Every finding on record at Garden Terrace Healthcare Center of Houston

Based on observation, interview and record review the facility failed to ensure each resident's bedside was adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area for 2 of 5 residents (Residents #2 and #3) reviewed for call lights. The facility failed to ensure Resident #2 and Resident #3's call lights were within reach. This failure could place residents at risk of not being able to request and receive prompt medical care and result in injury and harm. Findings include: 1. Record review of Resident #2's face sheet, dated 07/21/2026, reflected she was initially admitted to the facility on [DATE] and last re-admitted on [DATE]. She had medical diagnoses which included muscle weakness, Alzheimer's disease (a progressive brain disease that slowly destroys memory, thinking skills and the ability to carry out simple daily tasks), dementia (declining brain function related to thinking and judgement that is severe enough to impact daily life), and primary osteoarthritis (inflammation of joints which can be painful). Record review of Resident #2's Quarterly MDS, dated [DATE], reflected she had a BIMS score of 00, which indicated severe cognitive impairment related to thinking and memory. Resident #2 required clean-up assistance with eating, touching assistance with personal hygiene, moderate assistance with oral hygiene, and total assistance with showering, toileting and footwear. Resident #4 required moderate to maximal assistance with bed mobility, which included getting in and out of bed and sitting to standing and transferring to the toilet. Record review of Resident #2's care plan, last captured 07/21/2026, reflected she required ADL assistance as needed to attain the highest level of function r/t Dx: muscle weakness and difficulty walking, last revised 06/10/2026 with interventions which included 1-person assist with transfer and maximum assist with toileting and showering. Resident #2 needed supervision with eating and oral care. 2. Record review of Resident #3's face sheet, dated 07/21/2026, reflected she was initially admitted to the facility on [DATE] and last re-admitted [DATE]. Her medical diagnoses included anxiety (prolonged periods of worry and restlessness), unspecified protein-calorie malnutrition, type 2 diabetes mellitus (high blood sugar), muscle weakness, dehydration (dated 05/25/2025), neuromuscular dysfunction of bladder (injury or disease disrupts the electrical signals between the nervous system and bladder function. This condition can lead to symptoms such as urinary incontinence, difficulty in fully emptying the bladder, or an overactive bladder) and repeated falls and lack of coordination. Record review of Resident #3's Comprehensive MDS, dated [DATE], reflected she had a BIMS score of 00, which indicated severe cognitive impairment related to thinking and memory. Resident #2 required maximal to total assistance with oral and personal hygiene and dressing and was totally dependent on staff for toileting and showering. Resident #4 required total assistance with bed mobility, which included getting in and out of bed and transferring to the toilet. Record review of Resident #3's care plan, last captured 07/21/2026, she required ADL assistance as needed to maintain level of function, dated last revised 06/10/2026, with interventions which included assist with mobility and ADLs as needed. Observation and attempted interview in Resident #2's room on 07/21/2026 at 10:02 a.m., Resident #2 was heard yelling in her room and was observed lying in bed. Resident #2's call light wire was observed hanging off the quarter bed rails with the call light button facing toward the back and out of Resident #2's reach. CNA T came into the room and after state surveyor intervention took the call light and clipped it onto Resident #2's blanket, within reach. CNA N came into the room to assist with repositioning after Resident #2 requested to sit up and Resident #2 repeatedly asked him to get the brown package of her body and pointed at her blanket. Resident #2 was unable to answer questions regarding other topics. CNA T said CNA N was new, and he probably forgot to place it within the resident's reach. CNA T said call lights were used for residents to call staff in emergencies and if it was not within reach residents could have a fall and not be able to get in touch with staff and even thought Resident #2 and Resident #3 had never been able to use them, staff needed to ensure call lights were within reach. Observation and interview in Resident #3's room on 07/21/2026 at 10:15 a.m., Resident #3 was eating in bed and said hello but was unable to answer other questions and appeared confused. Resident #3 had her call light hanging from her bed rail close to the floor out of reach. The SW was called into the room and said she saw the call light was not within reach. CNA C came into the room to adjust the bed and said the call light should have been in reach The SW clipped the call light close to Resident #3's hand and said the call light was used to get help and if it was not within Resident #3 or any residents' reach, they would not get help when needed. The SW said anyone could put the call light within reach if they noticed it. Interview with CNA C on 07/21/2026 at 10:36 a.m., she said she talked to CNA N regarding Resident #2's call lights and re-educated him on ensuring call lights were in reach. CNA C said CNA N were new and he told her he knew call lights were supposed to be kept near residents, but he forgot to do it that morning. CNA C said everyone was responsible for checking to see call lights were within residents' reach even if residents, like Resident #2 and Resident # 3, did not use call lights because they were cognitively unable to. Interview with CNA N on 07/21/2026 at 10:46 a.m., CNA N said call lights were so residents could call for help and if they were not within reach residents would have no way to call for help or they could have a fall. CNA N received in-services on call lights since starting last week. CNA N said Resident #2 did not really use the call light, but it should be within reach. Interview with the DON on 07/21/2026 at 3:17 p.m., she said neither Resident #2 nor Resident #3 used the call light, but they still needed to have the call lights nearby. If call lights were not within reach, the DON said it would take longer to get help. Interview with the Administrator on 07/21/2026 at 3:46 p.m., she said call lights should be placed near residents and they could be injured or fall or need something and be unable to communicate with staff. Record review of the facility's policy titled Resident Call System, last reviewed 12/23/2025, read in part, .5. The call light should be positioned within reach of the resident.a. The call system must be accessible to residents while in their bed or other sleeping accommodations within the resident's room.

Based on observation, interview and record review the facility failed to ensure the services provided or arranged by the facility, as outlined by the comprehensive care plan met professional standards of quality for 1 of 5 residents (Resident #4) reviewed for services provided. The facility failed to ensure the Dietician recommended Med Pass (a nutritional supplement to prevent weight loss) on 07/15/2026 for Resident #4 was put into place. The recommendation was not implemented until 07/21/2026. This failure could place residents at risk of delayed treatment and a decline in weight and physical health. Findings include:Record review of Resident #4's face sheet, captured 07/21/2026, reflected a [AGE] year-old female who was originally admitted to the facility on [DATE]. Resident #4 had medical diagnoses which included chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe, primarily caused by long-term exposure to irritants like cigarette smoke and air pollution), unspecified severe protein-calorie malnutrition, hyperlipidemia (high fat in blood), polyneuropathy (nerve damage in limbs), muscle weakness, depression (prolonged periods of sadness and feelings of worthlessness) and cognitive communication deficit. Record review of Resident #4's comprehensive MDS, dated [DATE], reflected she had a BIMS score of 12, which indicated moderate cognitive impairment related to thinking and memory. Resident #4 required touching assistance with eating and oral hygiene. She had active diagnoses of unspecified severe protein-calorie malnutrition. She was not documented with 5% weight loss or gain since she was admitted . Record review of Resident #4's nutritional assessment/nutritional data collection, signed by the Dietician on 07/15/2026, it documented Resident #4 was able to make her preferences known and required a mechanically altered diet with thin liquid consistency due to her GERD (a chronic condition where stomach acid flows back into the esophagus and causes heartburn and irritation of the esophageal lining and could further cause difficulty swallowing) and protein calorie malnutrition and COPD (a lung disease that makes it difficult to breathe, primarily caused by long-term exposure to things like cigarette smoke and air pollution) diagnoses. Resident #4 was documented as having depression that would affect nutritional status. Resident #4 had a 50% meal intake average percentage over a week with no snacks ordered, scheduled or recommended. Resident #4 was at risk of involuntary weight loss from poor intake and COPD. The Dietician wrote, Med Pass 120ml BID Goal: stable or increase weight, PO intake 75%+. RD to monitor and available as needed. Record review of Resident #4's total order summary, she had the following:-Regular diet, regular texture, thin consistency with a start date of 07/09/2026 which had been discontinued.-Regular diet, mechanical altered texture, thin consistency with a start date of 07/13/2026, active.-Med Pass Supplement two times a day for supplement, give 120 ml. Document % taken, with a start date of 07/21/2026, active. Record review of Resident #4's July MAR, last captured 07/21/2026 at 11:57 a.m., she did not have any nutritional supplements provided since admission. Record review of Resident #4's care plan, dated 07/21/2026, reflected she was care-planned for being at risk for poor nutrition r/t variable meal intakes, low BMI, dx of PCM, increased needs with COPD and poor dental status with interventions which included monitoring weights as tolerated and trying to obtain weekly weights and monitor s/s of difficulty chewing or swallowing and refer to SLP as needed. Observation and interview with Resident #4 on 07/21/2026 at 10:15 a.m., revealed there was ground meat in a sauce and scrambled eggs on her plate on top of the bedside table and most of the meal was uneaten. Resident #4 said she could not eat the food because she did not like the texture. Resident #4 said the facility probably provided her with mash because they thought she did not have teeth, but she did. Resident #4 said she told everyone she did not like the food and did not remember the names of those she told. Interview with CNA C on 07/21/2026 at 10:36 a.m., she said she worked on Resident #4's floor and Resident #4 did not eat much. Resident #4 never told her she did not like the food. Interview and record review with the ST on 07/21/2026 at 12:27 p.m., she said another ST evaluated Resident #4 on 07/13/2026 and they placed her on a mechanical soft diet due to complaints of teeth pain. The ST also recalled hearing Resident #4's family member telling staff Resident #4 was on a soft diet at home. Interview with the Dietician on 07/21/2026 at 12:07 p.m., she said she sent her recommendations for residents to the DON either the same day or a day later after she visited, which meant she saw Resident #4 on 07/15/2026 and sent the email no later than 07/16/2026. The Dietician said when the DON received the recommendations, she would print out the orders for the physician or NP to sign and then the DON would upload the order into resident records. The Dietician said she hoped it would not take a week for orders to go in and could see orders being placed two days after she made recommendations. The Dietician did not think there was harm to the residents since there was no guarantee Resident #4 would have taken the Med Pass and found the facility provided snacks to residents and they constantly monitored residents for weight loss. Interview, observation and record review with Resident #4 on 07/21/2026 at 12:35 p.m., she said she never received supplements or protein shakes since she arrived last week. Resident #4 said she liked the food she was eating when she first arrived and said she was eating most of it but then the facility placed her on soft foods which she did not enjoy and did not eat. Resident #4 said her teeth pain was tolerable, and she planned to wait until after discharge to see a dentist. Resident #4 said she wanted to have her food type re-evaluated to see if she could eat regular food, which she could not remember who she told. Interview with Resident #4's facility NP on 07/21/2026 at 1:45 p.m., the NP said the dietician would come once a week on Wednesday and she would send the recommendations one or two days later to the facility to put in a book and the NP or the physician would sign recommendations into orders before it went into the resident records. The NP said once it was signed, she thought the orders should be on Friday or Monday, by the latest. The NP said the facility could have reached out to an on-call physician for orders on the weekends as well. The NP said she thought 4-5 days would be considered a delay in orders. The NP said she saw Resident #4 on 07/17/2026 and there were no complaints about Resident #4 not eating then. The NP could not remember if she signed Resident #4's orders for Med Pass that day but that it would have been documented somewhere. The NP said she was not aware of the Dietician documenting Resident #4 was eating 35% of her meals in a two-week average. Interview with the DON on 07/21/2026 at 3:17 p.m., the DON said the Dietician sent the recommendations late at night and the DON would print them out the next day and put it into folders for the physicians to sign. The DON said she had a busy day on 07/20/2026 and printed them out first thing on 07/21/2026 for the physicians to sign and uploaded today (07/21/2026). The DON said Resident #4's order for Med Pass was signed on 07/17/2026 by a physician. The DON said she would think about assigning nurses to track the recommendations and orders to ensure they were entered in quicker. The DON said the potential harm to Resident #4 of not getting Med Pass timely was weight loss. Interview with the Administrator on 07/21/2026 at 3:46 p.m., she said orders should be entered in when they were signed. If Resident #4 did not have her orders for Med Pass given per doctor's orders, she could have weight loss, dehydration and that could affect her cognitive status. Record review of the facility's policy titled Physician Orders last reviewed 02/27/2025, it read in part, A physician must personally approve in writing a recommendation that an individual be admitted to a facility. A physician, physician assistance or nurse practitioner must provide orders for the resident's immediate care and ongoing care of the resident. The facility is obligated to follow and carry out the orders of the prescriber in accordance with all applicable state and federal guidelines.4. The receiving nurse or therapist immediately enters telephone or verbal orders into the clinical software.6. Physician orders including the follow.b. Medications and Treatments. C. Diet.8. Any orders written by a consulting physician must be reviewed and signed by the resident's attending physician. This may be done by telephone order.

Based on interview and record review the facility failed to maintain, in accordance with accepted professional standards and practices, medical records on each resident that were complete and accurately documented for 1 of 5 residents (Resident #68) reviewed for accurate records. 1. LVN A failed to document Resident #5's RP's conversation and concerns about Resident #5's health and reason for the RP's chest x-ray request for Resident #5 in the progress notes on 07/08/2026. 2. LVN A and LVN B failed to document communication between the facility and the x-ray company. These failures could place residents at risk of delayed treatment due to their condition not being tracked and monitored by staff. Findings include: Record review of Resident #5's face sheet, dated 07/21/2026, reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and discharged [DATE]. His medical diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis and weakness following stroke affecting the right side), dysphagia following cerebral infarction (difficulty swallowing following stroke), urinary tract infection (infection of the urinary tract, which could cause pain, bleeding and inflammation of the area) (onset date 05/06/2026) and generalized muscle weakness. Record review of Resident #5's care plan, closed on 07/15/2026, reflected he had the following focus area:-impaired cognitive ability/impaired thought processes r/t impaired decision making with interventions including communicate with resident/family/caregivers regarding resident capabilities and needs, initiated on 04/10/2026. Record review of Resident#5's comprehensive MDS, dated [DATE], reflected he had a BIMS score of 12, which indicated moderate cognitive impairment related to memory and thinking. Resident #5 required touching assistance with eating and oral hygiene, moderate assistance with personal hygiene and maximal assistance with dressing and footwear. Record review of Resident #5's skilled nursing documentation, dated 07/08/2026 at 8:46 p.m., reflected his vitals were within normal limits and had normal findings with his cardiovascular and pulmonary systems. Record review of Resident #5's discharge care plan, dated 07/09/2026, reflected he did not have a BIMS completed. Resident #5 discharged with ADL assistance of clean-up assistance for eating, oral hygiene and moderate assistance with toileting, showering, dressing and personal hygiene. Interview with Resident #5's family member 07/21/2026 at 9:35 a.m., she said she asked LVN A to provide a chest x-ray for Resident #5 on 07/08/2026 in the evening but she did not. The family member said Resident #5 had a gathering that day and he appeared to have cold-like symptoms, so she wanted to confirm if Resident #5 had a virus or not through a chest x-ray. The family member said Resident #5 called her on 07/09/2026 in the morning. The RP was coughing and said no one came to treat him last night. The family member talked to LVN G and it seemed like LVN G was not given any information so that she could find the records of an x-ray. The family member said she was upset no one followed through with the x-ray and took Resident #5 out of the facility. The family member reported Resident #5's physician ordered an x-ray which came back as positive for an infection but the family member could not specify exactly what it was. Interview with LVN A on 07/21/2026 at 10:49 a.m., she said Resident #5's RP told her Resident #5 was coughing on 07/08/2026 around 7 p.m. to 8 p.m. When LVN A went to assess Resident #5, she saw he had congestion and a slight cough. LVN A offered a cough suppressant, but the RP did not want LVN A to administer it to Resident #5 and the RP asked for a chest x-ray. LVN A called in an order for a stat chest x-ray and the company said they would be there between 8 p.m. and 10 p.m. that day. LVN A verbally reported and showed the stat x-ray order to LVN B and told LVN B to follow up on it. LVN A found out later on an unknown date that the x-ray company never came that night. LVN A said she usually worked 6 a.m. to 2 p.m., but on 07/08/2026 she ended up working from 2 p.m. to 10 p.m. LVN A looked for the progress note of the conversation and reason for the stat x-ray order but was unable to find it. LVN A said the nurse providing care or having any communication was responsible for entering progress notes into a resident's record showed that care was provided and orders were placed. If resident records were not accurate and things were not documented as they happened, there could be miscommunication or not doing what you said you would. Interview with LVN B on 07/21/2026 at 11:14 a.m., she said she worked on 07/08/2026 during the night shift from 10 p.m. to 6 a.m. LVN B said she was not the nurse who created the x-ray order and she got the report from the previous nurse who said it was a x-ray and did not specify it was stat and she was unaware of the urgency. Later in the night, the x-ray company called and said they would be there in the morning, and she said okay because she assumed it was ordered as routine. When asked why she did not document the conversation, she repeatedly said she was not the one who called in the order and she did not call the x-ray company. LVN B said she told this to the oncoming nurse LVN D about the order. LVN B said if the order was not labelled or reported as stat, she would assume it was routine. LVN B said stat x-ray meant the company would come within four hours to do the x-ray. Interview with LVN G on 07/21/2026 at 2:01 p.m., she said she was an agency nurse who only worked that shift on 07/09/2026 in the morning. LVN G said when she got to the facility for her shift she was told by LVN D that Resident #5 had an x-ray ordered and the reason why the company did not come was because the order was entered as a routine and not a stat order and LVN G was told by LVN D to communicate with Resident #5 and his RP. LVN G said she was working for three hours by the time Resident #5's RP came and was upset and took Resident #5 out to see an outside physician. LVN G told her the company called and said they were on the way but the RP took Resident #5 and left. LVN G said the resident did not return to the facility after that. LVN G called the lab company and said they told her there were two orders in, one stat and one routine and both orders were placed the night before. LVN G said she observed Resident #5 with no symptoms and when she asked him if he wanted a PRN cough medication, he said no because he did not have a cough. LVN G said she remembered Resident #5 saying he did not want the x-ray and his RP wanted it. Interview with the DON on 07/21/2026 at 3:17 p.m., she said LVN A called her the night of 07/08/2026 about Resident #5's x-ray. The DON said LVN A had already put in an order for a routine x-ray (meaning there was no urgent need to have it done immediately) and the DON told her to get a new order for a stat x-ray, where someone would come within a short timeframe. The DON said orders put into a resident's record would immediately be communicated and sent to the company. The DON said later that night the company called the facility to ask about the order and LVN B did not convey a sense of urgency because she did not know it was a stat order. LVN A told her Resident #5 did not seem to have a cough, but the DON wanted her to go ahead and get the x-ray. The DON said LVN A should have put in a note regarding conversations between Resident #5, his RP and LVN A because it was communication for the team to be aware. The DON did not know why LVN A did not document a note about the situation. Interview with the Administrator on 07/21/2026 at 3:46 p.m., she said the chest x-ray order was to appease Resident #5's RP but conversations between the facility, family and the x-ray company should have been documented. If it was not documented, it was not done. Interview with Resident #5 on 07/21/2026 at 4:00 p.m., he said he felt ill that night and was coughing and had a runny nose and talked to the RP and LVN A about it in-person and LVN A agreed to get a chest x-ray and antibiotics for him. Resident #5 said he was feeling worse the next day and called the RP to say he did not get anything and the RP took Resident #5 out of the facility to see his own physician. Resident #5 said he had an infection but could not specify what kind. Record review of the facility's policy titled Nursing Documentation, last reviewed 08/29/2025, it read in part, .Medical Records - The medical record shall reflect a resident's progress toward achieving their person-centered plan of care objective and goals and the improvement and maintenance of their clinical, functional, mental and psychosocial status. Staff must document a resident's medical and non-medical status when any positive or negative condition change occurs. The medical record must also reflect the resident's condition and the car and services provided across all disciplines to ensure information is available to facilitate communication among the interdisciplinary team. The medical record must contain an accurate representation of the actual experience of the resident and include enough information to provide a picture of the resident's progress, including his/her response to treatment and/or services, and changes in his/her condition, plan of care goals, objectives and/or interventions.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #5) reviewed for comprehensive care plans. 1. Resident #5's care plan was not followed when he was transferred from his wheelchair to his bed with one-person assist and without a gait belt present on 05/22/2026 when he was care-planned for a two-person transfer with a gait belt. This failure could lead to residents not having their individual medical and physical needs met and lead to a decline in health.Record review of Resident #5's face sheet dated 05/21/2026, reflected he was a [AGE] year-old male initially admitted on [DATE] with hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis and weakness following a stroke), difficulty in walking, generalized muscle weakness and bilateral primary osteoarthritis in hip (pain in bone and joints in both hips) and a urinary tract infection (onset date 05/06/2026). Record review of Resident #5's Comprehensive MDS dated [DATE], reflected he had a BIMS score of 12 indicating moderate cognitive impairment related to thinking and memory. Resident #5 was coded for a wheelchair and walker. Resident #5 was coded as totally dependent on staff for toileting and showering. Record review of Resident #5's care plan dated 05/21/2026, reflected he had the following care areas:-Resident #5 required ADL assistance and therapy services as needed to maintain or attain highest level of function with muscle weakness and difficulty in walking as of 04/04/2026 with interventions including max assist (helper provides more than half to most of the effort) with transfers and with gait belt and to assist with mobility and ADLs as needed.-Resident #5 had an actual fall with no injury r/t weakness and poor balance with interventions including two person assist for all transfers with an initiated date of 04/30/2026 Record review of Resident #5's Kardex (a simplified documentation system which has key information in a resident's care plan) dated 05/22/2026, reflected he required max assist with transfers with gait belt. Interview with Resident #5 on 05/21/2026 at 1:47p.m., he said a nurse was helping him transfer form his wheelchair to the bed one time and she could not hold him up anymore and asked him to sit down. Resident #5 denied hitting his head or being in pain or hurt during hat transfer. Resident #5 said it was a while ago and did not remember the exact date. Resident #5 said he did not hit his head but said his energy goes in and out because he had a history of stroke. Resident #5 said that this only happened one time. Observation and interview on 05/22/2026 at 11:06a.m., revealed CNA M pulled on Resident #5's right arm while getting him out of the wheelchair. CNA M assisted Resident #5 with her arm under his right arm. Resident #5 assisted on his left side by pushing up on the wheelchair. CNA M guided him to the bed primarily by holding onto Resident #5's right arm and sat him down, with Resident #5 assisting with his left arm. During the transfer, LVN G was observed holding on to the wheelchair and assisting with holding his pants up by the pant leg. LVN G was not observed assisting with the physical act of transferring Resident #5 from his wheelchair to the bed. There was a gait belt hanging on Resident #5's dresser door. When asked why CNA M did not use a gait belt during the initial transfer from the wheelchair to the bed, CNA M said that she did not see one in the room and if she did not use the belt she could have hurt herself and the resident. CNA M was not aware Resident #5 was a two-person assist and that she would only know if therapy told her. Interview with LVN G on 05/22/2026 at 11:23a.m., LVN G said that she had training on safe transfers and LVN G knew that CNA M should have used a gait belt while transferring Resident #5 because gait belts were used so residents could be safely transferred and that not using a belt could lead to resident and staff injuries. LVN G said she knew Resident #5 was a two-person assist for transfers. When asked why she did not assist CNA M, LVN G said she did grab his pants to pull Resident #5 to the chair and she held the wheelchair but that was it. When asked what could have happened to Resident #5 with her not helping throughout the entire transfer, LVN G said Resident #5 could have fallen and been injured. Interview with the ADON on 05/22/2026 at 12:23p.m., she said doing one-person transfers without a gait belt was not a safe transfer and could lead to falls and injuries. When asked if CNA M and LVN G allowing for a one-person transfer without a gait belt was following Resident #5's care plan, the ADON said no, they did not follow the resident's care plan. Staff would be able to see the amount of supervision residents required in the Kardex which was a type of care plan document available to all staff in the resident's electronic health record. Interview with the MDS Coordinator on 05/22/2026 at 12:50p.m., she said her expectations would be for staff to follow the care plan. The MDS Coordinator said she changed Resident #5's care plan on transfers to two-person transfers with gait belt after his most recent fall. The MDS Coordinator said if the staff did not follow Resident #5's care plan he could have had another fall and that staff all knew and were educated on following resident care plans. Record review of the facility's policy titled Comprehensive Care Plans and Revisions last reviewed on 08/29/2025, reflected, The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care. Procedure 1. The facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care. Record review of the facility's policy on gait belts last reviewed 09/19/2025, reflected, Policy: The facility will provide Gait Belt Use in accordance with professional standards of practice, Make sure to follow evidence-based fall prevention practices, such as performing a fall risk assessment and instituting fall precautions, to reduce the risk of injury from a fall.

