Every finding on record at Greater Southside Health and Rehabilitation

Based on observations, Electronic Health Record review, hospital record review, staff interviews and policy review the facility failed to provide respiratory care and services by leaving residents in the dining room without oxygen in the tank when oxygen was required (Resident #45 and #67) and failed to suction a resident (Resident #5) appropriately in compliance with professional standards. Resident #5 was sent to the hospital for cough and increased secretions from their tracheostomy. Chest X-ray revealed atelectatic change (blocked airway). The facility reported a census of 74 residents.Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #45 documented a Brief Interview for Mental Status (BIMS) of 14 indicating no cognitive impairment. Review of Resident #45's EHR titled, Orders documented a physician's order for continuous oxygen between 2-5L (liters) via nasal cannula to keep oxygen saturation above 90%. Observation on 7/12/26 at 1:05 PM revealed Resident #45 sitting in the dining room on 2L of oxygen. The oxygen gauge was in the refill red zone. Observation on 7/12/26 at 1:39 PM revealed Resident #45 oxygen on 2L and empty. On 7/12/26 at 1:40 PM Staff C, Licensed Practical Nurse (LPN) / Assistant Director of Nursing (ADON) stated she will change the oxygen tank. Staff C took Resident #45 to room [ROOM NUMBER] and the concentrator applied. 2. The MDS dated [DATE] for Resident #67 documented a BIMS of 15 indicating no cognitive impairment. Review of Resident #67's EHR titled, Orders documented a physician's order for continuous oxygen between 2-5L to keep oxygen saturation above 90%. Observation on 7/12/26 at 1:39 PM revealed Resident #67 oxygen tanks in the red refill needed area. On 7/12/26 at 1:42 PM Staff C stated oxygen tanks should be changed out before they are empty. Staff C stated she was not sure exactly what the policy documented but would ask that she could get the policy on oxygen tanks. Staff C stated she would like to see the change of the tank before hitting the refill needed area on the gauge. On 7/12/26 at 1:44 PM Staff D, Certified Medication Assistant (CMA) / Certified Nurse Assistant (CNA) stated the oxygen needs to be checked every couple of hours and it takes a little bit for them to run out. Staff D explained anybody in the nursing staff can check the tank even a CNA can change the oxygen. On 7/12/26 at 1:51 PM Staff A, CNA stated if she noticed the oxygen is empty she would change the oxygen tank out. Staff A stated if the resident asks she will also change it out. On 7/13/26 at 1:16 PM the Director of Nursing (DON) stated as the oxygen tanks get lower the oxygen tanks should be replaced. The DON stated if any staff sees oxygen was in the red or getting low they should notify nursing staff or change it themselves. The DON stated the staff should be checking the tanks when they get residents up but Resident #45 and #67 like to sit in the dining room. Review of facility provided policy revised 4/24 titled, Policy/Procedure Oxygen Administration documented It is the policy of this facility that oxygen therapy is administered by a licensed nurse as ordered by the physician or as a nursing measure and an emergency measure until the order can be obtained. E-tanks will be changed out when they are empty and placed in the designated area to be refilled by the oxygen company. 3. The MDS dated [DATE] documented Resident #5 had a BIMS of 00 that indicated severe cognitive impairment. The MDS indicated that Resident #5 was dependent on staff for all care areas. The MDS further documented Resident #5's medical diagnoses for stroke, hemiplegia and respiratory failure. In section O on the MDS it identified oxygen therapy, suctioning and tracheostomy care. Review of EHR titled, Order Summary failed to document a physician order for suctioning of the tracheostomy. Further documentation revealed a discontinued physician order for suction of the trach and/or lavage as needed for excessive tracheal secretions with an order start date of 3/23/26 and discontinue date of 6/2/26 at 6:00 PM. Review of EHR titled, Care Plan documented suction tracheostomy as necessary with a date of initiation on 3/24/26 and revision date of 3/24/26. Review of EHR titled, Progress Notes from 6/2/26 - 7/20/26 documented Resident #5 received suctioning of her tracheostomy on 7/2/26 and 7/18/26. On 7/12/26 at 12:19 PM observation revealed copious amounts of brown mucus present at trach site and on upper chest. On 7/14/26 8:28 AM observation revealed copious amounts of brown mucus noted around trach site and upper chest. Observation on 7/14/2026 at 1:16 PM with Staff W, Registered Nurse (RN). She stated Resident #5 had mucous noted to trach collar and on chest. Staff W stated she was going to suction resident, removed gloves, performed hand hygiene, opened suction packaging, removed sterile glove packaging, placed sterile glove packaging on bed, applied sterile gloves, used her left hand grabbed and removed sterile square cardboard box and placed it on bedside table. Staff W used her left hand and grabbed the sterile water container, poured the sterile water into square cardboard, removed suction catheter from sterile field with right hand and repositioned