x 3.0 cm width x 0 cm depth. Review of a 10/25/23 wound assessment reveals that Resident #1's stage 3 pressure left heel pressure ulcer now measures 4.5cm length x 4.0 cm width x 0 cm depth, an increase from the previous 8/29/23 wound assessment. There are no weekly skin assessments completed between the two assessments above. Review of Resident #1's physician orders reveals the following order for his/her heel wound, Clean left heel wound with NS [normal saline], pat dry, skin prep around wound edges X2, apply solosite [wound gel] soaked gauze to WOUND BED ONLY and cover with two 4x4 gauze, apply tubigrip [bandage] daily until wound resolves. every evening shift for WOUND CARE, with a start date of 7/24/23. Per Resident #1's Treatment Administration Record, this order is not marked as complete for the time between 8/29/23 and 10/25/23 9 times during September 2023 and 4 times during October 2023. Per phone interview on 12/26/23 at 11:23 AM, the MDS Coordinator confirmed that Resident #1 did not have all their wound assessments completed weekly for their actual pressure ulcers and should have. 3. Per record review, Resident #99 has diagnoses that include diabetes, peripheral vascular disease, difficulty walking, and need for assistance with personal care. Resident #99 had a left great toe amputation on 6/15/23. Per record review, Resident #99 has the following care plan I am at risk for impaired skin integrity related to Diabetes and immobility, I have a left first toe partial amputation, revised on 6/19/23 with interventions that include, monitor skin daily and report any signs of skin breakdown, and conduct systemic skin inspection weekly and as needed. Document findings. Review of an 8/31/23 wound assessment reveals that Resident #99 has an unresolved, unchanged surgical incision from the left toe amputation site that measures 8 cm x 1 cm. Review of a 10/2/23 wound assessment reveals that Resident #99 continues to have an unresolved, unchanged surgical incision from the left toe amputation site. There are no measurements of this wound in this wound assessment. There are no weekly wound assessments from 9/1/23 through 10/1/23 in Resident #99's medical record. According to the facility's policy and professional standards, there should have been a minimum of four wound assessments during this time. Review of Resident #99's physician orders reveals the following order, Diabetic foot check q (every) day, report s/sx [signs and symptoms] of skin breakdown to MD [physician]. every evening shift every 7 day(s) for diabetes -Start Date 09/23/2023. Resident #99's Treatment Administration Record for September, October, November, and December 2023 reveal that diabetic foot checks were only completed only once a week. Per record review, a 12/1/23 progress notes state, writer was informed by resident in the AM that the three toes on the left foot (excluding little toe) were hurting and resident was concerned with getting an infection; toes were red and warm to touch, and Writer spoke with therapy regarding getting a bed extender for resident's bed; writer sees that resident is touching the foot of bed and it may be contributing to pressure on the resident's toes. Per a Physician note dated 12/1/23, Resident #99 was seen for left foot pain. The provider describes examination of the left toe to have a small amount of scab that the patient notes has improved. This note does not assess the wound completely; there are no measurements or documentation that the pervious incision has fully healed. Record review reveals the following physician order, Apply telfa [cotton pad] and kerlix [gauze] to left foot every other day until steri stips fall off. every evening shift every Wed, Sun for Wound care, with a start date of 9/10/23. This is marked as complete as scheduled on the TAR on all but three days scheduled (missing 9/20/23, 10/4/23, and 11/29/23). The continuation of wound care implies that the wound has not healed and still needs treatment. A Physician progress note dated 12/13/23 reveals .Patient has a stage 3 (full thickness skin loss) non-inflamed ulcer over his/her distal amputated first toe The note indicates that the patient's pain in his/her left foot is consistent with cellulitis will be treated with Keflex. The infected toe is Resident #99's left toe and his/her great left toe has an ulcer. A 12/13/23 wound assessment reveals a stage 2 pressure ulcer (Partial-thickness skin loss) on Resident #99's left great toe 1 cm x 0.5 cm in size and his/her left second toe has an area of trauma. There are no weekly wound assessments of this area between 10/2/23 and this note dated 12/13/23 in Resident #99's medical record. According to the facility's policy and professional standards, there should have been a minimum of ten wound assessments during this time since the last skin assessment. During a phone interview on 12/21/23 at 12:02 PM with the MDS Registered Nurse Coordinator, he/she confirmed that the weekly skin assessments were not completed consistently for Resident #99. Per interview on 12/26/23 at 10:35 AM, the Regional Nurse Consultant reviewed Resident #99's weekly skin assessments and was unable to produce skin assessments of Resident #99's left toe wound for the missing weeks mentioned above. 4. Per record review, Resident #7 has diagnoses that include spastic quadriplegic cerebral palsy (a physical disability that causes muscle rigidity that affects all four limbs and often a person's torso, facial, and oral muscles), and is at risk for developing pressure ulcers according to a 10/2/23 MDS (Minimum Data Set; a comprehensive assessment used as a care-planning tool). Resident #7 has the following care plan focus, I am at risk for fungal infections and/or impaired skin integrity related to Deconditioning, Immobility, Overall Physical Condition, Poor Nutritional Status, created on 3/3/2020. A 11/17/23 progress note reveals Writer was made aware of unstageable pressure area [full thickness tissue loss in which the base of the ulcer is covered by slough (non-viable tissue) and/or eschar (dry, non-viable tissue) in the wound bed] on residents right buttock. Resident states pressure area is painful. New tx [treatment] order to apply santyl [an ointment that removes dead tissue from wounds so they can start to heal] everyday shift and cover with allevyn [brand] foam dressing. Resident #7's care plan was revised to include the following focus, I have an alteration in skin integrity r/t decreased mobility. Unstageable pressure area on right buttock, created on 11/17/23 with an intervention for Assess and document status of wound/skin site(s) weekly and as needed, created on 11/17/23. Review of an initial wound assessment (Skin Assessment form in the electronic medical record) dated 11/17/23 reveals that Resident #7 has an in-house acquired unstageable pressure ulcer on the right buttock that is 3 cm X 2 cm in size. This assessment does not include characteristics of the necrotic tissue. There are no weekly wound assessments or evidence that progress, treatment, and care plan interventions were reviewed for the existing pressure ulcer from 11/18/23 through 12/14/23 in Resident #7's medical record. According to the facility's policy and professional standards, there should have been a minimum of three wound assessments during this time. Review of a 12/15/23 skin assessment form reveals that Resident #7 has a stage 3 pressure ulcer (full thickness skin loss) on the right buttock that is 3 cm x 2.8 cm in size. This assessment does not include characteristics of the wound and surrounding tissue. While it was expected that treatment would expose at least a stage 3 pressure ulcer following treatment, the wound did increase in size. There is no evidence that a medical provider was informed of the change of status of Resident #7's pressure ulcer. Because of this, there is no evidence in Resident #7's medical record that progress, treatment, and care plan interventions were reviewed at the time of the 12/15/23. There are no weekly wound assessments or evidence that progress, treatment, and care plan interventions were reviewed for the existing pressure ulcer from 12/16/23 through 12/26/23 in Resident #7's medical record. According to the facility's policy and professional standards, there should have been a minimum of one wound assessment during this time. Review of Resident #7's physician orders reveal the following, Santyl External Ointment 250 UNIT/GM (Collagenase) Apply to Right Buttock topically every evening shift for Wound Care, with a start date of 11/18/2023, and Right Buttock: Cleanse with NS, pat dry. Apply Santyl nickel thick to wound bed only. Cover with alleyvn foam dressing. every evening shift for Wound Care, with a start date of 11/18/2023. While the first order for Santyl is documented as complete in Resident #7's MAR, the second treatment order, which describes how the Santyl ointment is to be applied, and what type wound care is to be used, including cleaning and dressings, is not marked as complete for 12/6/23, 12/8/23, 12/12/23, 12/15/23, 12/17/23, 12/18/23, and 12/26/23. Per interview on 12/21/23 at approximately 9:30 AM, the Unit Manger confirmed that the above wound treatment orders were not documented as administered for Resident #7 for the above times. S/He indicated that s/he was unsure why there were no wound assessments completed between the 11/17/23 and the 12/15/23 assessments. 5. Record review reveals that Resident #107 was admitted to the facility on [DATE] and has diagnoses that include diabetes, obesity, and abnormalities of gait and mobility. Per Resident #107's MDS dated [DATE], s/he requires a mix of partial, substantial. and complete assistance for most ADLs excluding eating, is at risk for developing pressure ulcers, and does not have any unhealed pressure ulcers at the time of the assessment. Review of an admission skin assessment dated [DATE] skin reveals that Resident #107 has only a surgical incision on their chest which was present on admission. No other skin conditions are identified. There are no weekly skin assessments or wound assessments for the existing surgical incision from 7/26/23 through 8/21/23 in Resident #107's medical record. According to the facility's policy and professional standards, there should have been a minimum of three wound assessments during this time. Review of Resident #107's MAR shows a physician order for Left Heel: skin prep every shift for Deep Tissue injury [closed wound where the tissues beneath the surface have been damaged], with a start date of 8/10/23. There is no evidence that this wound was assessed when it was first discovered. An 8/22/23 skin assessment reveals that Resident #107 has an in-house acquired left heel pressure ulcer that measures 3 cm x 4 cm x 0 cm. There is no staging information or date for when this wound was acquired. Review of an 8/26/23 skin assessment reveals that Resident #107 has a newly identified in-house acquired pressure ulcer on the left lower leg. There is no staging information or measurements of this wound. Review of an 8/29/23 skin assessment reveals that Resident #107's left lower leg is now being documented as an abrasion that measures 3.5 cm x 1 cm x 0 cm and the left heel is measured to have the same area and is still not staged. Record review reveals that between 8/30/23 and 10/11/23 Resident #107 was missing two wound assessments and two wound assessments did not have the completed information. Review of a 10/12/23 skin assessment reveals that Resident #107's left lower leg abrasion has worsened to an unstageable left calf pressure ulcer that measures 4 cm x 3 cm x 1 cm and their left heel has worsened to a suspected deep tissue pressure injury that measures 2.5 cm x 1.5 cm x 0 cm. The following weekly wound assessments reveal that on 11/6/23 the pressure injury to Resident #107's heel increased in size to 5.5 cm x 3.5 cm x 0 cm, and on 11/16/23, Resident #107's left calf pressure ulcer has worsened to a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle) that measures 3.9 cm x 3.1 cm x 2.8 cm. Resident #107's care plan was not revised to reflect his/her actual skin conditions related to his/her calf until 11/2/23, 68 days after it was first assessed, and heel until 11/2/23, 72 days after it was first assessed. Per interview on 1/10/24 at 4:07 PM, the Director of Nursing confirmed that Resident #107 had incomplete and missing wound assessments and their care plan was not revised to reflect existing wounds when they were first identified. The facility wound management policy was requested on 1/9/24 at 10:20 AM. On 1/9/24 at approximately 3:00 PM, both the Director of Nursing and the Asisstant Director of Nursing were unable to produce an up to date wound management policy. On 1/11/24 at 8:10 AM, when asked to produce the current wound policy, the Unit Manager was only able to find a policy that was not applicable to the facility's wound assessment procedure. The policy that was available referred to using a photograph system to document wound progress which had stopped being used in the Spring of 2023. On 1/11/24 at 3:07 PM, the Chief Nursing Officer confirmed that the facility policy titled Pressure Ulcer, Pressure Injury & Other Skin Conditions: Initial Assessment, Care Planning, Ongoing Evaluation and Management (HAM, [NAME], SS, WAV, WMS) SNF, last revised on 2/27/2023, was the wound policy that the facility should be using for wound management even though the title does not include the facility's initials. 6. Record review reveals that Resident #43 has diagnoses that include diabetes, peripheral vascular disease, and reduced mobility. Per Resident #43's MDS dated [DATE], s/he is dependent on staff for all ADLs, is at risk for developing pressure ulcers, and does not have any unhealed pressure ulcers at the time of the assessment. Resident #43 has the following care plan focus, I have an alteration in skin integrity r/t pressure injury on right foot r/t impaired mobility, initiated on 11/2/23 with interventions to apply treatments as MD/NP orders and assess and document status of wound/skin site(s) weekly and as needed, initiated on 11/2/23. Review of a 11/6/23 skin assessment reveals that Resident #43 has an in-house acquired stage 2 right foot pressure ulcer measuring 1 cm x 1.5 cm x 0.1 cm and wound progress is described as improving. Review of a 11/15/23 skin assessment reveals that Resident #43's stage 2 right foot pressure ulcer measuring 1.1 cm x 1.7 cm x 0.1 cm and wound progress is described as worsening. There are no weekly wound assessments for the existing pressure ulcer from 11/16/23 through 11/29/23 in Resident #43's medical record. According to the facility's policy and professional standards, there should have been a minimum of one wound assessment during this time. Review of a 11/30/23 skin assessment reveals that Resident #43's right foot wound is now a stage 3 pressure ulcer measuring 6.5 cm x 4.5 cm x 0.5 cm and wound progress is described as worsening. Review of Resident #43's physician orders reveal the following, Medihoney Wound/Burn Dressing External Gel (Wound Dressings) Apply to Right Lateral Foot topically every day shift for Wound Care, started on 11/9/23 and discontinued on 11/15/23. Per the MAR, this order is not marked as complete for 2 of the 7 days ordered (11/14/23 and 11/15/23). There are orders for cleaning or dressing the right foot wound in the MAR or TAR from 11/9/23 through 11/15/23. Medihoney Wound/Burn Dressing External Gel (Wound Dressings) Apply to Right Lateral Foot topically every day shift for Wound Care Cleanse with wound cleanser, pat dry. Apply medihoney to wound bed only. Cover with allevyn foam dressing, with a start date of 11/16/23. Per the MAR, this order is not marked as complete for 3 of the 15 remaining days in November (11/18/23, 11/20/23 and 11/29/23). Per interview on 1/10/24 at 4:07 PM, the Director of Nursing confirmed that Resident #43 had incomplete and missing wound assessments and their care plan was not revised to reflect existing wounds when they were first identified. Per interview on 1/11/24 at 8:51 AM, the Regional Nurse Consultant confirmed that Resident #43's treatment orders for their right foot wound from 11/9/23 through 11/15/23 did not include instructions for cleaning and dressing the wound and should have. 7. Record review reveals that Resident #2 has diagnoses that include diabetes, severe obesity, and abnormalities of gait and mobility. Per Resident #2's MDS dated [DATE], s/he is dependent on staff for all ADLs excluding eating, is at risk for developing pressure ulcers, and does not have any unhealed pressure ulcers at the time of the assessment. Resident #2 has the following care plan focus, I am at risk for impaired skin integrity related to Diabetes, Incontinence, decreased mobility with hemiplegia [paralysis on one side of the body] s/p cva [status post stroke] and obesity related to skin folds, revised on 4/29/21, with interventions that include, Appy/administer treatments and barrier creams, as ordered, and conduct systemic skin inspections weekly and as needed. Document findings, initiated on 6/10/19. Review of a 11/24/23 skin assessment reveals that Resident #2 has a newly identified in-house acquired stage 2 pressure ulcer on the right buttock that measures 0.2 cm x 0.3 cm x 0.1 cm. There are no weekly wound assessments for the existing pressure ulcer from 11/26/23 through 12/12/23 in Resident #2's medical record. According to the facility's policy and professional standards, there should have been a minimum of two wound assessments during this time. Review of a 12/13/23 skin assessment reveals that Resident #2's right buttock stage 2 pressure ulcer has increased in size to 3 cm x 1 cm x 0.1 cm. This wound assessment is incomplete as it does not include characteristics of the wound. Resident #2's care plan does not reflect existing wounds until 12/18/2023, 25 days after the wound was first assessed. Per interview on 1/10/24 at 4:07 PM, the Director of Nursing confirmed that Resident #2 had incomplete and missing wound assessments and their care plan was not revised to reflect existing wounds when they were first identified. 46442