Based on observation, interview and record review the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #5) reviewed for accident hazards. -Resident #5 was transferred by CNA M with a one-person transfer and without a gait belt from wheelchair to bed on 5/22/26. This failure could place residents at risk of injury from unsafe transfers.Record review of Resident #5's face sheet dated 05/21/2026, reflected he was a [AGE] year-old male initially admitted on [DATE] with hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis and weakness following a stroke), difficulty in walking, generalized muscle weakness and bilateral primary osteoarthritis in hip (pain in bone and joints in both hips) and a urinary tract infection (onset date 05/06/2026). Record review of Resident #5's Comprehensive MDS dated [DATE], reflected he had a BIMS score of 12 indicating moderate cognitive impairment related to thinking and memory. Resident #5 was coded for a wheelchair and walker. Resident #5 was coded as totally dependent on staff for toileting and showering. Record review of Resident #5's care plan dated 05/21/2026, reflected he had the following care areas:-Resident #5 required ADL assistance and therapy services as needed to maintain or attain highest level of function with muscle weakness and difficulty in walking as of 04/04/2026 with interventions including max assist with transfers and with gait belt and to assist with mobility and ADLs as needed.-Resident #5 had an actual fall with no injury r/t weakness and poor balance with interventions including two person assist for all transfers.Record review of Resident #5's Kardex (a simplified documentation system which has key information in a resident's care plan) dated 05/22/2026, reflected he required max assist with transfers with gait belt. Interview with Resident #5 on 05/21/2026 at 2:00p.m., Resident #5 said he was weak on one side due to a stroke. Resident #5 said he had a fall a while back. He was assisted by an aide from his wheelchair to his bed when he lost strength in his legs and the aide told him she was going to bring him down to the ground. Resident #5 said he did not hit his head but said his energy goes in and out because he had a history of stroke. Resident #5 said that this only happened one time. Observation and interview on 05/22/2026 at 11:06a.m., revealed CNA M pulled on Resident #5's right arm while getting him out of the wheelchair. CNA M assisted Resident #5 with her arm under his right arm. Resident #5 assisted on his left side by pushing up on the wheelchair. CNA M guided him to the bed primarily by holding onto Resident #5's right arm and sat him down, with Resident #5 assisting with his left arm. CNA M guided him to the bed and sat him down all done without a gait belt on. LVN G assisted with holding Resident #5's pants up and held onto Resident #5's wheelchair while CNA M assisted Resident #5. There was a gait belt hanging on Resident #5's dresser door which was not used during the transfer. When asked why CNA M did not use a gait belt during the initial transfer from the wheelchair to the bed, CNA M said that she did not see one in the room. CNA M said she could have hurt Resident #5 if she did not use it during the transfer. CNA M said she was not aware Resident #5 was a two-person assist and that therapy educated staff on how much assistance residents needed for safe transfers. Interview with LVN G on 05/22/2026 at 11:23a.m., LVN G said that she had training on safe transfers and LVN G knew that CNA M should have used a gait belt while transferring Resident #5 because gait belts were used so residents could be safely transferred and that not using a belt could lead to both resident and staff injuries. LVN G said she knew Resident #5 was a two-person assist for transfers. When asked why she did not assist CNA M, LVN G said she did grab his pants to pull Resident #5 to the chair and she held the wheelchair but that was it. When asked what could have happened to Resident #5 with her not helping throughout the entire transfer, LVN G said Resident #5 could have fallen and been injured. Interview with the ADON on 05/22/2026 at 12:23p.m., the ADON said that doing one-person transfers without a gait belt was not a safe transfer and could lead to falls and injuries. When asked if CNA M and LVN G allowing for a one-person transfer without a gait belt was following Resident #5's care plan, the ADON said no, they did not follow the resident's care plan. Staff would be able to see the amount of supervision residents required in the Kardex which was a type of care plan document available to all staff in the resident's electronic health record. Interview with the MDS Coordinator on 05/22/2026 at 12:50p.m., she said her expectations would be for staff to follow the care plan. The MDS Coordinator said she changed Resident #5's care plan on transfers to two-person transfers with gait belt because he had a fall. The MDS Coordinator said if the staff did not follow Resident #5's care plan he could have had another fall and that staff should know to read and follow the plan. Record review of the facility's policy and procedures manual on transferring from bed to wheelchair, last reviewed on 05/19/2025 reflected, For a patient with diminished or absent lower-body sensation or one-sided weakness, immobility, or injury, transfer from a bed to a wheelchair may initially require partial support to full assistance by at least two people. Subsequent transfer of a patient with generalized weakness may be performed by one nurse; however, the weight and size of the patient may require the use of an assistive device to provide a more secure process for lifting, transferring, or repositioning the patient. Optional: gait belt, other personal protective equipment, pillows, supplies for fall precautions, transfer board. ImplementationVerify the practitioner's order.Review the patient's medical record for history of injuries, surgeries, weakness, paralysis or other neurologic deficits, and contraindications to transferring to a wheelchair, such as activity restrictions, instability, or an inability to sit in a wheelchair.Gather and prepare the necessary equipment and supplies. Make sure to follow evidence-based fall prevention practices, such as performing a fall risk assessment and instituting fall precautions, to reduce the risk of injury from a fall. Record review of the facility's policy on gait belts last reviewed 09/19/2025, reflected, Policy: The facility will provide Gait Belt Use in accordance with professional standards of practice, Make sure to follow evidence-based fall prevention practices, such as performing a fall risk assessment and instituting fall precautions, to reduce the risk of injury from a fall.

Based on observation, interview and record review, the facility failed to ensure that residents who are incontinent of bladder receive appropriate treatment and services to prevent urinary tract infections for 1 of 5 residents (Resident #5) reviewed for incontinent care. -CNA M and LVN G provided incontinent care for Resident #5 without changing gloves and sanitizing their hands in-between cleaning Resident #5's penis during wiping. These failures could cause residents to be at risk of urinary tract infection, pain, injury, poor hygiene, and hospitalization.Record review of Resident #5's face sheet dated 05/21/2026, reflected he was a [AGE] year-old male initially admitted on [DATE] with hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis and weakness following a stroke), difficulty in walking, generalized muscle weakness and bilateral primary osteoarthritis in hip (pain in bone and joints in both hips) and a urinary tract infection (onset date 05/06/2026). Record review of Resident #5's Comprehensive MDS dated [DATE], reflected he had a BIMS score of 12 indicating moderate cognitive impairment related to thinking and memory. Resident #5 was coded for a wheelchair and walker. Resident #5 was coded as totally dependent on staff for toileting and showering. Record review of Resident #5's labs, reflected he had a sample collected on 04/27/2026 and he tested positive for an abnormal urine culture which identified the organism as E. coli, a group of bacteria that could be spread by not wiping properly after incontinence episodes and could cause infections in the urinary tract. Record review of Resident #5's progress notes, reflected he had the following notes entered:-05/04/2026 at 1:27p.m., his UA orders were received and reviewed by his physician and came back positive for UTI and E. coli and was placed on antibiotics.-05/05/2026 at 12:54p.m., Resident #5's urologist called and ordered to discontinue his previous antibiotic nitrofurantoin and place him on a new order for 20 days of Bactrim for E.coli UTI.-05/17/2026 at 6:54p.m., Resident #5 complained of continued pain related to UTI during the shift. The RP expressed concerns the current medication might not be effective and requested a review of treatment plan along with request for another culture. Record review of Resident #5's care plan dated 05/21/2026, reflected he had the following care areas:-Resident #5 had a Urinary Tract Infection with interventions including checking at least every two hours for incontinent, washing, rinsing and drying soiled aeras and give antibiotic therapy as ordered until 05/26/2026. Observation and interview on 05/22/2026 at 11:06a.m., revealed LVN G touched the trash can with her gloves and used the same gloves to remove Resident #5's brief without removing gloves or sanitizing hands in between. CNA M used wipes to clean Resident #5's penis and then used the same soiled gloves to grab more wipes and proceeded to change gloves multiple times without proper hand hygiene. CNA M then wiped Resident #5 one more time and used the soiled gloves and grabbed baby powder. LVN G and CNA M used dirty gloves to pull Resident #5's clothes on, touched the wheelchair, Resident #5's shoes, and pulled back his curtain. There was a hand sanitizing station in Resident #5's room near the door and neither CNA M nor LVN G were observed utilizing the dispenser. CNA M said that every time there is a glove change staff should sanitize their hands to prevent infection and germs. LVN G was asked if she noticed the items she touched in the room with her gloves and what could occur from touching them during incontinent care and she replied that it could have spread infection. Interview with LVN G on 05/22/2026 at 11:23a.m., LVN G said that not using hand sanitizer between glove changes was not acceptable and she told Housekeeping already. LVN G said not following hand sanitizing protocols could lead to infections. LVN G said staff did spot checks once a shift. LVN G said her last in-service on hand hygiene was in March. LVN G said she requested Housekeeping refill the hand sanitizer in Resident #5's room when she left the room after incontinent care. Interview with the ADON on 05/22/2026 at 12:23p.m., the ADON said not changing gloves and hand sanitizing was not acceptable practice and a negative outcome would be infections for residents. The ADON said she had done training and spot checks for peri-care and infection control and PPE. Record review of the facility's policy titled Urinary Incontinence Management last revised 01/20/2026, reflected, Each resident who is incontinent of urine is identified, assessed and provided appropriate treatment and services to achieve or maintain as much normal bladder function as possible.to prevent urinary tract infections and to restore continence to the extent possible.Procedure: 1. A resident should be assessed at admission regarding continence status and whenever there is a change in urinary tract function.It is importance when completing the comprehensive assessments in the EHR to consider the following: a.history of urinary incontinence, including onset, duration and characteristics.previous treatment and/or management, including the response to the interventions and the occurrence of persistent or recurrent UTI.g. Functional and cognitive capabilities that could enhance urinary continence and limitations that could adversely affect continence.

Based on observation, interview, and record review, the facility failed to keep confidential all information contained in the resident's records, regardless of the form or storage method of the records and safeguard medical record information against loss, destruction, or unauthorized use for 1 of 5 residents (Resident #2) observed for privacy. -RN V left Resident #2's empty blister pack on the medication cart which could be observed by anyone walking by on 05/22/2026. This failure could put residents at risk of their personal health information being exposed to unauthorized personnel.Record review of Resident #2's face sheet dated 05/22/2026, reflected she was an [AGE] year-old female initially admitted on [DATE] with medical diagnoses including acute respiratory failure with hypoxia (not enough oxygen), muscle weakness, malignant neoplasm of unspecified site of left female breast (cancer in the left breast) and chronic kidney disease. Record review of Resident #2's physician's order summary dated 05/22/2026, reflected she had an active order with a start date of 04/24/2026 for Gabapentin Oral Capsule 300 mg, give 1 capsule by mouth one time a day for neuropathy (damage or dysfunction of the nerves, with symptoms including muscle weakness and shooting/burning pain). Observation and interview on 05/22/2026 at 9:22a.m. in the hallway near the nurse's station on Resident #2's hall, revealed Resident #2's blister pack for Gabapentin of 15 capsules and instructions to Give 1 capsule by mouth one time a day for neuropathy (nerve pain) with a pack date of 04/10/2026 and a fill date of 05/06/2026 was observed stuck between binders out in the open on a medication cart near the nurse's station. The blister pack was empty and had Resident #2's name and medication number on it. RN V was down the hall at another medication cart, and she walked down and saw the blister pack and took it and brought it to the medication room. RN V said that she was gathering empty blister packs for multiple residents to shred all at once and that she was going to dispose of Resident #2's blister pack as well but answered a call light and forgot to come back to grab the pack. RN V said that it should not have been left out and that anyone could get resident's information off of the pack. RN V stated she had training on HIPAA and resident rights to privacy. Interview with the ADON on 05/22/2026 at 12:23p.m., she said the blister pack being out in public view was not acceptable and it should have been checked and that it was a HIPAA violation because that was resident information. The ADON said staff were trained on protecting resident privacy. Interview with the Administrator on 05/22/2026 at 1:19p.m., the Administrator said that medication being left out to be seen by others was not acceptable practice because of HIPAA violation and patient safety and that her staff were trained on HIPAA. Record review of the facility's policy titled Notice of Privacy Practices last revised 02/13/2026, reflected, Understanding what is in your record and how your health information is used helps youto: ensure its accuracy better understand who, what, when, where, and why others may assess your health information make more informed decisions when authorizing disclosure to others. Our ResponsibilitiesThe facility is required to: maintain the privacy of your health information. provide you with a notice as to our legal duties and privacy practices with respect to informationwe collect and maintain about you. abide by the terms of this Notice of Privacy Practices. notify you if we are unable to agree to a requested restriction. notify you following a breach of unsecured health information.

Based on observation, interview, and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 (Resident #5) of 5 residents observed for infection control. -There was a breakfast tray left out in an open dining area on 05/21/2026 at 1:36p.m. -CNA M and LVN G provided incontinent care for Resident #5 without changing gloves and sanitizing their hands in-between cleaning Resident #5's penis and touching Resident #5's personal and physical environment and Resident #5's skin. These failures could have placed residents at risk by exposing them to care that could have led to the spread of infections, secondary infections, or communicable diseases.Record review of Resident #5's face sheet dated 05/21/2026, reflected he was a [AGE] year-old male initially admitted on [DATE] with hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis and weakness following a stroke), difficulty in walking, generalized muscle weakness and bilateral primary osteoarthritis in hip (pain in bone and joints in both hips) and a urinary tract infection (onset date 05/06/2026). Record review of Resident #5's Comprehensive MDS dated [DATE], reflected he had a BIMS score of 12 indicating moderate cognitive impairment related to thinking and memory. Resident #5 was coded for a wheelchair and walker. Resident #5 was coded as totally dependent on staff for toileting and showering. Record review of Resident #5's care plan dated 05/21/2026, reflected he had the following care areas:Record review of Resident #5's care plan dated 05/21/2026, reflected he had the following care areas:-Resident #5 had a Urinary Tract Infection with interventions including checking at least every two hours for incontinent, washing, rinsing and drying soiled aeras and give antibiotic therapy as ordered until 05/26/2026. Observation and interview on 05/21/2026 at 1:36p.m., revealed there was breakfast food left out in a large open area dining room behind the nurse's station with 80% full plate of oatmeal, eggs and liquids. CNA L came over and saw the tray and said it should not have been there, and it could be a cross-contamination issue and took it and walked toward the kitchen. Observation and interview on 05/22/2026 at 11:06a.m., revealed LVN G touched the trash can with her gloves and used the same gloves to remove Resident #5's brief without removing gloves or sanitizing hands in between. CNA M used wipes to clean Resident #5's penis and then used the same soiled gloves to grab more wipes and proceeded to change gloves multiple times without proper hand hygiene. CNA M then wiped one more time and used the soiled gloves and grabbed baby powder. LVN G and CNA M used dirty gloves to pull Resident #5's clothes on, touch the wheelchair, Resident #5's shoes and pulled back his curtain. CNA M said that every time there is a glove change staff should sanitize their hands to prevent infection and germs. LVN G was asked if she noticed the items she touched in the room with her gloves and what could occur from touching them during incontinent care and she replied that it could have spread infection. There was a hand sanitizer dispenser in the room which was empty neither CNA M nor LVN G accessed during incontinent care. Interview with LVN G on 05/22/2026 at 11:23a.m., LVN G said that not using hand sanitizer between glove changes was not acceptable and she told Housekeeping already. LVN G said not following hand sanitizing protocols could lead to infections. LVN G said staff did spot checks once a shift. LVN G said her last in-service on hand hygiene was in March. LVN G said the hand sanitizer dispenser was empty and that it was Housekeeping's responsibility to ensure it was filled. Interview with the ADON on 05/21/2026 at 4:20p.m., the ADON said residents could grab the tray and eat it after it was left out for a prolonged period of time and that it could have been an infection control concern. On 05/22/2026 at 12:23p.m., the ADON said not changing gloves and hand sanitizing was not acceptable practice and a negative outcome would be infections for residents. The ADON said she had done training and spot checks for peri-care and infection control and PPE. Interview with the Housekeeping Supervisor on 05/22/2026 at 1:10p.m., she said that it was housekeeping staff to check on the hand sanitizer machine when they enter the room and to let the Supervisor know to refill them and she said the staff must have forgotten to tell her about Resident #5's room needing a refill. The Housekeeping Supervisor said she checked the machines in rooms on 05/21/2026 and at random. Interview with the Administrator on 05/22/2026 at 1:19p.m., she said food items should have been taken back to the kitchen. When asked if it was an infection control concern or safety concern, she said that food was not left in the resident area and it was not located anywhere where patient care was occurring and residents did not go into that area. When asked if residents still had access to the area, the Administrator said they still could have gone into the area but that the area was not utilized. Record review of the CDC's printout on handwashing dated 02/16/2024, reflected, many diseases and conditions are spread by not washing hands with soap and clean, running water. Handwashing with soap is one of the best ways to stay healthy. Key times to wash hands. after using the toilet.after changing diapers. If soap and water are not readily available, you can use an alcohol-based hand sanitizer that contains at least 60% alcohol. Record review of the facility's policy titled Infection Prevention and Control Program (IPCP) and Plan last revised on 05/22/2026, reflected, .The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.Written standards, policies, and procedures for the program, which must include, but are not limited to: . (iii) Standard and transmission-based precautions to be followed to prevent spread of infections. (v). The circumstances under which the facility must prohibit associates with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi) The hand hygiene procedures to be followed by associates involved in direct resident contact.Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

Based on interview and record review, the facility failed to develop a person-centered baseline admission care plan for 1 of 3 residents (Resident #2) reviewed for baseline care plans in that:-The facility failed to develop a baseline care plan with goals, interventions, treatments, and psychosocial needs within 48 hours of admission for Resident #2.This failure could have affected new admission residents by not having their individual, medical, functional, and psychosocial needs identified and could cause a physical or psychosocial decline in health.Record review of Resident #2's face sheet dated [DATE] revealed she was an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses which included: fracture of the lower end of radius (broken wrist injury), hypertension (high blood pressure), and dementia (decline in mental ability).Record review of Resident #2's 15-day MDS assessment dated [DATE] revealed a BIMS score of 00 out of 15, indicating severely impaired cognition. Further review revealed Resident #2 needed extensive assistance to total care with ADL care with one staff assistance.Record review of Resident #2's care plan revealed the resident care plan was cancelled on [DATE]. It also revealed an entry on [DATE] with a status of full code by ADON.Record review of Resident #2's out-of-hospital DNR revealed the form was dated [DATE], a day before Resident #2 was discharged back to the facility from the hospital.During an interview on [DATE] at 1:19 p.m., the MDS Coordinator said she was not sure who canceled Resident #2's care plan. She said when a resident went to the hospital, the resident's orders would be discontinued, and the care plan would say canceled. The MDS Coordinator said when Resident #2 was readmitted on [DATE], the admitting nurse would have initiated the baseline care plan UDA, and that would have triggered the comprehensive care plan. She said the ADON entered the DNR manually on the old care plan after she had cancelled the previous DNR on [DATE] when Resident #2 was readmitted , and she did not communicate that she manually wrote on the previous care plan and changed Resident #2's code from DNR to full code. She said because the baseline care plan was not done, she would manually put the care areas back to the previous care plan, and she said she still needed to complete the comprehensive care plan. She said Resident #2's DNR paperwork was signed on [DATE], a day before she was discharged from the hospital, and she did not know why the ADON put full code. She said the DNR paperwork usually came with discharge paperwork. She said if the resident's baseline care plan UDA was not done, it could have affected the care provided for Resident #2.During an interview on [DATE] at 2:00 p.m., the DON said when Resident #2 was readmitted , the baseline care plan UDA was not triggered. When the DON was asked why the baseline care plan did not trigger, she said it was a question for PCC(Point Click Care is an electronic system used for documentation). The DON said that SW was involved in the DNR, and when the paperwork was uploaded on ([DATE]), the SW should have notified someone in nursing so the nursing staff would have changed the full code to DNR. The DON said Resident #2 would not have received the care because the care for the resident was not in the care plan. The DON said if the resident had a cardiac incident, the facility would have provided CPR, which was not what the resident wanted.During an interview on [DATE] at 2:10 p.m., the ADON said she did not know why the admitting nurse did not initiate the baseline care plan UDA for Resident #2. The ADON said she entered full code for Resident #2 manually. She said she did not have the out-of-hospital DNR at the time she entered full code. She said if the baseline UDA was not started, Resident #2 may not have had care provided appropriately. She said she was not aware the resident had an out-of-hospital DNR, and if the resident was provided with CPR, then the resident was not provided care according to the resident's wishes. The DON said if the baseline care plan was not initiated, then the MDS coordinator would not have known to complete the comprehensive care plan in 14 days.Record review of the facility policy on care planning, comprehensive, and routine updates issued: [DATE], review [DATE] revealed in part .Completion and implementation of the baseline care plan within 48 hours of a resident's admission was intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that were most likely to occur right after admission.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, and a system of medication records that enabled periodic accurate reconciliation and accounting of all controlled medications to meet the needs of 1 of 3 residents (Resident #1) reviewed for pharmacy services, in that:The facility failed to ensure Resident #1's control count sheet matched with the actual Lacosamide liquid medication.This failure could have placed residents at risk of not receiving their adequate dose of medication and drug diversion. Findings included:Record review of Resident #1's face sheet dated 4/06/26 revealed she was a [AGE] year-old male admitted to the facility on [DATE]. Resident #1 had diagnoses which included: diabetes mellitus (high blood sugar levels), hypertension (high blood pressure), and cerebral infarction (blockage in an artery supplying the brain blood).Record review of Resident #1's admission MDS assessment dated [DATE] revealed a BIMS score of 10 of 15, indicating moderately impaired cognition. Further review revealed Resident #1 needed extensive assistance to total care with ADL care with one staff assistance.Record review of Resident #1's April 2026 order summary report revealed in part, Lacosamide oral solution 10MG/ML, give 5ML two times a day for epilepsy. Ordered date 03/17/26.Record review of Resident #1's control count sheet for Lacosamide oral solution 10MG/ML, give 5ML two times a day revealed 45ML. Record review of Resident #1's MAR for April 2026 revealed Lacosamide oral solution 10MG/ML, give 5ML two times a day was administered last on 04/02/26 in AM and it was administered by LVN A.During observation of the nurse medication cart on unit E with the ADON and LVN A on 04/02/26 at 1:45 p.m., it was revealed Resident #1's Lacosamide 10mg/ML liquid medication count sheet reflected 45 ML while the medication bottle had 65 ML of liquid medication.During an interview on 04/02/26 at 1:46 p.m., the ADON said Resident #1's Lacosamide 10mg/ML usually came overfilled. She said the facility did not correct the count to match the total dosage on the medication label. She said she could not tell how much the bottle was overfilled from the 180 ML on the medication label and the count sheet for the medication. The ADON said it could be considered drug diversion when the liquid medication did not match the count sheet. She said she did not know how the medication would be corrected to match the count sheet, and none of the nurses had told her the liquid control medication did not match the count sheet. The ADON said she could guess the difference from the medication in the bottle was about 10 ML more than what was documented on the count sheet. The surveyor pointed out that the lines with numbers on the medication bottle increased by 40 ML and the middle line between the numbered lines increased by 20 ML. She did not respond or verify the variances by checking the lines and numbers on the medication bottle.During an interview on 04/02/26 at 3:02 p.m., LVN A said Resident #1's Lacosamide 10mg/ML liquid medication had more medication in the medication bottle than what was on the count sheet. LVN A said when the liquid medication did not match, as a nurse, she should have reported it to the DON and ADON. LVN A said she did not report it to the nurse managers, but she thought another nurse reported it. She said the nurse management said the liquid sometimes came with more medication than what was written on the bottle. She said the DON and ADON were supposed to verify the count of liquid control medication, and she was not sure what nurse managers were supposed to do. LVN A said when she counted the medication when she can to work today , and the medication was over and she signed the count sheet with the outgoing nurse because the medication had been over from 03/18/26 and all the nurses were aware. LVN A said when the documentation on the count sheet did not match the amount of medication left in the bottle, it was a discrepancy which had to be reported to prevent drug diversion.During an interview on 04/06/26 at 1:52 p.m., the DON said Resident #1's Lacosamide 10mg/ML may had come overfilled, and the nurses would continue to administer medication until the nurse gave the quantity that was on the label, and then the overage was destroyed. She said she was waiting for the pharmacy to give her directions on what to do. The DON said it could be drug diversion if there was a discrepancy between the control count sheet and actual medication. She said sometimes the medication came overfilled, and none of the nurses had told her Resident #1's Lacosamide 10mg/ML was overfilled.During an interview on 04/06/26 at 2:56 p.m., the Administrator said she was not clinical and she could not say if Resident #1's Lacosamide 10mg/ML was over than what was written on the paper. She said she was going to call the corporate nurse for more information on control liquid medication. She said she talked to the pharmacist and she said liquid medication came overfilled.Record review of the facility policy on drug diversion prevention program revised 12/04/2023 and revised 12/03/2025 revealed in part .To minimize the threat of drug diversion, incorporates clear-cut policies and practices that demonstrate a hardline, zero-tolerance approach to diversion to improve safety and quality of care for the residents. procedure #1.2. Facility should ensure the incoming and outgoing nurses counted all Schedule controlled substances and other medications with a risk of abuse or diversion at the change of each shift or at least once daily and documented the results on a 'Controlled Substance Count Verification/Shift Count Sheet'. Facility should:1.2.1 Reconcile the total number of controlled medications on hand, pursuant to the Controlled Substance Verification/Shift Count Sheet; and1.2.2 The facility should routinely reconcile the number of doses remaining in the package to the number of doses recorded on the Controlled Substance Verification/Shift Count Sheet to the medication administration record.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preference for 1 (Resident #1) of 3 residents reviewed for tracheal care. The facility failed to follow physician orders for Resident #1 by not performing the prescribed trach care as ordered. Specifically, the facility did not change the trach aerosol tubing, mask, jet nebulizer bottle, and water trap every Sunday on nights shift or change the trach ties every night shift on 10/11/25, 10/12/25, 10/13/25, 10/18/25, 10/19/25, 10/25/25, 10/26/25, 11/2/25, 11/3/25, 11/4/25, 11/5/25, 11/6/25, 11/7/25, 11/8/25, 11/9/25, 11/16/25, 11/23/25, 11/24/25, and 11/27/25. On 11/28/25, Resident #1 was admitted to the hospital due to brown emesis coming from his mouth and trach and Resident #1 was diagnosed with MRSA. On 12/4/25 at 3:40 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 12/5/25, the facility remained out of compliance at a severity level of no actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents at risk for delayed treatment, worsening of condition, and hospitalization. Findings included:Record review of Resident#1's face sheet reviewed 12/3/25, revealed a [AGE] year-old man who was admitted to the facility on [DATE]. His admitting diagnoses were lymphoma (cancer originated in lymphatic system) of other extranodal and solid organ sites, immunodeficiency (failure of the immune system to protect the body adequately from infection), dysphagia (difficulty swallowing), encounter for attention to tracheostomy, and bacteremia. Record review of Resident #1's care plan dated 10/23/25, revealed he utilized a feeding tube and tracheostomy. The goal was to not have any complications related to ostomy use and interventions/tasks listed to perform care as needed. Record review of Resident #1's medication orders dated 10/8/25, for trach care revealed staff were to change the trach aerosol tubing (plastic medical tubing used to deliver a fine mist of medicine or moisture (aerosol) into a patient's lungs via a tracheostomy tube), mask, jet nebulizer bottle (device that uses a stream of compressed air or oxygen to convert liquid medication or saline solution into a fine, inhalable mist or aerosol), and water trap (device used in humidification or ventilation circuits to collect condensation (excess water) and prevent it from flowing back into the patient's airway or damaging the equipment) every Sunday on night shift, change trach tie every night shift and prn, and suction trach every shift and prn for increased secretions. An order was in place to change the trach collar (delivers oxygen to the lungs but also provides humidification to prevent dryness and irritation) every night shift every Sunday and as needed but was discontinued on 11/13/25 and no new order was implemented. Record review of Resident #1's TAR for October 2025 2025 d revealed 1. Trach was suctioned every shift as ordered. No additional prn suctions were completed. 2. The trach ties were ordered to be changed daily. Review of the TAR revealed that these orders were not completed on 10/11/25, 10/12/25, 10/13/25, 10/18/25, 10/19/25, 10/25/25, and 10/26/25. 3. the trach aerosol tubing, mask, jet nebulizer bottle, and water trap had no documentation of being changed. Record review of Resident #1's TAR for November 2025 revealed 1. Trach was suctioned every shift as ordered. No additional prn suctions were completed, 2. The trach ties were ordered to be changed daily. Review of the TAR revealed that these orders were not completed on 11/2/25, 11/3/25, 11/4/25, 11/5/25, 11/6/25, 11/7/25, 11/8/25, , 11/9/25, , 11/16/25, , 11/23/25, , 11/24/25, , and 11/27/25. 3. the trach aerosol tubing, mask, jet nebulizer bottle, and water trap had no documentation of being completed. Record review of Resident #1's Respiratory Progress Notes by RT, dated 10/10/25, 10/17/25, 10/22/25, 10/23/25, 11/3/25, 11/7/25, 11/11/25, 11/21/25, and 11/26/25 indicated no distress. Record review of Resident #1's progress note documented by LVN D, dated 11/26/25 at 6:38 a.m., revealed that Resident #1 was sent to the hospital via EMS due to brown/black emesis (vomit) from mouth and trach. Resident #1 transferred via stretcher to hospital without any complications. In an interview on 12/3/25 at 12:02 p.m., LVN A stated she worked at the facility for two years on the 6:00 a.m. to 2:00 p.m. shift. She stated she suctioned Resident #1's trach prn, every shift, and the ties were changed daily and prn. LVN A stated the last time she performed trach care for Resident #1 was on 11/25/25 and she stated there was a slight odor a few weeks in 11/25 before they did a culture and started him on antibiotics. LVN A stated sometimes Resident #1 refused suctioning and he communicated with staff by pointing and shaking his head at commands or questions. LVN A stated , she could not explain why the trach collar was discontinued from his treatment orders because Resident #1 had a very strong cough and mucus would often wet the collar and ties. She stated Resident #1 had very thick mucus and his cough was so forceful that she could see particles of mucus on the mirror across the room. When LVN A was asked if she had ever completed the order to change the trach aerosol (change out the tubing of the trach), she said she did not document it because she washed it but did not change it. LVN A stated she changed the tubing but she could not remember documenting it and should have put it in the notes. She explained the purpose of changing out the aerosol equipment was for cleanliness and the harm in not changing out the equipment could be infections. In an interview on 12/3/25 at 12:35 p.m., CNA A stated she worked at the facility for almost 2 years and worked the 6:00 a.m. to 2:00 p.m. shift. She stated she never performed trach care for Resident #1 and only cleaned around his chest and under his neck. He produced a lot of mucus and he communicated with her by mouthing words and moving his hands. In an interview on 12/3/25 at 1:15 p.m. with the RT, she stated she saw Resident #1 a minimum of once weekly. Her role included trach care, training nursing staff, and documenting her visits and findings. She described him to have a very productive cough and produced a lot of secretions/mucus that required frequent monitoring due to the amount of secretions. She statedshe seldomly worked with patients that produced as much mucus as him and stated that he would need to be suctioned more than once a shift and there was a prn order in place. She stated she noticed an odor from his trach and that was why she requested a lab order. When asked if she noticed any issues with the trach care preformed at the facility, she stated she did not know if she should answer questions regarding the quality of the trach care prior to her session with him, but stated that every time she arrived at the facility, she performed complete trach care, and she would create a report to give to the DON and provide pictures and names to inform her of who needed more training. She advised to follow up with the DON regarding specifics of nursing care because she did not want to disclose that information. RT explained that the harm of not changing out equipment as ordered could be a possible infection and a soiled trach collar could lead to skin breakdowns around the neck. In an interview on 12/3/25 at 2:07 p.m., the DON stated she oversaw all trach care and there were no concerns that she could think of regarding trach care at the facility. She explained that Resident #1 produced a lot of secretions and he was suctioned frequently, which she described as every shift and noted that there was a prn order in place. She time lined that staff collected a sputum sample on 11/10/25, he was identified to have pseudomonas (a [NAME] of common bacteria found in soil, water, and plants, known for causing opportunistic infections in humans, especially those with weakened immune system) and was prescribed antibiotics to treat it. When asked what prompted staff to collect the sputum sample, she stated that she did not know because no SBAR, CIC, or progress note was documented in the resident's chart. The DON stated that she communicated with the RT after her visits, and RT did have concerns regarding his secretions and that was why he was placed on antibiotics. DON was informed that on the TAR, there was no documentation to sign off the completion of changing the aerosol tubing for October and November and she stated that she was not aware of this and would have to find out why. She explained that in the TAR or MAR, if an order was left blank it meant that it was not completed. DON was informed that there were several inconsistencies in the completion of changing out the trach ties as documented in the TAR, and most of these inconsistencies could be seen through weekend documentation. She had no idea why this was not completed. When asked why the order to change the trach collar every Sunday was discontinued on 11/13/25, she was not aware it was discontinued. DON explained the risk of these orders not being followed were infections and skin breakdown. She was notified that Resident #1 had a CIC that resulted in brown emesis coming from his mouth and trach on 11/28/25, but she did not follow up for additional details after he was admitted to the hospital. DON stated that Resident #1 would be welcomed back into the facility, but was unsure if he would return. In a phone interview on 12/3/25 at 2:52 p.m., the HSW, stated she reviewed the hospital progress notes and Resident #1 had MRSA bacterium in his sputum. The HSW read from the progress notes that there was blood on the trach upon his arrival to the hospital, and the trach had not been changed in a long time. In an observation and interview on 12/3/25 at 3:51 p.m., Resident #1 was sitting in his bed with trach and g-tube in place. He was alert and oriented but not easily understood when he tried to vocalize his responses to questions. His cough was productive and could be heard through his lungs. He was able to shake his head and shook yes when asked if he could understand me. When asked if the facility provided good trach care while he was there, he shook his head no. When asked if nurses were suctioning as needed and changing out the tubing equipment (pointed at the tube coming from his mask) he shook his head no. He was asked why they were not changing out the equipment as ordered, he mouthed because they didn't want to He was asked why not, was it too much work, and he shook his head yes. He was asked if he was going to return to the facility after hospital discharge and he shook his head no. In an interview on 12/3/25 at 4:10 p.m., the HDR stated he was not Resident #1's usual doctor and he was substituting in for the day so he was not very familiar with the case. He stated Resident #1 had MRSA bacterium, was admitted for pneumonia, and arrived with rust colored bloody sputum. He explained not having Resident #1's trach equipment changed regularly would put him at greater risk for infection His health outcome was multifactorial, which included improper care and him being immunocompromised (having a weakened immune system). In an interview on 12/4/25 at 11:13 a.m., LVN B stated she worked at the facility for one year usually the 10:00 p.m.- 6:00 a.m. shift. She stated the last time she performed trach care for Resident #1 was on 11/23/25 and she remembered changing all his equipment. She stated she did not put a progress note in, but the TAR would flag red if you did not document it. She stated because he had a lot of secretions, staff suctioned more often and there were prn orders in place. She explained that you had to suction Resident #1 every hour/hour and a half. She stated that she did not document this and could not recall documenting any completed prn orders. She explained that Resident #1 was alert and oriented and knew what was going on. He was able to answer questions by mouthing out words and shaking his head. In an interview on 12/4/25 at 1:25 p.m. with Resident #1's PCP, he stated he thought Resident #1 aspirated (breathing down the wrong pipe) the way it was conveyed by the nurse. He explained that in regard to the orders, Resident #1 was an immunocompromised patient with terminal cancer and everything had to be sterile (free from bacteria or other living microorganisms). Record review of the facility's policy titled Tracheostomy Care Policy reviewed 9/24/25 reflected the following: The facility will provide and perform tracheostomy care in accordance with physician orders and current standard of care.Procedure:1. Tracheostomy care will be performed daily and PRN unless otherwise noted by the physician. This procedure should be performed using sterile technique and includes the cleaning of the stoma and neck, cleaning or replacing inner cannula, (depending on type of trach- disposable or reusable), and replacing the tracheostomy tube holder and drainage sponge2. Tracheostomy patient should be assessed and documented on in the patient medical record at least every four hours. This was determined to be an Immediate Jeopardy (IJ) on 12/4/25 at 3:30 p.m. The ADM and DON were notified. The ADM was provided with the IJ template on 12/4/25 at 3:30 p.m. The following Plan of Removal submitted by the facility was accepted on 12/5/25 at 8:08 a.m. Plan of Removal: Re: IJ 12/4/2025 F695 Facility Failed to ensure that a resident who needs respiratory care, including tracheostomy and tracheal suctioning is provided. Corrective Action for Those Found to Have Been Affected by the Deficient Practice: Identified resident was transferred to the hospital for further evaluation and treatment. The identified resident will be re-admitted if orders for such. Education will be completed regarding following physician orders for trach care to include changing trach aerosol tubing, mask, nebulizer bottle, water trap, trach ties and trach color as ordered. This education will be provided to current licensed nursing staff by the Director of Nursing/Respiratory Therapist and/or Regional Nurse Consultant. This training will be provided prior to staff working and will be completed by 12-5-25. Licensed staff will not provide direct care to residents until training is completed. Divisional Clinical Nurse reviewed facility's policy and procedures for tracheostomy care. No changes made. No new patients/residents requiring tracheostomy care/tracheal suctioning will be admitted until 100% of licensed staff have been trained and deemed competent.Identification of Other Residents Having the Potential to be Affected: Two additional residents requiring respiratory/tracheostomy care and tracheal suctioning reside in the facility. Documentation of physician orders is current for these two residents. The two additional residents requiring respiratory/tracheostomy care and tracheal suctioning will be seen 12-4-25 by the attending physician, or medical director to ensure no negative assessment findings. No issues identified. DON/Designee conducted an audit of current residents and tracheostomy supplies to validate trach supplies were available at bedside. No issues identified. Measures/Systemic Changes to Ensure the Deficient Practice does Not Recur: The Director of Nursing will begin immediate in-servicing of LVN A, RN B, and LVN C, on the following and will be completed on 12-5-25. o Completion and documentation of physician ordered tracheostomy care.o Return demonstration of trach care w/competency documented. Licensed staff will ensure that the orders for trach care will include changing trach aerosol tubing, mask, nebulizer bottle, water trap, trach ties and trach collar as ordered. DON/designee will review MARs/TARs daily (to include weekends) to validate trach care orders are carried out. LVN A, RN B, and LVN C, (same comment as above) staff will not be allowed to begin their shift until they have received the education/competency as noted above. Licensed weekend staff will be provided with 1:1 re-education on care for patients with tracheotomies. The education will include competency for tracheal care, suctioning, tubing changes, and documentation. Ongoing Monitoring: The Director of Nursing, Assistant Director of Nursing or Regional Nurse Consultant will complete the following until substantial compliance has been met and achieved:o Daily audits of residents requiring respiratory/tracheostomy care and tracheal suctioning will be reviewed to ensure that physician orders for such are documented. The facility will continue to provide the in-servicing as noted above to newly hired licensed staff, annually and as needed. The Director of Nursing or Assistant Director of Nursing will audit licensed nurses training and competency records to ensure tracheostomy care/tracheal suctioning training compliance. Nurse Managers will round on trach patients on weekends to validate trach care performed and there are no signs/symptoms of infection. Any issues identified will be addressed immediately. All components of this plan of correction will be submitted to the facility QAPI meeting and additional recommendations will be made until substantial compliance has been achieved.The Director of Nursing, Assistant Director of Nursing and Regional Nurse Consultant is responsible for the corrections and continued monitoring. The Medical Director was notified and agrees with the plan of removal. Completion Date: 12-4-25 Monitoring Day 1: 12/5/25Trach care observations:Resident #1 was in the hospital on [DATE]. He did not plan to return to the facility. In an observation and interview on 12/5/25 at 10:47 a.m., LVN A and RN D prepared to preform trach care for Resident #2. RT provided hands on education and a skills test earlier that morning, and Resident #2 declined to have staff preform full trach care but she allowed the staff to do a hands on walk through to show their knowledge of proper trach care. LVN A, verbalized the steps for tracheostomy suctioning and site care, including use of sterile supplies, identification of clean versus dirty hands, suctioning until resistance or cough, limiting suction passes to 10-15 seconds, and proper disposal of equipment. Each step was simulated with the supplies and was performed according to resident orders. RN D, was present and assisted with supply management to maintain a sterile environment. LVN A further verbalized cleaning the stoma using a single-wipe technique, drying the site, reapplying dated trach collar and gauze, preventing moisture at the site, and increasing oxygen as indicated during care. Monitoring observations reflected staff's ability to complete appropriate tracheostomy care procedures. Resident #2 was able to communicate by mouthing words and writing commands. She was admitted on [DATE] and voiced no concerns with trach care from staff. During an interview and observation on 12/5/25 at 11:30 a.m., RN E was observed simulated tracheostomy care or Resident #3. RN E had preformed trach care 10 minutes prior to observation and a simulated trach care and interview was requested to support Resident #3's comfortability. RN E simulated tracheostomy care and showed proper tracheostomy practices, including ensuring trach ties were dated and changed daily to prevent skin breakdown, verifying inner cannula changes, and documenting care and PRN use in the clinical record. RN E stated on 12/5/25, staff demonstrated their grasp of the training by preforming it back to the RT, testing, and competency validation following training taught by the RT. During demonstration, RN E was observed wiping down the bedside table, preparing supplies, donning (put on) sterile gloves for suctioning, connecting saline to the catheter, advancing the catheter to resistance, applying suction while withdrawing for a limited duration, and repeating suctioning as indicated by secretions. RN E verbalized changing gloves between tasks, removing and replacing gauze, cleaning and drying the stoma, applying new gauze, and discarding supplies after completion of care. RN E further verbalized assessment of sputum characteristics, appropriate response if secretions were abnormal, and oxygen management during careInterviews: In an interview on 12/5/25 at 11:16 a.m., the stated that in the recent training, she taught staff how to do resident assessments upon entering the room, use of Airvo (a respiratory device delivering warm, humidified high-flow oxygen to spontaneously breathing patients) for residents with long-term tracheostomies or increased secretions, suctioning techniques, emergency equipment availability at the bedside, and the importance of hyperoxygenation prior to suctioning. RT reported that training included teach-back methods, identification and correction of improper technique during practice, and reinforcement of sterile versus dirty hand use. RT stated that suctioning should be limited to 10-15 seconds per pass, with advancement to resistance and withdrawal while applying suction. RT further stated that staff were required to complete return demonstrations, testing, and competency validation, and that documentation and follow-up were completed to ensure staff understanding and compliance following training. Nursing staff were interviewed on 12/5/25 between 11:10 am - 2:43 p.m. These staff members included ADON, LVN D, RN D, WCN, LVN E, LVN F, LVN G, LVN H, LVN I, RN B, and RN C. All nursing staff interviewed reported that they recently received tracheostomy-care training with respiratory therapy and nursing leadership. Staff stated the training reviewed tracheostomy care, suctioning technique, use of Airvo and oxygen equipment, tubing and trach-tie changes, infection control practices, and proper documentation of routine and PRN orders. Staff reported that training included hands-on instruction, teach-back, return demonstrations, and opportunities to ask questions. Staff verbalized understanding of suctioning limits (10-15 seconds per pass), using sterile supplies, recognizing resistance, preventing tissue injury, managing secretions, maintaining skin integrity, and ensuring orders are in place for all care provided. Staff stated they felt the training was thorough, helpful, and served as a refresher. All staff interviewed reported feeling confident in their ability to safely perform tracheostomy care and suctioning going forward and stated they understood expectations and available support if they had any questions. In an interview on 12/5/25 at 3:07 p.m. with FMD, he stated the facility conducted monthly QAPI meetings to review quality indicators, including falls, patient care, pharmacy services, weight monitoring, and physician services, with participation from the DON, ADON, WCN, pharmacy, and other disciplines as needed. He stated tracheostomy care practices and treatment plans were reviewed and updated, with involvement from respiratory therapy and nursing to ensure appropriate treatment and follow-through. FMD reported that residents with tracheostomies, catheters, and g-tubes were routinely reviewed. He stated a prevention, detection, and correction process was in place, beginning with nursing leadership and extending through nursing staff, respiratory therapy, and physicians to ensure responsibilities were clearly defined. FMD further stated weekend orders were reviewed by the DON and FMD. He stated efforts were made to maintain consistent follow-through and appropriate assessments to support resident safety and quality of care. Record Review:Record review revealed that Resident #2 and Resident #3 were assessed to identify any care issues and orders were reviewed to ensure they reflected residents' needs and prn orders were placed. No issues found. Record review showed all nursing staff completed in person training on 12/4/25 and 12/5/25 with the ADON, DON, or RT. Skilled demonstrations were completed for Tracheostomy tube change and documented on a checklist. The ADM was notified on 12/5/25 at 3:40 p.m. that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on record review and interview, the facility failed to provide and document sufficient preparation and orientation of residents to ensure safe and orderly transfer or discharge from the facility for 2 of 5 resident (CR#1 and CR # 2) reviewed for transfer, discharge rights, and discharge summary. - LVN P failed to complete a discharge summary for CR #1 - LVN M failed to complete a discharge summary for CR #2. These failures could place residents at risk of disruption in the continuity of care. Findings include: Record review of CR #1's undated face sheet revealed he was admitted to the facility on [DATE] and discharged from the facility on 03/21/25 with diagnoses of Pulmonary embolism (a blockage in the pulmonary arteries of the lungs), Protein-calorie malnutrition (insufficient intake of protein and calories), acute right heart failure (chronic condition in which the heart does not pump blood as well as it should), and dementia (memory loss). Record review on 06/19/25 of the discharge summary revealed CR #1 did not have a completed discharge summary. CR #1's discharge summary revealed the recapitulation of the stay, physical assessment, and discharge instructions were blank. Review of the discharge summary also revealed, no signature by the resident, resident representative, or transportation service. Record review of CR #1's EMRdid not reveal documentation of the resident's discharge on the day of discharge, including, the mode of transportation, diet, discharge vitals/assessment, or provided education. Record review of CR #2's undated face sheet revealed he was admitted to the facility on [DATE] and discharged from the facility on 04/05/25 with diagnoses of Complications of Cardiac Prosthetic devices, implants, and grafts (structural valve deterioration, infection, and leaks from mechanical bioprosthetic valves), Protein-calorie malnutrition (insufficient intake of protein and calories), atrial fibrillation (irregular rapid heart rate that cause poor blood flow). Record review of CR#2's discharge summary,dated 04/05/25, revealed the resident was discharged home accompanied by a family member. Review of the summary also revealed the recapitulation of the stay was left blank, and no signature from the resident or their representative. An attempted telephone interview with the Ombudsman on 6/19/2025 at 12:54 PM was unsuccessful, and a voice mail message was left. During an interview on 06/19/25 at 1:43 PM, the DON said each department was responsible for completing their section in the discharge summary. She said she expected the charge nurse to complete a discharge progress note in the electronic medical record at time of discharge. The discharge summary was to be completed by the IDT for all residents, with a copy provided to the resident, their family, or the facility where the resident was being admitted . She said the IDT consisted of department heads including Rehab, Social Services, Nursing, and Dietary. The DON said the risk of not completing a discharge summary could place the resident at risk for missing follow up appointments, missed medications, and delayed communication. During an interview on 06/19/25 at 1:58 PM, LVN P said the Unit Managers were supposed to complete the discharge summary, which included a recapitulation of the resident's stay. She said there was no reason why a discharge summary and/or progress note should not be completed. She said the summary should include discharge teaching, medications, diet, follow-up appointments, and special instructions. She said a progress note should also be completed to include the mode of transportation. She said she did not know why she had not completed the discharge summary for CR #2. LVN P said the risk of not completing the discharge summary could lead to a resident's decline because their plan of care would not continue without the completed discharge summary. During a telephone interview on 6/19/25 at 3:19 PM, LVN M said a discharge progress note and a completed discharge summary were part of a resident's EMR, and the DON overlooked the process. She said the discharge summary should be signed and given to the resident, RP, or admitting facility at time of discharge. LVN M said failure to complete a discharge summary could result in inadequate care for a resident. During an interview on 06/19/25 at 4:00 PM, the Administrator said discharge summary was a collaboration from the IDT. The Administrator said the discharge summary included a recapitulation of the resident's stay at the facility, including medications and follow-up appointments. The Administrator said she also did not notify the ombudsman of the residents' discharge. She said she was aware of the regulation requiring notification to the ombudsman regarding the discharge of CR#1 and CR#2; however, she forgot to make a notification for both residents. The Administrator said failure to complete a discharge summary and notify the ombudsman placed the resident at risk of not knowing what was needed for continuity of care. Record review of the policy, Transfer and Discharges revised date 4/22/25 read in part . Policy: The facility will follow the limited conditions under which CMS has outlined how the facility may initiate transfer or discharge of a resident, the documentation that must be included in the medical record, and who is responsible for making the documentation. Additionally, the facility will ensure the information that must be conveyed to the receiving provider for residents being transferred or discharged to another healthcare setting is provided in accordance with federal guidance. The facility will also provide transfer/discharge notice to the resident/responsible party in accordance with federal regulations. The facility should refer to Notice of Transfer or Discharge Policy for additional details. Documentation: [NAME] the facility transfers or discharges a resident under any of the circumstances specified, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. (i) Information provided to the receiving provider must include a minimum of the following: a. Contact information of the practitioner responsible for the care of the resident. b. Resident representative information including contact information c. Advance Directive information d. All special instructions or precautions for ongoing care, as appropriate e. Comprehensive care plan goals; f. All other necessary information, including a copy of the resident's discharge summary .