Per interview and record review, the facility failed to provide medications as ordered by the prescriber to meet the needs of each resident for 4 of 35 sampled residents (Resident #7, #52, #102, and #81). Findings include: 1. Per record review, Resident #7 has diagnoses that include spastic quadriplegic cerebral palsy (a physical disability that causes muscle rigidity that affects all four limbs and often a person's torso, facial, and oral muscles), polyneuropathy (nerve damage which can cause symptoms including pain and trouble swallowing), dysphagia (difficulties swallowing), and anarthria (loss of speech). Resident #7's 10/2/23 Minimum Data Set (MDS; a comprehensive assessment used as a care- planning tool) dated 10/2/23 reveals that s/he shows indicators of pain daily. A 10/16/23 progress note indicates that Resident #7 has difficulties with oral secretions. Physician orders reveal that Resident #7 has orders to receive oxyCODONE HCl Oral Solution 5 MG/5ML (Oxycodone HCl) Give 5 ml by mouth three times a day for pain, which began on 2/20/23. Per review of Resident #7's MAR (Medication Administration Record) for November 2023 and December 2023, and confirmed by MAR administration notes, Resident #7 did not receive their scheduled oxycodone twice on 11/16/23 (afternoon and evening), three times on 12/8/23 (morning, afternoon, and evening) and two times on 12/9/23 (morning and afternoon) because the medication was not available. There is no evidence in Resident #7's medical record that a physician was notified of the missed doses on 11/26/23 or 12/8/23 and was not notified until after the first missed dose on 12/9/23. On 12/21/23 at approximately 9:30 AM, the Unit Manager confirmed that neither s/he nor the physician were notified every time Resident #7 did not receive their oxycodone and should have been. Physician orders reveal that Resident #7 has orders to receive Scopolamine Transdermal Patch 72 Hour 1 MG/3DAYS (Scopolamine) Apply 1 patch transdermally every 72 hours for Secretions and remove per schedule, which began on 10/17/23. Per review of Resident #7's MAR (Medication Administration Record) for October through December 2023, and confirmed by MAR administration notes, Resident #7 did not receive their scheduled scopolamine patch 9 out of the 21 scheduled times through 12/22/23 (10/29/23, 11/4/23, 11/13/23, 11/19/23, 11/22/23, 12/4/23, 12/13/23, 12/19/23, and 12/22/23) because the medication was not available. There is no evidence in Resident #7's medical record that a physician was notified of the missed doses. As a result, Resident #7 experienced significant, untreated pain. See F760 for more information. Per interview on 12/21/23 at 2:55 PM, the Regional Nurse Consultant confirmed that Resident #7 was not administered his/her oxycodone and scopolamine as ordered and a physician was not notified of each of the missing medication administrations and should have been. 2. Per record review, Resident #52 was admitted to the facility on [DATE] with diagnoses that include post-traumatic stress disorder (PTSD), traumatic brain injury with impulsive behaviors, anxiety disorder, bipolar disorder, and psychotic disorder (other than schizophrenia). Resident #52 had a physician order for Invega Sustenna Suspension 234 MG/1.5ML (Paliperidone Palmitate; an atypical antipsychotic) Inject 1.5 ml intramuscularly one time a day every 28 day(s) for PTSD/BIPOLAR DISORDER, with an order date of 11/9/2023 and a start date of 11/13/2023. Per Resident #52's MAR, and confirmed by a 12/11/23 progress note, Resident #52 was scheduled to have this medication administered on 12/11/23, 28 days following the 11/13/2023 administration, but it was not administered because the medication was not available. As a result, Resident #52 was at increased risk for increased behavioral and mental health symptoms. See F760 for more information. A physician note dated 12/14/23 reveals [S/He] admits [his/her] depression has been a bit worse lately . At times, [s/he] has thoughts of suicide, but denies any active plan. This note continue paliperidone palmitate injection 234 mg IM monthly. This note does not address that Resident #52 did not receive their dose three days prior (12/11/23) when it was scheduled to be administered. Per interview on 12/21/23 at 11:30 AM, the Unit Manager stated that s/he was unaware that Resident #52 did not receive his/her Invega Sustenna as ordered and should have been notified. Per interview on 12/21/23 at 2:55 PM, the Director of Nursing was unaware that Resident #52 was not administered his/her Invega Sustenna as ordered. After bringing this medication omission to the facility's attention, the facility obtained the medication from the pharmacy and a new physician order. Resident #52 was administered the medication on 12/23/2023, twelve days after the scheduled order. 3. Per record review Resident #102 has diagnoses that include diabetes requiring daily insulin. A 12/11/23 Endocrinology consult note shows a new medication order for Ozempic related to diabetes management. Resident #102 has a physician order for Ozempic (0.25 or 0.5 MG/DOSE) 2 MG/3ML Solution pen-injector INJECT 0.25MG SUBCUTANEOUSLY EVERY MORNING FOR 7 DAYS; INJECT 0.5MG SUBCUTANEOUSLY EVERY MORNING FOR 7 DAYS;INJECT 1MG SUBCUTANEOUSLY EVERY MORNING FOR 7 DAYS, with a start date of 12/14/23. Per Resident #102's MAR and confirmed by a 12/14/23 progress note, Resident #102 did not receive their Ozempic on 12/14/23 because the medication was available. This order was discontinued on 12/19/23 and a new order for Ozempic was placed with a start date of 12/20/23. Per Resident #102's MAR, s/he received his/her first does of Ozempic, 6 days after the initial start date. There is no evidence in Resident #102's medical record that a physician was notified of the missed dose between 12/14/23 and 12/18/23. 4. Per record review Resident #81 has diagnoses that include acute transverse myelitis (inflammation of the spinal cord; symptoms may include pain), anxiety, and lower back pain. Physician orders reveal that Resident #81 has orders to receive New Age Naturals Advanced Hemp Gummies 100 MG Give 1 gummy by mouth three times a day for pain / anxiety, which began on 11/17/23. Per review of Resident #81's MAR for December 2023, and confirmed by MAR administration notes, Resident #81 did not receive their scheduled hemp gummies 1 time on 12/9/23, 1 time on 12/20/23, 3 times on 12/21/23, 3 times on 12/22/23, 3 times on 12/23/23, and 1 time on 12/24/23 because the medication was not available.

Based on observation, interview, and record review, the facility failed to provide pain management to a resident experiencing pain for 1 of 35 sampled residents (Resident #7) related to not providing pain medication per physician orders and not administering pain medication that met professional standards of practice resulting in Resident #7 having significant, untreated pain. Findings include: Per record review, Resident #7 has diagnoses that include spastic quadriplegic cerebral palsy (a physical disability that causes muscle rigidity that affects all four limbs and often a person's torso, facial, and oral muscles), polyneuropathy (nerve damage which can cause symptoms including pain and trouble swallowing), dysphagia (difficulties swallowing), and anarthria (loss of speech). Resident #7's 10/2/23 Minimum Data Set (MDS; a comprehensive assessment used as a care-planning tool) dated 10/2/23 reveals that s/he shows indicators of pain daily and is assessed to have a BIMS of 15 (brief interview for mental status; a cognitive assessment score indicating cognitive intactness). Resident #7's care plan states that I have pain or have the potential in an alteration in my comfort r/t [related to] history of bladder and breast Cancer, Chronic Physical Disability r/t spastic CP [cerebral palsy], quadriplegia, polyneuropathy and bilateral knee pain created on 3/3/2020, with a goal that My pain will be managed daily, created on 3/3/2020. Interventions include Provide medication as ordered, created on 2/23/2023, and Assess characteristics of pain: location, severity on a scale of 0-10, type, frequency, precipitating factors, alleviating factors and vital signs or Non-verbal indications of pain as needed, created on 12/29/2021. Physician orders reveal that Resident #7 has orders to receive oxyCODONE HCl Oral Solution 5 MG/5ML (Oxycodone HCl) Give 5 ml by mouth three times a day for pain, which began on 2/20/23. Per review of Resident #7's MAR (Medication Administration Record) for November 2023 and December 2023, and confirmed by MAR administration notes, Resident #7 did not receive their scheduled oxycodone twice on 11/16/23 (afternoon and evening), three times on 12/8/23 (morning, afternoon, and evening) and two times on 12/9/23 (morning and afternoon) because the medication was not available. There is no evidence in Resident #7's medical record that a physician was notified of the missed doses on 11/26/23 or 12/8/23 and was not notified until after the first missed dose on 12/9/23. On 12/21/23 at approximately 9:30 AM, the Unit Manager confirmed that neither s/he nor the physician were notified every time Resident #7 did not receive their oxycodone and should have been. Pain assessments during the above periods reveal the following: On 11/16/23, at the time medications were due, Resident #7 had pain assessments of 0 for the afternoon and a 5 for the evening; on 12/8/23, at the time medications were due, Resident #7 did not have pain assessments documented (morning, afternoon, and evening) but additional pain assessments for that day were documented as a 0; on 12/9/23, at the time medications were due, Resident #7 did not have pain assessments documented (morning and afternoon) but additional pain assessments for those times were documented as a 0 and a 4. However, the accuracy of these pain assessments are questionable based on the following interviews and record reviews. Record review and interview reveal that Resident #7 suffers greatly when his/her pain is not managed. Per interview on 12/21/23 at approximately 9:30 AM, the Unit Manager explained that Resident #7 is normally in pain. S/He explained that while Resident #7 is unable to communicate by speech, s/he can communicate clearly non-verbally. S/He explained that Resident #7's pain can be assessed with a numerical pain scale but sometimes staff use the PAINAD (an instrument for measurement of pain in noncommunicative patients). Weekly psychological service progress notes dated from 10/20/23 through 12/8/23 indicate that Resident #7 had been working on coping skills related to feeling frustrated with communication and being able to verbalize his/her pain. A 12/8/23 psychological services progress note Patient was alert and fully oriented. Patient reported she was in a lot of pain and was feeling uncomfortable. This note was from a day where Resident #7's pain was only documented as a 0 for the entire day. A 12/15/23 clinical treatment therapy plan of care note reveals, Patient reported depressive symptoms related to [his/her] situation, including pain. Ability to effectively communicate continues to be very frustrating for [him/her] Assessments from this visit indicated that Resident #7 had severe anxiety disorder and moderate depression; an increase from the previous 8/11/23 assessment. Per interview on 12/21/23 at 9:45 AM, Resident #7 indicated that s/he is in pain most of the time and the pain reaches a level of 10 often. S/he indicated that the pain medications do help a little but not completely. When asked about the two days in December when s/he did not receive her pain medication, s/he indicated that his/her pain was very bad. Per interview on 12/21/23 at 2:55 PM, the Regional Nurse Consultant confirmed that Resident #7 was not administered his/her oxycodone as ordered and a physician was not notified of each of the missing medication administrations and should have been. 2. Per observation on 12/19/23 at approximately 10:00 AM, Resident #7 was lying in bed with a red substance dripping from his/her mouth onto a towel placed on his/her chest. An unknown amount of the red substance was collected on the towel. Resident #7 was unable to reposition his/herself in the bed. Per interview on 12/19/23 directly following this observation, the Registered Nurse (RN) caring for Resident #7 explained that the red substance was oxycodone and it was normal for it to be dripping out of his/her mouth because s/he has difficulty swallowing. The two pain assessments recorded before and after this observation were documented as a 7 out of 10 for severity (10 being the highest severity) at 8:36 AM and a 6 out of 10 at 2:12 PM. Per facility policy titled Medications Administration Methods, last modified on 7/12/2022, and professional nursing standards, when administering medications, the nurse must watch each resident take the medication and ensure the medication is swallowed unless the resident has an order for self-administration. Per interview on 12/20/23 at 2:27 PM, the Unit Manager stated that Resident #7 is normally in pain. S/He confirmed that the nurse administering the medication should have stayed with Resident #7 to make sure that the pain medication was administered all the way. Reference: Open Resources for Nursing (Open RN); Ernstmeyer K, [NAME] E, editors. Nursing Skills [Internet]. Eau [NAME] (WI): [NAME] Valley Technical College; 2021. Chapter 15 Administration of Enteral Medications. Available from: https://www.ncbi.nlm.nih.gov/books/NBK593215/

Based on interview and record review, the facility failed to ensure that 3 eligible residents (Residents #50, #270, and #80) on one unit received the influenza vaccine. As a result, one unvaccinated resident (Resident #50) developed influenza and required hospitalization for dehydration and abnormal lung sounds, and two residents (Resident #270 and #87) were at increased risk for contracting influenza and/or developing influenza complications. 1. Per record review, Resident #50 was admitted to the facility on [DATE] with diagnoses that include diabetes and severe kidney disease. S/He was recently assessed at the emergency room related to elevated kidney function labs and a urinary tract infection according to a 12/16/23 emergency visit note. Resident #50 is considered high risk for influenza complications because of his/her diagnoses and nursing home admission. An undated form titled Vaccination Review: Consent/Declination Resident Form, entered into Resident #50's medical record with the effective date of 11/20/23, reveals that his/her vaccination history was assessed for influenza, Covid-19, and pneumococcal. The form indicates that s/he did not receive a 2023 influenza vaccine. Under decision to vaccinate, the choices not eligible, consented, and declined are all left blank. The resident, nor their representative, did not sign off that they were provided education or that they consented or declined the administration of the influenza vaccine. There is no evidence that Resident #50 received the influenza vaccine in his/her medical record or that s/he had a medical contraindication to receive the vaccine. Per interview on 12/18/2023 at 9:07 AM, Resident #50 stated that s/he does not feel good at all and was needing to rest. A 12/18/23 physician visit note reveals that Resident #50 was complaining of a scratchy throat which started late the night before/earlier that morning. A 12/18/23 progress note reveals that Resident #50 had a rapid flu test and was positive for influenza A. A 12/21/23 physician note reveals the following: HPI [history of present illness]: Patient seen because of continued illness with influenza. When I saw the patient [s/he] was sleeping [s/he] was arousable [s/he] was alert. But [s/he] had a hard time staying awake. The patient has not been eating or drinking. Despite the staff efforts to constantly come in and give [him/her] fluids. [S/He] does not feel like eating or drinking [s/he] has been feeling quite sick. No ear pain no eye symptoms mild stuffy nose no sore throat no difficulty breathing but [s/he] does have a persistent cough. [S/He] feels nauseated no abdominal pain no. The nausea is the main reason [s/he] cannot eat or drink anything at this time . Physical Exam: This patient appears to be in mild to moderate distress. [S/He] was retching when I came in the room. After I woke [him/her]. It started within a few seconds. [S/He] does not have tenting but [his/her] mucous membranes are dry. [S/He] appears to be very tired. [S/He] is alert and oriented. Lungs have nonspecific coarse sounds throughout .Assessments/Plans: Influenza due to identified novel influenza A virus with other manifestations . Patient is dehydrated and also has abnormal lung sounds. And not able to take fluids we are not able to start an IV here. Patient will need to go to the ER [emergency room ] for further evaluation and treatment. A 12/21/23 transfer form reveals that Resident #50 was transferred to the emergency roiagnom on [DATE] for the following reason: flu, n/v [nausea/vomiting], poor appetite, decreased fluid intake . Additional Relevant Information: poor kidney function, ID [infectious disease] patient, dx [diagnosed ] w/ FLU. A 12/21/23 hospital admission note reveals the following: Assessment: Resident #50 is a 60 y.o. [year old] [gender] with a PMHx [past medical history] significant for T2DM [type 2 diabetes mellites] c/b [complicated by] neuropathy [nerve damage], retinopathy [disease of the retina] and CKD4 [stage 4 kidney disease]. HTN [hypertension], Seizure disorder (on Keppra [seizure medication]), left TMA [transmetatarsal amputation; removal of part of the foot] (2019) and recent hospitalization (10/20-11/6) for osteomyelitis [bone infection] as a result of a burn with course complicated by shock secondary to GBS bacteremia [bloodstream infection] (now s/p [status post] right BKA [below knee amputation]), as well as type II NSTEMI [heart attack] who presents with 3-5 days of increased confusion, poor PO [by mouth] intake in the setting of new diagnosis FluA and ongoing treatment for a UTI [urinary tract infection] with cefpodoxime [antibiotic]. Patient likely with multifactorial toxic/metabolic encephalopathy [brain disease that alters brain function or structure] due to infection, dehydration, and buildup of metabolites [substance resulting from the metabolism of a drug] with [his/her] PTA [prior to admission] medication in the setting of poor renal [kidney] function. In addition, chest x-ray results reveal possible pneumonia in the left lung base, very faint and appearance and visible only on the lateral view, therefore equivocal. Per interview on 12/21/23 at 9:07 AM, the Director of Nursing/Infection Preventionist explained that Resident #50 did not receive an influenza vaccine because s/he was on antibiotics and staff have been instructed not to vaccinate residents that are taking antibiotics. Per interview on 12/26/23 at approximately 9:30 AM, the Attending Physician stated that being on antibiotics is not a contraindication to receive vaccinations. 2. Record review reveals that Resident #270, who is [AGE] years old, was admitted to the facility on [DATE] with diagnoses that include cerebral infarction (stroke), diabetes, and asthma. Resident #270 is considered high risk for influenza complications because of his/her age, diagnoses, and nursing home admission. Resident #270 also resides on a unit at the facility where there is an active case of influenza. An undated form titled Vaccination Review: Consent/Declination Resident Form, entered into Resident #270's medical record with the effective date of 12/6/23, reveals that his/her vaccination history was assessed for influenza, Covid-19, and pneumococcal. The form indicates that s/he did not receive a 2023 influenza vaccine. Under decision to vaccinate, the choices not eligible, consented, and declined are all left blank. The resident, nor their representative, did not sign off that they were provided education or that they consented or declined the administration of the influenza vaccine. There is no evidence that Resident #270 received the influenza vaccine in his/her medical record or that s/he had a medical contraindication to receive the vaccine. 3. Per record review, Resident #87, who is [AGE] years old, was admitted to the facility on [DATE] with diagnoses that include COPD (Chronic Obstructive Pulmonary Disease), diabetes, heart disease, and kidney disease. Resident #87 is considered high risk for influenza complications because of his/her age, diagnoses, and nursing home admission. Resident #87 also resides on a unit at the facility where there is an active case of influenza. A form titled Vaccination Review: Consent/Declination Resident Form, dated 12/14/23, reveals that Resident #87 vaccination history was assessed for influenza, Covid-19, and pneumococcal. The form indicates that s/he did not receive a 2023 influenza vaccine. Under decision to vaccinate, the choices not eligible, consented, and declined are all left blank. There is no evidence that Resident #87 received the influenza vaccine in his/her medical record or that s/he had a medical contraindication to receive the vaccine. Per interview on 12/26/23 at approximately 1:45 PM, the Director of Nursing/Infection Preventionist was unable to determine why Residents #270 and #87 did not receive the influenza vaccine by looking at their vaccination review forms.