Based on interview and record review, the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for 1 (Resident #1) of 5 residents whose records were reviewed for pressure ulcer care. 1. The facility failed to minimize Resident #1's exposure to moisture and keep the skin clean of fecal contamination, after the resident was discovered to have moisture associated skin damage to her sacral region. 2. The facility failed to implement Resident #1's wound care treatment orders to a facility acquired wound to her sacral region, which led to the decline of the wound from a stage III to a stage IV pressure ulcer. Resident #1 was admitted to the hospital with a diagnosis of sepsis, Staphylococcus aureus, and gram-negative rods. An IJ was identified on 07/04/24 at 5:27 pm. The IJ template was provided to the facility on [DATE] at 5:27 pm. While the IJ was removed on 07/07/24, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to monitor the implementation of the plan of removal. This failure could place residents at risk of the formation of new or worsening skin breakdowns and a decrease in their quality of life and care. Findings included: Record review of Resident #1's face sheet on 07/02/24 revealed an eighty-year-old woman who was admitted to the facility on [DATE]. Her admitting diagnoses were Myasthenia [NAME] (neuromuscular disorder causing weakness of skeletal muscles), elevated white blood count, Type 2 Diabetes (insulin resistance), hypertension (high blood pressure), and syncope and collapse (fainting and passing out). Record review of Resident #1's care plan dated 05/23/24 revealed that she had urinary incontinence, and her goal was to have no skin break downs. Interventions for this focus were to assist with toileting as needed and to perform peri care as needed. Record review of Resident #1's BIMS score dated 05/23/24(clinical assessment to determine resident's strength and needs) a score of 7out of 15 indicating the resident was, moderately impaired. Record review of Resident #1's Admission/Readmission assessment dated [DATE] noted that there was moisture associated skin damage to the peri area. Record review of Resident #1's Braden Scale for predicting pressure score risk and risk factors, completed by physician dated 06/04/24 described the skin as very moist and she was chairfast, as her ability to walk was severely limited or non-existent. Nutrition was noted to be adequate, and friction and shear posed as a potential problem because the resident would occasional slide down in the chair or bed. Additional risk factors were a history of pressure ulcers (prior to facility admittance), urinary or bowel incontinence, bedfast, decreased, or impaired bed/ chair mobility, and diabetes. On a score of 1-18, Resident #1 was identified as a 15, indicating a mild risk. Record review of Resident #1's Progress Notes during a visit with physician on 06/06/24, revealed that her skin had no suspicious lesions and was described as warm and dry. Record review of Resident #1's wound care notes from the WCD documented that he initially viewed the sacral wound on 06/12/24. The wound was debrided at bedside and the new orders given were santyl/calcium alginate and zinc oxide applied to the wound with the recommendation of a low air mattress for wound stabilization. Resident #1's wound to the sacral region was documented as a stage III pressure ulcer. Record review of Resident #1's wound care notes from the WCD, dated 06/19/24, revealed that her wound on the sacral region had declined to stage IV pressure ulcer. Orders were to use Santyl/calcium alginate and zinc oxide applied to the wound with the recommendation of a low air mattress for wound stabilization. Record review of Resident #1's TAR ordered on 06/07/24, revealed to cleanse the sacrum with non-saline wound cleanser, pat dry, apply TAO (triple antibiotic ointment) and zinc oxide, cover with clean dry dressing daily until healed. On 06/19/24, the TAR reflected that the orders for the sacrum were to cleanse with non-saline or wound cleanser, pat dry, apply Santyl/calcium alginate, zinc oxide, and apply dressing. No orders were added on 6/12/24. Record review of Resident #1's facility progress notes stated that on 06/23/24, CNA A reported that during a transfer, Resident #1 began to shake, was drowsy, and eyes rolled to the back of her head. She had a bowel movement that saturated her brief, pants, and ran onto the wheelchair. Resident was sent out to hospital. Record review of Resident #1's hospital admittance record dated 06/26/24 revealed a diagnosis of sepsis, the Sacral wound culture identified Staphylococcus aureus, and the urine culture from 6/23/24 showed Gram-negative rods (bacteria commonly found in infections). In an interview on 07/03/24 at 1:24 pm, CNA A stated that Resident #1 would often have bowel movements and she would need to be changed frequently. She explained that her diarrhea was so bad that when she performed peri care, she would have to change the bedding as well. She stated that the bandages on her sacrum wound were often saturated during peri care and the wound care nurse would redress it if she was there. She explained that on 06/23/24, she saw the wound for the first time and saw feces inside of the wound once she removed the bandage. She alerted WCN A to come clean the wound because CNAs were not allowed to bandage them. In an interview on 07/03/24 at 1:59 pm with Nurse A, she stated that she only saw the wound once upon her initial admission assessment and had no idea of its deterioration or saturation during incontinent care. She stated that she never touched the wound because she said that it was always covered, and the wound was cleaned daily by a WCN. Nurse A explained that Resident #1 used the restroom a lot and the staff tested her for c-diff (bacterium known for causing diarrheal infections), but her results came back negative. She stated that when she returned from the hospital on 06/04/24, she was on antibiotics. She explained that no one had told her that Resident #1's wound was getting worst and although she performed monthly skin assessments, she was not assigned Resident #1's room number. In an interview on 07/03/24 at 2:14 pm with CNA B, she stated that she worked PRN but when she worked with Resident #1, she remembered her having frequent bowl movements. She remembered her having a wound on her bottom but could recall how it looked. In an interview on 07/03/24 at 2:22 pm with Nurse B, he stated he performed Resident #1's readmission skin assessment on 06/04/24 and he did not know she had a sacral wound until after her discharge on 06/23/24. During her readmission skin assessment, she had excoriation and redness to her sacral region, but it was not a pressure sore. Upon her return, she was also prescribed an antibiotic for a chronic UTI . He was not aware if she had frequent bowel movements and he also had never seen the WCD. He expressed that if the wound was covered in fecal matter he would change the bandage, but he never had to. CNA's were not permitted to change bandages but they would alert the nurse if something needed to be done. He stated in his previous years of working at the facility, the WCN would tell the nurse the status of the wound so that they could add it to their 24-hour report. In an interview on 07/03/24 at 4:04 pm with WCN A, she explained that she was originally a floor nurse and was asked to become the WCN on 06/10/24. She was supposed to receive training from WCN B on 06/10/24- 06/14/24, however she only received training 06/10, 06/11, and 06/14. After rounds with the wound WCD on 06/12/24, she was supposed to complete charting and input new orders from the doctor into the computer. These orders were sent to DON B and WCN B. WCN A did not have access to receive orders at that time and were given to her by DON B, WCN did not have time to finish updating the orders the treatment log and DON B told her that she would get WCN B to input them before his last day on 06/14/24. WCN A stated she had a feeling the orders were not in, but DON B ensured her they had already been updated by WCN B. WCN A stated that she continued with the order entered on 06/07/24 and no air mattress was given to Resident #1 until 06/19/24. WCN A stated that she did not feel secure in this position when she first started because she did not receive a lot of training. She recalled a conversation she had with WCN B when she asked him how do you know if the wound was improving or getting worst in which he replied, you don't. She explained that she received her first official wound training on 07/02/24 and she now felt more confident in this position. She stated that every time she conducted wound care, she would change Resident #1 because she was always covered in urine and feces due to loose, f requent stools, and her bandage would be saturated through. She believed she was the only one to change the bandage because she always initialed and dated the bandage. The next day, the same bandage would still be on her wound. On 06/23/24 during a transfer from the bed to wheelchair with CNA A, Resident #1 became very weak and lethargic. CNA A stated that her eyes had rolled into the back of her head and that she had begun to shake, but it had stopped once she entered the room. WCN A checked Resident #1's BP was 96/60. Initially, WCN A instructed CNA A to transfer her back into the bed because she had a history of syncope . In doing so, Resident #1 had a bowel movement that saturated through her brief, bottoms, and onto the wheelchair. The stool was described as yellowish brown, and a stool sample was collected. The Physician was notified, and Resident #1 was sent to the hospital. In an interview on 07/03/24 at 4:49 pm with WCN B, he stated he was hired in October 2023 as the admissions nurse but ended up preforming wound care prior to his last days. He stated he had stepped in the role as the treatment nurse because the census was low and that determined the number of hours he could work. In order to receive more hours, he decided to preform wound care under the supervision of the WCD. His last week at the facility was from 06/10/24 - 06/14/24, and he was instructed to train WCN A on how to treat wounds, input orders, and update notes into the resident portal. On 06/12/24, he did not round with the WCD because he did not work that day and he still believed the wound to be a moisture associated skin damage. Prior to 06/12/24, Resident #1's orders were to put zinc oxide on her sacrum, and he stated that he did not receive orders from the wound doctor because he could not access his email. He explained that all orders and progress notes from the WCD went directly to DON B, and she would print them out and give them to him. He stated that he did not recall Resident #1 having new orders for Santyl/calcium and she was not on a low-pressure mattress prior to his last day on 06/14/24. He stated that inputting orders were the WCN's responsibility, but it would ultimately fall on DON B since she was the only one to receive them. WCN B stated that when he worked with Resident #1, her bandage on the sacral region would not be saturated through, but he knew it would be same bandage from the day before due to his initials and the date he had written on it. In an interview on 07/03/24 at 5:11 pm with DON A, she stated that she started on 06/24/24 but was familiar with facility policy and Resident #1's file. She said that DON B's last day as the DON was on 06/13/24. She explained that WCN B did have access to the orders because only the WCN and the DON had the permissions to access the WCD's portal. She said that WCN B told DON B that he had completed entering the orders in the system, however as the DON , DON A stated she would have followed up to make sure it had been completed. She had noticed that upon her original admittance of 05/22/24 until her second readmittance on 06/04/24, resident #1 had already been on several round of antibiotics and she was also taking an 850mg twice daily dosage of metformin, which had the tendency to create loose stools. She stated all nurses have the responsibility to change bandages and it was crazy that were not changing Resident #1's bandages if saturated after a bowel movement. She explained the detriment in not keeping a sacral wound clean would be risk of sepsis and infections. In regard to WCN A's training, the facility was under the impression that WCN B would extend his resignation a few days longer to complete his training with WCN A, but he changed his mind and proceed to make his last day on 06/14/24. Normally, WCN A would have gone to the facility's sister facility to receive more detailed wound care training, however the facility was temporarily closed due to water damage from a storm that hit the region earlier that season. She was trained and check listed for her skills on 07/03/24 with a regional wound care nurse. DON B was contacted by phone on 07/04/24 at 11:40 am for an interview. She did not answer. A voicemail and text message were left requesting a call back. The Administrator was notified of the IJ on 07/04/24 at 5:27 pm and given the IJ template due to the above failures and a POR was requested. The POR was accepted on Friday 07/05/24 at 1:05 pm, and reflected the following: Failure: o The facility failed to ensure Resident #1 received proper wound care and implement physician's orders. Corrective Action for resident found to be affected: o Resident was discharged to the hospital on June 23,2024. Identification of others having the potential to be affected: o An audit was completed on July 4, 2024 by the DON and ADON to ensure residents with wounds have appropriate wound / treatment orders in place. No new areas identified with no negative findings. o Skin assessments were completed on July 4, 2024 by the nursing admin team to include the Director of nursing, assistant director of nursing, nursing supervisor and wound care nurse for current residents to ensure all wounds have physicians orders in place for treatments for those identified with wounds. No new areas were identified with no negative findings. o Braden Scales were reviewed and updated by the nursing admin team to include the Director of nursing, assistant director of nursing, nursing supervisor and wound care nurse for current residents on July 4, 2024. Measures / systemic changes to ensure the deficient practice does not recur: o Education of licensed nursing staff related to wound care / dressing changes to include completing dressing changes as needed on all shifts starting on July 4, 2024. Nursing staff will not be allowed to work until they have received the education which will be provided prior to the start of their shift. o Education of licensed nursing staff related to obtaining and implementing physicians orders for residents with wounds starting on July 4, 2024. Nursing staff will not be allowed to work until they have received the education and will receive education prior to the start of their shift. o Education of licensed and certified nursing staff related to incontinent care and keeping residents clean and dry starting on July 4, 2024. Nursing and certified nursing assistant staff will not be allowed to work until they have received the education and will receive education prior to the start of their shift. o Education of certified nursing staff related to notifying a licensed nurse when a dressing is soiled starting on July 4, 2024. Nursing staff will not be allowed to work until they receive the education which will be completed prior to the start of their shift. o All education will be completed by the Director of nursing or the Assistant Director of Nursing or designee. o Director of Nursing, Assistant Director of nursing or nursing supervisor will observe wound care twice weekly. o Director of Nursing, Assistant Director of Nursing and Nursing Supervisor and wound care nurse were educated by the Regional Director of Clinical Services on July 4, 2024. o Medical Director was notified of the IJ on July 4, 2024. o Root cause analysis completed on July 5, 2024, and taken to QAPI . o QAPI to be conducted on July 5, 2024. Facility Plan to ensure compliance: o QAPI will be completed on July 5, 2024. o Education will be completed prior to nursing staff working. o Education will be provided upon hire for new associates. o New admissions will be reviewed daily to ensure residents admitted with wounds have a physician's order for treatments. o Random rounds will be completed daily by licensed nursing staff to ensure residents are clean and dry and that dressings are clean and dry. o DON / Designee will audit residents with wounds weekly to ensure proper treatments are in place. Audit will be completed by reviewing residents with wounds physician's orders. o DON / Designee will do random rounds 3-5 times a week visualizing residents with wounds to ensure dressings are clean and dry. o Weekly skin assessments will be monitored 5X per week to ensure completion. In an interview on 07/05/24 at 10:39 am with DON B, she stated that her last day as the DON at the facility was on 06/16/24 but she currently worked PRN. She stated that to her knowledge, Resident #1 was admitted with a wound, but she could not describe how it looked initially, what wound stage it was, or how it had progressed. On 06/15/24, DON B saw the wound for the first time, after a CNA told her that the bandage had fallen off and it needed to be redressed. At the time, the wound had yellow sloughing on it but there was no odor. She asked WCN A what was the treatment orders for the sacral wound and she stated that the WCD gave new orders on 06/12/24. DON B stated that she instructed WCN B to put the updated orders for residents in the system on 06/13/24 and he informed her that it had been completed. DON B recalled that she looked through some of the new orders for wounds, but she did not look through all of them and stated she spot checked the system to see if they had been updated. She explained that normally after the WCD finished rounding at the facility, they wound meet and discuss the orders for each resident. However, that day , she did not arrive to facility until later and did not get to touch base with the WCD. Once the WCD had finished his rounds and uploaded his paperwork, DON B would print the orders off and hand them to the WCN. She stated that she was not 100% sure if WCN B had access to the portal where she retrieved the orders from because WCN B had transitioned into the position because it was open. On 06/12/24, DON B pulled the orders for WCN A because she did not have access to them, and she could not confirm if she had access after she left on 06/16/24 because she did not follow up. She explained that after she saw the wound on 06/15/24, she checked the orders in the system and saw a PRN (she could not recall what it stated) that she felt was not appropriate for the condition of the wound. WCN A told her that there were new orders for Resident #1, and she told her to make sure they were carried out, however she did not contact the WCD about the status of her access. In an interview attempt physician was contacted by phone on 07/05/24 at 10:55 am and on 07/06/24 at 11:00 am. He did not answer, and a voicemail was left regarding a call back. Monitoring/Verification of Plan of removal The POR was reviewed as followed. The facility created a binder and numbered each tab in the binder with the completed documented necessary to fulfill the plan. Saturday, July 06, 2024, at 10:30am Identification of others having the potential to be affected: o An audit was completed on July 4, 2024, by the DON and ADON to ensure residents with wounds have appropriate wound / treatment orders in place. No new areas identified with no negative findings. -Reviewed the POR binder and saw that there were 14 residents out of 39 residents currently at the facility with wounds. The 14 residents with wounds had their treatment order reconciled and examined on 07/04/24 for accuracy. All treatment orders were accurate. o Skin assessments were completed on July 4, 2024, by the nursing admin team to include the Director of nursing, assistant director of nursing, nursing supervisor and wound care nurse for current residents to ensure all wounds have physician's orders in place for treatments for those identified with wounds. No new areas were identified with no negative findings. -Skin sweeps were documented and completed for 36 residents at the facility. The census was 30, but two residents were discharged , and one was at the hospital. o Braden Scales were reviewed and updated by the nursing admin team to include the Director of nursing, assistant director of nursing, nursing supervisor and wound care nurse for current residents on July 4, 2024. Measures / systemic changes to ensure the deficient practice does not recur: -Review of Braden skin assessment reflected that 36 assessment had been completed for each resident in the facility. The updated scores were reflected on the resident roster and a copy of each Braden assessment was provided to the surveyor. Although there was a current census of 39 residents, 2 residents were discharged , and 1 was in the hospital. o Policies and procedures related to wound care and treatments were reviewed and utilized for education. -Review of the policies showed no changes. o Education of licensed nursing staff related to wound care / dressing changes to include completing dressing changes as needed on all shifts starting on July 4, 2024. Nursing staff will not be allowed to work until they have received the education which will be provided prior to the start of their shift. -Review of employee roster showed that there were 48 direct care staff at the facility. Of these staff, the DON stated that all full time and part-time employees had been educated. The number of employees on 07/05/24 revealed that 29 employees had been educated on wound care and dressing changes. The DON informed the investigator that the remainder of employees she was not aware of who they were, or they were active employees. DON Consulted with the corporate hiring staff and got an updated number for the employee roster. A total of 38 direct care staff were identified. Of these 38 staff, 3 staff members were on vacation for 2 weeks and one staff member was on 6 months of medical leave. Out of 34 staff currently working, 6 were left to be interviewed. This consisted of DON B, an interim treatment nurse, and the others were CNA's. Topics covered were what to do when a dressing came off during changing and nurses were responsible for wound care of each shift if needed, treatment order policy and skin integrity, and the PU policy was reviewed. A total 29 signatures were on the sign in sheet for staff. o Director of Nursing, Assistant Director of Nursing and Nursing Supervisor and wound care nurse were educated by the Regional Director of Clinical Services on July 4, 2024. -This review reflected that both ADON's, DON, and WCN were educated by the regional director of clinical services. Topics included wound care, physician orders, monitoring of wounds, wound treatment, and policies and procedures. Sunday, July 07, 2024 Reviewed the education of licensed and certified nursing staff related to incontinent care and keeping residents clean and dry starting on July 4, 2024. Nursing and certified nursing assistant staff will not be allowed to work until they have received the education and will receive education prior to the start of their shift. Reviewed the education of certified nursing staff related to notifying a licensed nurse when a dressing is soiled starting on July 4, 2024. Nursing staff will not be allowed to work until they receive the education which will be completed prior to the start of their shift. In an interview on 07/07/24 at 1:03 pm with CNA A, she stated she worked the 6am- 2pm shift. She attended the wound care in-service and was told to always notify the nurses. Staff must notify the nurses immediately if they see any changes in the skin. If giving incontinent care, staff should always let the nurse know that there should be a new bandage on the wound and clean it good. If a resident had wounds, staff were to reposition every 2 hours. The abuse coordinator was the administrator. In an interview o n 07/07/24 at 1:07 pm with CNA C, she stated that she worked the 2pm- 10pm shift. She explained that in the in- service they covered and were taught to make sure when you are with a patient with wounds, clean them, and if you have to take off the bandage, notify the nurse immediately so they can change it. They covered wounds to make sure if they did have a wound, they must be turned and repositioned every 2 hours. Staff must make sure they are comfortable. The abuse coordinator was the administrator and staff reported to the charge nurse too, but especially the administrator. In an interview on 07/07/24 at 1:57 pm with CNA D, she stated she worked 6am -2pm shift. The in-service covered at the facility had a patient with wounds and how to do patient care. If the wound was contaminated by feces, CNAs were to let the nurse know so that the nurse could come and change the bandage. If staff noticed changes to the skin or to a wound, they were to alert the nurse. If a person had a wound on their bottom, aides were to reposition or turn them every 2 hours to get them off the wound. The abuse coordinator was the ED . In an interview on 07/ 07/24 at 2:05 pm with CNA E she stated she worked that the 10pm- 6am shift. For CNA's, they covered that if staff go in and clean a person with wounds, if they have a BM and it goes into the dressing, they taught them how to properly clean it and properly take off the bandage. Aides were to clean them properly and notify the nurse immediately. If staff saw changes in a resident's skin, they were to report it and she would notate it in the resident portal. Aides used the zinc oxide cream and another cream as a preventative measure so residents would not get new wounds. Staff were supposed to reposition every 2 hours. She stated personally she would check on residents every hour because they would flip over because they didn't like to stay in the same position. The abuse coordinator was the administrator. In an interview on 07/07/24 at 1:33 pm with CNA B, she stated she worked the 2pm- 10pm shift. They had an in-service for incontinent care and wounds. If aides saw a wound developing on a resident or any changes developing on the wound, they should let a nurse know. If the bandage was soiled or had fallen, aids would not replace it, but they should let the nurse know about immediately. As an aid, when a resident had a wound on the bottom, they were to make sure the resident stayed dry and if possible, we would put a wedge on the resident so they can stay off the wound. Staff were to reposition them every 2 hours. The abuse coordinator was the administrator. In an interview on 07/07/24 at 1:54 pm with CNA F, she stated she worked the 2pm- 10pm shift. The in-service covered: staff were to make sure that the dressing was dry. If it was soaked through or off, aids were to go call the nurse so they could change it and put on a new one. Aids should notify the nurse as soon as they noticed any changes to the skin or the wounds. Residents should reposition them every 2 hours. The abuse coordinator was the administrator. In an interview on 07/07/24 at 2:02 pm with Nurse C, she stated she worked the 2pm-10pm shift. The facility in-service covered skin integrity and how they assessed the wound. If a CNA saw a soiled bandage, they should tell her. She would then take it off, clean it, and apply a new dressing according doctors treatment plan. A nurse should change a residents wound dressing whenever it was soiled or whenever it needed to be. A resident with wounds should be repositioned every two hours. Treatment orders for wounds are found in the doctor's medication order and they must follow whatever the WCD prescribed. The abuse coordinator is the Admin . In an interview on 07/07/24 at 3:35pm pm with Nurse D, she stated she worked the 10pm- 6am shift. Nurses were educated on wound policy, reminded that they needed to check to see what wound orders consisted of, not to wait for the wound nurse, and if they should carry out wound care if they saw that it was needed. If they saw anything, they should notify the doctor. If nurses saw a wound dressing that needed to be changed, they needed to check the orders and carry it out. They have an order for everything. Staff should not take anything upon yourself but must carry the order out exactly how it was stated. If changes were noticed, they were to describe the wound and tell the doctor. Aids (CNAs) were to notify the nurses immediately. Nurse D stated they did have an order for creams, but if she saw any redness, she would still notify the doctor. A resident should be repositioned every 2 hours, and if they started to complain, she would work with them for their comfort. The administrator was the abuse coordinator. In an interview on 07/07/24 at 3:42 pm with Nurse E, she stated worked the 6am- 2pm shift. She explained that the in-service covered when the dressing was soiled, the CAN's were to notify the nurse will remove the dressing and preform wound care. Redress the wound. She would retrieve the orders from the TAR and follow them exactly how they are in the TAR. The wound care was daily, but some wounds have orders for as needed. A nurse might change the bandage on a wound if the bandage is soiled or off. Daily and as needed. The CNA should notify us immediately of any skin changes and she would notify the doctor as soon as permissible. A resident should be repositioned as need and every 2 hours. They covered abuse and neglect, and the abuse coordinator was the ED or administrator . In an interview on 07/07/24 at 3:48 pm with WCN A, she stated she worked Monday through Friday and started her shift at 6am until her tasks were completed. She explained that aids were taught what to do when they see the bandage soiled. They were to tell wither herself or the nurse so it could be changed. Nurses must be notified of any changes they see. She stated that she also did skin sweeps to check everyone's skin and the Braden scales skin test. Nurses were allowed to do wound care when they are working, and they have orders in the computer for it. Staff now understood the expectations and WCN A felt they were willing to do everything. She also said that nurse have access to the keys on her cart and they knew what type of medication to use. The orders were in the computer, and she also updated PRN orders for all wounds. Nurses should notify the doctor if they saw any signs of infection, like discharge or saw any changes on the wound itself. The abuse coordinator was the administrator. All residents should be repositioned every 2 hours or sooner. WCN A also clarified that she now had access to get wound orders from the WCD, who directly sent her the information after each visit. In an interview on 07/07/24 at 3:29 with Nurse A, the stated that in the case a CNA told a nurse that the wound was declining, nurse would have to report to wound doctor or the doctor in charge. If the CNA told the nurses that the dressing was coming off, or like if they had a BM, nurses were to change the dressing. All aides (CNAs) must notify us immediately. The treatment card displayed the treatment orders. Nurses preformed skin integrity sweeps on residents weekly and it can be viewed in the computer if there was a scheduled date. Residents with wounds should be repositioned every 2 hours at least. The abuse coordinator was the administrator. In an inter [TRUNCATED]

Based on observation and interview the facility failed to ensure the menus were followed for 3 meal services prepared for 36 of 36 residents. The facility failed to ensure the menu was followed for the lunch meals on 5/21/24 and 5/22/24 and the dinner meal on 5/22/24. These failures could place residents at risk for dissatisfaction, poor intake, and/or weight loss. The findings included: Interview on 05/21/24 at 10:20 AM with [NAME] A revealed the kitchen manager is out on medical leave and the manager from another facility comes in a few times a week to order food and check the menu. [NAME] A said she was not aware of any complaints from residents about the food. Observation on 5/21/24 at 11:00 AM of the dining room revealed a posted weekly menu which displayed the following to be served for lunch: Garlic pepper pork loin with gravy, seasoned beans and sauteed squash, cornbread, cream pie. Observation on 5/21/24 at 12:25 PM of lunch meal served to residents was: Baked Ham, diced beets, buttered noodles, dinner roll, cheesecake. Interview on 5/22/24 at 10:50 AM with Administrator revealed the Interim Dietary Manager from a sister facility comes on Wednesday, Thursday, and Friday. She does the food ordering and sanitation checks and reviews the menus. Administrator reported she was working on hiring a dietary manager . Observation on 05/22/24 at 11:30 AM of the dining room revealed a posted weekly menu which displayed the following to be served for lunch: Turkey tetrazzini, Harvard beets, dinner roll, coconut cream pudding. Observation on 05/22/24 at 11:40 AM of lunch preparations in the kitchen revealed the meal being prepared for lunch was Spaghetti, mixed vegetables, dinner roll, and a fresh fruit cup. An interview with [NAME] B revealed that the Kitchen Manager has been out for a couple of weeks for medical leave. [NAME] B said for lunch they did not have turkey, so they could not have what was on the menu and she made spaghetti instead. [NAME] B reported that they offer the meal to the resident and if they do not want it, they will make something else for them. For Residents that they know have particular foods that they do not eat, they make them an alternative meal to serve. [NAME] B said sometimes a resident will want just a sandwich, so they make them a sandwich. Observation on 05/22/24 at 12:15 PM of lunch meal served to residents in the dining room: Spaghetti, mixed vegetables, dinner roll, fresh fruit. No residents were observed eating an alternative meal. Observation on 05/22/24 at 3:18 PM of preparations for dinner revealed the evening meal to consist of: Lemon pepper fish, mashed potatoes, veggie blend, chocolate cookie. Dinner menu listed on weekly menu was: Western egg bake, fried potatoes, muffin, cinnamon apples, sugar cookie. Interview on 5/23/24 at 9:35 AM with [NAME] B. [NAME] B said when they did not have the ingredients needed for the meal listed on the menu, she tried to come up with something similar using the same main ingredients. Se said he had to get the menu change approved by the Interim Dietary Manager or Administrator. Interview on 5/23/24 at 11:30 AM with Interim Dietary Manager reveals she has been filling in since May 2nd for the Dietary Manager that went out on medical leave. Responsibilities include kitchen staffing, menus, ordering, ensuring correct diets, completion of logs, and sanitation. Food is ordered according to the planned menu. The staff here is not used to following the menu. Interim Dietary Manager reported that she tries to make sure the correct food is here so that the menu can be followed. The procedure is for the cook to get any menu changes approved by the dietitian but there has not been a dietitian on staff. Interim Dietary Manager revealed that she was aware that the Cooks have not been following the menu, but it is a work in progress to get them to follow the menu. I'm doing the best I can with 2 facilities. Interim Dietary Manager planned to do an in-service with the kitchen staff on following the menu and structure the process so things will run more smoothly. Interim Dietary Manager said she was going to work on menu items always available.