Based on interview and record review, the facility failed to ensure 2 of 35 sampled residents (Residents #7 and #52) are free from significant medication errors related to missed medication administration. As a result, Resident #7 experienced significant, untreated pain and Resident #52 was at increased risk for increased behavioral and mental health symptoms. Findings include: 1. Per record review, Resident #7 has diagnoses that include spastic quadriplegic cerebral palsy (a physical disability that causes muscle rigidity that affects all four limbs and often a person's torso, facial, and oral muscles), polyneuropathy (nerve damage which can cause symptoms including pain and trouble swallowing), dysphagia (difficulties swallowing), and anarthria (loss of speech). Resident #7's 10/2/23 Minimum Data Set (MDS; a comprehensive assessment used as a care-planning tool) dated 10/2/23 reveals that s/he shows indicators of pain daily and is assessed to have a BIMS of 15 (brief interview for mental status; a cognitive assessment score indicating cognitive intactness). Resident #7's care plan states that I have pain or have the potential in an alteration in my comfort r/t [related to] history of bladder and breast Cancer, Chronic Physical Disability r/t spastic CP [cerebral palsy], quadriplegia, polyneuropathy and bilateral knee pain created on 3/3/2020, with a goal that My pain will be managed daily, created on 3/3/2020. Interventions include Provide medication as ordered, created on 2/23/2023. Physician orders reveal that Resident #7 has orders to receive oxyCODONE HCl Oral Solution 5 MG/5ML (Oxycodone HCl) Give 5 ml by mouth three times a day for pain, which began on 2/20/23. Per review of Resident #7's MAR (Medication Administration Record) for November 2023 and December 2023, and confirmed by MAR administration notes, Resident #7 did not receive their scheduled oxycodone twice on 11/16/23 (afternoon and evening), three times on 12/8/23 (morning, afternoon, and evening) and two times on 12/9/23 (morning and afternoon) because the medication was not available. There is no evidence in Resident #7's medical record that a physician was notified of the missed doses on 11/26/23 or 12/8/23 and was not notified until after the first missed dose on 12/9/23. On 12/21/23 at approximately 9:30 AM, the Unit Manager confirmed that neither s/he nor the physician were notified every time Resident #7 did not receive their oxycodone and should have been. Pain assessments during the above periods reveal the following: On 11/16/23, at the time medications were due, Resident #7 had pain assessments of 0 for the afternoon and a 5 for the evening; on 12/8/23, at the time medications were due, Resident #7 did not have pain assessments documented (morning, afternoon, and evening) but additional pain assessments for that day were documented as a 0; on 12/9/23, at the time medications were due, Resident #7 did not have pain assessments documented (morning and afternoon) but additional pain assessments for those times were documented as a 0 and a 4. However, the accuracy of these pain assessments are questionable based on the following interviews and record reviews. Record review and interview reveal that Resident #7 suffers greatly when his/her pain is not managed. Per interview on 12/21/23 at approximately 9:30 AM, the Unit Manager explained that Resident #7 is normally in pain. S/He explained that while Resident #7 is unable to communicate by speech, s/he can communicate clearly non-verbally. S/He explained that Resident #7's pain can be assessed with a numerical pain scale but sometimes staff use the PAINAD (an instrument for measurement of pain in noncommunicative patients). Weekly psychological service progress notes dated from 10/20/23 through 12/8/23 indicate that Resident #7 had been working on coping skills related to feeling frustrated with communication and being able to verbalize his/her pain. A 12/8/23 psychological services progress note Patient was alert and fully oriented. Patient reported she was in a lot of pain and was feeling uncomfortable. This note was from a day where Resident #7's pain was only documented as a 0 for the entire day. A 12/15/23 clinical treatment therapy plan of care note reveals, Patient reported depressive symptoms related to [his/her] situation, including pain. Ability to effectively communicate continues to be very frustrating for [him/her] Assessments from this visit indicated that Resident #7 had severe anxiety disorder and moderate depression; an increase from the previous 8/11/23 assessment. Per interview on 12/21/23 at 9:45 AM, Resident #7 indicated that s/he is in pain most of the time and the pain reaches a level of 10 often. S/he indicated that the pain medications do help a little but not completely. When asked about the two days in December when s/he did not receive her pain medication, s/he indicated that his/her pain was very bad. Per interview on 12/21/23 at 2:55 PM, the Regional Nurse Consultant confirmed that Resident #7 was not administered his/her oxycodone as ordered and there was no evidence that a physician was notified of each of the missing medication administrations and should have been. 2. Record review, interviews, and observations reveal that Resident #7 has trouble with oral secretions which began in October 2023. Due to Resident #7's diagnoses of spastic quadriplegic cerebral palsy and dysphagia, troubles managing oral secretions would put him/her at increased risk for aspiration and skin breakdown. A 10/16/23 progress note indicates that Resident #7 was having difficulty breathing. S/He had an oxygen saturation of 79% on room air, was tachycardic (fast heartrate), required oxygen, and suctioning due to mucus in his/her throat. The physician was made aware and Resident #7 was prescribed a scopolamine patch (used to reduce mucus and salvia production). A 12/19/23 nurse note states, Resident presenting with secretions, congestion, and a non-productive cough. Per interview on 12/20/23 at 2:27 PM, the Unit Manager revealed that Resident #7 has trouble with oral secretions. On 12/21/23 at 9:45 AM, Resident #7 was observed having a weak, mucous cough. A 12/21/23 physician note states [Resident #7] has difficulty with oral secretions. Physician orders reveal that Resident #7 has orders to receive Scopolamine Transdermal Patch 72 Hour 1 MG/3DAYS (Scopolamine) Apply 1 patch transdermally every 72 hours for Secretions and remove per schedule, which began on 10/17/23. Per review of Resident #7's MAR (Medication Administration Record) for October through December 2023, and confirmed by MAR administration notes, Resident #7 did not receive their scheduled scopolamine patch 9 out of the 21 scheduled times through 12/22/23 (10/29/23, 11/4/23, 11/13/23, 11/19/23, 11/22/23, 12/4/23, 12/13/23, 12/19/23, and 12/22/23) because the medication was not available. There is no evidence in Resident #7's medical record that a physician was notified of the missed doses. Per interview on 12/21/23 at 2:55 PM, the Regional Nurse Consultant confirmed that Resident #7 was not administered his/her scopolamine as ordered and a physician was not notified of each of the missing medication administrations and should have been. Per interview on 12/26/23 at approximately 1:45 PM, the Director of Nursing stated that s/he was unaware that Resident #7 did not receive his/her scopolamine patch on the above dates. S/He stated that s/he and the provider should have been notified because there was atropine (which can also be used to treat oral secretions) available in the facility and staff could have gotten an order for that while the medication was unavailable. 3. Per record review, Resident #52 was admitted to the facility on [DATE] with diagnoses that include post-traumatic stress disorder (PTSD), traumatic brain injury with impulsive behaviors, anxiety disorder, bipolar disorder, and psychotic disorder (other than schizophrenia). Per interview and observation on 12/18/2023 at 10:30 AM, Resident #52 stated that s/he was on medications for his/her mood swings. S/He expressed concerns about losing his/her independence and relying on staff who were inattentive and rough with his care needs. During this interview Resident #52 expressed feelings of sadness and became weepy and for a few moments, s/he withdrew from the conversation in tears. Resident #52 had a physician order for Invega Sustenna Suspension 234 MG/1.5ML (Paliperidone Palmitate; an atypical antipsychotic) Inject 1.5 ml intramuscularly one time a day every 28 day(s) for PTSD/BIPOLAR DISORDER, with an order date of 11/9/2023 and a start date of 11/13/2023. Per Resident #52's MAR, and confirmed by a 12/11/23 progress note, Resident #52 was scheduled to have this medication administered on 12/11/23, 28 days following the 11/13/2023 administration, but it was not administered because the medication was not available. A physician note dated 12/14/23 reveals [S/He] admits [his/her] depression has been a bit worse lately . At times, [s/he] has thoughts of suicide, but denies any active plan. This note continue paliperidone palmitate injection 234 mg IM monthly. This note does not address that Resident #52 did not receive their dose three days prior (12/11/23) when it was scheduled to be administered. Per interview on 12/21/23 at 11:30 AM, the Unit Manager stated that s/he was unaware that Resident #52 did not receive his/her Invega Sustenna as ordered and should have been notified. Per interview on 12/21/23 at 2:55 PM, the Director of Nursing was unaware that Resident #52 was not administered his/her Invega Sustenna as ordered. After bringing this medication omission to the facility's attention, the facility obtained the medication from the pharmacy and a new physician order. Resident #52 was administered the medication on 12/23/2023, twelve days after the scheduled order.

Based on interview and record review the facility failed to ensure 2 of 4 residents sampled (Residents #1, and #2) received appropriate supervison to reduce accident hazards and risks, and to assess interventions for effectiveness. Findings include: 1. Resident #1 was an [AGE] year-old-person admitted to the facility from an acute care hospital where s/he had been hospitalized following several falls at home. Resident #1 had diagnosis that included Parkinson's disease, Alzheimer's dementia, glaucoma, generalized muscle weakness and repeated falls. Approximately one week after Resident #1 was admitted to the facility s/he sustained a fall while attempting to use the bathroom without assistance. A review of the care plan revealed Resident #1 required the assist of one person and his/her walker for ambulation (walking). The care plan review also revealed no updates with new interventions following this fall. On [DATE] Resident #1 sustained another fall while in the bathroom unsupervised. Resident #1 was transported to the hospital emergently and found to have significant trauma sustained during the fall. Problems managed by the hospital included cervical spine fracture of C1 and C2, acute minimally displaced fracture of right occipital condyle (the bony segment on the back of the skull that articulates with the neck allowing the skull to move side-side, up and down and rotate), multiple minimally displaced fractures of the bony nasal septum and nasal bones, a short segment right vertebral artery dissection (a flap like tear of the inner lining of the vertebral artery, which is located in the neck and supplies blood to the brain). A review of the record of hospitalization stated Resident #1 died while hospitalized . During an interview on [DATE] at 11:30AM with the Director and Assistant Director of Nursing it was confirmed that there had been no interdisciplinary team meeting to discuss care plan revisions and aside from attaching a sign stating call don't fall to Resident #1's walker no additional measures to provide supervision to ensure safety, or to reduce risk of injury from falls had been implemented. 2. Resident #2 was admitted to the facility with diagnoses to include multiple sclerosis, anxiety, chronic depression, quadriplegia, and muscle spasticity which puts him/her at risk of falling out of bed. Resident #2 had a recorded (Brief Interview of Mental Status) BIMS score of 14 indicating intact cognition. Resident # 2 was reliant on a blow bell to summon assistance as he/she was unable to use his/her upper extremities to push a call bell button for assistance. Per record review, on [DATE] at 5:42 AM Resident #2 was found on the floor and was emergently sent to the local emergency room for evaluation and returned to the facility without significant injury. Further review reveals a Physicians order dated [DATE] stating Nurse must visualize blow call light placement every hour while (Resident) is in bed. D/T (due to) muscle spasms moving his/her body away from blow straw. Every hour for safety checks while in bed visually verify blow call light is in correct placement, this order is to be signed off in the MAR hourly as a safety measure. On [DATE] at approximately 11:34 AM the DNS was interviewed regarding the circumstances and outcome of the facility investigation. The DNS stated and provided documentation providing the nurse on duty had falsified the documentation by signing off the hourly checks at 0300, 0400 and 0500 on [DATE] although he/she admitted to not having done the checks because of a nurse call-out s/he was trying to find coverage for. As a result of this Resident #2 reported the fall from bed took place at 0300, the documentation indicates that he/she was found on the floor at 0542. The Director of Nursing confirmed at 11:34 AM on [DATE] that the nurse on duty the night of this incident did not ensure this resident's safety or prevent the fall by failing to follow physician orders and further s/he incorrectly documented on the MAR that s/he had performed these tasks.

Based on interviews and record review the facility failed to update a care plan following a fall, to prevent further falls and/or reduce the risk of injury for one of five residents included in the investigation sample (Resident #1). Findings include: Per record review, Resident #1 was an [AGE] year-old-person admitted to the facility from the acute care hospital with admission diagnosis including Parkinson's disease, Alzheimer's dementia, diabetes type 2, glaucoma, muscle weakness, chronic kidney disease and repeated falls. Approximately one week after Resident #1 was admitted to the facility s/he sustained a fall while attempting to use the bathroom without assistance. A review of the care plan revealed Resident #1 required the assist of one person and his/her walker for ambulation (walking). The care plan review also revealed no updates with new interventions following this fall, to prevent further falls or reduce the risk of injury from falls. On 5/1/23 Resident #1 sustained another fall, was transported to the hospital emergently and found to have significant trauma sustained during the fall. Problems managed by the hospital included cervical spine fracture of C1 and C2, acute minimally displaced fracture of right occipital condyle (the bony segment on the back of the skull that articulates with the neck allowing the skull to move side-side, up and down and rotate), multiple minimally displaced fractures of the bony nasal septum and nasal bones, a short segment right vertebral artery dissection (a flap like tear of the inner lining of the vertebral artery, which is located in the neck and supplies blood to the brain). During an interview on 5/15/23 at 11:30 AM with the Director and Assistant Director of Nursing they agreed the care plan had not been updated following the 4/21/23 fall until 5/1/23 which was following the traumatic second fall. See also F689.

Per interview and record review, the facility failed to provide treatment to an existing pressure injury for 3 applicable residents [Residents #1, #2 and #4] consistent with facility policy and professional standards of practice. Facility policy titled Skin Conditions, Wounds and Pressure Ulcers (Assessment and Monitoring Program), last modified on 2/3/2023 states Identified skin conditions and/or wounds will be reassessed weekly by a registered nurse until the presence of the condition is resolved, and The medical provider will review and assess the progress of skin conditions and/or wounds during required visits, or when necessary, and document in the medical record. 1. Record review reveals Resident #4 was readmitted to the facility with diagnoses that include congestive heart failure, end stage renal disease (ESRD), type 2 diabetes, history of spinal fusion, emphysema, and need for assistance with personal care on 9/14/22 following a hospital stay related to septic shock and pneumonia. Resident #4's care plan includes the following care plan focus: Skin integrity: I [Resident #4] am at risk for impaired skin integrity related to Activity Intolerance, Deconditioning, Immobility, actual skin breakdown r/t [related to] decline in status/refusal of repositioning 9/6/22, initiated on 6/13/2022. Interventions include conduct systemic skin inspections weekly and as needed. Document findings, initiated on 07/26/2022, and monitor skin condition daily and report any signs of skin breakdown, initiated on 06/13/2022. Review of Resident #4's wound evaluations on 11/23/2022 reveal a stage 2 pressure ulcer [partial-thickness skin loss with exposed dermis] on the right ischial tuberosity [sit bone located in the buttock] measuring 1.1 cm x 0.5 cm and an abscess on the spine [surface intact] measuring 1.9 cm x 0.6 cm. Resident #4's Minimum Data Set (MDS; a comprehensive assessment used as a care-planning tool), dated 12/3/2022, reveals that Resident #4 is at risk for developing pressure ulcers/injuries and has one stage 2 pressure ulcer. Review of Resident #4's wound evaluations on 12/6/2022 reveal a stage 2 pressure ulcer on the right ischial tuberosity measuring 2.5 cm x 1.3 cm. There are no additional wounds identified during this evaluation. There are no wound evaluations for Resident #4 from 12/7/2022 through 1/5/2023. Review of Resident #4's wound evaluations on 1/6/2023 reveal a stage 2 pressure ulcer on the right buttock measuring 2.5 cm x 1.3 cm, a stage 2 pressure ulcer on the left buttock measuring 5.1 cm x 2.6 cm, and a stage 2 pressure ulcer on the left buttock measuring 3.9 cm x 3.3 cm. Resident #4's discharge MDS, dated [DATE], reveals that Resident #4 has one stage 2 pressure ulcer, one stage 3 pressure ulcer [full thickness skin loss], and one stage 4 pressure ulcer [full thickness skin and tissue loss]. There is no evidence in Resident #4's medical record that the provider was notified of the worsening and/or developing of Resident #4's pressure ulcers and no documentation that the medical provider reviewed and assessed Resident #4's skin condition and/or wounds. Review of Resident #4's physician's orders reveal the following: Cleanse right ischial tuberosity wound with NSS [normal saline solution], pat dry, cover with Allevyn foam [foam dressing] every shift for skin condition start date 11/26/22. There are no treatment orders for the other two identified pressure ulcers from readmission on 11/23/2022 through hospital transfer on 1/9/2023, or evidence that wound care was completed. A hospital note dated 1/10/2023 states that Resident #4 is found to be in likely septic shock from acute [and] chronic SSTI [skin and soft tissue infections] of [his/her] back/buttocks in setting of baseline chronic hypotension. The provider note reveals the following about Resident #4's clinical condition: Over the past 24 hours, there has been a high probability of sudden, clinically significant or life threatening deterioration in the patient's condition, which include the following diagnoses which I have managed: Active problems: ESRD, septic shock, decubitus skin ulcer [bedsore], wound infection complicating hardware, sequela, delirium. 2. Record review reveals Resident #2 was admitted to the facility on [DATE] with diagnosis that include end stage renal disease, chronic pressure ulcers, type 2 diabetes, osteomyelitis [bone infection], history of MRSA [Methicillin-resistant Staphylococcus aureus; antibiotic resistant infection] infection, paraplegia, and need for assistance with personal care. A 12/14/2023 provider note reveals that Resident #2 is complaining of heel wounds. The provider exam reveals a left heel PU [pressure ulcer] and left lateral distal foot PU noted and significant. These notes also reveal additional known pressure ulcers and a recent wound infection. Review of Resident #2's wound evaluations show the last wound evaluations for December 2022 were completed on 12/14/2022. There are multiple entries in the SWIFT system [wound photograph evaluation documentation system] prior to 12/14/2022. These entries are not labeled, and some wounds are tracked on multiple wound assessment entries. There is no way to accurately determine a comprehensive report of Resident #2's skin based on review of the SWIFT evaluations and there is no comprehensive skin evaluation documentation in Resident #2's medical record. Physician orders reveal that Resident #2 was being treated for skin injuries of the left heel, coccyx, left thigh, and right shin in December 2022. The treatment administration record reveals the following order: skin examination report to RN and document in Medical Record if new skin condition is identified every day shift every Tuesday start date 10/25/2022. The treatment record reveals that Resident #2's skin assessment was not completed between 12/14/2022 and 12/27/2022 as ordered. A 12/27/2023 progress note reveals that Resident #2 was transferred to the hospital due to showing signs of sepsis. There is no documentation of the condition of his/her skin at this time. A 1/26/2023 transfer of care note from the hospital reveals that Resident #2 was admitted to the hospital on 12/27/2022 related to heel ulcers and ultimately septic shock. The provider writes that Resident #2 presented from the facility with AMS [altered mental status] and fever. In the ED [s/he] was found to have worse LE [left extremity] ulcers and a known sacral ulcer. Orthopedics evaluated the patient with concerns for osteomyelitis due to bedside debridement with probing to bone of his L [left] calcaneus [heel bone] . was started on cefepime and vancomycin for osteomyelitis causing septic shock and was admitted to the MICU. 3. Record review reveals Resident #1 was admitted to the facility on [DATE] with diagnoses that included complete paraplegia [paralysis of the legs and lower body], type 2 diabetes, morbid obesity, and a bed confinement status. Resident #1's care plan includes the following care plan focus: Skin integrity: I [Resident #1] am at risk for impaired skin integrity related to 5 (or more) medications, DM [diabetes], cardiac disease, paralysis, Immobility and an ostomy [surgical opening in the abdomen to allow stool to exit the body], initiated on 4/27/2021 with an intervention to monitor skin condition weekly and report any signs of skin breakdown, initiated on 4/27/2021. Resident #1's care plan does not address an actual wound until 1/25/2023. Review of Resident #1's wound evaluations on 12/14/2022 reveal a stage 2 pressure ulcer on the right calf measuring 1.0 cm x 0.6 cm. Resident #1's 1/27/2023 wound evaluations on reveal a stage 2 pressure ulcer on the right calf measuring 1.4 cm x 0.7 cm. There are no wound evaluations for this wound from 12/15/2022 through 1/26/2023. Review of Resident #1's physician's orders reveal the following: cleanse right calf lateral wound with NSS, pat dry, apply bacitracin and cover with Allevyn border foam every evening shift, with a start date of 11/25/2022. Resident #1's treatment administration record reveals that wound care was not documented as complete or refused for 12 days between 12/14/2022 through 1/19/2023. 4. On 3/21/2023 at approximately 3:00 PM, the Director of Nursing stated that there is no way to find comprehensive documentation of a Residents' skin injuries and/or wounds after a weekly skin assessment. Nursing staff check that it has been completed on the treatment record and any new wounds will be documented in a wound assessment. S/He stated s/he became aware of these problems in January 2023 and confirmed that the skin assessment and monitoring policy had not been followed for Residents #1, #2, and #4. Record review and interview with the Director of Nursing on 3/21/2023 at 3:30 PM reveal that the facility implemented corrective action for the above deficiencies. The facility completed a house wide audit of skin to ensure all wounds were identified and all wounds had treatment orders, hired new staff including a Registered Nurse to review wound evaluations weekly, implemented a new admission check list to ensure wound assessments were documented, and completed education with direct care staff. The facility continues to review skin and wound conditions for all residents with wounds weekly at a customer at risk meeting. Based on corrective actions completed by 2/17/2023, prior to the onsite investigation, this citation is designated as past non-compliance.