Based on observations, interviews and record reviews, the facility failed to ensure a resident receiving enteral feeding received appropriate care and services to prevent complications of enteral feeding for 1 (Resident #11) of 3 Residents reviewed for gastrostomy tube management. The facility failed to address the redness and dried red drainage around Resident #11's stoma (skin and entrance to the stomach) at the G tube (gastrostomy tube) site (a surgically placed device to give direct access to the stomach for feeding, hydration and medicine). This failure could place residents with G-tubes at risk of pain, infection, decline in health and hospitalization . Findings included: Record review of Resident #11's annual MDS for resident assessment and care screening dated 03/15/2024 revealed she had persistent vegetative state/no discernible consciousness. She had impairment on both sides of upper and lower extremities. She used a wheelchair for mobility, and she was dependent on helpers for all ADLs. She was always incontinent of urine and bowel. Section K, swallowing/nutritional status revealed she had a feeding tube. Record review of Resident #11's active physician orders dated 05/21/2024 revealed: NPO (nothing by mouth), order date 11/01/2023; enteral feed (feeding tube that allows liquid food to enter the stomach or intestine through a tube) order every shift, enteral access site care, verify tube securement is in place with an order date of 11/01/2023. Record review of Resident #11's MAR/TAR for May 2024 dated 05/21/24 at 2:00 PM, revealed LVN B documented G-tube care: clean with normal saline, pat dry with gauze and apply split drain sponge with tape, was completed during night shift on 05/20/2024. Record review of Resident #11's undated care plan revealed the focus - resident required tube feeding r/t swallowing problems. The interventions included: provide local care to G-tube site as ordered and observe for s/sx of infection at tube site, abdominal pain, tenderness. Date initiated was 12/13/2023. Focus - Resident requires Enhanced Barrier Precaution d/t G-tube. Date initiated was 04/14/2024. Goal - Resident will remain free from active infection with MDROS (multi-drug resistant organisms). Interventions included: wear gown and gloves during high contact activities. Focus - Resident has communication problem r/t Neurological symptoms after anoxic brain injury, nonverbal and unable to communicate needs. Intervention: anticipate and meet needs. Observation on 05/21/2024 at 10:27 AM, Resident #11 was lying in bed on her right side with the HOB raised and receiving tube feeding. Her eyes were open. She did not respond to greetings. CNA F and LVN A had completed incontinent care. There was a dry dressing taped over the G-tube site that was dated 05/21. LVN A loosened the dressing and the skin around the G-tube was pinkish-red in color. No drainage was noted. Observation and interview on 05/23/2024 at 8:42 AM, Resident #11 had dry dressing taped over the G-tube site that was dated 05/23. RN D loosened the dressing to view the skin. The skin around the G-tube site was a brighter red and encompassed a larger area than on 5/21/24. There was dark blackish-red dried drainage that crusted off to the side of the stoma. RN D stated the night shift was responsible for the dressing changes once a day. RN D stated she did not receive any report regarding the G-tube exit site from the night shift nurse. RN D stated that it was red and looked like it got irritated. RN D stated she would notify the MD right away as it would need Mupirocin (antibiotic ointment). RN D stated it was about a week ago when she last saw the G-tube exit site and it did not look red. RN D stated she would also notify the wound care nurse so the wound care doctor would be informed to assess the site. RN D stated the risk to the resident would be infection. In an interview on 05/23/2024 at 8:48 AM, the MD stated she saw Resident #11 and said the G-tube exit site was red and looked like a little cellulitis (a bacterial skin infection) which was not uncommon with G-tubes. The MD stated she was not notified of any redness on 5/21/2024 but maybe the NP was notified. In an interview on 05/23/2024 at 8:55 AM, Resident #11's RP stated the exit site had been red for a few days and that she was expecting the night nurse to anchor the G-tube with tape to keep it from getting tugged when they move her. The RP stated when the staff move Resident #11 around the G-tube sometimes gets pulled. RP stated she had seen Resident #11 crying when this happens, and it makes her upset to see Resident #11 cry in pain. In an interview on 5/23/2024 at 9:08 AM, LVN A stated she thought the redness around Resident #11's G-tube site was ongoing, and the night nurse did not report anything new. LVN A stated the protocol was to clean the site daily and call MD if there were any changes. LVN A stated Bacitracin (a topical antibiotic) or Triple Antibiotic Cream would have to be ordered by the physician. LVN A stated the nurses were responsible for changing the dressing and assessing the site. LVN A stated she did not work with Resident #11 very much. She stated on 5/21/2024 all she did was give her medications via the G-tube and the dressing had just been changed by night shift. LVN A stated normally if the dressing is intact, she would check the tubing prior to medication administration and would not typically look at the G-tube site unless there was drainage seen through the dressing or the dressing was loose. When asked the question, why did she not follow up with the redness to the exit site on 5/21/2024 after she observed the exit site with the Surveyor, LVN A stated she would have had to check to see if there were any orders and she did not know if there were orders at the time because she did not check. In a telephone interview on 05/23/2024 at 10:57 AM, LVN B states she did take care of Resident #11 on 5/21/2024 and that she changed the dressing to the G-tube exit site. She said the exit site had some redness and this was not new for her since Resident #11 was transferred from another unit one week ago. LVN B stated the exit site should look normal skin color and not red. LVN B stated she assumed it was red from the G-tube getting tugged on during turning/repositioning. LVN B stated she meant to return and check to see if the redness cleared up. LVN B stated she did not document because she did not get a chance to return and check on the exit site. LVN B stated the facility policy was to document, monitor, alert the wound care nurse to evaluate and recommend that it be added to the Plan of Care. On 5/23/2024 at 11:33 AM a telephone call was placed to LVN C, whose initials were documented as providing enteral access site care to Resident #11 on 05/23/2024. The voicemailbox was full. Surveyor was unable to reach LVN C or leave a message. In a telephone interview on 05/23/2024 at 12:13 PM, the NP stated she received a call from the facility on 05/2/1/2024 regarding Resident #11 but it had to do with elevating the HOB for tube feedings and not about the G-tube exit site. The NP stated she would expect to be notified of any changes to the stoma (G-tube exit site) or she would expect the wound care nurse to notify the wound care physician. On 05/23/2024 at 12:40 PM the DON stated the nurse taking care of residents was responsible for changing the G-tube dressing daily. The nurses are all charge nurses. The DON stated she expects the charge nurse to check for skin integrity, that there should be no impaired skin, ensure the tube is intact, that there are no rashes or anything abnormal. The DON stated the skin should be intact and a normal color for the resident. The DON states she expected the nurses to write a change in condition for redness, or irritation that could be an infection and to report to the physician. The DON stated there was always a risk of infection with a G-tube. The DON stated the night shift nurses were responsible for dressing changes. The DON stated for change in condition the nurse would document and put it on the 24-hour log to communicate to others. The DON said she was not present during the observation of skin irritation to Resident's #11's G-tube exit site and she did not know what could have caused the redness or skin irritation because she was not a doctor. The DON stated if the dressing were dry and intact, she would not check the exit site unless there was a reason to such as drainage. The DON stated it would be best practice to check the G-tube exit site prior to administering medications or feedings. In an interview on 05/23/2024 at 12:45 PM, the Medical Doctor stated irritation to the G-tube site could be caused by a reaction to the tubing material or leakage from the stoma. The Medical Doctor stated tugging on the tubing would not likely cause irritation. The Medical Doctor stated any changes should be notified to the provider the moment it is seen, to avoid complications like irritation or leakage. In an interview on 05/23/2024 at 2:55 PM, RN E stated she was the weekend treatment/wound care nurse and was not usually at the facility Mondays through Fridays, but the facility called her in to assist. RN E stated she did see Resident #11's G-tube exit site. RN E stated the skin had hypergranulation (a condition where the tissue becomes swollen, red, moist). RN E stated yes, the skin was an angry red color and had dried blood present. RN E stated wound care does not look at G-tube sites unless requested by the charge nurse. RN E stated the charge nurse is supposed to write a change in condition form, put an order in and after the order is in, the wound care nurse will evaluate and notify the wound care physician. RN E stated it was important to communicate these changes d/t the risk of infection and sometimes if bad enough, the resident may have to go to the hospital for tube replacement. Record review of the facility policy and procedure titled: Enteral Access Device (EAD) Site Care and Management, issued: 08/08/2023; reviewed on 08/31/2023, read in part: Policy - the facility will provide enteral access device site care and management in accordance with physician orders and professional standards of practice .Care of the feeding tube: .2.The licensed nurse will ensure the feeding tube is secured externally to prevent accidental dislodgement Because the Percutaneous endoscopic gastrostomy tube (G-tube) . exit through the abdominal wall, they require careful skin care at the exit site to maintain skin integrity and prevent infection Caring for the gastrostomy tube .Assess the tube exit site for new or increasing pain and signs of skin breakdown, redness, edema, leakage, induration (skin hardening), and bleeding .Special Considerations: if skin problems develop, consult a wound, ostomy and continence nurse if available .Complications associated with enteral feeding tube exit site care may include: .infection .leakage .pressure injury formation .Documentation associated with enteral feeding tube exit site care includes: .appearance of exit site, including any signs of infection: redness, swelling, drainage .

Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of 2 of 6 residents (CR #1 and Resident #1) reviewed for pharmacy services in that: - The facility failed to administer pain medications to Resident #1 as ordered upon admission after the resident reported pain at 10 out of 10. - The facility failed to acquire and administer medications to Resident #1 as ordered upon admission, with some seizure meds not administered until 2 days after admission. - The facility failed to accurately administer Resident #1's seizure medication Clobazam as ordered by administering Clobazam 10 mg tablets instead of 5mg films as documented in the EMR - The facility failed to retrieve Resident #1 initial dose of medications from the facility emergency kit. - The facility failed to administer medications timely to Resident #1. - The facility failed to administer tramadol to CR #1 as ordered upon admission after the resident reported pain at 5 out if 10. These failures could place residents at risk of not receiving medications as ordered by their physician, inadequate disease management, uncontrolled pain, seizures and serious harm. Findings included: Resident #1 Record review of Resident #1's Face Sheet dated 11/01/23 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: unspecified convulsion, type 2 diabetes, neuropathy (nerve pain), heart failure and high cholesterol. Record review of Resident #1's Admission MDS dated [DATE] and printed on 11/01/22 at 09:22 AM revealed, intact cognition as indicated by a BIMS score of 13 out of 15. Record review of Resident #1's Baseline Care Plan dated 10/23/23 revealed, Focus: pain, goal- resident will express pain relief, interventions- pain meds as ordered and evaluate the effectiveness of pain interventions. Record review of Resident #1's Hospital Discharge Instructions dated 10/23/23 at 12:54 PM revealed, Resident #1 admitted to the hospital due to seizures and was observed having a seizure on 10/13/23 during a neurological consultation. Resident #1 discharged with the following medications with instructions for the next administered dose: - Clobazam (a benzodiazepine controlled substance used to treat seizures) 10mg tablets, 1/2 tablet by mouth twice a day. Last dose given on 10/23/23 at 09:04 PM. - Gabapentin (used for nerve pain) 100 mg- take 2 capsule 3 times a day. Last dose given 10/23/23 at 08:57 AM. - Lacosamide (a controlled substance used to treat seizures) 200 mg- take 1 tablet 2 times a day. - Atorvastatin (used to treat high cholesterol) 80 mg- take 1 tablet by mouth nightly. Last dose given 10/22/23 at 08:53 PM. - Levetiracetam( used to treat seizures) 1000 mg- take 11/2 tablets by mouth 2 times a day. - Apixaban (a blood thinner) 5 mg- 1 tablet by mouth 2 times a day. Last dose 10/23/23 at 08:57 AM. - Metformin (used to control blood sugar) 500 mg- 1 tablet by mouth 2 times a day with meals. Record review of Resident #1's Admission assessment dated [DATE] and signed by LVN A revealed, Resident #1 arrived at the facility at 03:05 PM, and the resident's medications were verified by NP A. LVN A wrote Resident #1 was reporting pain 10/10 at the time both feet stated she suffers from neuropathy. Record review of Resident #1's Pain Level Summary dated 10/23/23 at 6:56 PM signed by LVN A revealed, Resident #1 reported pain at 10 out 10. Record review of Resident #1's Progress Notes dated 10/25/23 at 09:51 PM and signed by LVN A revealed. clobazam 5mg tablets just arrived from pharmacy NP verbal order per DON to give when it arrived. Record review of Resident #1's Pharmacy Records dated 10/30/23 revealed, - An electronic prescription for Lacosamide 200 mg was not sent until 10/24/23 at 02:09 PM. - An electronic prescription for Clobazam 5 mg film (a backordered product) instead of Clobazam 10 mg tablets as ordered on the hospital discharge records was first sent to the pharmacy on 10/24/23 at 07:01 PM. Record review of Resident #1's Order Summary dated 10/26/23 revealed, the following medications were entered on admission (10/23/23) but were started on 10/24/23 the day after Resident #1 admitted to the facility: - Apixaban 5 mg- 1 tablet by mouth 2 times a day - Atorvastatin 80 mg- take 1 tablet by mouth nightly. - Clobazam 5 mg Film, give 5 mg by mouth twice a day. The order was entered incorrectly as film instead of tablets as ordered in the hospital discharge, - Gabapentin 100 mg- - take 2 capsule 3 times a day. - Lacosamide 200 mg- take 1 tablet 2 times a day. - Levetiracetam 1000 mg- take 11/2 tablets by mouth 2 times a day. - Metformin 500 mg- 1 tablet by mouth 2 times a day with meals. Record review of Resident #1's Order Summary dated 10/31/23 at 12:38 PM revealed, - Clobazam 10 mg- give 1/2 tablet by mouth 2 times a day- ordered on 10/26/23 Record review of Resident #1's Physician Order dated 10/31/23 revealed, Donepezil 10 mg- 1 tablet by mouth at bedtime for dementia. Record review of Resident #1's October MAR printed 11/01/23 at 09:37 AM revealed, Resident #1 did not receive the following medication. - Apixaban 5 mg- 1 tablet by mouth due in the evening of 10/23/23. - Atorvastatin 80 mg- take 1 tablet by mouth due in the evening of 10/23/23. - Clobazam 5 mg Film- give 5 mg mouth due in the evening of 10/23/23, on 10/24/23 due at 08:00 AM and 4:00 PM, on 10/25/23 due at 8:00 AM. - Gabapentin 100 mg- - take 2 capsules by mouth due in the evening of 10/23/23. - Lacosamide 200 mg- take 1 tablet by mouth due in the evening of 10/23/23 and on 10/24/23 due at 08:00 AM and 04:00 PM. - Levetiracetam 1000 mg- take 11/2 tablets by mouth due in the evening of 10/23/23. - Metformin 500 mg- 1 tablet by mouth due in the evening of 10/23/23. - Donepezil 10 mg 1 tablet by mouth due at 9 PM on 10/31/23. Resident #1 was administered Clobazam 5 mg Film on the following days when the medication was not available: 10/25/23 scheduled for the 4:00 PM evening dose. 10/26/23 scheduled for the 8:00 AM morning dose. Record review of Resident #1's Medication Audit Report dated 11/01/23 at 01:27 PM revealed, the facility failed to administer medications timely (+/- 1 hr. of the scheduled administration time) to Resident #1 on 69 different occasions between 10/24/23 and 11/01/23 with no documented reason: The morning of 10/24/23 1- Gabapentin 100 mg- 2 capsules scheduled for 08:00 AM and administered at 10:34 AM. 2- Levetiracetam 1000 mg- 1 1/2 tablets. Scheduled for 08:00 AM and administered at 10:34 AM. 3- Metformin 500 mg- 1 tablet with meals. Scheduled for 08:00 AM and administered at 10:34 AM. 4- Apixaban 5 mg- 1 tablet . Scheduled for 08:00 AM and administered at 10:34 AM. The evening of 10/24/23 5- Gabapentin 100 mg- 2 capsules. Scheduled for 04:00 PM and administered at 05:25 PM. 6- Levetiracetam 1000 mg- 1 1/2 tablets. Scheduled for 04:00 PM and administered at 05:25 PM. 7- Metformin 500 mg- 1 tablet with meals. Scheduled for 04:00 PM and administered at 05:25 PM. 8- Apixaban 5 mg- 1 tablet . Scheduled for 04:00 PM and administered at 05:25 PM. The morning of 10/25/23 9- Gabapentin 100 mg- 2 capsules scheduled for 08:00 AM and administered at 09:20 AM. 10- Levetiracetam 1000 mg- 1 1/2 tablets. Scheduled for 08:00 AM and administered at 09:21 AM. 11- Metformin 500 mg- 1 tablet with meals. Scheduled for 08:00 AM and administered at 09:21 AM. 12- Apixaban 5 mg- 1 tablet . Scheduled for 08:00 AM and administered at 09:20 AM. 13- Lacosamide 200 mg- 1 tablet. Scheduled for 08:00 AM and administered at 09:21 AM. The afternoon of 10/25/23 14- Gabapentin 100 mg- 2 capsules scheduled for 12:00 PM and administered at 02:28 PM. The evening of 10/25/23 15- Gabapentin 100 mg- 2 capsules. Scheduled for 04:00 PM and administered at 06:39 PM. 16- Levetiracetam 1000 mg- 1 1/2 tablets. Scheduled for 04:00 PM and administered at 06:39 PM. 17- Metformin 500 mg- 1 tablet with meals. Scheduled for 04:00 PM and administered at 06:39 PM 18- Apixaban 5 mg- 1 tablet . Scheduled for 04:00 PM and administered at 06:39 PM. 19- Lacosamide 200 mg- 1 tablet. Scheduled for 04:00 PM and administered at 06:40 PM. 20- Clobazam 5mg film- 5 mg. Scheduled for 04:00 PM and administered at 09:53 PM. 21- Gabapentin 100 mg- 2 capsules. Scheduled for 08:00 PM and administered at 09:32 PM. The morning of 10/26/23 22- Gabapentin 300 mg- 1 capsule scheduled for 08:00 AM and administered at 10:03 AM. 23- Levetiracetam 1000 mg- 1 1/2 tablets. Scheduled for 08:00 AM and administered at 10:03 AM. 24- Metformin 500 mg- 1 tablet with meals. Scheduled for 08:00 AM and administered at 10:03 AM. 25- Apixaban 5 mg- 1 tablet . Scheduled for 08:00 AM and administered at 10:03AM. 26- Clobazam 5 mg film- 5 mg. Scheduled for 08:00 AM and administered at 10:03 AM. 27- Lacosamide 200 mg- 1 tablet. Scheduled for 08:00 AM and administered at 10:03 AM. The morning of 10/27/23 28- Gabapentin 300 mg- 1 capsule scheduled for 08:00 AM and administered at 09:14 AM. 29- Levetiracetam 1000 mg- 1 1/2 tablets. Scheduled for 08:00 AM and administered at 09:14 AM. 30- Metformin 500 mg- 1 tablet with meals. Scheduled for 08:00 AM and administered at 09:14 AM. 31- Apixaban 5 mg- 1 tablet . Scheduled for 08:00 AM and administered at 09:14 AM. 32- Clobazam 5 mg- 5 mg. Scheduled for 08:00 AM and administered at 09:14 AM. 33- Lacosamide 200 mg- 1 tablet. Scheduled for 08:00 AM and administered at 09:14 AM. The evening of 10/27/23 34- Gabapentin 300 mg- 1 capsule. Scheduled for 04:00 PM and administered at 05:28 PM. 35- Levetiracetam 1000 mg- 1 1/2 tablets. Scheduled for 04:00 PM and administered at 05:29 PM. 36- Apixaban 5 mg- 1 tablet . Scheduled for 04:00 PM and administered at 05:28 PM. 37- Lacosamide 200 mg- 1 tablet. Scheduled for 04:00 PM and administered at 05:28 PM. The evening of 10/28/23 38- Gabapentin 100 mg- 2 capsules. Scheduled for 04:00 PM and administered at 05:50 PM. 39- Levetiracetam 1000 mg- 1 1/2 tablets. Scheduled for 04:00 PM and administered at 05:50 PM. 40- Apixaban 5 mg- 1 tablet . Scheduled for 04:00 PM and administered at 05:50 PM. 41- Lacosamide 200 mg- 1 tablet. Scheduled for 04:00 PM and administered at 05:50 PM. 42- Clobazam 10 mg- 1/2 tablet. Scheduled for 08:00 PM and administered at 09:13 PM The morning of 10/29/23 43- Gabapentin 300 mg- 1 capsule scheduled for 08:00 AM and administered at 10:10 AM. 44- Levetiracetam 1000 mg- 1 1/2 tablets. Scheduled for 08:00 AM and administered at 10:11 AM. 45- Metformin 500 mg- 1 tablet with meals. Scheduled for 08:00 AM and administered at 10:11 AM. 46- Apixaban 5 mg- 1 tablet . Scheduled for 08:00 AM and administered at 10:10 AM. 47- Clobazam 5 mg- 5 mg. Scheduled for 08:00 AM and administered at 10:10 AM. 48- Lacosamide 200 mg- 1 tablet. Scheduled for 08:00 AM and administered at 10:10 AM. The evening of 10/29/23 49- Gabapentin 100 mg- 2 capsules. Scheduled for 04:00 PM and administered at 05:41 PM. 50- Levetiracetam 1000 mg- 1 1/2 tablets. Scheduled for 04:00 PM and administered at 05:44 PM. 51- Apixaban 5 mg- 1 tablet . Scheduled for 04:00 PM and administered at 05:41 PM. 52- Lacosamide 200 mg- 1 tablet. Scheduled for 04:00 PM and administered at 05:48 PM. The evening of 10/30/23 53- Clobazam 10 mg- 1/2 tablet. Scheduled for 08:00 PM and administered at 09:31 PM The evening of 10/31/23 54- Gabapentin 100 mg- 2 capsules. Scheduled for 05:00 PM and administered at 08:05 PM. 55- Levetiracetam 1000 mg- 1 1/2 tablets. Scheduled for 04:00 PM and administered at 08:05 PM. 56- Apixaban 5 mg- 1 tablet . Scheduled for 04:00 PM and administered at 08:05 PM. 57- Lacosamide 200 mg- 1 tablet. Scheduled for 04:00 PM and administered at 08:05 PM. 58- Clobazam 10 mg- 1/2 tablet. Scheduled for 08:00 PM and administered at 09:59 PM 59- Metformin 500 mg- 1 tablet with meals. Scheduled for 04:00 PM and administered at 08:05 PM The morning of 11/01/23 60- Gabapentin 100 mg- 2 capsules scheduled for 08:00 AM and administered at 10:03 AM. 61- Levetiracetam 1000 mg- 1 1/2 tablets. Scheduled for 08:00 AM and administered at 10:03 AM. 62- Metformin 500 mg- 1 tablet with meals. Scheduled for 08:00 AM and administered at 10:03 AM. 63- Apixaban 5 mg- 1 tablet . Scheduled for 08:00 AM and administered at 10:03 AM. 64- Clobazam 5 mg- 5 mg. Scheduled for 08:00 AM and administered at 10:03 AM. 65- Lacosamide 200 mg- 1 tablet. Scheduled for 08:00 AM and administered at 10:03 AM. Record review of Review of Resident #1's October Progress Notes revealed, Resident #1's seizure medications were not available upon admission and documentation was as follows: - 10/24/23 AT 5:24 PM signed by LVN B- Clobazam 5 mg Oral Film and Lacosamide 200 mg Tablets were on order. There was no documentation of notifying the NP/MD, Administrator or DON that the medications were unavailable. - 10/24/23 at 09:07 AM signed by LVN B- Clobazam 5 mg Oral Film was on back order. There was no documentation of notifying the NP/MD, Administrator or DON that the medications were unavailable. There was no documentation of notifying the NP/MD, Administrator or DON that medications were unavailable prior to the surveyor notifying the facility of the unavailable medications on 10/24/23 at approximately 4:00 PM. Record review of the facility undated EKit Contents revealed the facility had the following medications: - 4 tablets of Donepezil 5 mg. - 4 capsules of Gabapentin 100 mg - 4 tablets of Levetiracetam - 4 tablets of Metformin Record review of Resident #1's Individual Control Drug Records revealed, the facility received Clobazam 10 mg tablets for Resident #1 on 10/25/23 and nursing staff retrieved and administered the following doses: - 10/25/23 1/2 tablet at 09:58 PM administered by LVN A - 10/26/23 1/2 tablet at 10 AM administered by LVN B An observation and interview on 10/25/23 at 09:40 AM revealed, Resident #1 lying in bed, well dressed, well fed in no immediate distress. She said when she admitted 2 days ago her pain medications were not available as well as some other medications on her med list. Resident #1 said when she arrived at the facility she had pain at 10 out 10 and it was so bad she could not sleep but the facility did not administer her Gabapentin because her medication had not arrived yet. Resident #1 said she was currently experiencing pain and needle pain in both her feet but she could not provide a pain scale. In an interview on 10/25/23 at 09:45 AM, the Surveyor notified LVN B, that Resident #1 was reporting pain in her feet. She said she had just administered Gabapentin to Resident #1 and the resident did not report pain. LVN B said she would assess Resident #1 for pain again. In an interview on 10/25/23 at 03:33 PM, the IP said she had not heard anything about Resident #1's seizure medications being on backorder and medications should be started based on the orders on the hospital discharge records. She said Resident #1's admitted nurse should have addressed the residents pain by administering her ordered Gabapentin stat and failure to administer medications as ordered could result in uncontrolled pain and an increased risk of seizures. In an interview on 10/25/23 at 04:50 PM, the IP said she nor the DON were notified of any delays in the receiving or administration of Resident #1's seizure meds. She said she did not know the resident's Clobazam was not available, or there were delays receiving her Lacosamide. In an interview on 10/25/23 at 05:14 PM, the Surveyor notified the DON and Administrator that Resident #1's medication was unavailable and on back order. The DON and Administrator said they were never informed by nursing staff about any availability issues with Resident #1's seizure meds and they would immediately talk to the NP to get an alternative. They said failure to receive seizure medications as orders placed residents at risk of seizures. In an interview on 10/25/23 at 05:35 PM, the DON said that NP B was calling in an alternative to Resident #1's Clobazam and that the resident's Lacosamide was delayed due the provider sending in a late eScript. In an interview on 10/26/23 at 09:25 AM, the pharmacist said, the facility first received an eScript for Lacosamide 200 mg for Resident #1 on 10/24/23 at 01:09 PM and NP B verbally called in a prescription for Clobazam 10 mg on 10/25/23 at 05:30 PM. He said NP B sent in a prescription for Clobazam 5 mg Film and not tablets on 10/24/23 at 07:00 PM but that medication has been unavailable due to manufacturer production issues for a prolonged period of time so it would not be available, In an interview on 10/26/23 at 10:22 PM, NP B said she was not Resident #1's admitting NP and that she was first notified of Clobazam being unavailable for Resident #1 in the evening of 10/25/23. She said she saw the patient on Tuesday 10/24/23 but did not receive any notifications of medication availability issues until Wednesday 10/25/23. NP B said when a resident admits after 6 PM nursing staff is expected to call in the medication with the on-call provider. She said she was not aware that Resident #1 discharge orders were for 1/2 of the 10 mg tablets and never for the film. NP B said she expects medications should be ordered and next doses administered pursuant to the hospital discharge orders. NP said prior to the evening of 10/25/23 she was not notified that Resident #1 did not receive any seizure meds (Levetiracetam, Lacosamide, Clobazam) on the evening of her admission, Lacosamide and Clobazam on 10/24/23 and the Clobazam on the morning of 10/25/23. She said once she was notified of the issues with the Clobazam she immediately called in a prescription to the pharmacy for a 3 days' supply of Clobazam 10 mg tablets. She said the resident received her first dose of the tablets were on the evening of 10/25/23. NP B said she expected nursing staff to notify her of any mediation availability issues immediately so she could place an order for an alternative and the pharmacy could do a stat delivery. NP B said failure to administer medications like Levetiracetam, Clobazam and Lacosamide placed residents at risk for seizures. She said she saw Resident Tuesday, 10/24/23, and the resident complained of pain on her big toe so she prescribed Tylenol as needed, but she was never informed that the resident complained of pain or the facility failing to administer her Gabapentin on admission when the resident reported pain at 10 out of 10. NP B said she expected nursing staff to have administered Gabapentin to Resident #1 upon admission if she reported pain at 10 out 10, she believed the medication was available in the EKit, and that she should have been notified of the resident's pain. She said on 10/25/23 she saw the resident to follow up on her seizure and pain medications and the resident complained of bilateral intermittent pain in her feet so she started Resident #1 on Tylenol #3 (a controlled substance used to treat pain) and increased her dose of Gabapentin. NP B said nursing staff should have notified her of Resident #1's continued pain. In an interview on 10/26/23 at 10;40 AM, LVN A said she was the admitting nurse for Resident #1 on 10/23/23. She said when a new resident is admitting the facility the nurse gets a verbal report from the discharging facility before the resident arrives and once the resident arrive they receive the discharge packet. LVN A said the residents medications are verified with the NP from the discharge packet and the medications are started based on the documented next dose. She said she could not remember when she entered Resident #1's medication to start but the resident reported pain at 10 out of 10 so she gave her Gabapentin and received/administered an order for Tylenol but she did not document it in the MAR or EMR. LVN A said Resident #1 said her feet were hurting really bad so she contacted NP A who gave her verbal orders for Tylenol but she never documented the order in the chart. When asked if Resident #1 continued to have pain after admission she said she honestly, didn't remember. NP A said she did not go back to check on the resident until 9/10 PM and she did not call the NP to follow up on Resident #1's pain. LVN A said nursing staff are expected to follow up with the provider for issues regarding pain or medications but it was too busy that night. LVN A said she couldn't say Resident #1's Levetiracetam or other seizure meds were on her mid when she talked to the NP and she would not know if the medication was in the EKit or not. She said she did not realize that she entered Resident #1's Clobazam as a film instead of tablets and she said failure to enter medications/administer medications as ordered could place residents at risk of continued/uncontrolled pain, seizures, medication error, adverse reactions and unavailability of medications. In an interview on 10/26/23 at 01:30 PM, NP A said she was the admitting nurse for Resident #1 on 10/23/23. She said LVN A called her and read the resident's hospital discharge medications to her and she gave an order to start all medications as listed in the discharge record. NP A said she did not make any changes to Resident #1's medication order included formulations to be administered or start times. She said she expected Resident #1's medications to be started according to the next dose due as listed on the hospital record. NP A said she did not give LVN A instructions to change from Clobazam tablets to Clobazam film and LVN A never reported that Resident #1 was experiencing pain at 10 out 10 upon admission. She said she expected LVN A to administer Gabapentin to the resident as ordered if she experienced pain, she said she did not order any additional pain medications because she was not aware the resident was reporting pain, and she expected to be notified if the resident was having pain so she could take appropriate action. NP A said she was not aware nor was she informed that Lacosamide and Clobazam were controlled substances required an eScript so she did not send a prescription to the pharmacy. NP A said she remembers this specifically because LVN A was concerned about Resident #1 receiving her Zolpidem (a controlled substance used for sleep) so she made sure to notify the MD to send the prescription. NP A said Resident #1 attending physician was changed immediately after admission so she was no longer her provider, but she said failure to administer medications as orders could place Resident #1 at risk for continued/irretractable pain and seizures. In an interview on 10/31/23 at 12:13 PM, the IP said the facility never administered the Clobazam 5 mg film to Resident #1 just the 10 mg pills. In an interview on 11/01/23 at 12:10 PM, LVN A said Resident #1 had just received a brand new order for Donepezil on 10/31/23 so she did not received it on the night of 10/31/23 because it was not available. LVN A said she did not know that Donepezil was available in the EKit. She said there was a list of medications that could be dispensed from the EKit but she does not believe she checked. LVN A said she started working with the facility in January of 2023 and she was never really trained on using the EKit, or admission medication reconciliation and she just learned on her own. She said failure to administer medication as ordered could place residents at risk for untreated health conditions. CR #1 Record review of CR #1's Face Sheet dated 10/25/23 at 11:42 AM revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included: femur fracture and an encounter for orthopedic aftercare. The resident discharged to the hospital on 08/11/23 and never returned to the facility. Record review of CR #1's MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 01 out of 15. Record review of CR #1's Admission assessment dated [DATE] and signed by LVN C revealed, CR #1 admitted to the facility on [DATE] at 10:22 PM, reported pain to her left knee at a level of 05 out of 10 and the resident had a surgical incision site as well as open area/wound. Record review of CR #1's Pain Level Summary dated 08/02/23 at 10:27 PM revealed, CR #1 reported pain at 05 out of 10, Record review of CR #1's Physician Order dated 08/03/23 at 01:05 AM revealed Tramadol (pain medication) 50 mg- 1 tablet every 6 hours as needed for moderate and severe pain. Record review of CR #1's August MAR revealed, CR #1 did not receive Tramadol 50 mg upon admission from 08/02/23-08/05/23. In an interview on 10/25/23 at 02:15 PM, Family Member #1 said the resident admitted to the facility in August after surgery. She said the resident was in pain and the facility did not administer the resident's pain medications. She said when she visited her mother on 08/05/23 she was in severe pain when she tried to reposition her. In an interview on 10/31/23 at 04:54 PM, LVN C said she did not remember CR #1. In an interview on 11/01/23 at 01:40 PM, the DON said upon admission nursing staff are expected to reconcile the resident's medications with the provider, ensuring the medication is correct (including the formulation) and matches the discharge orders. He said medications are to be started based on the documented next dose in the discharge orders and if a medication is unavailable it should be retrieved from the EKit or the prescriber should be notified of medication unavailability and an alternative therapy should be requested. The DON said the pharmacy can provide a STAT order which can be delivered within a few orders for critical medications. He said once medications are available for a new admission they should be administered as ordered+/- 1 hr. of its scheduled time and failure to administer medications as ordered could place residents at risk for increased/uncontrolled pain, increased seizure risk and adverse reactions. The DON said prior to medication administration nurses need to ensure that the medication to be administered matches the order down to the formulation ( film vs. tablet) and any discrepancies should be addressed prior to medication administration. The DON said nurses are expected to document accurately and timely and failure to document accurately placed resident at risk of incorrect documentation missed diagnoses, delay in care and overdose. Record review of LVN C's undated training record revealed, LVN C had not attempted her training on Pain Assessment and Management that was assigned on 12/15/22 and there was no documented assigned training on Skin Care and Wound Care. Record review of the facility provided pharmacy Quick Reference document with no revision date revealed, If you place a new order after the daily cut-off times, and the medication is not in your EDK, fax the order and CALL the pharmacy to the inform them of the new order and when the resident will need the medication. New admissions, critical need medications are always available even after hours, CALL the pharmacy. Ordering [NAME]: Monday-Friday the cut off time for new medication orders and new admissions medications was 6:00 PM. All SNF facilities have the potential for 2 deliveries per day- leaving the pharmacy at 01:00 PM and 08:00 PM release times. Any new order must be received by the pharmacy 2 hours prior to the delivery release time and any critical medication-please call the pharmacy. Record review of the facility policy titled Medication Shortages/Unavailable Medication revised 01/01/22 revealed,2- If a medication is unavailable during normal pharmacy hours. 2.2- If the next available delivery causes delay or missed dose in the resident's medication schedule, facility nurse should obtain the medication from the emergency medication supply to administer the dose. 2.3- If the medication is not available in the emergency medication supply, facility staff should notify pharmacy and arrange for an emergency delivery, if necessary. 5- If the medication is unavailable from Pharmacy or a third party pharmacy, and cannot be supplied from the manufacturer, facility should obtain alternate Physician/Prescriber orders, as necessary. When the pharmacy notifies the facility that a medication is unavailable due to a recall or manufacturer issue, facility staff should notify the physician/prescriber for a new order. 9-when a missed dose is unavoidable, facility nurse should document the missed dose and the explanation such documentation should include: a description of the circumstance of the medication shortage, a description of pharmacy's response upon notification and actions taken. Record review of the facility policy Medication Administration Times revised 01/01/22 revealed, 2- Facility should commence medication administration within 60 minutes before the designated times of administration and should be completed by 60 minutes after the designated times of administration.