Based on record review and interview, the Licensed Pharmacist failed to ensure that an irregularity was identified and reported to the facility for 1 of 5 residents reviewed (Resident #1) Findings include: Per record review, Resident #1 was admitted to the facility on [DATE] from an acute care hospital following a small bowel obstruction (SBO) necessitating an exploratory laparotomy secondary to a perforated stercocolitis. The resident has a long-standing diagnosis of Hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone). This condition was treated with Levothyroxine 100mcg a day (a medication replacing the missing thyroid hormone Thyroxine and is taken indefinitely, although the dose may change over time). Upon admittance to the facility the Transition of Care (TOC) from the hospital indicated the resident should continue to take the Levothyroxine. On 3/23/2022 the facility physician saw the resident for an admission visit and noted the Hypothyroidism Diagnosis and indicated the condition was well-managed, and there were currently no symptoms of thyroid disease present. The physician ordered a Thyroid Stimulating Home (TSH) test to be draw on the next laboratory (lab) draw and will adjust dosing of Levothyroxine as needed based on lab value and will continue to follow with periodic lab work. The resident did have lab work including a TSH drawn on 3/29, 5/18band 5/23/2022, and none of those labs were indicative of levels within the therapeutic range and finally a lab draw on 6/15/2022 did indicate the therapeutic level had been reached. The resident went out to the hospital on 7/21/2022 returning on 7/29/2022. When the resident returned to the facility the TOC indicated Levothyroxine 100mcg a day for only 30 days. On 7/29/2022 a nurse documented that all TOC medications were entered into the system and the Nurse Practitioner (NP) stated s/he had seen the TOC and to go ahead with the order, but clarification was needed for the Intravenous Therapy (IV) Protonix (a medication used to treat gastroesophageal-reflux-disease - GERD) since the facility does not provide that medication as an IV. There was no mention of the fact that the Levothyroxine was only ordered for 30 days. The resident once again went to the hospital on 8/1/2022 and returned on 8/6/2022 again the TOC indicated Levothyroxine 100mcg for 30 days only. On 8/6/22 a nurses reviewed the orders from the TOC over the phone with the on-call provider and no changes to the orders were made at that time, despite the fact that the Levothyroxine was only ordered for 30 days from the previous 7/29/2022 date of discharge from the hospital. On 8/29/2022 the resident received her last dose of the Levothyroxine 100mcg per the 30-day physician order on the TOC from the hospital and the medication dropped off the Medication Administration Record (MAR) at that time. There is no evidence in the Electronic Health Record (EMR) of anyone questioning why the medication, that is required to be taken indefinitely was no longer ordered. The consultant pharmacist conducted the required Medication Regime Review on 8/11, 9/7, 10/6, 11/8 and 12/5/2022. Part of the Medication Regime Review is to review the resident's medical chart including current medications and report irregularities. On each of these dates the pharmacist documented no recommendations at this time, despite the fact the TOC incorrectly listed only 30 days of Levothyroxine in July 2022 and the resident was no longer receiving Levothyroxine as of 8/30/2022, and that treatment with Levothyroxine is lifelong. The resident went without Levothyroxine for 2 days in August 2022, 30 days in September 2022, 31 days in October 2022, 30 days in November 2022 and 19 days in December 2022, when the resident returned to the hospital and laboratory tests showed a very high TSH level and an undetectably low Thyroxine level (Free T4). While at the hospital there was concern that there was no evidence on her medication list from the facility that she was taking Levothyroxine, as she had previously been taking when being seen at the hospital. The December 2022 hospitalization also showed the resident was diagnosed with Parainfluenza and Pericardial Effusion which was likely in the setting of inflammatory state given viral infection versus overt hypothyroidism. S/he was found to be bradycardic likely a reflection of his/her hypothyroidism. Levothyroxine was restarted and a request for follow up laboratory testing be done to monitor the Thyroxine levels. The resident was returned to the facility on ,d+[DATE] and remains in the facility at present and laboratory testing has been done to monitor Thyroxine levels. Per interview with the physician who treated the resident at the hospital, had this lack of Levothyroxine continued it could have been life threatening and quite possibly had the resident's Thyroxine been in the therapeutic range the December hospitalization could have been avoided. Per interview on 12/27/2022 at approximately 12:15pm the acting Director of Nursing (DNS) confirmed that the pharmacist did not report any irregularities to the facility for the 5 monthly Medication Regime Reviews that were conducted during the time that the Levothyroxine was not being given to the resident.

Based on interview and record review, the facility failed to ensure 1 of 5 applicable residents (Resident #1) are free of significant medication errors. Findings include: Per record review, Resident #1 was admitted to the facility on [DATE] from an acute care hospital following a small bowel obstruction (SBO) necessitating an exploratory laparotomy secondary to a perforated stercocolitis. The resident has a long-standing diagnosis of Hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone). This condition was treated with Levothyroxine 100mcg a day (a medication replacing the missing thyroid hormone Thyroxine and is taken indefinitely, although the dose may change over time). Upon admittance to the facility the Transition of Care (TOC) from the hospital indicated the resident should continue to take the Levothyroxine. On 3/23/2022 the facility physician saw the resident for an admission visit and noted the Hypothyroidism Diagnosis and indicated the condition was well-managed, and there were currently no symptoms of thyroid disease present. The physician ordered a Thyroid Stimulating Home (TSH) test to be draw on the next laboratory (lab) draw and will adjust dosing of Levothyroxine as needed based on lab value and will continue to follow with periodic lab work. The resident did have lab work including a TSH drawn on 3/29, 5/18, and 5/23/2022, and neither of those labs were indicative of levels within the therapeutic range and finally a lab draw on 6/15/2022 did indicate the therapeutic level had been reached. The resident went out to the hospital on 7/21/2022 returning on 7/29/2022. When the resident returned to the facility the TOC indicated Levothyroxine 100mcg a day for only 30 days. The facility has a system in place that 2 nurses are to verify that orders are correct before placing them into the resident record, neither nurse noted anything about the fact that the Levothyroxine for only prescribed for a 30-day period of time despite the fact that treatment with Levothyroxine is lifelong. On 7/29/2022 a nurse documented that all TOC medications were entered into the system and the Nurse Practitioner (NP) stated s/he had seen the TOC and to go ahead with the order, but clarification was needed for the Intravenous Therapy (IV) Protonix (a medication used to treat gastroesophageal-reflux-disease - GERD) since the facility does not provide that medication as an IV. There was no mention of the fact that the Levothyroxine was only ordered for 30 days. On 8/1/2022 the NP saw the resident for a readmission visit and documented incorrectly under the current medications list - Levothyroxine 150mcg a day. The NP also documented that a medication reconciliation had been completed and that diagnostic testing had been reviewed. During this visit the resident requested to return to the hospital for continued issue with constipation and recurrent episodes of SBO and the resident was transported to the hospital. The resident returned on 8/620/22 and again the TOC indicated Levothyroxine 100mcg for 30 days only. On 8/6/2022 a nurses reviewed the orders from the TOC over the phone with the on-call provider and no changes to the orders were made at that time, despite the fact that the Levothyroxine was only ordered for 30 days from the previous 7/29/2022 date of discharge from the hospital. A second nurse also reviewed the orders for accuracy. On 8/29/2022 the resident received her last dose of the Levothyroxine 100mcg per the 30-day physician order on the TOC from the hospital and the medication dropped off the Medication Administration Record (MAR) at that time. There is no evidence in the Electronic Health Record (EMR) of anyone questioning why the medication, that is required to be taken indefinitely was no longer ordered. On 9/30/2022 the NP saw the resident for a regular visit and again documented incorrectly that the current medications included Levothyroxine 150mcg a day. Again, the NP documented that a medication reconciliation had been completed and that diagnostic testing had been reviewed. On 8/11, 9/7, 10/6, 11/8 and 12/5/2022 the consultant pharmacist conducted the required Medication Regime Review and on each of these dates documented no recommendations at this time, despite the fact the TOC incorrectly listed only 30 days of Levothyroxine in July 2022 and the resident was no longer receiving Levothyroxine as of 8/30/2022, and that treatment with Levothyroxine is lifelong. The resident went without Levothyroxine for 2 days in August 2022, 30 days in September 2022, 31 days in October 2022, 30 days in November 2022 and 19 days in December 2022, when the resident returned to the hospital and laboratory tests showed a very high TSH level and an undetectably low Thyroxine level (Free T4). There was concern that there was no evidence on her medication list from the facility that she was taking Levothyroxine, as she had previously been taking when being seen at the hospital. The December 2022 hospitalization also showed the resident was diagnosed with Parainfluenza and Pericardial Effusion which was likely in the setting of inflammatory state given viral infection versus overt hypothyroidism. S/he was found to be bradycardic likely a reflection of his/her hypothyroidism. Levothyroxine was restarted and a request for follow up laboratory testing be done to monitor the Thyroxine levels. The resident was returned to the facility on ,d+[DATE] and remains in the facility at present and laboratory testing has been done to monitor Thyroxine levels. Per interview with the physician who treated the resident at the hospital, had this lack of Levothyroxine continued it could have been life threatening and quite possibly had the resident's Thyroxine been in the therapeutic range the December hospitalization could have been avoided. Per interview on 12/27/2022 at approximately 12:15pm the acting Director of Nursing (DNS) confirmed that the resident did not receive the required dose of Levothyroxine from August 30th until s/he was readmitted to the hospital on December 19, 2022.

Based on record review and staff interview, the physician failed to ensure that the onsite review of the resident's total program of care included accurate medication reconciliation and monitoring of medications for 1 of 5 residents (Resident #1). Findings include: Per record review, Resident #1 was admitted to the facility on [DATE] from an acute care hospital following a small bowel obstruction (SBO) necessitating an exploratory laparotomy secondary to a perforated stercocolitis. The resident has a long-standing diagnosis of Hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone). This condition was treated with Levothyroxine 100mcg a day (a medication replacing the missing thyroid hormone Thyroxine and is taken indefinitely, although the dose may change over time). Upon admittance to the facility the Transition of Care (TOC) from the hospital indicated the resident should continue to take the Levothyroxine. On 3/23/2022 the facility physician saw the resident for an admission visit and noted the Hypothyroidism Diagnosis and indicated the condition was well-managed, and there were currently no symptoms of thyroid disease present. The physician ordered a Thyroid Stimulating Home (TSH) test to be draw on the next laboratory (lab) draw and will adjust dosing of Levothyroxine as needed based on lab value and will continue to follow with periodic lab work. The resident did have lab work including a TSH drawn on 3/29, 5/18 and 5/23/2022, and none of those labs were indicative of levels within the therapeutic range and finally a lab draw on 6/15/2022 did indicate the therapeutic level had been reached. The resident went out to the hospital on 7/21/2022 returning on 7/29/2022. When the resident returned to the facility the TOC indicated Levothyroxine 100mcg a day for only 30 days. On 7/29/2022 a nurse documented that all TOC medications were entered into the system and the Nurse Practitioner (NP) stated s/he had seen the TOC and to go ahead with the order, but clarification was needed for the Intravenous Therapy (IV) Protonix (a medication used to treat gastroesophageal-reflux-disease - GERD) since the facility does not provide that medication as an IV. There was no mention by the NP of the fact that the Levothyroxine was only ordered for 30 days. On 8/1/2022 the NP saw the resident for a readmission visit and documented incorrectly under the current medications list - Levothyroxine 150mcg a day. The NP also documented that s/he had spent 40 minutes on patient care and that a medication reconciliation had been completed and that diagnostic testing had been reviewed. The note also indicates that the plan of care was reviewed, and s/he agreed with the plan. During this visit the resident requested to return to the hospital for continued issue with constipation and recurrent episodes of SBO and the resident was transported to the hospital. The resident returned on 8/6/2022 and again the TOC indicated Levothyroxine 100mcg for 30 days only. On 8/6/2022 a nurses reviewed the orders from the TOC over the phone with the on-call provider and no changes to the orders were made at that time, despite the fact that the Levothyroxine was only ordered for 30 days from the previous 7/29/2022 date of discharge from the hospital. On 8/29/2022 the resident received her last dose of the Levothyroxine 100mcg per the 30-day physician order on the TOC from the hospital and the medication dropped off the Medication Administration Record (MAR) at that time. There is no evidence in the Electronic Health Record (EMR) of anyone questioning why the medication, that is required to be taken indefinitely was no longer ordered. On 9/30/2022 the NP saw the resident for a regular visit and again documented incorrectly that the current medications included Levothyroxine 150mcg a day. Again, s/he documented that they had spent 40 minutes on patient care and that a medication reconciliation had been completed and that diagnostic testing had been reviewed and that the plan of care was reviewed, and s/he agreed with the plan. The resident went without Levothyroxine for 2 days in August 2022, 30 days in September 2022, 31 days in October 2022, 30 days in November 2022 and 19 days in December 2022, when the resident returned to the hospital and laboratory tests showed a very high TSH level and an undetectably low Thyroxine level (Free T4). While at the hospital there was concern that there was no evidence on his/her medication list from the facility that s/he was taking Levothyroxine, as she had previously been taking when being seen at the hospital. The December 2022 hospitalization also showed the resident was diagnosed with Parainfluenza and Pericardial Effusion which was likely in the setting of inflammatory state given viral infection versus overt hypothyroidism. S/he was found to be bradycardic likely a reflection of his/her hypothyroidism. Levothyroxine was restarted and a request for follow up laboratory testing be done to monitor the Thyroxine levels. The resident was returned to the facility on ,d+[DATE] and remains in the facility at present and laboratory testing has been done to monitor Thyroxine levels. Per interview with the physician who treated the resident at the hospital, had this lack of Levothyroxine continued it could have been life threatening and quite possibly had the resident's Thyroxine been in the therapeutic range the December hospitalization could have been avoided. Per interview on 12/27/2022 at approximately 12:15pm the acting Director of Nursing (DNS) confirmed that the NP had incorrectly documented the dose of Levothyroxine on 2 occasions and appeared unaware that the Levothyroxine had dropped off the MAR and that the resident was no longer receiving this medication.