Based on interview and record review, the facility failed to provide necessary treatment and services to promote healing and prevent worsening pressure sores for 1 of 7 residents (CR#1) reviewed for pressure sores. -The facility failed to enter orders and provide wound care for CR #1's sacrum upon admission resulting in the resident going from shearing/redness to a stage 3 pressure ulcer. This failure could place residents at risk of worsening of current sores or the development of new pressure sores. Finding Included: Record review of CR #1's Face Sheet dated 10/25/23 at 11:42 AM revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included: femur fracture and an encounter for orthopedic aftercare. The resident was transferred to the hospital on 08/11/23 and never returned to the facility. Record review of CR #1's MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 01 out of 15. Record review of CR #1's Hospital Records dated 08/02/23 at 10:21 AM revealed, CR #1 admitted to the hospital on 07/21/23 and discharged on [DATE] CR was admitted to the hospital after experiencing a fall resulting in a hip fracture that required surgery. There was no documentation of CR #1 suffering from any wounds to her sacrum, her skin was noted to have no significant lesions or rashes. Record review of CR #1's Admission assessment dated [DATE] and signed by LVN C revealed, CR #1 admitted to the facility on [DATE] at 10:22 PM, with an open area/wound. The wounds was described as sacrum- shearing and redness. Record review of CR#1's NP Progress Notes dated 08/03/23 signed by NP B revealed, there was no documentation of a sacral wound. Record review of CR#1's NP Progress Notes dated 08/04/23 signed by NP B revealed, there was no documentation of a sacral wound. Record review of CR #1's Wound Observation Tool dated 08/04/23 at 05:12 PM and signed by the DON revealed, CR #1 admitted with a surgical wound to her lower left leg on 08/02/23 and the wound measured 2.5 cm x 0.1 cm and had 3 staples. There were no signs of infection, CR #1 reported no pain and the current treatment plan was to apply TAO and cover with a dry dressing. There was no documentation of a sacral wound. Record review of CR #1's August Progress Notes dated revealed, - 08/05/23 at 9:23 PM signed by LVN E-, resident daughter called 911 an insisted that resident go to memorial [NAME] at med center resident stated that she wanted to go for concerns about wound care on call md notified. - 08/11/23 at 06:53 PM, signed by LVN F- resident had an unwitnessed fall and was transferred to the hospital. Record review of CR #1's Order Summary Report revealed, there were no wound care orders active prior to 08/05/23. - Orders for Zinc Oxide paste- apply to sacral area topically every shift for skin protectant was entered on 08/05/23. - Cleanse sacral wound to Sacrum with Vashe solution, pat dry, apply Medihoney/calcium cover with dressing every day shift for sacral wound was entered on 08/07/23 and started on 08/08/23. Record review of CR #1's August MAR revealed, - the order for Zinc Oxide paste to the sacral order was entered on 08/05/23 at 05:44 PM and the first documented application was on the 08/05/23 night shift. Zinc Oxide was first applied to CR #1's sacrum on 08/06/23 at 03:37 AM. - the order to cleanse sacral wound to Sacrum with Vashe solution, pat dry, apply Medihoney/calcium cover with dressing every day shift for sacral wound was entered on 08/07/23 at 10:35 PM and it was first performed on 08/08/23. Record review of CR #1's Surgical Consult note dated 08/07/2 at 07:16 PM and signed by the Wound Care MD revealed, wound location- sacrum; cause: pressure injury/ulcer- wound stage: unstageable pressure injury. Preoperative indication- breakdown of tissue slough or dead tissues, poor healing; signs of infection: none. Procedure performed: surgical removal of subcutaneous tissue resulting in a post-operational wound area of 6X8X0.2 cm (48sq cm); wound progress: first visit. Operative note: CR #1 had a wound on her sacrum that was debrided (surgical removal of damage tissue). CR #1's sacral wound had signs of tissue breakdown which will need continuing surveillance and will likely require future debridement. Healing of these wound cannot be guaranteed as a result of the patient diagnoses/risk factors that affect the progress of this wound The patient has a chronic wound which may not heal and may worsen because of chronic comorbidities. Prognosis: prognosis for the patient's sacrum is poor. Record review of CR#1's NP Progress Notes dated 08/08/23 signed by NP B revealed, sacral wound present- unable to assess. There was no plan for the treatment of CR #1 sacral ulcer. Record review of CR #1's Skilled Wound Care Communication Log dated 08/08/23 revealed, a pressure injury/ulcer that was 6X8X0.2cm after debridement that had 50 % slough (a yellowish, moist, stringy substance that is a byproduct on inflammation during wound healing) and 50 % granulation (appearance of red, bumpy tissue in the wound bed as a wound heals) and no signs of infection. The recommended treatment was Calcium Alginate and Honey Daily. The wound was noted to be present on admission and unstageable. Record review of CR #1's Wound Observation Tool dated 08/10/23 at 03:03 PM and signed by the DON revealed, CR #1 had a stage 3 pressure ulcer with granulation and slough with moderate serous drainage that measured 6X8X0.2 cm, had possible deep tissue injury and no signs of infection. Record review of CR#1's NP Progress Notes dated 08/11/23 signed by NP B revealed, Skin- left hip incision. Sacral Ulcer stage 3- 6X8X0.2 cm. Diagnosis/Assessment/Plan- sacral ulcer treatment with local wound care with Medihoney and Calcium Alginate In an interview on 10/25/23 at 11:00 AM, the DON said when CR #1 on the day admitted to the facility a skin assessment was performed and the nurse should have entered orders for the default wound care protocol until the wound care doctor saw the patient. He said after reviewing the patient's chart he did not see any reason after CR #1's admission on 08/02/23 she did not receive wound care until 08/05/23. He said he was not aware that CR #1 called 911 for the resident to go to the hospital due to concerns for wound care. In an interview on 10/25/23 at 11:32 AM, the DON said the floor nurses perform wound care but he was responsible for auditing to ensure wound care is being administered. He said the facility had default wound care orders to provide immediate care before the resident was seen by the wound care doctor. He said CR #1 should have had wound care orders for her wound to her sacrum upon admission. In an interview on 10/25/23 at 02:15 PM, CR #1's family member said the resident did not admit to the facility with a wound to her sacrum and she saw no indication of a bed sore in the hospital. She said on 08/05/23 she came to see her mother in the morning and observed an open wound while turning her and with no dressing. She said she asked the floor nurse what care was being provided for her mother's wounds and the staff member said she didn't have to tell her anything. CR #1's family member said she called 911 later that evening due to her concerns of inadequate wound care. In an interview on 10/25/23 at 03:48 PM, LVN C said she was the admitting nurse for CR #1 but does not remember much except CR #1 was a sweet, nice lady. She said when a resident admits nursing staff are expected to assess the residents and any identified wound should have orders entered for immediate care and the facility had specific default wound care orders depending on the state of the wound. LVN C said she did not remember if she saw any wounds on CR #1, she did not have the authority to stage wounds, and staging was performed by the RN. LVN C said failure to enter orders for immediate care of wound could place residents at risk of worsening of the wound or infection. In an interview on 10/25/23 at 04:19 PM, LVN D said she was not CR #1's admitting nurse. She said on an unknown date between 08:00 AM and 01:00 PM CR #1's family member asked what the facility was doing for her mother's wound and asked to see the resident's medical record. LVN D said she would not be able to provide the family member with the record and the family member would have to wait for the appropriate department to arrive to make her request. LVN D said when she went to provide incontinence care to CR #1 she observed a wound on her sacrum that looked like abrasions and shearing but she did not remember if the resident had wound care orders. She said she remembers CR #1 as having a surgical incision with staples that was covered by a dressing and she did not think CR #1 had orders for Zinc Barrier cream that would be the appropriate treatment for abrasions/shearing. LVN D said failure to enter wound care orders and failure to receive wound care could place residents at risk for adverse reactions, worsening of wounds and infection. In an interview on 10/26/23 at 11:08 PM, the Wound Care MD said every newly admitted resident should receive a full skin assessments to identify any wounds that might be present. He said any newly identified wounds should receive wound care orders based on the facility's default standing orders to be performed daily. The Wound care MD said he was never notified of CR #1 not receiving wound care upon admission and he said based on his assessment, the application of Zinc Oxide was not appropriate because it only treats minimal breakdown that is moisture associated. The Wound Care MD said based on his assessment on 08/07/23, treatment with Honey + Calcium Alginate was appropriate for CR #1's wound. He said CR #1's wound measured at 6x8 cm after debridement with visible slough and it was unstageable. The Wound care doctor said he was unable to determine the stage of the wound even though he had a measured dent because the depth of a wound on different body types (skinny/fat/muscular) could determine the stage. The Wound Care MD said he was notified that the sacral wound was present on admission and it was not normal for a wound to go from shearing/redness to a stage 3 pressure ulcer during the short time CR #1 was admitted . In an interview on 10/31/23 at 03:49 PM, the IP said if a resident had redness/shearing at admission they should have received orders for barrier cream to start immediately upon admission. In an interview on 11/01/23 at 01:40 PM, the DON said any residents with wounds observed upon admission should receive immediate orders for care per the facility protocol. He said failure to enter orders per the protocol could result in adverse outcomes/worsening of wounds and the admission LVN did not have the ability to determine the severity of CR #1's wounds and it was beyond her scope. The DON said failure to perform wound care could lead to worsening of wounds and failure to identify and document wounds accurately could result in missed diagnoses, and delay in care. Record review of the facility policy Basic Skin Management revised 11/28/22 revealed, orders are required for skin and wound care. There are wound care protocol order in the EMR. Record review of the facility policy titled Skin Integrity & Pressure Ulcer/Injury Prevention and Management revised 03/31/23 revealed, provide associates and licensed nurses with procedures to manage skin integrity, prevent pressure ulcer/injury. 7- When skin breakdown occurs, it requires attention and a change in plan of care may be indicated to treat the resident. Record review of the facility undated Wound Care Order Protocol provided on 10/31/23 revealed, All admissions with wounds, including surgical, need wound care orders. Nurse completing admission is responsible for entering wound care orders in [EMR] and entering wound consult order. The documented protocol orders were as follows: - If the wound is draining and has exposed wound bed- cleanse wound with NS/Vashe, pat dry, lightly pack with Vashe moistened gauze and cover with dressing daily and PRN. - If the wound is not draining and has an exposed wound bed- cleanse with Vashe/NS, pat dry, apply triad paste and cover with a dry dressing daily and PRN. - If resident has a surgical wound with sutures and staples- Betadine paint, let air dry and cover with dry dressing daily and PRN. - If resident has a deep tissue injury- Betadine paint and cover with foam dressing daily/PRN. - For all redness- apply barrier cream after each incontinent episode. FAILURE TO COMPLY WITH POLICY WILL RESULT IN DISCIPLINARY ACTION.

Based on interview and record review the facility failed to ensure licensed nurses had the specific competencies and skill sets necessary to care for residents' needs as identified through resident assessment and described in the plan of care and the facility failed to provide care which included but not limited to assessing, evaluating, planning and implementing resident care plans and responded to resident needs for 1 of 1 residents (Residents #1) and 1 of 3 nurses (LVN A) reviewed for nurse competency. 1. The facility failed to ensure LVN A was trained to admit residents, reconcile medications, administer medications, and assess pain prior to providing nursing services. This failure could place residents at risk of receiving inadequate care and harm. Findings included: Resident #1 Record review of Resident #1's Face Sheet dated 11/01/23 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: unspecified convulsion, type 2 diabetes, neuropathy (nerve pain), heart failure and high cholesterol. Record review of Resident #1's Admission MDS dated [DATE] and printed on 11/01/22 at 09:22 AM revealed, intact cognition as indicated by a BIMS score of 13 out of 15. Record review of Resident #1's Baseline Care Plan dated 10/23/23 revealed, Focus: pain, goal- resident will express pain relief, interventions- pain meds as ordered and evaluate the effectiveness of pain interventions. Record review of Resident #1's Hospital Discharge Instructions dated 10/23/23 at 12:54 PM revealed, Resident #1 admitted to the hospital due to seizures and was observed having a seizure on 10/13/23 during a neurological consultation. Resident #1 discharged with the following medications with instructions for the next administered dose: - Clobazam (a benzodiazepine controlled substance used to treat seizures) 10mg, 1/2 tablet by mouth twice a day. Last dose given on 10/23/23 at 09:04 PM. - Gabapentin (used for nerve pain) 100 mg- take 2 capsule 3 times a day. Last dose given 10/23/23 at 08:57 AM. - Lacosamide (a controlled substance used to treat seizures) 200 mg- take 1 tablet 2 times a day. - Atorvastatin (used to treat high cholesterol) 80 mg- take 1 tablet by mouth nightly. Last dose given 10/22/23 at 08:53 PM. - Levetiracetam( used to treat seizures) 1000 mg- take 11/2 tablets by mouth 2 times a day. - Apixaban (a blood thinner) 5 mg- 1 tablet by mouth 2 times a day. Last dose 10/23/23 at 08:57 AM. - Metformin (used to control blood sugar) 500 mg- 1 tablet by mouth 2 times a day with meals. Record review of Resident #1's Admission assessment dated [DATE] and signed by LVN A revealed, Resident #1 arrived at the facility at 03:05 PM, and the resident's medications were verified by NP A. NP A wrote Resident #1 was reporting pain 10/10 at the time both feet stated she suffers from neuropathy. Record review of Resident #1's Pain Level Summary dated 10/23/23 at 6:56 PM signed by LVN A revealed, Resident #1 reported pain at 10 out 10. Record review of Resident #1's Order Summary dated 10/26/23 revealed, the following medications were entered on admission (10/23/23) but were started on 10/24/23 the day after Resident #1 admitted to the facility: - Apixaban 5 mg- 1 tablet by mouth 2 times a day - Atorvastatin 80 mg- take 1 tablet by mouth nightly. - Clobazam 5 mg Film, give 5 mg by mouth twice a day. The order was entered incorrectly as film instead of tablets as ordered in the hospital discharge, - Gabapentin 100 mg- - take 2 capsule 3 times a day. - Lacosamide 200 mg- take 1 tablet 2 times a day. - Levetiracetam 1000 mg- take 11/2 tablets by mouth 2 times a day. - Metformin 500 mg- 1 tablet by mouth 2 times a day with meals. Record review of Resident #1's October MAR printed 11/01/23 at 09:37 AM revealed, Resident #1 did not receive the following medication. - Apixaban 5 mg- 1 tablet by mouth due in the evening of 10/23/23. - Atorvastatin 80 mg- take 1 tablet by mouth due in the evening of 10/23/23. - Clobazam 5 mg Film- give 5 mg mouth due in the evening of 10/23/23, on 10/24/23 due at 08:00 AM and 4:00 PM, on 10/25/23 due at 8:00 AM. - Gabapentin 100 mg- - take 2 capsules by mouth due in the evening of 10/23/23. - Lacosamide 200 mg- take 1 tablet by mouth due in the evening of 10/23/23 and on 10/24/23 due at 08:00 AM and 04:00 PM. - Levetiracetam 1000 mg- take 11/2 tablets by mouth due in the evening of 10/23/23. - Metformin 500 mg- 1 tablet by mouth due in the evening of 10/23/23. - Donepezil 10 mg 1 tablet by mouth due at 9 PM on 10/31/23. Record review of the facility undated EKit Contents revealed the facility had the following medications: - 4 tablets of Donepezil 5 mg. - 4 capsules of Gabapentin 100 mg - 4 tablets of Levetiracetam - 4 tablets of Metformin An observation and interview on 10/25/23 at 09:40 AM revealed, Resident #1 lying in bed, well dressed, well fed in no immediate distress. She said when she admitted 2 days ago her pain medications were not available as well as some other medications on her med list. Resident #1 said when she arrived at the facility she had pain at 10 out 10 and it was so bad she could not sleep but the facility did not administer her Gabapentin because her medication had not arrived yet. Resident #1 said she was currently experiencing pain and needle pain in both her feet but she could not provide a pain scale. In an interview on 10/26/23 at 09:25 AM, the pharmacist said, NP B sent in a prescription for Clobazam 5 mg Film and not tablets on 10/24/23 at 07:00 PM but that medication has been unavailable due to manufacturer production issues for a prolonged period of time so it would not be available, In an interview on 10/26/23 at 10;40 AM, LVN A said she was the admitting nurse for Resident #1 on 10/23/23. She said when a new resident is admitting the facility the nurse gets a verbal report from the discharging facility before the resident arrives and once the resident arrive they receive the discharge packet. LVN A said the residents medications are verified with the NP from the discharge packet and the medications are started based on the documented next dose. She said she could not remember when she entered Resident #1's medication to start but the resident reported pain at 10 out of 10 so she gave her Gabapentin and received/administered an order for Tylenol but she did not document it in the MAR or EMR. LVN A said Resident #1 said her feet were hurting really bad so she contacted NP A who gave her verbal orders for Tylenol but she never documented the order in the chart. When asked if Resident #1 continued to have pain after admission she said she honestly, didn't remember. NP A said she did not go back to check on the resident until 9/10 PM and she did not call the NP to follow up on Resident #1's pain. LVN A said nursing staff are expected to follow up with the provider for issues regarding pain or medications but it was too busy that night. LVN A said she couldn't say Resident #1's Levetiracetam or other seizure meds were on her mind when she talked to the NP and she would not know if the medication was in the EKit or not. She said she did not realize that she entered Resident #1's Clobazam as a film instead of tablets and she said failure to enter medications/administer medications as ordered could place residents at risk of continued/uncontrolled pain, seizures, medication error, adverse reactions and unavailability of medications. In an interview on 10/26/23 at 01:30 PM, NP A said she was the admitting nurse for Resident #1 on 10/23/23. She said LVN A called her and read the resident's hospital discharge medications to her and she gave an order to start all medications as listed in the discharge record. NP A said she did not make any changes to Resident #1's medication order included formulations to be administered or start times. She said she expected Resident #1's medications to be started according to the next dose due as listed on the hospital record. NP A said she did not give LVN B instructions to change from Clobazam tablets to Clobazam film and LVN B never reported that Resident #1 was experiencing pain at 10 out 10 upon admission. She said she expected LVN B to administer Gabapentin to the resident as ordered if she experienced pain, she said she did not order any additional pain medications because she was not aware the resident was reporting pain, and she expected to be notified if the resident was having pain so she could take appropriate action. NP A said she was not aware nor was she informed that Lacosamide and Clobazam were controlled substances required an eScript so she did not send a prescription to the pharmacy. NP A said she remembers this specifically because LVN B was concerned about Resident #1 receiving her Zolpidem (a controlled substance used for sleep) so she made sure to notify the MD to send the prescription. NP A said Resident #1 attending physician was changed immediately after admission so she was no longer her provider, but she said failure to administer medications as orders could place Resident #1 at risk for continued/irretractable pain and seizures. In an interview on 10/31/23 at 02:38 PM, the Medical Records Director said the facility did not complete nor have records of annual competency assessments for nursing staff. In an interview on 10/31/23 at 02:40 PM, the DON said the facility did not assess new hires that certain competencies were expected with their professional license. He said during orientation, new nurses are asked about areas of concern and additional training is provided on identified areas. In an interview on 10/31/23 at 03:05 PM, the IP said no one actually assesses nursing competency. Competency is signed off based on the online training. In an interview on 11/01/23 at 12:10 PM, LVN A said Resident #1 had just received a brand new order for Donepezil on 10/31/23 so she did not received it on the night of 10/31/23 because it was not available. LVN A said she did not know that Donepezil was available in the EKit. She said there was a list of medications that could be dispensed from the EKit but she does not believe she checked. LVN A said she started working with the facility in January of 2023 and she was never really trained on using the EKit, or admission medication reconciliation and she just learned on her own. She said failure to administer medication as ordered could place residents at risk for untreated health conditions. In an interview on 11/01/23 at 01:40 PM, training records for LVN A showed she was not trained on medication reconciliation/medication administration/documentation. He said he was responsible for ensuring training is completed by staff prior to working on the floor. When asked if staff with inadequate training should be allowed on the floor, the DON said each nurses licensure represented her nursing competency. In an interview on 11/01/23 at 02:35 PM, the Administrator said she was unaware that LVN A had not attempted her online training modules. She said on hire nursing staff go through a healthcare academy that has assigned courses they must complete. When asked if nursing staff should be on the floor if their training was not attempted/completed, the Administrator would not answer. She said training involved on the job training, training at orientation and continuous training during employment. In an interview on 11/01/23 at 02:55 PM, the DON said there was no competency check off completed on nurses on hire or annually but the facility would be providing assessments going forward. Record review of the facility Employee Roster dated 10/25/23 at 10:15 AM revealed, LVN A was hired on 01/30/23. Record review of LVN A's undated training record revealed, LVN A had not attempted majority of her training including: - Pain Assessment and Management which was assigned on 01/31/23. - Introduction to Nursing documentation which was assigned on 01/31/23. - Drug Diversion Prevention Program which was assigned on 04/20/23. - Nursing Staff Policies Attestation which was assigned on 01/31/23. - Introduction to Skin Care and Wound Care which was assigned on 01/31/23. Record review of the facility provided pharmacy Quick Reference document with no revision date revealed, If you place a new order after the daily cut-off times, and the medication is not in your EDK, fax the order and CALL the pharmacy to the inform them of the new order and when the resident will need the medication. New admissions, critical need medications are always available even after hours, CALL the pharmacy. Ordering [NAME]: Monday-Friday the cut off time for new medication orders and new admissions medications was 6:00 PM. All SNF facilities have the potential for 2 deliveries per day- leaving the pharmacy at 01:00 PM and 08:00 PM release times. Any new order must be received by the pharmacy 2 hours prior to the delivery release time and any critical medication-please call the pharmacy. Record review of the facility policy titled Medication Shortages/Unavailable Medication revised 01/01/22 revealed,2- If a medication is unavailable during normal pharmacy hours. 2.2- If the next available delivery causes delay or missed dose in the resident's medication schedule, facility nurse should obtain the medication from the emergency medication supply to administer the dose. 2.3- If the medication is not available in the emergency medication supply, facility staff should notify pharmacy and arrange for an emergency delivery, if necessary. 5- If the medication is unavailable from Pharmacy or a third party pharmacy, and cannot be supplied from the manufacturer, facility should obtain alternate Physician/Prescriber orders, as necessary. When the pharmacy notifies the facility that a medication is unavailable due to a recall or manufacturer issue, facility staff should notify the physician/prescriber for a new order. 9-when a missed dose is unavoidable, facility nurse should document the missed dose and the explanation such documentation should include: a description of the circumstance of the medication shortage, a description of pharmacy's response upon notification and actions taken. Record review of the facility policy Medication Administration Times revised 01/01/22 revealed, 2- Facility should commence medication administration within 60 minutes before the designated times of administration and should be completed by 60 minutes after the designated times of administration.