Based on record review and interviews, the facility failed to ensure that residents were free from neglect for 1 of 5 residents reviewed (Resident #1). Findings include: Per record review, Resident #1 was admitted to the facility on [DATE] from an acute care hospital following a small bowel obstruction (SBO) necessitating an exploratory laparotomy secondary to a perforated stercocolitis. The resident has a long-standing diagnosis of Hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone). This condition was treated with Levothyroxine 100mcg a day (a medication replacing the missing thyroid hormone Thyroxine and is taken indefinitely, although the dose may change over time). Upon admittance to the facility the Transition of Care (TOC) from the hospital indicated the resident should continue to take the Levothyroxine. On 3/23/2022 the facility physician saw the resident for an admission visit and noted the Hypothyroidism Diagnosis and indicated the condition was well-managed, and there were currently no symptoms of thyroid disease present. The physician ordered a Thyroid Stimulating Home (TSH) test to be draw on the next laboratory (lab) draw and will adjust dosing of Levothyroxine as needed based on lab value and will continue to follow with periodic lab work. The resident did have lab work including a TSH drawn on 3/29, 5/18 and 5/23/2022, and none of those labs were indicative of levels within the therapeutic range and finally a lab draw on 6/15/2022 did indicate the therapeutic level had been reached. The resident went out to the hospital on 7/21/2022 returning on 7/29/2022. When the resident returned to the facility the TOC indicated Levothyroxine 100mcg a day for only 30 days. The facility has a system in place that 2 nurses are to verify that orders are correct before placing them into the resident record, neither nurse noted anything about the fact that the Levothyroxine for only prescribed for a 30-day period of time despite the fact that treatment with Levothyroxine is lifelong. On 7/29/2022 a nurse documented that all TOC medications were entered into the system and the Nurse Practitioner (NP) stated s/he had seen the TOC and to go ahead with the order, but clarification was needed for the Intravenous Therapy (IV) Protonix (a medication used to treat gastroesophageal-reflux-disease - GERD) since the facility does not provide that medication as an IV. There was no mention of the fact that the Levothyroxine was only ordered for 30 days. On 8/1/2022 the NP saw the resident for a readmission visit and documented incorrectly under the current medications list - Levothyroxine 150mcg a day. The NP also documented that a medication reconciliation had been completed and that diagnostic testing had been reviewed. During this visit the resident requested to return to the hospital for continued issues with constipation and recurrent episodes of SBO and the resident was transported to the hospital. The resident returned on 8/6/2022 and again the TOC indicated Levothyroxine 100mcg for 30 days only. On 8/6/2022 a nurses reviewed the orders from the TOC over the phone with the on-call provider and no changes to the orders were made at that time, despite the fact that the Levothyroxine was only ordered for 30 days from the previous 7/29/2022 date of discharge from the hospital. A second nurse also reviewed the orders for accuracy. On 8/29/2022 the resident received her last dose of the Levothyroxine 100mcg per the 30-day physician order on the TOC from the hospital and the medication dropped off the Medication Administration Record (MAR) at that time. There is no evidence in the Electronic Health Record (EMR) of anyone questioning why the medication, that is required to be taken indefinitely, was no longer ordered. On 9/30/2022 the NP saw the resident for a regular visit and again documented incorrectly that the current medications included Levothyroxine 150mcg a day. Again, the NP documented that a medication reconciliation had been completed and that diagnostic testing had been reviewed. On 8/11, 9/7, 10/6, 11/8 and 12/5/2022 the consultant pharmacist conducted the required Medication Regime Review and on each of these dates documented no recommendations at this time, despite the fact the TOC incorrectly listed only 30 days of Levothyroxine in July 2022 and the resident was no longer receiving Levothyroxine as of 8/30/2022, and that treatment with Levothyroxine is lifelong. The resident went without Levothyroxine for 2 days in August 2022, 30 days in September 2022, 31 days in October 2022, 30 days in November 2022 and 19 days in December 2022. The physician at the hospital for the 12/19/2022 inpatient admittance, indicated that endocrine was consulted because the resident was found to be overtly hypothyroid. Laboratory tests showed a very high TSH level and an undetectably low Thyroxine level (Free T4). While at the hospital there was concern that there was no evidence on her medication list from the facility that she was taking Levothyroxine, as she had previously been taking when being seen at the hospital. The December 2022 hospitalization also showed the resident was diagnosed with Parainfluenza and Pericardial Effusion which was likely in the setting of inflammatory state given viral infection versus overt hypothyroidism. S/he was found to be bradycardic likely a reflection of his/her hypothyroidism. Levothyroxine was restarted and a request for follow up laboratory testing be done to monitor the Thyroxine levels. The resident was returned to the facility on ,d+[DATE] and remains in the facility at present and laboratory testing has been done to monitor Thyroxine levels. Per interview with the physician who treated the resident at the hospital, had this lack of Levothyroxine continued it could have been life threatening and quite possibly had the resident's Thyroxine been in the therapeutic range the December hospitalization could have been avoided. Per interview on 12/27/2022 at approximately 12:15pm the acting Director of Nursing (DNS) confirmed that there were opportunities for both the NP and the pharmacist to realize that the Levothyroxine was no longer being given and that there was a system failure that led to medical neglect. Per review of this record, and multiple interviews, there was a facility multi-system failure to prevent medical neglect of Resident #1, and there was harm as a result. See citations at F711, F756, and F760 for more detail and confirmations.

Based on staff interview and record review, facility staff failed to ensure that 3 applicable residents (Resident # 35, Resident #16, & Resident #198) received treatment and care in accordance with professional standards of practice. Findings include: Facility staff did not document the provision of care for Resident # 35's Foley catheter as ordered by the physician. There is a physician order dated 8/1/22 for urinary Foley catheter care every shift for infection control and as needed. Per review of the Treatment Record (TAR), catheter care was not documented as done on 7 occasions in October 2022 and on 7 occasions in November 2022. There is a physician order for urinary output - verify documentation and notify provider if output is less than 100 ml (milliliter) per shift every shift for output. Review of the TAR indicates that urinary output was not documented as done on 25 occasions in October and 23 occasions in November 2022. The above was confirmed by the Unit Manager on 12/6/22 at 3:36 PM. 45667 2.) Resident #16 required emergent care related to having the retention balloon of the Foley catheter overfilled. Per record review Resident #16 has diagnosis including unspecified dementia and neuromuscular dysfunction of the bladder requiring the use of a Foley catheter. A Foley catheter is a semi-rigid but flexible tube used to drain the bladder while blocking the urethra. A practitioner inserts the catheter through the urethra to the bladder then inflates the circumferential collar (located at the tip of the catheter) called the retention balloon to keep the catheter from being expelled. On 11/12/22 it was noted that Resident #16 had bloody urine in the Foley catheter collection bag. Two nurses attempted to remove the catheter to change it but due to resistance they were unable to remove it, per instructions from the physician Resident #16 was sent to the emergency room . The emergency department notes stated, There was resistance to deflating the catheter balloon, but with some pressure and patience it was able to start being emptied. Shockingly, there ended up being over 90 cc of water in the balloon. Once this was fully emptied, the catheter was able to be removed. New catheter was placed, and urine analysis did show evidence of infection. This could have contributed to the dysfunction, though the large amount of fluid in the balloon certainly was part of the issue. Facility procedure protocol entitled Catheterization, Insertion of Indwelling Catheter for [gender removed] Residents with an approval date of 01/23/2018 reviewed. Step 15 states .insert catheter an additional 1 to 2 inches beyond the point at which urine began to flow and inflate balloon lumen of catheter with sterile water. USE WATER AMOUNT SPECIFIED IN PHYSICIANS'S ORDER. Step 23 states Nurse: Document required or pertinent information in appropriate records, and consult immediate supervisor, if necessary. DOCUMENT SIZE OF CATHETER, CONDITION OF GENITAL AREA, TYPE OF DRAINAGE SYSTEM. NOTE AMOUNT, COLOR AND ODOR OF URINE. Per record review Resident #16 had the following provider order: 16 French (#16 refers to the size of the catheter to be used) to gravity for neurogenic bladder, change monthly for maintenance, bladder scan if UOP (urinary output) < 200 cc, notify provider if residual =/> 200 cc or if UOP <100 cc. It is noted the order does not contain an amount of water to be used to inflate the balloon. Further record review revealed there was no documentation from the nurse as required by the facility's written procedure protocol. On December 7, 2022, at approximately 2 PM a facility #16 French foley catheter and catheter insertion kit was requested for viewing, the RN Supervisor provided the requested catheter and confirmed this was the type used throughout the facility. In addition to being marked with 16 Fr (#16 French) it was also marked 30mL/cc which indicates how much fluid the retention balloon should be filled with. The contents of the insertion kit were viewed a syringe prefilled with 30 mL/cc was included in the kit to be used when inflating the retention balloon. Without a complete Provider order and with the lack of nursing documentation the standard of care as outlined in the Facility Procedure Protocol was not met resulting in an emergent transport of Resident #16. 3.) Review of Res. #198's medical record revealed on 7/10/22 the resident suffered a fall at 4:55 PM. The next morning, on 7/11/22, Nursing Notes record Resident complaining of aching right hip pain, 10/10 [on a scale of 0 to 10, 0= no pain, 10 = worst pain] . Resident unable to stand on her right leg due to her right hip pain. She did not want to attempt range of motion with writer because it hurts too much. Nursing Notes later the same day record Resident was seen by Nurse Practioner status post fall related to nursing reports of right hip pain and decreased ability to bear weight on right side. New order received and entered to obtain x-ray 2 views of right hip and pelvis. Further review of Nurses Notes reveal no further notes regarding the ordered x-ray for Res. #198's hip pain on 7/11, 7/12, and 7/13/22. Review of orders for Trident Care, the facility's Radiology service, reveal an order for a radiology exam dated 7/14/22, 3 days after the Nurse Practioner order for an x-ray was entered. A notation on the Trident Care order reads not done. Nurses Notes on 7/14/22 record Writer spoke with Nurse Practioner to update on resident status .Order received to send to emergency room for evaluation and treatment if unable to obtain right hip x-ray today related to decreased ability to bear weight status post fall. Review of Res. #198's medical record regarding the emergency room visit reveals the resident was diagnosed with 'a closed, non-displaced greater trochanteric fracture' [bony protrusion on the femur (thighbone)]. An interview was conducted with the acting Director of Nursing [DON] on 12/7/22 at 12:38 PM. The DON confirmed there was no documentation regarding why the x-ray ordered on 7/11/22 was not completed for 3 days until the resident was sent to the Emergency Department, and no documentation that the Nurse Practioner was notified that the x-ray was not completed as ordered for 3 days after the order was written.

Based on interview and record review the facility failed to properly manage the care of a Foley catheter for one applicable resident (Resident #16). Resident #16 is an [AGE] year old person with diagnosis including unspecified dementia and neuromuscular dysfunction of the bladder requiring the use of a Foley catheter. A Foley catheter is a semi-rigid but flexible tube used to drain the bladder while blocking the urethra. A practitioner inserts the catheter through the urethra to the bladder then inflates the circumferential collar (located at the tip of the catheter) called the retention balloon to keep the catheter from being expelled. Physician orders include an order to flush the catheter twice daily with 120 cc of normal saline to maintain patency and prevent urine related debris from collecting and resulting in a blockage. A Foley catheter has two ports that are accessable to the practitioner. One port is used to inflate the balloon with water using the syringe provided in the catheritization kit, the other port is to be used to irrigate the catheter. The irrigant is pushed via a syringe into the specified port, the irrigant then drains into the collection bag along with the urine being drained from the bladder. On 11/12/22 Resident #16 was emergently sent to the hospital after two facility nurses were unable to remove the catheter for replacement. The emergency department notes stated, There was resistance to deflating the catheter balloon, but with some pressure and patience it was able to start being emptied. Shockingly, there ended up being over 90 cc of water in the balloon. Once this was fully emptied, the catheter was able to be removed. New catheter was placed, and urine analysis did show evidence of infection. This could have contributed to the dysfunction, though the large amount of fluid in the balloon certainly was part of the issue. Per record review Resident #16 had the following provider order: 16 French (#16 refers to the size of the catheter to be used) to gravity for neurogenic bladder, change monthly for maintenance, bladder scan if UOP (urinary output) < 200 cc, notify provider if residual =/> 200 cc or if UOP <100 cc. It is noted the order does not contain an amount of water to be used to inflate the balloon. Further record review revealed there was no documentation from the nurse as required by the facility's written procedure protocol. On December 7, 2022, at approximately 2 PM a facility #16 French foley catheter and catheter insertion kit was requested for viewing, the RN Supervisor provided the requested catheter and confirmed this was the type used throughout the facility. In addition to being marked with 16 Fr (#16 French) it was also marked 30mL/cc which indicates how much fluid the retention balloon should be filled with. The contents of the insertion kit were viewed a syringe prefilled with 30 mL/cc was included in the kit to be used when inflating the retention balloon. On 12/7/22 at 12:10 PM the DON confirmed knowledge of this event and revealed it was suspected that someone had attempted to flush the catheter using the incorrect access port resulting in the balloon being significantly overfilled. Refer also to F684.

Based on observation, record review, and staff interviews, the facility failed to provide pain management in accordance with the resident's preferences for 1 of 27 sampled residents [Resident #302]. Findings include: Findings include: Per record review, Resident #302 was admitted to the facility on [DATE] for subacute rehab with multiple orthopedic injuries and fractures following a motor vehicle accident. Resident #302 has a physician order for OxyCODONE HCl Tablet 15 MG Give 1 tablet by mouth every 4 hours as needed for pain -Start Date-11/30/2022. Resident #302's care plan does not include a care area focus for pain, pain management goals, or interventions for pain management. Per observation and interview on 12/5/2022 at 09:35 AM, Resident #302 reported that his/her pain is not being managed. S/he stated that s/he has asked the nursing staff to wake him/her up at night to give administer his/her PRN [as needed] oxycodone but they won't wake him/her up to give it to him/her and because of that, s/he is unable to manage their pain throughout the rest of the day. Resident #302 reported to have a 9/10 pain level during interview and was observed moaning with a distorted face multiple times during the interview. A provider note dated 12/5/22 states Patient endorses chronic discomfort, moderately well managed with current regimen. Patient verbalizes pain at baseline today mildly increased with movement secondary to acetabular fracture, however, a social service note dated 12/5/22 states [Patient]states that [his/her] pain meds are still not right. Feels [s/he] is not being given in a timely manner. Worried that [s/he] won't get if falls asleep as they are prn. Per interview on 12/6/2022 at 3:00 PM, a Licensed Practical Nurse [LPN] stated s/he was aware the resident #302 wanted to be woken up for his/her PRN medication at night but nursing staff won't wake him/her up for PRN medications because there is a policy not to wake up residents and s/he has a history of drug seeking. Per interview on 12/07/22 at 7:40 AM, the Unit Manager stated that Resident #302 should have a care plan for pain and that nursing staff should not wake up a resident to administer PRN medications, even if they ask. Per interview on 12/7/2022 at 8:20 AM, the Director of Nursing [DON] stated that there was not a policy prohibiting nursing staff from waking up a resident on request for PRN medications and nursing should follow his request to wake him up. The DON confirmed that there should be a care plan for pain.

Based on medical record review, staff and resident interview, review of the facility internal investigation of the incident, and review of facility policies, the facility failed to ensure that 2 of 2 residents reviewed received adequate supervision and assistance to prevent accidents. Finding include: Per record review, Resident #1 was being transported to a medical appointment by a private transportation company on 10/18/19. The facility made the arrangements with the transportation company to get the resident to the medical appointment. Per the resident, during interview on 11/4/19 at 10:30 AM, the driver picked him/her up inside the building, took them out to the van, secured his/her wheelchair to the floor of the van and placed a seat belt across his/her body. S/he reported s/he did not know if it was secured properly. About 15 minutes into the transport the resident reported hearing a clicking noise and felt the wheelchair lurch forward and s/he placed her/his hand on the back of the driver's seat to prevent themselves from falling out of the wheelchair. The driver stopped the vehicle and pushed the resident back and then continued driving. A few minutes later the resident again heard the clicking noise and yelled to the driver, who then stopped abruptly, and the resident slid out of the wheelchair with one leg being wedged under the driver's seat and was not sure where their other leg was wedged. The resident did report extreme pain. Emergency Medical Services (EMS) were called and the resident was transferred to the hospital and subsequently diagnosed with [REDACTED]. Per the facility incident report, staff and resident interviews, the resident was taken from the facility by the driver of the van. The Director of Nursing Services confirmed on 11/4/19 at 4:15PM that the driver is responsible for taking the resident from the facility and securing them inside the van. Additionally, during the facility's internal investigation, it was discovered that a 2nd resident, Resident #2, was injured on 10/16/19 while being transported to a medical appointment by the same transportation company. The resident reported to the facility that their wheelchair fell backward, causing back and neck pain. The resident did not report the incident to the facility at the time it happened. Although the facility does have their own van to use for appointments, the Administrator reports being unable to hire enough qualified staff to operate it on a regular basis. Per review of facility documents, there is a 1-page form titled New Vendor Information Form that was completed by the transportation company, with basic contact information and signed by the owner of the company. The form does not address protocols, in writing, for assuring safety requirements for residents. The facility transportation policy and procedure guide is very generic and geared to facilities in New York State. The facility was unable to provide an actual contract with the transportation company, and they have nothing that would indicate the training and education that a driver would or should have received prior to being allowed to transport a resident. The facility has no knowledge about vehicle maintenance, and whether the equipment to secure a wheelchair in the van was in good operating condition to maintain resident safety. During interview on 11/4/19 at 1:33 PM the Administrator confirmed that the facility does not have a written contract with the transportation company. There is nothing in a written policy that delineates how residents get to the van from the facility or who is responsible to make sure that the resident is secured in place before transport.

Based on staff interviews, medical record reviews and review of policies and procedures, the facility failed to have a contract with the transportation company that specified, in writing, the responsibilities of the transportation services company versus the facility responsibility in maintaining resident safety. Per record review, Resident #1 was being transported to a medical appointment by a private transportation company on 10/18/19. Per the incident report, staff and resident interviews, the resident was taken from the facility by the driver of the van. Per the resident, during interview on 11/4/19 at 10:30 AM, the driver secured his/her wheelchair to the floor of the van and placed a seat belt across his/her body, s/he reported s/he did not know if it was secured properly. About 15 minutes into the transport the resident reported hearing a clicking noise and felt the wheelchair lurch forward and s/he placed her/his hand on the back of the driver's seat to prevent themselves from falling out of the wheelchair. The driver stopped the vehicle and pushed the resident back and then continued driving. A few minutes later the resident again heard the clicking noise and yelled to the driver, who then stopped abruptly, and the resident slid out of the wheelchair with one leg being wedged under the driver's seat and was not sure where their other leg was wedged. Emergency Medical Services (EMS) were called and the resident was transferred to the hospital and subsequently diagnosed with [REDACTED]. Although the facility does have their own van to use for appointments, the Administrator reports being unable to hire enough qualified staff to operate it on a regular basis. Per review of facility documents, there is a 1-page form titled New Vendor Information Form that was completed by the transportation company, with basic contact information and signed by the owner of the company. The form does not address protocols, in writing, for assuring safety requirements for residents. The facility transportation policy and procedure guide is very generic and geared to facilities in New York State. The facility was unable to provide an actual contract with the transportation company, and they have nothing that would indicate the training and education that a driver would or should have received prior to being allowed to transport a resident. The facility has no knowledge about vehicle maintenance, and whether the equipment to secure a wheelchair in the van was in good operating condition to maintain resident safety. During interview on 11/4/19 at 1:33 PM, the Administrator confirmed that the facility does not have a written contract with the transportation company. There is nothing in a written policy that delineates how residents get to the van from the facility or who is responsible to make sure that the resident is secured in place before transport.

Based on staff interviews and record review, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible for 1 applicable Resident (Resident #1). Findings include: Per staff interview and record review, Resident # 1 received full [MEDICAL CONDITION] to staff's failure to follow proper procedure when serving a hot food item. On 5/4/18, Resident # 1 requested a staff Licensed Nursing Assistant (LNA) to heat some soup that belonged to Resident # 1. Per record review and confirmed by staff interview, the LNA did not take the temperature of the soup prior to serving it to Resident #1. The LNA placed the soup within the Resident's reach and left the room. The clinical record notes that Resident #1 has hand tremors. The facility Microwave Ovens and Safety policy states to check temperature with a clean, sanitized food thermometer or T-stick. The policy also states Allow foods to stand covered for 2 minutes after cooking (unless otherwise indicated) to obtain temperature [MEDICATION NAME]. Under the Patient Safety section of the policy, it states to Allow food to sit uncovered for approximately 2 to 7 minutes after the standing time before serving. Facility documentation indicates that the LNA was not aware of the policy to check the food temperature with the strip. The Assistant Director of Nurses (ADON) confirmed on 5/31/18 at 9:50 AM that the LNA did not check the temperature of the soup after heating as per facility policy and did not wait the required time period prior to serving soup as per policy.

Based upon interview and record review, the facility failed to ensure that 1 of 5 residents were free from sexual abuse by a resident with known intentional sexual behaviors. (Resident #2). Findings include: Per review of Physician Nursing Home Follow-Up Note dated 7/28/16 and confirmed with the Director of Nursing (DON) on 8/8/16 at 10:30 AM, the Physician Nursing Home Follow-Up Note states, This morning during shift change around 7 AM (Resident #1) was found to have (his/her) hands in the pants and adult diaper of (Resident #2) .A nurse forcibly removed (his/her) hands. (S/he) was combative with staff as well as trying to grab other residents. (S/he) was also verbally aggressive using the F word and saying that (s/he) wanted to F staff. Per staff interview on 8/8/16 at 2:12 PM, staff stated stated as s/he was leaving the (Nursing) Unit, s/he saw (Resident #1's) hands in (Resident #2's) pants. Stated (Resident #1) is a strong (person), and resisted (the nurse) removing (Resident #1's) hands. (S/he) was using the F word towards (the nurse). Per record review, Resident #2 has a [DIAGNOSES REDACTED]. The facility was aware of Resident #1's behaviors prior to 7/28/16, which put this resident at risk for abusing others. Per record review and confirmed per interview with DON on 8/8/16 at 10:12 AM, Resident #1 was evaluated three times by a Geriatric Psychiatrist on 5/26/16, 7/7/16, and 7/21/16 for sexually inappropriate behaviors. On 7/7/16 the Geriatric Psychiatrist's evaluation states that the sexual behaviors are believed to be intentional, the resident does not deny the allegations and the resident is not apologetic. In addition, the DON confirmed on 8/8/16 at 10:12 AM that the Geriatric Psychiatrist note on 7/21/16 states that the resident continues with the sexual behaviors, is not able to be redirected and that the resident verbalized that s/he does not care if s/he is making others uncomfortable. Multiple staff notes document vulgar, sexually inappropriate statements made by the resident and aggressive sexual actions. An example of this type of behavior is as follows. Per record review of progress notes dated 7/25/16 14:40 (late entry for 7/25/16 0930) (Resident #1) noted propelling self in hallway near dining room. (Resident #1) was grabbing both staff and other residents in their privates stating 'F**k me you w****s or c***s. and I'm going to F**k you too.' This was done to both males and females. Redirection, explanation of inappropriateness all ineffective MD, DON and Social svcs aware. Refer also to F250 and F323.

Per interview and record review, social services failed to assure medically related social services needs were met for three residents in the applicable sample. (Residents #1, #2, and #3). Findings include: 1. Per record review and confirmed during interview with the Director of Nursing (DON) on 8/8/16 at 10:30 AM, Resident #1 was witnessed sexually abusing Resident #2 on 7/28/16. Per record review on 8/8/16 at 1:24 PM, the Social Service Specialist (SSS) failed to address Resident #1's ongoing difficulties with personal interactions with other residents and staff of the facility, and there was no evidence the SSS provided the medically necessary social services to develop a comprehensive plan that is resident-specific to improve or adequately monitor interactions with other residents and staff. Per record review there are no social service notes concerning specific behavioral interventions that are specific to Resident #1's needs and preferences, ongoing re-evaluations, nor discussions with Resident #1's spouse (who has power of attorney (POA)) related to developing specific strategies to decrease inappropriate sexual behaviors by Resident #1 directed towards nursing staff that occurred in the facility from May 2016 to 7/28/16. The SSS stated s/he talked with Resident #1's spouse (POA) about the sexual behaviors, but no evidence that a discussion occurred or that the SSS was working with the POA on a comprehensive plan to address the behaviors. Per record review and confirmed during interview with the Case Manger/Social Services Supervisor on 8/8/16 at 1:31 PM, Resident #1's behavioral care plan was not revised concerning sexual behaviors following three Geriatric Psychiatrist evaluations for sexual behaviors on 5/26/16, 7/7/16, and 7/21/16. Resident #1's behavioral care plan initiated on 5/19/16 and was not revised until 7/25/16, despite ongoing severe behaviors prior to 7/25/16. When the care plan was revised on 7/25/16, it was not revised to reflect new, meaningful, resident-specific strategies to address psychosocial well-being. Refer to F223. 2. Per record review and interview on 8/8/16 at 1:24 PM, the Social Service Specialist confirmed Resident #2's medical record does not contain Social Service documentation concerning follow up of sexual abuse by Resident #1 on 7/28/16. The Social Service Specialist provided the surveyor with a hand written note on lined paper with Resident #2's initials describing social service contact on 7/28/16 with Resident #2, which per interview, was not part of the legal medical record. 3. Per record review and interview on 8/8/16 at 1:24 PM, the Social Service Specialist confirmed there is no written social service note in Resident #3's medical record concerning a minor resident to resident altercation between Resident # 1 and Resident #3. The Social Service Specialist provided the surveyor with a hand written note on lined paper with Resident #3's initials describing social service contact on 7/28/16 with Resident #3, which per interview was not part of the legal medical record.

Based upon interview and record review, the facility failed to provide adequate supervision to protect residents for 1 resident in the applicable sample with a history of intentional sexually inappropriate behaviors and physical aggression towards staff. (Resident #1) Findings include: 1. Per record review, Resident #1 had multiple instances of aggressive and sexually inappropriate behaviors with staff since admission in May 2016 and during the month of July 2016. Dates of documented aggressive and/or sexually inappropriate behaviors during July include 7/3, 7/4, 7/7, 7/8, 7/9, 7/14, 7/17, 7/18, 7/19, 7/20, 7/25, 7/26, and 7/27/16. Despite the ongoing behaviors, the facility failed to provide adequate supervision to protect other residents from incidents related to the behaviors. Per record review and confirmed during interview with the Case Manger/Social Services Supervisor on 8/8/16 at 1:31 PM, Resident #1's behavioral care plan was not updated concerning his/her sexual behaviors following three Geriatric Psychiatrist evaluations for sexual behaviors on 5/26/16, 7/7/16, and 7/21/16. The behavioral care plan was written 5/19/16 and not updated until 7/25/16, despite ongoing severe behaviors prior to 7/25/16. On 7/25/16, Resident #1's care plan was revised to include 1:1 supervision to be provided to Resident (effective 7/25/16), which was changed to 15 minute checks later that day. The 15 minute checks were not effective in protecting other residents. Per review of Physician Nursing Home Follow-Up Note dated 7/28/16 and confirmed with the Director of Nursing (DON) on 8/8/16 at 10:30 AM, the Physician Nursing Home Follow-Up Note states, This morning during shift change around 7 AM (Resident #1) was found to have (his/her) hands in the pants and adult diaper of (Resident #2) .A nurse forcibly removed (his/her) hands. (S/he) was combative with staff as well as trying to grab other residents. (S/he) was also verbally aggressive using the F word and saying that (s/he) wanted to F staff. Per interview and record review on 8/8/16 at 1:53 PM, the Assistant Director of Nursing (ADON) confirmed that after (Resident #1) was separated from (Resident #2) on 7/28/16, Resident #1 was brought to the nurse's station. At the nurse's station, Resident #1 grabbed Resident #3's arm and leg. Resident #3 had a red mark on his/her arm where s/he was grabbed. Refer also to F223 and F250.

Based upon record review and staff interview the facility failed to ensure that 3 of 17 residents in the survey sample were free from neglect or mistreatment (Residents #1, #3, #5). The findings include: 1. Per review of the facility medical record, Resident #1 was admitted to the facility on [DATE]. He/she had [DIAGNOSES REDACTED]. Per review of the facility's internal investigation written statement by a staff physical therapist, on 10/18/13 Resident #1 reported to the therapist that the LNA that provided his morning care that day, "was upset that an LNA called out." The LNA "slammed" the rolling walker and chair. The resident reported that he/she "had the call light on so long (he/she) was incontinent in bed." The therapist reported that when he/she went to adjust the resident's stockings, he/she noted that Resident #1 had "dried feces all over pants/back and covering w/c (wheelchair). Patient stated (he/she) thought (he/she) smelled something." The therapist reported that he/she went directly to the unit manager (UM) and the social services director (to report the incident). Per review of the social services director's statement dated 10/18/13, he/she interviewed Resident #1 with the UM. Resident #1 reported "putting his call light on and waiting about 20 minutes on the edge of (his/her) bed." When the LNA arrived, (the resident) told her you are too late "I[***]myself." He/she said the LNA "got upset" stating "its not my fault I am filling in for someone else, there's not enough staff." The resident said the LNA seemed "really upset to have to clean him up." He/she said the LNA "threw his dirty clothes around the room" and said that the LNA was "rough but that it didn't necessarily hurt." The resident said that he/she could smell something and realized that he/she still had BM (bowel movement) all over his/her back. The resident reported that he/she "prefers to not have (him/her) as his LNA". The resident was upset that (the LNA) also "left clothes with BM on the floor." Per review, the resident's 9/16/13 admission Minimum Data Set (MDS) assessment documented that Resident #1 is cognitively aware and able to understand and be understood; required extensive assistance of one for bed mobility, dressing, personal hygiene and toileting and extensive assistance for transfers. His/her 9/2013 activities of daily living (ADL) log and his/her 10/16/13 Resident Profile listed toileting as requiring extensive assistance. His/her 9/10/13 Physical sheet lists the resident as "wheel chair mobility dependent." Per review of the facility policy for abuse, "Patients have the right to be free of verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, and neglect of the patient as well as mistreatment, neglect, and misappropriation of patient property." (POL:504-01) Per 11/6/13 interview with the facility DNS at 2:45 PM, the involved LNA was suspended immediately and his/her employment was terminated and a copy of the investigation was sent to the Board of Nursing. 2. Per 11/4/13 medical record review, Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per review of the resident's 8/12/13 Minimum Data Set (MDS) annual assessment, Resident #3 had cognitive and memory impairments; required extensive assistance for bed mobility, dressing, personal hygiene and toileting; was totally dependent and required the extensive assistance of 2 persons for transfers. Balance was assessed as not steady for moving on and off the toilet, only able to stabilize with human assistance; He/she was assessed as at risk for the development of pressure ulcers. Resident #3's 10/14/13 "Resident Profile," the LNA plan of care, specified that the resident be transferred to the toilet with the assistance of two persons and a transfer disc. Per review of the facility investigation dated 10/22/13, two facility LNA's (LNA #1 and LNA #2) transferred Resident #3 to the toilet using a gait belt at 1:15 PM. LNA #1 went on a break right after the transfer leaving his/her gait belt on the resident and stated the call bell was near the resident. LNA #1 could not recall if he/she told anyone she/he was going on a break. When he/she returned to the floor, he/she finished his/her rounds, documented and then went home. LNA #2 stated that after transferring Resident #3 to the toilet, he/she went on to care for other residents leaving LNA #1 by the bathroom door, and then went on a break, returned for rounds, documented and went home. LNA #2 reported that LNA #1 typically had Resident #3 on his/her assignment and assumed LNA #1 would know how to transfer the resident, so did not look up the resident's transfer status. In LNA #2's written statement dated 10/23/13, he/she reported that he/she assumed that Resident #3 had been transferred back (from the toilet) but was not around to witness and was unaware that he/she was still on the toilet when he/she left to go home. Per review of the facility's internal investigation written statement by a facility physical therapist, on 10/22/13 at 4:00 PM the therapist reported trying to find Resident #3 for therapy. He/she spotted his/her leg rests outside a common area bathroom door. The therapist wrote, upon opening the bathroom door... Resident #3 "was close to falling off the toilet, left unsupervised without the use of transfer disc (gait belt still on pt (patient), so (he/she) hadn't transferred himself)." "Quickly asked for assist, pt was so tired it took 3 people to help him stand pivot to chair. Pt diaphoretic and fatigued. Asked pt how long (he/she) felt he had been in the bathroom 'I'm not sure, probably about an hour.' This pt should never be left unsupervised!" The therapist added an addendum to his/her statement, "This (resident) was drenched in sweat and so tired! (He/she) is unable to keep (his/her) eyes open (unable to do therapy at this time!) ((His/her) transfer disc was still in (his/her) room)." Per 11/5/13 at 10:10 AM interview with the facility physical therapist, he/she reported finding the resident on the toilet in the bathroom on 10/22/13 with his wheelchair in front of him; he/she reported that the resident's transfer status states for toileting is 2 person assist and the use of a transfer disc; "they are supposed to be with him and not leave." Per 11/6/13 interview at 11:21 AM with the ADNS, he/she reported that he/she was on duty the day of the incident. He/she reported that Resident #3 does not consistently use his call light, "that is why the LNA should have stayed with (him/her)." Per 11/6/13 interview with the facility Director of Nursing at 2:45 PM, LNA #1's employment was terminated and a copy of the facility investigation was sent to the Board of Nursing. 3. Per record review, Resident #5 had a history of [REDACTED]. The resident utilized a wheelchair for mobility. On the morning of 10/23/13, Resident #5 was sitting in their room in a wheelchair. At approximately 10:40 AM, a housekeeper entered the room of the resident to clean. The housekeeper stated that the resident was not very responsive when greeted, and appeared to be trying to stand up from the wheelchair. The housekeeper left the room and found a nurse nearby to relay the concern that the resident was trying to get up. Per interview with the housekeeper, s/he stated that the nurse told them to ring the call light so the LNAs would respond. The housekeeper then told the other nurse on the unit about Resident #5 attempting to stand. This nurse also told the housekeeper to put on the call light to alert the LNAs. When the housekeeper returned to the room to mop the floor, Resident #5 was more alert, and agreed to stay in the wheelchair while the floor was drying. A second housekeeper was delivering clean laundry to the rooms at approximately 10:50 AM, and went to the door of Resident #5's room. S/he observed the resident was standing in front of their wheelchair. The housekeeper then looked out in the hall to find a staff person, and saw no one was around. When the housekeeper looked back in the room, s/he witnessed Resident #5 fall forward to the floor. The resident sustained [REDACTED]. After diagnostic tests showed no apparent internal head injury, the resident was sent back to the facility, however did pass away the following morning at the facility. On 11/6/13, the LNAs working on the day of the fall were each interviewed. There were four LNAs working on that unit on 10/23/13. At the time Resident #5 fell , two of the LNAs were out on a break, and the remaining two LNAs were together assisting a resident who required a two person transfer. The nurses on the unit passing medications did not respond to the concerns of the first housekeeper, both telling him/her to activate the call light for the LNAs, although there was no LNAs available at that time. Per interview on 11/6/13 at 3:55 PM, the Administrator confirmed that the usual staffing for that unit was 5 LNAs on the day shift, and that there were only 4 scheduled the day of 10/23/13, and that only one of the LNAs at a time should have been out on a lunch break to assure adequate monitoring of residents. The Administrator also stated that the housekeeping staff needs to be supported by the nursing staff when they express a concern about a resident, and that prompt response from the staff who were alerted of the situation may have avoided the resident's fall.