Based on interview, observation and record review the facility failed to, consult with the resident's physician; and notify, consistent with his or her authority the resident representative when there was a change in condition and a need to alter treatment significantly for 1 of 5 residents (Resident #1) reviewed for notification of changes. - The facility failed to notify the provider of an observed change of condition in Resident #1's OT and ST. - The facility failed to notify the provider when Resident #1's Clobazam and Lacosamide (anticonvulsant medications) were unavailable/had not been delivered from the pharmacy - The facility failed to notify the provider when Resident #1 reported experiencing pain during admission. These failure could place residents at risk of delayed identification and treatment of undiagnosed illnesses, hospitalization , pain, and suffering. Findings included: Record review of Resident #1's Face Sheet dated 11/01/23 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: unspecified convulsion, type 2 diabetes, neuropathy (nerve pain), heart failure and high cholesterol. Record review of Resident #1's Admission MDS dated [DATE] and printed on 11/01/23 at 09:22 AM revealed, intact cognition as indicated by a BIMS score of 13 out of 15. Record review of Resident #1's Baseline Care Plan dated 10/23/23 revealed, Focus: pain, goal- resident will express pain relief, interventions- pain meds as ordered and evaluate the effectiveness of pain interventions. There was no mention of seizures on the baseline care plan. Record review of Resident #1's Hospital Discharge Instructions dated 10/23/23 at 12:54 PM revealed, Resident #1 admitted to the hospital due to seizures and was observed having a seizure on 10/13/23 during a neurological consultation. Resident #1 discharged with the following medications with instructions for the next administered dose: - Gabapentin (used for nerve pain) 100 mg- take 2 capsule 3 times a day. Last dose given 10/23/23 at 08:57 AM. - Lacosamide (a controlled substance used to treat seizures) 200 mg- take 1 tablet 2 times a day. - Clobazam 10 mg- 1/2 tablet by mouth 2 times a day. - Levetiracetam( used to treat seizures) 1000 mg- take 11/2 tablets by mouth 2 times a day. Record review of Resident #1's Admission assessment dated [DATE] and signed by LVN A revealed, Resident #1 arrived at the facility at 03:05 PM, and the resident's medications were verified by NP A. LVN A wrote Resident #1 was reporting pain 10/10 at the time both feet stated she suffers from neuropathy (nerve pain). Record review of Resident #1's Pain Level Summary dated 10/23/23 at 6:56 PM signed by LVN A revealed, Resident #1 reported pain at 10 out 10. Record review of Resident #1's Order Summary dated 10/26/23 revealed, - Clobazam 5 mg Film, give 5 mg by mouth twice a day. The order was entered incorrectly as film instead of tablets as ordered in the hospital discharge, - Gabapentin 100 mg- - take 2 capsule 3 times a day. - Lacosamide 200 mg- take 1 tablet 2 times a day. Record review of Resident #1's Order Summary dated 10/31/23 at 12:38 PM revealed, - Clobazam 10 mg- give 1/2 tablet by mouth 2 times a day- ordered on 10/26/23 Record review of Resident #1's October MAR printed 11/01/23 at 09:37 AM revealed, Resident #1 did not receive the following medication. - Clobazam 5 mg Film- give 5 mg mouth due in the evening of 10/23/23, on 10/24/23 due at 08:00 AM and 4:00 PM, on 10/25/23 due at 8:00 AM. - Gabapentin 100 mg- - take 2 capsules by mouth due in the evening of 10/23/23. - Lacosamide 200 mg- take 1 tablet by mouth due in the evening of 10/23/23 and on 10/24/23 due at 08:00 AM and 04:00 PM. Record review of Review of Resident #1's October Progress Notes revealed, Resident #1's seizure medications were not available upon admission and documentation was as follows: - 10/24/23 AT 5:24 PM signed by LVN B- Clobazam 5 mg Oral Film and Lacosamide 200 mg Tablets were on order. There was no documentation of notifying the NP/MD, Administrator or DON that the medications were unavailable. - 10/24/23 at 09:07 AM signed by LVN B- Clobazam 5 mg Oral Film was on back order. There was no documentation of notifying the NP/MD, Administrator or DON that the medications were unavailable. There was no documentation of notifying the NP/MD, Administrator or DON that medications were unavailable prior to the surveyor notifying the facility of the unavailable medications on 10/24/23 at approximately 4:00 PM. - On 10/31/23 at 01:45 PM signed by LVN D revealed, the NP placed an order for STAT labs due to Resident #1's altered mental status Record review of Resident #1's OT Treatment Notes dated 10/27/23 signed by the OT revealed, actively participates with skilled interventions. Record review of Resident #1's OT Treatment Notes dated 10/30/23 signed by the OT revealed, patient required extra time to process and sequence tasks at hand. Verna; cues given for task initiation during dressing tasks. Record review of Resident #1's ST Treatment Notes dated 10/27/23 signed by the ST revealed: Patient given a photo and instructed to recreate the model given several puzzle pieces. Completed the task with 70% accuracy given 0% cues increasing to 100% accuracy given min verbal/visual cues. Barriers impacting treatment-no Record review of Resident #1's ST Treatment Notes dated 10/30/23 signed by the ST revealed, Patient completed the task with 50% accuracy given 0% cues increasing to 70% accuracy given mod verbal/visual cues. Barriers impacting treatment-yes. Record review of Resident #1's ST Treatment Notes dated 10/31/23 signed by the ST revealed, Patient completed the task with 40% accuracy given 0% cues increasing to 70% accuracy given min-mod verbal/visual cues. Noted patient required more cuing to initiate each task during today's session. Barriers impacting treatment: yes limitations learning complex information. Record review of Resident #1's Psychiatric Physician Progress Notes dated 10/31/23 revealed, Resident #1's ordered medication Clobazam has a side effect of paranoia. He wrote the Resident #1 was drowsy and said she hears things and sees people which was kind off upsetting. Resident #1 was positive for visual and auditory hallucinations, with mild paranoia, apathetic(showing or feeling no interest, enthusiasm or concern) and anergic (continual feeling of tiredness, lack of energy or sleepiness which is often a symptom of mental health disorders). Resident #1's hallucinations are likely post ictal (due to a seizure) and from side effects of Clobazam. Record review of Resident #1 Provider Progress Note dated 10/31/23 written by NP B revealed, Resident #1 was seen for evaluation of acute changes related to somnolence incoherence, drowsiness and disorientation. NP B met with the Resident #1's family member and the surveyor in the resident's room at which point the family member said she was concerned about Resident #1's disorientation/pain and wanted to know what her current medications were. Patient noted sitting by bedside in no immediate distress but appeared weak and slower in responding to questions. Diagnosis, Assessment and Plan- Altered Mental status, unspecified, concern of disorientation/incoherence/drowsiness; will order labs. Lethargy- order labs, lower Gabapentin, discontinue Tylenol and monitor for worsening of symptoms. An observation and interview on 10/25/23 at 09:40 AM revealed, Resident #1 lying in bed, well dressed, well fed in no immediate distress. She said when she admitted 2 days ago her pain medications were not available as well as some other medications on her med list. Resident #1 said when she arrived at the facility she had pain at 10 out 10 and it was so bad she could not sleep but the facility did not administer her Gabapentin because her medication had not arrived yet. Resident #1 said she was currently experiencing pain and needle pain in both her feet but she could not provide a pain scale. There was no observed cognitive deficit, Resident #1 was energetic and very responsive. In an interview on 10/25/23 at 09:45 AM, the Surveyor notified LVN B, that Resident #1 was reporting pain in her feet. She said she had just administered Gabapentin to Resident #1 and the resident did not report pain. LVN B said she would assess Resident #1 for pain again. In an interview on 10/25/23 at 01:00 PM, the Administrator said the IP had the authority to answer questions regarding the facilities nursing practices because at the time she assisted the DON in performing nursing administration tasks. In an interview on 10/25/23 at 04:50 PM, the IP said she nor the DON were notified of any delays in the receiving or administration of Resident #1's seizure meds. She said she did not know the resident's Clobazam was not available, or there were delays receiving her Lacosamide. She said the NP/MD had not been notified. In an interview on 10/25/23 at 05:10 PM, the Surveyor notified the DON and Administrator that Resident #1's medication was unavailable and on back order. The DON and Administrator said they were never informed by nursing staff about any availability issues with Resident #1's seizure meds and they would immediately talk to the NP to get an alternative. She said the NP/MD had not been previously notified. In an interview on 10/26/23 at 09:25 AM, the pharmacist said, the facility first received an eScript for Lacosamide 200 mg for Resident #1 on 10/24/23 at 01:09 PM and NP B verbally called in a prescription for Clobazam 10 mg on 10/25/23 at 05:30 PM. He said NP B sent in a prescription for Clobazam 5 mg Film and not tablets on 10/24/23 at 07:00 PM but that medication has been unavailable due to manufacturer production issues for a prolonged period of time so it would not be available, In an interview on 10/26/23 at 10:22 AM, NP B said she was not Resident #1's admitting NP and that she was first notified of Clobazam being unavailable for Resident #1 in the evening of 10/25/23. She said she saw the patient on Tuesday 10/24/23 but did not receive any notifications of medication availability issues until Wednesday 10/25/23. NP B said when a resident admits after 6 PM nursing staff is expected to call in the medication with the on-call provider. She said she was not aware that Resident #1 discharge orders were for 1/2 of the 10 mg tablets and never for the film. NP B said she expects medications should be ordered and next doses administered pursuant to the hospital discharge orders. NP B said prior to the evening of 10/25/23 she was not notified that Resident #1 did not receive any seizure meds (Levetiracetam, Lacosamide, Clobazam) on the evening of her admission, Lacosamide and Clobazam on 10/24/23 and the Clobazam on the morning of 10/25/23. She said once she was notified of the issues with the Clobazam she immediately called in a prescription to the pharmacy for a 3 days' supply of Clobazam 10 mg tablets. NP B said she expected nursing staff to notify her of any medication availability issues immediately so she could place an order for an alternative and the pharmacy could do a stat delivery. NP B said failure to administer medications like Levetiracetam, Clobazam and Lacosamide placed residents at risk for seizures. She said she saw Resident Tuesday, 10/24/23, and the resident complained of pain on her big toe so she prescribed Tylenol as needed, but she was never informed that the resident complained of other pain or the facility failing to administer her Gabapentin on admission when the resident reported pain at 10 out of 10. NP B said she expected nursing staff to have administered Gabapentin to Resident #1 upon admission if she reported pain at 10 out 10, and that she should have been notified of the resident's pain. She said on 10/25/23 she saw the resident to follow up on her seizure and pain medications and the resident complained of bilateral intermittent pain in her feet so she started Resident #1 on Tylenol #3 (a controlled substance used to treat pain) and increased her dose of Gabapentin. NP B said nursing staff should have notified her of Resident #1's continued pain. In an interview on 10/26/23 at 10;40 AM, LVN A said she was the admitting nurse for Resident #1 on 10/23/23. She said when a new resident is admitting the facility the nurse gets a verbal report from the discharging facility before the resident arrives and once the resident arrives they receive the discharge packet. LVN A said the residents medications are verified with the NP from the discharge packet and the medications are started based on the documented next dose. She said she could not remember when she entered Resident #1's medication to start but the resident reported pain at 10 out of 10 so she gave her Gabapentin and received/administered an order for Tylenol but she did not document it in the MAR or EMR. LVN A said Resident #1 said her feet were hurting really bad so she contacted NP A who gave her verbal orders for Tylenol but she never documented the order in the chart. When asked if Resident #1 continued to have pain after admission she said she honestly, didn't remember. LVN A said she did not go back to check on the resident until 9 or10 PM and she did not call the NP to follow up on Resident #1's pain. LVN A said nursing staff are expected to follow up with the provider for issues regarding pain or medications but it was too busy that night. LVN A said she couldn't say Resident #1's Levetiracetam or other seizure meds were on her mind when she talked to the NP and she would not know if the medication was in the EKit or not. She said she did not realize that she entered Resident #1's Clobazam as a film instead of tablets and she said failure to enter medications/administer medications as ordered could place residents at risk of continued/uncontrolled pain, seizures, medication error, adverse reactions and unavailability of medications. In an interview on 10/26/23 at 01:30 PM, NP A said she was the admitting nurse for Resident #1 on 10/23/23. She said LVN A called her and read the resident's hospital discharge medications to her and she gave an order to start all medications as listed in the discharge record. NP A said she did not make any changes to Resident #1's medication order included formulations to be administered or start times. She said she expected Resident #1's medications to be started according to the next dose due as listed on the hospital record. NP A said she did not give LVN A instructions to change from Clobazam tablets to Clobazam film and LVN A never reported that Resident #1 was experiencing pain at 10 out 10 upon admission. She said she expected LVN A to administer Gabapentin to the resident as ordered if she experienced pain, she said she did not order any additional pain medications because she was not aware the resident was reporting pain, and she expected to be notified if the resident was having pain so she could take appropriate action. NP A said she was not aware nor was she informed that Lacosamide and Clobazam were controlled substances required an eScript so she did not send a prescription to the pharmacy. NP A said she remembers this specifically because LVN A was concerned about Resident #1 receiving her Zolpidem (a controlled substance used for sleep) so she made sure to notify the MD to send the prescription. NP A said Resident #1 attending physician was changed immediately after admission so she was no longer her provider, but she said failure to administer medications as orders could place Resident #1 at risk for continued/irretractable pain and seizures. An observation and interview on 10/31/23 at 10:25 AM, Resident #1 appeared confused, she just stared down when asked questions by the surveyor. When the resident would response her answers were short phrases and were not always appropriate. Resident #1's family member said Resident #1 had been experiencing increased confusion since 10/25/23. She said on admission Resident #1's cognition upon admission was the same as it was at home, she had no kind of confusion, and her only limitations were physical which is why she was receiving therapy. The family member said she was concerned about Resident #1's medications because changes were made in the hospital, she said Resident #1's Levetiracetam was changed in the hospital and some additional seizure medications were started. The family member said she was the resident's POA and she was never notified of any difficulties acquiring Resident #1's seizure medication. The family member said she was really concerned about the confusion because it could stop her therapy progression. The family member said Resident #1 was mentally below her baseline at admission and her last ST session was not as successful as the previous weeks. She said she had informed an unknown nurse of Resident #1's increased confusion, wanted to see the doctor and she was awaiting a response. In an interview on 10/31/23 at 10:48 AM, NP B said she was not notified about a mental change of condition in Resident #1 and she saw the resident yesterday (10/30/23). An observation and interview on 10/31/23 at 11:05 AM revealed, NP B assessing Resident #1. When NP B asked the resident how she was doing she said my sister wants to talk to you. When NP B asked the resident questions, she was slow to answer, stared off and provided short answers. In an interview on 10/31/23 at 11:23 AM, NP B said Resident #1 appeared to be more sedated, delayed in her responses and stared at her sister when she was asked questions. She said the resident had experienced a change since she last saw her, and that previously Resident #1 provided robust answers and held conversations. NP B said Resident #1 had experienced a change of condition, so she would order labs and make some changes to her medication regimen. The NP said prior to seeing the resident today (10/31/23) she had not been notified or observed of Resident #1 experiencing a change of condition. In an interview on 10/31/23 at 01:32 PM, the ST said she had noticed a change of condition in Resident #1 compared to the previous week. She said the resident was more delayed when she worked with her yesterday. She said Resident #1 took longer to complete tasks and required more queuing. The ST said Resident #1 is not as verbose now and would only provide 1 word answers. When asked who she notified, the ST said she just documented it in her notes. In an interview on 10/31/23 at 12:00 PM, LVN D said she did not have enough conversation with Resident #1 to determine if she was confused but did appear tired today. She said upon admission the resident was not slow to respond, very chatty and interactive. In an interview on 10/31/23 at 01:45 PM, the OT said upon admission Resident #1 was talkative, carrying on conversations, alert, active and energetic. She said now Resident #1 is more flat and she has to initiate conversations with the resident. The OT said the resident spends most of their interactions with her eyes closed. She said the change of condition is more visible in her ADL tasks, specifically dressing. The OT said previously Resident #1 would initiate dressing if her clothes were placed in front of her but now she just stares at the clothes and requires queuing/prompting to initiate dressing. The OT said she had not notified her observed changes in Resident #1 she just documented it in her notes. In an interview on 10/31/23 at 01:56 PM, the DON said he was not aware of a change of condition in Resident #1 prior to the surveyor notifying the facility in the morning (10/31/23). He said therapy never notified him and his expectation was that therapy staff would notify nursing administration as well as the providers of any resident change of condition. In an interview on 10/31/23 at 02:23 PM, LVN B said Resident #1 looked loopy and drowsy this morning. She said therapy staff normally notify nursing of any observed changes in residents but they had not informed her of any changes today. In an interview on 10/31/23 at 04:45 PM, the IP said she was not aware Resident #1 had hallucinations and delusions. She said the resident was previously very chatty with her and she had not noticed and was not notified about a mental change of condition prior to the surveyor bringing it up. In an interview on 10/31/23 at 04:51 PM, the Psychiatric MD said his first time seeing Resident #1 was today (10/31/23), due to a request made by the DON. He said Resident #1 was having visual and auditory hallucinations currently and experiencing some scary thoughts. The Psychiatric MD said Resident #1 said her son would jump off a building. He said these Hallucinations were most likely due to her order for Clobazam and most likely a side effect due to a seizure. He said seizure side effects could last from days to a couple of weeks. The Psychiatric MD said it was not advisable to discontinue Resident #1's Clobazam because the benefits of the treatment outweighed the risk. In an observation and interview on 11/01/23 at 11:50 AM, Resident #1 was observed to be eating a facility plated meal. She was slow to respond to the surveyor's questions and when asked how she was feeling she answered sister fills my pill box. Resident #1 appeared confused and suffering from increased cognitive impairment in comparison to the surveyors observation on 10/25/23. In an interview on 11/01/23 at 12:55 PM, the Rehab director said Resident #1 was working with OT, PT and ST. He said review of notes show that therapy staff had observed a decline in Resident #1 cognition (observed by ST), and decline in dressing ADL (observed by OT). The Rehab Director said normally, therapy staff would notify the nurse on the floor, him and nursing administration of any changes of condition like what Resident #1 experience. He said he was first notified of Resident #1's decline after I notified the facility on 10/31/23. The Rehab director said in Resident #1's decline there was a communication failure as well as some issues with clinical judgement. He said failure to communicate acute change of conditions could place residents at risk of worsening health conditions. In an interview on 11/01/23 at 01:40 PM, the DON said some side effects of seizures included prolonged lethargy, change in cognition and change in function. He said after her was notified of Resident #1's change of condition by the surveyor on 10/31/23 he immediately requested the Psychiatric MD see the Resident. He said prior to 10/31/23 there were no indications that Resident #1 needed to be followed by psychiatric services. The DON said the expectation is that any person who observes a change of condition notify nursing management, and the provider if possible. He said failure to give the appropriate notifications following changes of condition could place residents at risk of decline in health, late identification of acute problems and worsening health. Record review of the facility policy titled Changes in Resident's Conditions or Status revised 08/09/23 revealed, Notification of Changes- A facility must immediately inform th resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representatives(s) when there is: b- a significant change in the resident's physical, mental or psychosocial status (that is a deterioration in health, mental ) c- a need to alter treatment significantly (a need to discontinue an existing treatment due to adverse consequences, or to commence a new form of treatment).