Based on record review and interviews facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 3 of 17 residents in the sample.( Residents # 5, 7) Findings include: 1. Per record review, Resident #5 had a history of [REDACTED]. The resident utilized a wheelchair for mobility. On the morning of 10/23/13, Resident #5 was sitting in their room in a wheelchair. At approximately 10:40 AM, a housekeeper entered the room of the resident to clean. The housekeeper stated that the resident was not very responsive when greeted, and appeared to be trying to stand up from the wheelchair. The housekeeper left the room and found a nurse nearby to relay the concern that the resident was trying to get up. Per interview with the housekeeper, s/he stated that the nurse told them to ring the call light so the LNAs would respond. The housekeeper then told the other nurse on the unit about Resident #5 attempting to stand. This nurse also told the housekeeper to put on the call light to alert the LNAs. When the housekeeper returned to the room to mop the floor, Resident #5 was more alert, and agreed to stay in the wheelchair while the floor was drying. A second housekeeper was delivering clean laundry to the rooms at approximately 10:50 AM, and went to the door of Resident #5's room. S/he observed the resident was standing in front of their wheelchair. The housekeeper then looked out in the hall to find a staff person, and saw no one was around. When the housekeeper looked back in the room, s/he witnessed Resident #5 fall forward to the floor. The resident sustained [REDACTED]. After diagnostic tests showed no apparent internal head injury, the resident was sent back to the facility, however did pass away the following morning at the facility. On 11/6/13, the LNAs working on the day of the fall were each interviewed. There were four LNAs working on that unit on 10/23/13. At the time Resident #5 fell , two of the LNAs were out on a break, and the remaining two LNAs were together assisting a resident who required a two person transfer. The nurses on the unit passing medications did not respond to the concerns of the first housekeeper, both telling him/her to activate the call light for the LNAs, although there was no LNAs available at that time. Per interview on 11/6/13 at 3:55 PM, the Administrator confirmed that the usual staffing for that unit was 5 LNAs on the day shift, and that there were only 4 scheduled the day of 10/23/13, and that only one of the LNAs at a time should have been out on a lunch break to assure adequate monitoring of residents. The Administrator also stated that the housekeeping staff needs to be supported by the nursing staff when they express a concern about a resident, and that prompt response from the staff who were alerted of the situation may have avoided the resident's fall. 2 . Per record review on 11/04/13 of Resident #7's care plan, who has a [DIAGNOSES REDACTED]. The care plan also notes no caregivers of the opposite sex. On 09/09/13 during the evening shift at approximately 8:00 PM a resident of the opposite sex (resident #6) enter the room and proceeded to kiss and touch Resident #7. Per interviews on the evening of 11/05/13 and on the morning of 11/06/13 with the four staff who worked the evening of 09/09/13, two staff stated that they were either on supper break or a short break, one stated that s/he was administering medications on the other hall and one staff member stated that s/he was answering call lights and/or providing care. It took staff approximately ''10 -15 minutes to answer the call light'', although all four staff were not sure how long ( resident #6) had been in Resident #7's room prior to the call light being turned on . Staff further stated that Resident #7 is unable to call out for help or use a regular button type call light, so a 'touch pad' type is placed on the resident''. Staff further acknowledged that they were not sure if Resident #7 used the call light or if it got accidentally turned on by the other resident and stated that the resident was upset by this incident. The Unit Manager on 11/05/13 at 1:15 PM confirmed that Resident #7's the highest practicable physical, mental, and psychosocial well-being was not maintained.

Based on record review and staff interviews, the facility failed to assure sufficient staff to provide nursing and supervision to maintain the highest practicable well-being of each resident according to residents' assessments and individual plans of care. (Resident #7 and #5) Findings include: 1. Per record review on 11/04/13 of Resident #7's care plan, who has a [DIAGNOSES REDACTED]. The care plan also notes no caregivers of the opposite sex. On 09/09/13 during the evening hours at approximately 8:00 PM a resident of the opposite sex (Resident #6) entered the room and proceeded to kiss and touch Resident #7. Per interviews on the evening of 11/05/13 and in the morning of 11/06/13 with the four staff who worked the evening shift on 09/09/13, two staff stated that they were either on supper break or a short break, one stated that s/he was administering medications on the other hall and one staff member stated that s/he was answering call lights and/or providing care. It took staff approximately ''10 -15 minutes to answer (Resident #7's) the call light'', although all four staff were not sure how long Resident #6 had been in Resident #7's room. Per review of the census, Eighteen out of twenty-three residents on this unit need at least one person assist and several residents need 2 person Hoyer lift assistance. Per interview on 11/05/13 at 11:55 AM the District Clinical Director stated ''we're working on it...trying to hire and to get the aides we need...maybe we need to do something different during those periods during the highest needs''. 2. Per record review, Resident #5 had a history of [REDACTED]. The resident utilized a wheelchair for mobility. On the morning of 10/23/13, Resident #5 was sitting in their room in a wheelchair. At approximately 10:40 AM, a housekeeper entered the room of the resident to clean. The housekeeper stated that the resident was not very responsive when greeted, and appeared to be trying to stand up from the wheelchair. The housekeeper left the room and found a nurse nearby to relay the concern that the resident was trying to get up. Per interview with the housekeeper, s/he stated that the nurse told them to ring the call light so the LNAs would respond. The housekeeper then told the other nurse on the unit about Resident #5 attempting to stand. This nurse also told the housekeeper to put on the call light to alert the LNAs. When the housekeeper returned to the room to mop the floor, Resident #5 was more alert, and agreed to stay in the wheelchair while the floor was drying. A second housekeeper was delivering clean laundry to the rooms at approximately 10:50 AM, and went to the door of Resident #5's room. S/he observed the resident was standing in front of their wheelchair. The housekeeper then looked out in the hall to find a staff person, and saw no one was around. When the housekeeper looked back in the room, s/he witnessed Resident #5 fall forward to the floor. The resident sustained [REDACTED]. After diagnostic tests showed no apparent head injury, the resident was sent back to the facility, however did pass away the following morning at the facility. On 11/6/13, the LNAs working on the day of the fall were each interviewed. There were four LNAs working on that unit on 10/23/13. At the time Resident #5 fell , two of the LNAs were out on a break, and the remaining two LNAs were together assisting a resident who required a two person transfer. The nurses on the unit passing medications did not respond to the concerns of the first housekeeper, both telling him/her to activate the call light for the LNAs, although there was no LNAs available at that time. Per interview on 11/6/13 at 3:55 PM, the Administrator confirmed that the usual staffing for that unit was 5 LNAs on the day shift, and that there were only 4 scheduled the day of 10/23/13, and that only one of the LNAs at a time should have been out on a lunch break to assure adequate monitoring of residents. The Administrator also stated that the housekeeping staff needs to be supported by the nursing staff when they express a concern about a resident, and that prompt response from the staff who were alerted of the situation may have avoided the resident's fall.

Based on record review and staff interview, the facility failed to ensure that services provided or arranged by the facility meet professional standards of quality regarding actions and precautions taken when a resident with a head injury from a fall was attended to by staff, for 1 of 7 resident reviewed. (Resident #1) The findings include: 1. Per review of the medical record for Resident #1, the record indicates that Resident #1 was readmitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Per the facility internal investigation dated [DATE], the investigation indicates that Resident #1 was in his/her room and was being transferred from his/her bed to a shower chair, utilizing the assistance of two Licensed Nursing Assistants (LNA's) and a mechanical lift (Hoyer). The investigation indicates that the LNA's used the Hoyer lift (mechanical lift) and had "completed a successful transfer to the shower chair" and "without warning and to their complete surprise, (Resident #1) fell backwards in the shower chair hitting the floor." The investigation also indicates that Resident #1 was bleeding from the head while laying on the floor and verbally indicated to the LNA's and LPN that his/her "head hurt". The internal investigation indicates that the Licensed Practical Nurse (LPN) instructed the LNA's to move Resident #1 from the floor utilizing a Hoyer lift and place Resident #1 back to bed so the LPN could take vital signs and check to resident. There was no evidence that a qualified professional properly assessed the resident prior to the resident being moved, and there was no evidence that staff took measures to stabilize the resident's neck/spine during the transfer. The internal investigation indicated that Resident #1 was hospitalized on [DATE] for a subdural hematoma (bleeding in the brain) and a T 11 fracture (spinal fracture). The hospital documentation indicated that the subdural hematoma and T11 fracture were a result of the fall. Per interview with the LPN on [DATE], he/she confirmed that Resident #1 had fallen backward in the shower chair after being Hoyer lifted from the bed to the shower chair. The LPN confirmed that he/she observed Resident #1 on the floor on his/her back with head on floor. The LPN stated that the LNA had part of the residents head in his/her hand and the other part of the head was on the floor. The LPN confirmed that the resident was bleeding from a laceration on the back of the head and was verbalizing that his/her head hurt. The LPN confirmed that he/she instructed the aides to hoyer the resident from the floor and place back in bed and that once in bed, the LPN assessed the resident for injuries. The LPN stated that after Resident #1 was placed back to bed, when the head of the bed was raised the resident verbalized pain in his/her back and the LPN lowered the residents head back down. The LPN indicated that he/she did not know that if a person who has fallen and is complaining of head pain and bleeding from the head that the standard of practice is to not move the resident to avoid further injury and pain to the resident. Per review of the facility policy/procedure titled "Head Injury" and dated [DATE], the policy indicates that the nurse is to "look for obvious signs of injury, such as lacerations, bleeding, ecchymosis and depressed areas of head and do not move the resident." Review of the facility policy and procedure titled Care of a Patient with Possible Injury, it indicates to "call for assistance and do not move patient." "Do an initial assessment to check for life threatening injuries, e.g., bleeding, fractures and neck injuries, if there is a question of hip, or spinal fracture, do not move patient. Stabilize only." *Reference: Adult First Aid/CPR/AED Ready Reference. "Head, Neck, or Spinal Injuries" http://www.redcross.org. Accessed [DATE].

Based regulatory violations found at the Immediate Jeopardy level at F281 and F323, the facility is not Administered in a manner that enables it to use its resources effectively to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Findings include: 1. The Administrator failed to assure that services provided or arranged by the facility meet professional standards of quality regarding actions and precautions taken when a resident with a head injury as a result of a fall was attended to by staff. Refer to F281. 2. The Administrator failed to assure that the environment was as free of accident hazards as is possible regarding the use of mechanical lifts and transfer techniques used by staff, and that each resident receives adequate supervision and assistance devices to prevent accidents. Refer to F323.

Based on observation, staff interview and record review the facility failed to ensure that the environment for 5 of 7 residents identified (#1, #2, #3, #5 and #8) was as free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent accidents. The findings include: 1. Per review of the medical record for Resident #1, the record indicates that Resident #1 was readmitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Per review of the facility internal investigation dated [DATE], the investigation indicates that Resident #1 was in his/her room and was being transferred from his/her bed to a shower chair, utilizing the assistance of two Licensed Nursing Assistants (LNA's) and a mechanical lift (Hoyer). The investigation indicates that the LNA's used the hoyer lift and had "completed a successful transfer to the shower chair" and "without warning and to their complete surprise, (Resident #1) fell backwards hitting the floor." The internal investigation indicated that Resident #1 was hospitalized on [DATE] for a subdural hematoma (bleeding in the brain) and a T 11 fracture (spinal fracture). The hospital documentation indicated that the subdural hematoma and T11 fracture were a result of the fall. Review of the Nursing Admission Assessment completed on [DATE] indicates that Resident #1 "has bilateral impairment to both lower extremities." Review of the Comprehensive Assessment (MDS) dated on [DATE] and [DATE] indicates that Resident #1 was a total assist with transfers. The assessment dated [DATE] indicates that Resident #1 has "very limited mobility"( makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.) The assessment also indicates the Resident #1 is "chairfast" (ability to walk severely limited or nonexistent. Cannot bear weight and/or must be assisted into chair or wheelchair.) Per review of the physical therapy documentation starting on [DATE], it indicates that Resident #1 was receiving therapy services related to decreased functional ability. Per interview and demonstration of incident with 2 facility LNA's on [DATE], LNA #1 indicated that he/she was behind the shower chair, Resident #1 was hoyered into the shower chair and was sitting comfortably in the chair, the LNA #1 indicated that the hoyer was away from the chair and all of a sudden the chair with Resident #1 in it flipped backwards onto the LNA, and Resident #1 and the LNA landed on the floor with Resident #1 hitting his/her head on the floor and complaining of head pain. LNA #1 indicated that she was facing the resident but did not see how Resident #1's shower chair flipped over. LNA #1 demonstrated how the incident occurred. Per interview and demonstration on [DATE] with LNA #2, he/she indicated that Resident #1 was hoyered from the bed to the shower chair successfully, and that Resident #1 was sitting in the shower chair comfortably, not moving when suddenly Resident #1 flipped backwards in the chair hitting the floor and his/her head and was complaining of head pain. LNA #2 indicated in interview that he/she was looking at Resident #1 when the chair flipped backward and LNA #2 never saw any movement from Resident #1 in the chair. LNA #2 indicated also in interview that the Hoyer lift was moved completely away from the shower chair and did not cause the chair to flip. Per direct observation by the state surveyor on [DATE], the shower chair utilized for Resident #1 was observed along with several other bariatic shower chairs in the shower room on the unit. The state surveyor sat in the shower chairs and attempted to flip the wheelchair backwards by pushing feet against the wall and the floor. The state surveyor was unable to make the shower chair tip backwards, despite having full mobility and strength. All four wheels remained on the floor at all times. Per observation on [DATE], at 2:45 PM, 2 facility LNA's were observed transferring another resident, Resident #8, from his/her bed to the resident's wheelchair utilizing a hoyer lift. LNA#1 identified his/her self as and LNA Coordinator and that his/her responsibilities included training new LNA staff. Residen #8t was observed being lifted in the hoyer lift over the bed with one LNA controlling the mechanical lift and the other LNA standing behind the wheelchair at the foot of the bed. At no time while the resident was suspended in the hoyer over the bed and moved to over the wheelchair was the resident observed to be being physically secured by the LNA. It was observed that once Residen #8t was suspended over the wheelchair, the LNA Coordinator tipped the standard wheelchair backwards holding the left handle with one hand and the LNA Coordinator grabbed the back of the sling that held the resident and pulled the sling backward and guided the resident as the hoyer lowered that resident into the chair that was tipped backward by the LNA. The LNA Coordinator was observed tipping the wheelchair backwards with one hand the entire time the resident was being lowered into the chair. The LNA Coordinator did not place the wheelchair on all four wheels and the wheelchair remained tipped and held by one hand by the LNA Coordinator until the resident was in the wheelchair and the hoyer pad disconnected from the hoyer and the hoyer moved away from the resident wheelchair by LNA #2. The LNA Coordinator indicated that he/she utilizes this practice "all the time" to ensure that the resident is properly positioned in the wheelchair. The LNA Coordinator indicated that he/she instructs the new LNA's to perform hoyer transfers in this manner, by tipping chairs back during transfers. Per interview with a facility employee on [DATE], he/she indicated that on [DATE] he/she had observed LNA #1 and LNA #2 doing the transfer of Resident #1 with the hoyer. The facility employee indicated that he/she observed the LNA's to have the shower chair tipped backwards during the transfer that resulted in injury and the LNA that was behind Resident #1 in the shower chair had the chair tipped and leaning against his/her body and the LNA did not have his/her hands placed on the shower chair at all. The facility employee indicated that just after the employee left the room he/she heard thru the open door a crash and yells for help. The facility employee indicated when he/she returned to the room, Resident #1 was on the floor in the shower chair on top of the LNA and indicating that his/her head hurt. Per review of the facility policy and procedure titled Mechanical Lift, dated [DATE] indicates that during the mechanical transfer of a resident "one staff member is to guide the patient and one staff member is to maneuver the lift." Per interview with the facility Administrator on [DATE], he/she confirmed that in his/her investigation of the [DATE] incident with Resident #1, the Administrator asked LNA #1 and #2 specifically if "they had tipped the wheelchair back for better positioning". The Administrator confirmed that question was asked specifically because the Administrator was a licensed therapist and has seen staff utilize this during transfers in her career. The facility investigation was deemed inconclusive and there was no evidence the facility discovered the unsafe practice of tipping back chairs described above, from the period of [DATE] to when the facility was alerted by the state surveyors on [DATE]. There was no evidence that facility staff included observations of actual transfers using the hoyer lift during their investigation of the [DATE] incident. Due to the inability of the facility to identify the potential root cause of the [DATE] incident, no corrective action was taken until at least [DATE], when the facility was informed of the Immediate Jeopardy determination. 2. Per review of the medical record for Resident #1 on [DATE], the record indicated that on [DATE], Resident #1 was being hoyered into a wheelchair. While being lowered into the chair, the top of the hoyer bar swung and connected with residents forehead. Per review of the Physicians Progress note dated [DATE], Resident #1 wanted to be seen because Resident #1 had been hit by a hoyer in his/her right eye two days prior and Resident #1 was indicating he/she had blurry vision and since he/she was hit with the hoyer it has been worse. The physician progress notes [REDACTED]. Per consultant report dated [DATE], Resident #1 was seen by Ophthalmology and diagnosed with [REDACTED]. Per review of the facility policy titled Accidents and Supervision to Prevent Accidents dated [DATE], the policy indicates that the facility will "investigate accidents and develop a plan of action to prevent the accident from recurring." Per interview with the facility Administrator, he/she confirmed that no investigation had been done to identify the cause of incident and potential interventions to help prevent reoccurrence. Per interview with the Unit Manager on [DATE], he/she reviewed the medical record and the comprehensive care plan and was unable to identify any interventions put into place to ensure that Resident #1 would not be injured again after the [DATE] incident of being hit in the eye by the hoyer. 3. Per record review on [DATE], Resident #2 on [DATE] the incident note indicates that Resident #2 "had a bruise of unknown origin discovered on Resident #2's right outer eye, purple in color measuring 7 cm (centimeters) long and 2 cm wide." Per review of the facility internal investigations there was no evidence that this documented incident on [DATE] of a bruise of unknown origin was investigated and a cause of the bruising of the right eye was determined. Per review of the medical record, Resident #2 had [DIAGNOSES REDACTED]. Per review of the medical record it indicates that Resident #2 is a 2 person assist with activities of daily living and uses 2 persons for transfers. Per review of the facility policy titled Accidents and Supervision to Prevent Accidents dated [DATE], the policy indicates that the facility will "investigate accidents and develop a plan of action to prevent the accident from recurring." Per interview with the facility Administrator and Director of Nursing, they confirmed that no internal investigation had been completed to determine that cause of the bruise of unknown origin identified on Resident #2 on [DATE] and development of interventions to prevent reoccurrence. 4. Per review of the medical record on [DATE], Resident #5 has [DIAGNOSES REDACTED]. Per review of the medical record, Resident #5 had numerous falls. Review of the Comprehensive Assessment it indicates that Resident #5 has had falls and the comprehensive care plan identifies Resident #5 at "high risk for falls". Per review on [DATE] Resident #5 was found on the floor after sliding out of wheelchair. On [DATE], Resident #5 again was found on the floor and again on [DATE] Resident #5 was found on the floor. Review of the records indicate that on [DATE] the facility asked therapy to evaluate the resident for positioning needs. The documentation indicates that resident refused any interventions by the facility to prevent reoccurrence. Per interview with the Unit Manager, he/she reviewed the progress notes, therapy notes and comprehensive care plan and was unable to provide evidence that the falls on ,[DATE] and ,[DATE] were reviewed and interventions placed to prevent reoccurrence of falls. 5. Per review of the medical record for Resident #3, on [DATE] at 1430, Resident #3 was found in his/her room, laying on the floor on his/her back in the doorway. Resident #3 was unresponsive, no response to sternal rub, extremities were flaccid, blood pressure was ,[DATE], pulse was 69, respirations were 18, resident was sent to ER. Per review of the emergency room record on [DATE], Resident #3 was pronounced dead upon arrival. Per review of the facility's internal investigations there was no evidence that the facility investigated the possible cause for the fall. Per review of the facilities policy and procedure titled "Falls Management" it indicates that falls are to be investigated for the cause of the event immediately after emergency care has been given and the patient's condition stabilized. Per review of the facility policy and procedure titled "Accidents and Supervision to Prevent Accidents, the facility is to investigate all accidents and develop a plan of action to prevent the accident from reoccurring." Per interview with the Director of Nursing he/she was unable to provide an internal investigation regarding the fall on [DATE] of Resident #3, where resident expired after being transported status [REDACTED]. Per interview with the Intake Department for the Division of Licensing and Protection there is no record that and investigation was conducted concerning possible cause of the [DATE] fall that proceeded Resident's #3 death on [DATE].

Based on record review, observation and staff interview the facility failed to ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individuals clinical condition demonstrates that they were unavoidable and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sore from developing for 3 of 3 resident's reviewed (#1, #2,and #3) identified. The findings include: 1. Per record review on conducted on 7/17/13, the medical record for Resident #1 indicated that Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Per review of the medical record, the physician summary dated 6/20/13 by the referring physician indicated that Resident #1 had history of 2 healed stage 3 pressure areas on both right and left outer ankle and currently had no open skin areas. Per review of the progress notes dated 6/21/13, the notes indicated on admission Resident #1 skin was intact with no open areas. The progress notes dated 6/24/13 indicate no areas of irritation on the coccyx or bilateral buttocks. Per review of the progress notes dated 6/25/13 small area on bilateral ankles, heels/ankles elevated off bed with mat per OT orders to relieve pressure area sites. Per review of the progress note dated 6/29/13 left outer ankle measures .5 cm x .8 cm, surrounding area is blanchable pink, area on right ankle measures .9 cm x .9 cm surrounding area is blanchable pink. Per review of the progress notes dated 7/2/13 weekly pressure area report indicated that Resident #1 has no new onset pressure areas, there is an "unstageable" area on the right ankle measuring 0.8 cm x 0.6 cm. Per review of the skin report dated 7/2/13 indicates blister located on the right rear knee area measured 11 cm x 7 cm. Per skin report dated 7/5/13 skin report indicates area were blisters were is now open and area measures 5 cm in diameter. Per record dated 7/6/13 the right front knee has cluster area measuring 15 cm x 11 cm, large area lateral back knee measuring 5 cm x 3 cm, all areas open and draining. Per review of the pressure report dated 7/8/13 the report indicates a right elbow new onset pressure area measuring 11 cm x 1 cm x 1 cm, a new onset stage 2 coccyx pressure area measuring 1 cm x 4-16 sq cm with noted undermining of area, and a new onset right buttock suspected deep tissue injury 2 cm x 1 cm. Review of the progress notes indicated that there was no documentation that indicated that the primary physician was notified of facility acquired pressure areas identified by staff on 7/8/13 on the coccyx or the right buttock. There was no documentation that orders were obtained for treatment of [REDACTED]. Per review of the daily monitoring/pressure ulcer sheets they indicated that only the right outer ankle and right outer heel were being monitored and the sheets noted that the right outer heel was monitored 5 days out of a possible 23 days and the right outer ankle was monitored 6 times since the area was noted on 6/24/13. There was no monitoring noted in the documentation for the elbows, coccyx or buttock areas. Per review of the comprehensive care plan titled Actual Alteration in skin integrity (non pressure related) r/t fluid filled blisters initiated 7/2/13 indicates staff is to keep heels off loaded when in bed, positioning devices under knees/between knees, and maintain pressure redistribution to wheelchair. The care plan titled "Actual alteration in skin integrity (Pressure Ulcer) indicates that staff is to complete the daily monitoring pressure ulcer report, turn and position as needed. Per review of the ADL profile sheet there was no indication that Resident #1 had any needed preventative devices to reduce pressure, or that Resident #1 was to be turned and positioned as needed. Per review of the Licensed Nurses Aides daily documentation sheets, under the section of protection devices there was no documentation that the any pressure reducing devices for heels or elbows were utilized. Per review of the facility policy and procedure "Prevention and treatment of [REDACTED]." 2. Per record review Resident #2 was readmitted to the facility after hospitalization related to a fall. Per review of the Admission examination form dated 5/20/13 and signed by the referring physician Resident #2 did not have any skin integrity issues upon admission. Per review of the comprehensive assessment ((MDS) dated [DATE] Resident #2 was at risk for pressure areas. Per review of the progress notes dated 6/3/12, the notes indicate Resident #2 has a sheer area on the left buttock and deep tissue pressure injury to right heel. Per review of the Licensed Nurses Aides daily documentation sheets , under the section of protection devices there was no documentation that the any pressure reducing devices for heels or elbows was utilized. Per review of the Daily monitoring/pressure ulcer sheets for June and July there were 17 days in June that there was no documentation that Resident #2's heels were monitored. Per review of the daily monitoring/pressure ulcer sheet 13 days documented that the pressure area either remained the same or deteriorated. Per review of the facility policy and procedure titled Prevention and treatment of [REDACTED]. Review of the medical record indicates that there was no documented evidence the attending physician was notified that Resident #2's wound was not healing and had deteriorated on several occasions. 3. Per record review of Resident #3, he/she was admitted to the facility on [DATE] and per the physicians admission examination dated 5/15/13, Resident #3 had no skin integrity issues upon admission. Per review of the progress notes 5/15/13, no pressure areas seen. A 5/22/13 assessment indicates resident is at risk for skin integrity issues and pressure ulcers. The progress notes indicate that on 6/13/13 Resident #3 has a new area, intact blister on back of right heel. The progress notes dated 6/14/13 indicate that the right heel blister is unstageable, measuring 2.4 cm x 1 cm. Per interview on 7/18/13 with the LNA Coordinator, he/she confirmed that the ADL profile sheet was utilized by the LNA's to know what specific care is to be provided to the resident. After review by the LNA Coordinator of the ADL profile sheet he/she confirmed that the ADL profile sheet did not reflect that any pressure relieving devices needed to be were utilized, did not reflect any positioning requirements were utilized, and did not reflect the need to turn and position Resident #1. Per interview with the LNA Coordinator on 7/18/13 he/she reviewed the LNA daily documentation sheets for Resident #1, #2 and #3 and confirmed that the LNA's only documented (via code) that skin moisturizers/lotions were used ion the resident, no devices were documented to have been used on the daily documentation sheet. Per interview with the ADNS and Unit Manager on 7/18/13, they reviewed the documentation and confirmed that Resident #1, #2 and #3 were admitted to the facility without pressure areas and developed pressure areas during their admissions and were avoidable. The UM and ADNS also confirmed that after review of the documentation that the primary physician had not been notified of the coccyx and buttock pressure areas for Resident #1 and that there was no treatment obtained for these pressure areas. Per interview the ADNS indicated that the blisters on the right knee of Resident #1 were pressure related to the utilization of a hoyer pad and the seat cushion of Resident #1's wheelchair created pressure on the back of the knee.

Based upon closed record review and interview, the facility failed to provide necessary treatment and services to promote healing, prevent infection and prevent a Stage 2 pressure ulcer (partial thickness skin loss involving the epidermis, dermis or both) from progressing to a Stage 4 pressure ulcer (full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures) for Resident #1. Findings include: Per record review on [DATE], and confirmed during interview at 1:27 PM with the DNS (Director of Nursing Services), the Weekly Skin Assessment for Resident #1 documents that on [DATE], Resident #1 had a Stage 2 pressure ulcer present upon admission on the sacrum and coccyx which measured 5 cm (centimeters) x 2.7 cm. On [DATE], the Stage 2 pressure ulcer measured 5 cm x 3 cm. On [DATE], the pressure ulcer measured 10 cm by 4 cm and was documented as a Stage 4. Per record review on [DATE], the Discharge Planning Notes dated [DATE] documents that Resident #1 was admitted to Starr Farm on [DATE] from FAHC. Prior to hospitalization , Resident #1 was living at home with his/her spouse. The resident was ambulating and needed help with Activities of Daily Living and was no longer able to complete household chores or errands. Resident #1's goals were to return home when physically able. Per staff interview on [DATE] 10:38 AM, the Social Worker confirmed the admission plan for Resident #1 was for rehabilitative Physical Therapy and Occupational Therapy and the plan was for Resident #1 to return home. Per record review on [DATE], and confirmed during interview with the Registered Dietician at 4:05 PM, the admission "Medical Nutritional Therapy Assessment" dated [DATE] did not include a nutritional assessment that included the presence of the Stage 2 pressure ulcer which was present upon admission. Per record review on [DATE], and confirmed during interview with the Registered Dietician at 3:55 PM, the MDS 3.0, Review of Indicators for Nutritional Status dated [DATE] for Resident #1 states, the "Resident's diet provides adequate energy and protein, however resident's diet is poor" and does not include documentation that Resident #1 had a stage 2 pressure ulcer present upon admission. Per record review on [DATE], and confirmed during an interview with the Unit Manager at 3:21 PM, the Alteration in Nutritional Status care plan does not include a nutritional assessment related to promoting wound healing for Resident #1 who was admitted with a Stage 2 pressure ulcer present upon admission [DATE] and progressed to a Stage 4 pressure ulcer on [DATE]. Per staff interview on [DATE] 1:18 PM, the Director of Nursing (DNS) stated the facility does not have a specific policy for residents admitted with a pressure ulcer and that nursing conducts an assessment per the facility's Initial Resident Assessment Policy and uses the Pressure Ulcer Risk Assessment Tool. Per record review on [DATE], the Pressure Ulcer Risk Assessment Tool dated [DATE] scores Resident #1 as a "14" (not high risk). Per notation on the the scoring sheet, a total score of 12 or less represents high risk for developing pressure ulcers. The assessment tool dated [DATE] scores the resident as a "17" (not high risk) and the [DATE] assessment tool (completed the same day the resident's pressure ulcer was documented as progressing to a Stage 4) also scores the resident as a "17". Per interview with the DNS on [DATE] at 1:27 PM, the DNS confirmed that the Pressure Ulcer Risk Assessment Tool scores are incongruent with the Weekly Pressure Ulcer Condition Report. Per staff interview on [DATE] at 4:05 PM, the Registered Dietician stated the facility typically conducts a "Weight and Skin meeting" weekly on all residents with a Stage 2 or greater pressure ulcer. The Registered Dietician stated the "Weight and Skin" meeting includes all the unit managers, registered dietician and Director of Nursing Services, and they call in rehab staff as needed. Per staff interview on [DATE] at 4:14 PM, the Unit Manager confirmed that a weekly weight and skin meeting did not occur for Resident #1. On [DATE] at 4:05 PM, the Registered Dietician verified there is no documentation in Resident #1's record that the weekly "Weight and Skin" meeting occurred. Per record review on [DATE], the Physician's Progress Notes for Resident #1 dated [DATE], labeled "Acute Visit", documents a large sacral ulcer with necrotic tissue at center and [DIAGNOSES REDACTED] (redness) at edges, and states Resident #1 is very ill with a history of [MEDICAL CONDITION] (congestive obstructive [MEDICAL CONDITION] disease), now with worsening respiratory status, large infected sacral ulcer, pneumonia, [MEDICAL CONDITION], and [MEDICAL CONDITION]. Per record review on [DATE], a Physician order [REDACTED]. The facility Resident Transfer Form states: "reason for transfer: positive blood culture and increased temp". Per record review on [DATE], the Resident Progress Note dated [DATE] states " Family came in to discuss next steps. Transferred at 1515 (3:15 PM) to FAHC with family to meet him at ED. The RN viewed decubitus ulcer today when dressing change was done. Extremely foul odor. Wound large, necrotic, with yellow and red borders. Has an active blood infection". Per staff interview on [DATE] at 5:00 PM, the Administrator stated s/he was aware that Resident #1 died after being transferred to FAHC from Starr Farm. Also see F325 and F279.

Based upon interview and record review, the facility failed to ensure acceptable parameters of nutritional status and protein levels to promote wound healing for Resident #1 who was admitted with a pressure ulcer. Findings include: Per record review on [DATE], and confirmed during interview with the DNS at 1:27 PM, the Weekly Skin Assessment for Resident #1 documents that on [DATE], Resident #1 had a Stage 2 pressure ulcer (partial thickness skin loss involving the epidermis, dermis or both) present upon admission on the sacrum and coccyx which measured 5 cm x 2.7 cm. On [DATE] the Stage 2 pressure ulcer measured 5 cm x 3 cm. On [DATE] the pressure ulcer measured 10 cm by 4 cm and was documented as a Stage 4 (full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures). Per record review on [DATE], and confirmed during interview with the Registered Dietician at 4:05 PM, the admission "Medical Nutritional Therapy Assessment" dated [DATE] did not include a nutritional assessment that included the presence of a Stage 2 pressure ulcer, which was present upon admission. Per record review, Nutritional interventions to promote wound healing (increased protein, vitamin C, and zinc) were not ordered until [DATE], after the pressure ulcer had progressed to a Stage 4. Per record review on [DATE], and confirmed during interview with the Unit Manager at 3:21 PM, the Alteration in Nutritional Status care plan does not include a nutritional assessment related to promoting wound healing for Resident #1 who was admitted with a Stage 2 pressure ulcer present upon admission [DATE] and progressed to a Stage 4 pressure ulcer on [DATE]. Per record review on [DATE], and confirmed during an interview with the Registered Dietician at 3:55 PM, the MDS 3.0, Review of Indicators for Nutritional Status dated [DATE] for Resident #1 states, the "Resident's diet provides adequate energy and protein, however resident's diet is poor", and does not include documentation that Resident #1 had a Stage 2 pressure ulcer present upon admission. Per staff interview on [DATE] at 4:05 PM, the Registered Dietician stated the facility typically conducts a "Weight and Skin meeting" weekly on all residents with a Stage 2 or greater pressure ulcer. The Registered Dietician stated the "Weight and Skin" meeting includes all the unit managers, registered dietician and Director of Nursing Services, and they call in rehab staff as needed. Per staff interview on [DATE] at 4:14 PM, the Unit Manager confirmed that a weekly weight and skin meeting did not occur for Resident #1. On [DATE] at 4:05 PM, the Registered Dietician verified there is no documentation in Resident #1's record that the weekly "Weight and Skin" meeting occurred. Per record review on [DATE], the Physician's Progress Notes for Resident #1 dated [DATE], labeled "Acute Visit", documents a large sacral ulcer with necrotic tissue at center and [DIAGNOSES REDACTED] (redness) at edges, and states Resident #1 is very ill with a history of [MEDICAL CONDITION] (congestive obstructive [MEDICAL CONDITION] disease), now with worsening respiratory status, large infected sacral ulcer, pneumonia, [MEDICAL CONDITION], and [MEDICAL CONDITION]. Per record review on [DATE], a Physician order [REDACTED]. The facility Resident Transfer Form states: "reason for transfer: positive blood culture and increased temp". Per record review on [DATE], the Resident Progress Note dated [DATE] states " Family came in to discuss next steps. Transferred at 1515 (3:15 PM) to FAHC with family to meet him at ED. The RN viewed decubitus ulcer today when dressing change was done. Extremely foul odor. Wound large, necrotic, with yellow and red borders. Has an active blood infection". Per staff interview on [DATE] at 5:00 PM, the Administrator stated s/he was aware that Resident #1 died after being transferred to FAHC from Starr Farm. Also see F279 and F314