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for 1 of 7 residents (CR #1) reviewed for quality of care. - The facility failed to accurately enter and provide wound care to CR #1 surgical incision site and sacrum after admission for surgical aftercare on 08/03/23 and 08/04/23. This failure could place residents at risk of worsening of current wounds as well as infection. Findings Included Record review of CR #1's Face Sheet dated 10/25/23 at 11:42 AM revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included: femur fracture and an encounter for orthopedic aftercare. The resident was transferred to the hospital on 08/11/23 and never returned to the facility. Record review of CR #1's MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 01 out of 15. Record review of CR #1's Hospital Records dated 08/02/23 at 10:21 AM revealed, CR #1 admitted to the hospital on 07/21/23 and discharged on [DATE] CR #1 was admitted to the hospital after experiencing a fall resulting in a hip fracture that required surgery. There was no documentation of CR #1 suffering from any wounds to her sacrum, her skin was noted to have no significant lesions or rashes. Record review of CR #1's Admission assessment dated [DATE] and signed by LVN C revealed, CR #1 admitted to the facility on [DATE]at 10:22 PM, with a surgical incision and an open area/wound. The wounds were described as left hip/thigh- incision in three places, covered with gauze/dry dressing; sacrum- shearing and redness. Record review of CR#1's NP Progress Notes dated 08/03/23 signed by NP B revealed, Skin- left hip incision with dressing intact. There was no documentation of a sacral wound. Record review of CR#1's NP Progress Notes dated 08/04/23 signed by NP B revealed, Skin- left hip incision with dressing intact. Record review of CR #1's Wound Observation Tool dated 08/04/23 at 05:12 PM and signed by the DON revealed, CR #1 admitted with a surgical wound to her lower left leg on 08/02/23 and the wound measured 2.5 cm x 0.1 cm and had 3 staples. There were no signs of infection, CR #1 reported no pain and the current treatment plan was to apply TAO and cover with a dry dressing. Record review of CR #1 Order Summary Report revealed there were no wound care orders active prior to 08/05/23. - Orders for wound care to left lower extremity wound- clean with NS, apply TAO and cover with non-stick dressing daily was entered on 08/04/23 but was not started until 08/05/23. Record review of CR #1 August Progress Notes dated revealed, - 08/05/23 at 04:40 PM signed by the IP-, LVN D performed wound care to CR #1's surgical wound. This was the first documentation of wound care. - 08/05/23 at 9:23 PM signed by LVN E-, resident (family member) called 911 an insisted that resident go to (a hospital) at med center resident stated that she wanted to go for concerns about wound care on call md notified. - 08/11/23 at 06:53 PM, signed by LVN F- resident had an unwitnessed fall and was transferred to the hospital. Record review of CR #1's August MAR revealed, Orders for wound care to left lower extremity wound- clean with NS, apply TAO and cover with non-stick dressing daily was entered on 08/04/23 at 04:38 PM and the first time the treatment was performed was on 08/08/23. Record review of CR #1's Surgical Consult note dated 08/07/23 at 07:16 PM and signed by the Wound Care MD revealed, . Preoperative indication- breakdown of tissue slough or dead tissues, poor healing; signs of infection: none. Procedure performed: surgical removal of subcutaneous tissue resulting in a post-operational wound area of 6X8X0.2 cm (48sq cm); wound progress: first visit. Operative note: CR #1 had a wound on her sacrum that was debrided (surgical removal of damage tissue). Record review of CR#1's NP Progress Notes dated 08/08/23 signed by NP B revealed, sacral wound present- unable to assess. There was no plan for the treatment of CR #1 sacral ulcer. Record review of CR#1's NP Progress Notes dated 08/11/23 signed by NP B revealed, Skin- left hip incision. Sacral Ulcer stage 3- 6X8X0.2 cm. Diagnosis/Assessment/Plan- sacral ulcer treatment with local wound care with Medihoney and Calcium Alginate In an interview on 10/25/23 at 11:00 AM, the DON said when CR #1 on the day admitted to the facility a skin assessment was performed and the nurse should have entered orders for the default wound care protocol until the wound care doctor saw the patient. He said after reviewing the patient's chart he did not see any reason why after CR #1's admission on 08/02/23 she did not receive wound care until 08/05/23. The DON said he assessed CR #1' He said he was not aware that CR #1 called 911 for the resident to go to the hospital due to concerns for wound care. In an interview on 10/25/23 at 11:32 AM, the DON said the floor nurses perform wound care but he is responsible for auditing to ensure wound care is being administered. He said the facility had default wound care orders to provide immediate care before the resident was seen by the wound care doctor. He said CR #1 should have had wound care orders for her surgical site upon admission. In an interview on 10/25/23 at 01:00 PM, the Administrator said the IP had the authority to answer questions regarding the facilities nursing practices because at the time she assisted the DON in performing nursing administration tasks. In an interview on 10/25/23 at 01:15 PM, the DON said he is responsible for wound observations upon admission because LVNs are not qualified to stage wounds. He said if a resident presented with redness and shearing as well as a surgical incision he should have looked at both sites. The DON said he knew he looked at CR #1's incision site. The DON said failure to provide wound care upon admission placed residents at risk for worsening of wounds and infections. In an interview on 10/25/23 at 02:15 PM, CR #1's family member said the the dressing to her mother's surgical incision site appeared old/dingy and hanging off like no one was changing it. She said she asked the floor nurse what care was being provided for her mother's wounds and the staff member said she didn't have to tell her anything. CR #1's family member said she called 911 later that evening due to her concerns of inadequate wound care, she said at the facility her mother's wound worsened, with her surgical site appearing red/inflamed but once she went to the hospital it got better. In an interview on 10/25/23 at 03:48 PM, LVN C said she was the admitting nurse for CR #1 but does not remember much except CR #1 was a sweet, nice lady. She said when a resident admits nursing staff are expected to assess the residents and any identified wound should have orders entered for immediate care and the facility had specific default wound care orders depending on the state of the wound. LVN C said she did not remember if she saw any wounds on CR #1, she did not have the authority to stage wounds, and staging was performed by the RN. LVN C said failure to enter orders for immediate care of wound could place residents at risk of worsening of the wound or infection. In an interview on 10/25/23 at 04:19 PM, LVN D said she was not CR #1's admitting nurse. She said on an unknown date between 08:00 AM and 01:00 PM CR #1's family member asked what the facility was doing for her mother's wound and asked to see the resident's medical record. LVN D said she would not be able to provide the family member with the record and the family member would have to wait for the appropriate department to arrive to make her request. LVN D said she remembered CR #1 as having a surgical incision with staples that was covered by a dressing and she did not think CR #1 had orders for Zinc Barrier cream that would be the appropriate treatment for abrasions/shearing. LVN D said failure to enter wound care orders and failure to receive wound care could place residents at risk for adverse reactions, worsening of wounds and infection. In an interview on 10/26/23 at 11:08 PM, the Wound Care MD said every newly admitted resident should receive a full skin assessments to identify any wounds that might be present. He said any newly identified wounds should receive wound care orders based on the facility's default standing orders to be performed daily. In an interview on 11/01/23 at 01:40 PM, the DON said any residents with wounds observed upon admission should receive immediate orders for care per the facility protocol. He said failure to enter orders per the protocol could result in adverse outcomes/worsening of wounds and the admission LVN did not have the ability to determine the severity of CR #1's wounds and it was beyond her scope. The DON said failure to perform wound care could lead to worsening of wounds and failure to identify and document wounds accurately could result in missed diagnoses, and delay in care. Record review of the facility policy Basic Skin Management revised 11/28/22 revealed, orders are required for skin and wound care. There are wound care protocol order in the EMR. Record review of the facility policy titled Skin Integrity & Pressure Ulcer/Injury Prevention and Management revised 03/31/23 revealed, provide associates and licensed nurses with procedures to manage skin integrity, prevent pressure ulcer/injury. 7- When skin breakdown occurs, it requires attention and a change in plan of care may be indicated to treat the resident. Record review of the facility undated Wound Care Order Protocol provided on 10/31/23 revealed, All admissions with wounds, including surgical, need wound care orders. Nurse completing admission is responsible for entering wound care orders in [EMR] and entering wound consult order. The documented protocol orders were as follows: - If the wound is draining and has exposed wound bed- cleanse wound with NS/Vashe, pat dry, lightly pack with Vashe moistened gauze and cover with dressing daily and PRN. - If the wound is not draining and has an exposed wound bed- cleanse with Vashe/NS, pat dry, apply triad paste and cover with a dry dressing daily and PRN. - If resident has a surgical wound with sutures and staples- Betadine paint, let air dry and cover with dry dressing daily and PRN. - If resident has a deep tissue injury- Betadine paint and cover with foam dressing daily/PRN. - For all redness- apply barrier cream after each incontinent episode. FAILURE TO COMPLY WITH POLICY WILL RESULT IN DISCIPLINARY ACTION.

Based on record review and interviews, the facility failed to ensure one (Resident (R) 16) of seven residents reviewed for abuse was free of abuse in the facility. This failure caused R16 to experience fear and anxiety related to the incident that resulted in her seeking alternate placement, as well as severe pain that required hospitalization . Findings include: Record review of R16's 06/07/21 Admission Record, found in the Reports section of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with healing fractures of the left tibia (shinbone)left humerus (long bone of the arm), and left rib and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of R16's admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 05/24/21, revealed she had minimal cognitive impairment, was able to make herself understood and understand others, and did not exhibit any signs of [CONDITION(S)], mood symptoms, or behaviors. Record review of a 06/04/21, 11:10 PM Provider Investigation Report, located in the investigation file in the Administrator's office, documented an incident of abuse of between R16 and R17 that occurred on 06/04/21 at 10:30 PM in R16's room. Review of the final report on 06/10/21 revealed, [R17] pushed [R16] aside on her bed, got on top of her, and touched her breast. [R17] was immediately removed from [R16's] room. He was taken to nurses' station for closer observation. [R16] was medicated for pain. Head to toe assessment completed. Family member notified; physician notified. Orders were obtained for x-rays. [R17] was placed on one-to-one with hospice nurse and was discharged . [R16] was transferred to a local hospital on 06/05/21 per resident request .Investigation findings: confirmed . [R17] was discharged from facility. [R16] was sent to a local hospital per resident request on 06/05/21. Facility conducted Abuse and Neglect in-service with staff. Record review of R17's 06/07/21 Admission Record documented he was admitted to the facility on [DATE] for a hospice respite stay with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of R17's progress notes, located in the Progress Notes tab of the EMR, revealed R17 had previously stayed for several short respite stays between 10/22/20 and 5/26/21. There was one episode of the resident wandering through the halls and into another resident's room on 10/24/20, but there were no instances of contact with another resident or inappropriate interactions with other residents. He had a care plan in place for wandering and dementia. Record review of R17's Care Plan, located in the Care Plan tab of the EMR, revealed a 10/18/19 Care Plan addressing R17's wandering risk. The approaches included: Encourage to participate in activities to divert from exit seeking behavior [and] Provide for safe wandering - resident is an elopement risk. A 10/18/19 behavior Care Plan documented, [R17] exhibits impulsive behavior and resists care due to dementia with hallucinations. The approaches included: Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed . [and] Observe for behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Record Review of an 06/04/21 Incident Report, located in the investigation file and written by Registered Nurse (RN) 2, revealed, This nurse arrived the unit by 10 PM, during my rounds, to check my residents before taking the report, this nurse heard resident shouting for help from [R16's room], this nurse quickly ran to the resident's room to assist her, upon entering the resident room, noted a male resident on top of the female resident, trying to push her over on her weaker and fractured side (left) nurse called for assistance and have [sic] the male resident removed from the female resident room . [R16] stated that she was sleeping and felt someone pulling her blanket, she opened her eyes and saw the male resident on her bed trying to push her over and touching her inappropriately 'the male resident was on me' she said. R16 was alert and oriented to person, place, time, and situation, and had pain at a level six out of ten following the incident. Record review of an 06/04/21 statement by the Administrator, located in the investigation file, revealed, I spoke with [R16] via phone speaker. [R16] explained the incident. Stated she had fallen asleep and then felt someone covering her feet with the blanket. She woke up thinking it was the nurse but did not recognize the man. He then walked around her left side of the bed. Same side as her injuries. He tried to get under the covers and started pushing her over. She started [sic] screaming for help, then he got on top of her. He touched her breasts. Nurse came in when she started screaming. Nurse had a difficult time getting him off of her but was able to. He caused pain to her left side. States she has a history of fractures in her shoulder, knee, and rib. She stated she was in pain. We assured her that nurse will be administering pain medication and contacting her doctor. She stated she would not feel comfortable knowing he was still in the facility. We assured her that he would not come in her room again and we were working on discharging him . [R17] admitted to facility today, June 4th, 2021, for a respite stay with hospice. Resident was taken to the nurse's station after he was removed from [R16's] room for closer monitoring. After speaking with [R16], I instructed nurse to contact family for [R17] regarding discharging him back home. Review of R16's progress notes following the incident, located in the Progress Notes tab of the EMR, revealed: On 06/05/21 at 2:20 AM, Resident reported to this nurse that she is very nervous and can not sleep because of what happened, she was reassured. Will continue to monitor her. On 06/05/21 at 8:26 AM, Resident slept very well after she was reassured, due medication given to her this morning, resident did not show any sign of fear, pain medication given as needed. On 06/05/21 at 4:30 PM, Patient called 911, familiy member states patients [sic] pain was unbearable. Nurse went in to assess patient, but patient refused and told nurse familiy member has called 911 already. Family member picked up her moms [sic] belongs [sic], patient left at 1720 [5:20 PM]. Record review of R16's 06/05/21 hospital notes, found in the investigation file, revealed, The patient states that last night she was sexually assaulted by a dementia patient that lives with her in the nursing home and since then has been more in pain because he was squeezing her breast and was laying on top of her, hurting her limbs more than they were prior to the incident. R16 had severe, constant pain in her lower limbs. X-ray results were negative for fracture or hardware displacement. The report documented, Sexual assault victim; multiple contusions; safety risk unable to return home; needing new placement. During an interview an 06/25/21 at 10:50 AM, the Administrator, who served as the facility's abuse coordinator, stated the investigation substantiated that R16 was abused when R17 was on top of R16, and he touched her breast. She stated R16 was afraid of being in the facility when R17 was here, and he had to be moved to another unit because of her fear. She also voiced pain and ended up calling 911 to go to the hospital. R17 was put on one-to-one supervision until he was discharged around 4:00 AM on 06/05/21. Record review of the facility's 05/15/20 Protection of Residents: Reducing the Threat of Abuse & Neglect policy documented, Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation of any type by anyone. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone. This includes but is not limited to: staff, other residents, consultants, volunteers, staff from other agencies serving our residents, family members, the resident representative, friends, or any other individuals. It is the policy and practice of this facility that all residents will be protected from all types of abuse, neglect, misappropriation of resident property, and exploitation.

Based on interview and record review the facility failed to implement their written abuse/neglect policies and procedures regarding training staff and protecting one of six sampled residents from neglect. (Resident #3) These failures affected one resident and placed 16 residents at risk for neglect due to the possibility that they may not receive the proper transfer by Certified Nurse Aide (CNA) A. Incident # 4 Findings include: Review of the facility's Abuse Program: Protection of Residents: Reducing the Threat of Abuse & Neglect revised dated 04/07 revealed: " ... The following guidelines incorporate policies and procedures for identifying, investigating, reporting, and reducing the risks of alleged abuse, neglect, mistreatment and/or misappropriate of property ... Regulations 483.13 Resident Behavior and Facility Practices ... F224 (c) Staff treatment of [REDACTED]. Definitions ... Neglect The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. " Resident #3 Record review of Resident #3's face sheet revealed that she was admitted on [DATE] and readmitted to the facility on [DATE]. The Resident's [DIAGNOSES REDACTED]. Record review of the facility's incident report dated 12/30/11 revealed:" incident Category: Neglect ... Investigation Summary: Resident #3 is a [AGE] year old female who was admitted to nursing home on 12/27/2011 her [DIAGNOSES REDACTED]. Resident #3 requires two person assist with transfer. On 12/29/11 at approximately 11:10 a.m. Certified Nurse Aide (CNA) A was in the shower room preparing to give Resident #3 a shower. CNA A decided to use the easy stand up lift to transfer Resident #3 from the wheeel(sic) chair to the shower chair. While Resident #3 was in the wheel chair CNA A secured the standup lift harness and lifted Resident #3 as a test first. When CNA A saw that it seemed ok he proceeded to lift Resident #3 all the way and then took down her pants and briefs. At this point Resident #3 began to slide out of the harness, CNA A attempted to break the fall by supporting Resident #3 as she slid to the floor where she landed on her bottom and bumped her head. CNA A immediately called Unit Manager C to come and help. NP was notified she assessed Resident #3 and gave orders to send her to the emergency room (ER) for further evaluation. Interview revealed CNA A knew Resident #3 required two person assist with transfers but because he was able to transfer her safely with a gait belt he thought he could safely transfer her using Hoyer lift by himself. " Record review of Computerized tomography (CT) (a noninvasive method of diagnosing disorders of the body) dated 12/29/11 revealed: "CT Spine cervical without contrast. Findings: Unenhanced CT of the cervical spine is interpreted. There is moderate to large right central disk protrusion which measured 6 mm in AP dimension extrudes inferiorly minimally. There is also a fairly large disk extrusion of the C5-6 level which is broad based and poorly defined on the axial images due to artifact related to the shoulders. There is mild encroachment on the left neural foremen suspected There is slight compression and deformity in superior endplate of C7 of indeterminate age. Impression: 1. Mild compression deformity of the superior endplate of C7 of indeterminate age. This can be further evaluated with MRI or whole body bone scan. Previous imaging if available may be helpful in further evaluation. 2. No displaced fracture is identified. 3. There are moderate to large disk extrusion at the C4-5 and C5-6 level with mild to moderate canal stenosis suggested." Record review of Resident #3's Minimum Data Set ((MDS) dated [DATE] revealed under cognitive patterns, Resident was able to repeat back to the interviewer three words that she was asked to repeat, she knew the correct year, correct month and the correct day of the week. Record review of Resident #3's MDS dated [DATE] revealed; Transfers- How resident moves between surfaces including to or from: bed, chair, wheelchair, standing position. Resident was total dependence on staff and needed two plus person physical assist. Under bathing; Resident #3 was totally dependent on staff and needed two plus person physical assist for bathing. Record review of Resident #3 ' s Daily Care Guide dated 2/1/12 revealed " ... Safety devices and appliances Wheelchair Press. Dev ....Interventions: Hoyer lift for transfers with 2 person assist. Record review of Resident #3's care plans dated 1/13/12 revealed: " Problem/ Need: Resident #3 requires staff assistance of 1-2 for all activities of daily living(ADLs) related to recent compression fracture and pelvic fracture, pain and muscle weakness. Goals: will increase independence with ADLs 4/13/12, Will be able to participate in part of ADL ' s. Approaches: Two person assist with transfers, bed mobility, toileting and bathing. Further review of Resident #3's care plans dated 1/13/12 revealed Resident is at risk for falls with significant injury related to dementia, pain, incontinence, antidepressant use as evidence by(AEB) history of falls with pelvic fracture and compression. Goals & Target date: Resident #3 will not experience any injuries related to falls 4/13/12. Approaches: Two person assist with transfers for safety. Hoyer lift to be utilized for all transfers. Record review of Resident #3's Nurse Practitioner progress notes dated 2/2/12 revealed "... Resident was admitted to the hospital on Dec. 20, 2011 with urosepsis and poor control of diabetes. She was discharged back to nursing home and she fell sustained fracture of C7, T3 and T2. She is presently in a sling has neck and shoulder pain." Observation on 2/1/12 at 10:43 a.m. revealed Resident #3 was sitting in her wheelchair, she had on a soft neck brace. In an interview at this time Resident #3 stated that she had been in the facility for 11 weeks and she would be going home on Monday or Tuesday. In continued interview Resident #3 stated that she fell and fractured or broke her neck when CNA A was putting her in the shower chair. She stated the staff had always given her bed baths because she could not move. Resident stated that her family member talked to the facility staff and said it was supposed to be two people transferring her. Resident also stated that I could talk to her family member about the incident. In an interview on 2/1/12 at 6:50 p.m. Resident #3's family member stated Resident #3 's neck was fractured. The family member stated that Resident #3 was dropped by CNA A and the facility staff told her that there was supposed to be two people transferring Resident #3 instead of one person. In a telephone interview on 2/1/12 at 7:00 pm CNA A stated that he was working with Resident #3 using the easy lift and Resident legs were not as strong as he thought. In continued interview he stated that he got the resident to the shower and lifted her one time to test the easy lift and it seemed ok He stated that Resident #3 fell when he lifted her from the wheelchair to the shower chair. CNA A stated that the fall hurt Resident #3. In continued interview he stated that he was supposed to use two people with the lift. CNA A stated that day for some reason he did not get a second person because he was not thinking. In further interview CNA A stated that he had training on using lifts before, after the incident and he would be coming in to work tomorrow at 2 pm. In an interview on 2/3/12 at 12:46 p.m. the Director of Nurses (DON) stated that they did not have documentation of monitoring CNA A, but they are monitoring. In an interview on 2/3/12 at 12:48 p.m. the Administrator stated because the incident was not intentional "that is why they did an in -service and staff competencies and corrective action." In further interview the Administrator was asked what was neglect according to the facility ' s policies and procedures. The Administrator read the policy, did not answer the question and asked the Surveyor should the facility terminate CNA A. The Administrator was informed that the Surveyor could not say if she should terminate CNA A. The CMS 672 listed 17 residents dependent on staff for transfer.

Based on observation and interview the facility failed to ensure that one of six sampled residents (Resident #3) received adequate supervision and assistance devices to prevent an accident and that the environment was free from accident hazards in one of four units. (Unit B) The facility failed to: -- ensure that Resident #3 was transferred by two persons and was not dropped when one staff used a mechanical lift resulting in her neck injury. -- lock the shower room door where chemicals and razor blades were in the unlocked storage cabinet. These failures resulted in a neck injury to Resident #3 and placed 19 residents at risk of injury by having access to chemicals and razor blades. Incident # 4 Findings include: Resident #3 Record review of Resident #3's face sheet revealed that she was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident ' s [DIAGNOSES REDACTED]. Record review of the facility ' s incident investigation report dated 12/30/11 revealed: incident Category: Neglect ... Investigation Summary: Resident #3 is a [AGE] year old female who was admitted to nursing home on 12/27/2011 her [DIAGNOSES REDACTED]. Resident #3 requires two person assist with transfer. On 12/29/11 at approximately 11:10 a.m. Certified Nurse Aide (CNA) A was in the shower room preparing to give Resident #3 a shower. CNA A decided to use the easy stand up lift to transfer Resident #3 from the wheeel(sic) chair to the shower chair. While Resident #3 was in the wheel chair CNA A secured the standup lift harness and lifted Resident #3 as a test first. When CNA A saw that it seemed ok he proceeded to lift Resident #3 all the way and then took down her pants and briefs. At this point Resident #3 began to slide out of the harness, CNA A attempted to break the fall by supporting Resident #3 as she slid to the floor where she landed on her bottom and bumped her head. CNA A immediately called Unit Manager C to come and help. NP was notified she assessed Resident #3 and gave orders to send her to the emergency room (ER) for further evaluation. Interview revealed CNA A knew Resident #3 required two person assist with transfers but because he was able to transfer her safely with a gait belt he thought he could safely transfer her using (mechanical) lift by himself. " Record of review of Computed tomography (CT) report dated 12/29/11 revealed: " CT Spine cervical without contrast. Findings: Unenhanced CT of the cervical spine is interpreted. There is moderate to large right central disk protrusion which measured 6 mm in AP dimension extrudes inferiorly minimally. There is also a fairly large disk extrusion of the C5-6 level which is broad based and poorly defined on the axial images due to arlifact related to the shoulders. There is mild encroachment on the left neural foremen suspected There is slight compression and deformity in superior endplate of C7 of indeterminate age. Impression: 1. Mild compression deformity of the superior endplate of C7 of indeterminate age. This can be further evaluated with MRI or whole body bone scan. Previous imaging if available may be helpful in further evaluation. 2. No displaced fracture is identified. 3. There are moderate to large disk extrusion at the C4-5 and C5-6 level with mild to moderate canal stenosis suggested. " Record review of Resident #3 ' s care plans dated 1/13/12 revealed: " Problem/ Need: Resident #3 requires staff assistance of 1-2 for all activities of daily living(ADLs) related to recent compression fracture and pelvic fracture, pain and muscle weakness. Goals: will increase independence with ADLs 4/13/12, Will be able to participate in part of ADL ' s. Approaches: Two person assist with transfers, bed mobility, toileting and bathing. Further review of Resident #3 ' s care plans dated 1/13/12 revealed Resident is at risk for falls with significant injury related to dementia, pain, incontinence, antidepressant use as evidence by(AEB) history of falls with pelvic fracture and compression. Goals & Target date: Resident #3 will not experience any injuries related to falls 4/13/12. Approaches: Two person assist with transfers for safety. Hoyer lift to be utilized for all transfers. Record review of Resident #3's Minimum Data Set ((MDS) dated [DATE] for cognitive patterns revealed that Resident was able to repeat back to the interviewer three words that she asked to repeat, she knew the correct year, correct month and the correct day of the week. Record review of Resident 3's MDS dated [DATE] for functional status revealed; Transfers- How resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath toilet). Resident was total dependence on staff and needed two plus person physical assist. Under bathing (How resident takes full- bath/shower, sponge bath and transfers in/out of tub/ shower (excludes baths and showers)). Resident #3 was total dependent on staff and two plus person physical assist for bathing. Record review of Resident #3 ' s Daily Care Guide dated 2/1/12 revealed " ... Safety devices and appliances Wheelchair Press. Dev ....Interventions: Hoyer lift for transfers with 2 person assist. Record review of Resident #3's Nurse Practitioner (NP) progress notes dated 2/2/12 revealed "... Resident was admitted to the hospital on Dec. 20, 2011 with urosepsis and poor control of diabetes. She was discharged back to nursing home and she fell sustained fracture of C7, T3 and T2. She is presently in a sling has neck and shoulder pain." Observation on 2/1/12 at 10:43 a.m. revealed Resident #3 was sitting in her wheelchair, she had on a soft neck brace. In an interview at this time Resident #3 stated that she had been in the facility for 11 weeks and she was going to go home on Monday or Tuesday. In continued interview Resident stated that she fell and fractured or broke her neck when CNA A was putting her in the shower chair. She stated the staff had always given her bed baths because she could not move. Resident stated that her family member talked to the facility staff and said it was supposed to be two people transferring her. Resident also stated that I could talk to her family member about the incident. In an interview on 2/1/12 at 6:50 p.m. Resident #3 ' s family member stated Resident #3 ' s neck was fractured. In continued interview she stated that Resident #3 was dropped by CNA A and the facility staff told her that it was supposed to be two people transferring Resident #3 instead of one person. In an interview on 2/1/12 at 7:00 pm CNA A stated that he was working with Resident #3 using the easy lift and Resident legs were not as strong as he thought. In continued interview he stated that he got the resident to the shower and lifted her one time to test the easy lift and it seemed ok. In further interview he stated that Resident #3 fell when he lifted Resident from the wheelchair to the shower chair. CNA A stated that the fall hurt Resident #3. In continued interview he stated that he was supposed to use two people with the lift. CNA A stated that day for some reason he did not get a second person because he was not thinking. In further interview CNA A stated that he had training on using lifts before, after the incident and he would be coming in to work tomorrow at 2 pm. In an interview on 2/3/12 at 12:46 p.m. the Director of Nurses (DON) stated that they did not have documentation that they are monitoring CNA A but they are. In an interview on 2/3/12 at 12:48 p.m. the Administrator stated because the incident was not intentional that is why they did an in -service and staff competencies and corrective action. In further interview the Administration was asked what was neglect according to the facility ' s policies and procedures. The Administrator read the policy and asked Surveyor should the facility terminate CNA A. The Administrator was informed that Surveyor could not say if she should terminate CNA A. Shower Room Observation on 2/1/12 at 9:53 a.m. revealed that the shower room door on Unit B was unlocked and the supply storage cabinet was unlocked with the key inside of the lock. Further observations at this time revealed that inside the storage cabinet was a box of razors and several different containers of hygiene products. Observation on 2/1/12 at 9:53 a.m. revealed that the shower room door on Unit B was open and unlocked. Further observation at this time revealed that there was an unlocked cabinet with the key inside of the lock. Observation on the inside of the cabinet revealed the following items:1 box of 50 disposable razors, two containers of deodorant 1.5 fl oz label revealed keep out of reach of children, 3 cans of shaving cream 1.5 oz label reads keep out of reach of children, skin lotion 31.8 fl oz label revealed external use only. In an interview on 2/1/12 at 10:01 a.m. the Director of Environmental Services stated that if someone is doing showers and inside shower room with residents the door is to be unlocked. She also stated that the door is not locked when no one is in the shower room. In continued interview she stated the key is supposed to be left hanging down on the cabinet and the cabinet door is supposed to be locked. In an interview on 2/1/12 at 10:41 a.m. Unit Manager C stated the shower room should not be locked, the shower room only should have toilet paper. Razors, shaving cream, hygiene products should not be put in the cabinets in the shower room. The CMS 672 listed 20 residents dependent on staff for transfer and cognitive impairment.