catheter to the left hand, Staff W moved the suction catheter back to the right hand, did not change sterile gloves, did not change sterile suction catheter and continued with the left hand to remove oxygen trach collar while holding suction catheter in her right hand. Staff W with her right hand placed the catheter down into the tracheostomy cannula to suction. Staff W placed suction catheter tip into sterile water and re-applied oxygen collar to trach with left hand. Staff W explained she was going to suction another pass and removed the oxygen collar with left hand and advanced suction catheter into tracheostomy with right hand and suctioned resident. Staff W obtained pulse ox reading at 98% after suctioning with 3 liters oxygen. Staff W further explained she was going to suction one more time and advanced suction catheter with her right hand into the tracheostomy cannula. Staff W used gauze to remove mucus from the tracheostomy site and around the oxygen collar and placed new gauze under tracheostomy cannula and oxygen collar, removed gloves and performed hand hygiene. On 7/14/26 at 1:44 PM observed Staff W perform suctioning to Resident #5 with sterile technique. On 7/15/26 at 10:38 AM the Director of Nursing (DON) acknowledged concerns with tracheostomy care. Review of Resident #5 document titled, Hospital H&P dated 7/19/26 documented Resident #5's chief complaint of cough and increased secretions from trach. Physical exam documented tracheostomy presented with malodorous secretions. Chest X-ray image report documented left basilar opacities favored to represent atelectatic change; although mild infiltrate, including sequelae of aspiration cannot be extruded. On 7/22/26 at 1:57 PM the DON stated Resident #5 was sent out of the facility on 7/19/26 and was admitted to the hospital for observation though was unaware of the cause for admission. The DON stated the resident returned to the facility on 7/22/26. The DON further explained she was unable to locate a physicians order for Resident #5 to be suctioned from the tracheostomy site and stated she would expect to see a physician order if the nurse was performing suctioning on the resident. On 7/24/26 at 8:34 AM Staff AA, Nurse Practitioner (NP) stated she does rounds at the facility weekly and is familiar with Resident #5. Staff AA stated she was aware of Resident #5's recent hospitalization. Staff AA explained she was unaware that the suction order for the tracheostomy was discontinued as she did not give the facility an order to discontinue that order. Staff AA stated the nursing staff at the facility had been suctioning the resident then without an active order because she had witnessed it during rounds at the facility. Staff AA further explained her expectations would be for the nursing staff to obtain a new order for suctioning the tracheostomy before suctioning the resident. Staff AA stated that she believed if suctioning of Resident #5's tracheostomy was done appropriately; it could have prevented her from needing to be hospitalized . A facility provided policy dated 9/2018 titled, Care and Cleaning of Tracheostomy documented equipment of sterile suction catheter and sterile gloves to be used. The procedure steps included when opening a tracheostomy tray keeping contents sterile, to set up sterile field, put on sterile gloves, suction resident, remove soiled tracheostomy dressing and drop into plastic discard bag along with soiled gloves and replace gloves with sterile gloves. A facility provided policy dated 4/26 titled, Physician Orders documented all physician orders will be followed through upon the written order by a personnel licensed to write orders and/or take verbal orders from the provider. Verbal orders for drugs and treatments shall be received only by licensed nurses, psychiatric technicians, pharmacists, nurse practitioners, physicians, physicians' assistants (from their supervising physician only), and certified respiratory therapists when the orders relate specifically to respiratory care.

Based on observation, clinical record review, staff interview, and policy review the facility failed to provide appropriate incontinence care for one (Resident #8) of one resident reviewed. The facility reported a census of 74 residents. Findings include:The Minimum Data Set (MDS) assessment for Resident #8, dated 6/6/26, included a diagnosis of urinary tract infection in the past 30 days. The MDS identified the resident was dependent on staff for toilet hygiene and was occasionally incontinent of urine and bowel. The MDS indicated the resident had a Brief Interview for Mental Status score of 12, indicating mild cognitive impairment. Observation on 7/14/26 at 7:21 AM Staff V, Certified Nurse Assistant entered Resident #8's room and applied gloves. With the resident lying in bed, Staff V lowered the resident's brief and wiped straight down the peri area with 1 wipe. Staff V turned the resident to her side and removed the visibly wet brief. Staff V used a new wipe and proceeded to wipe both buttocks and between the buttocks with the same side of 1 wipe, and folded the wipe and wiped each buttock 2 more times, not cleansing the complete peri area or hips. Staff V applied a new brief, removed her gloves and reapplied new gloves, no hand hygiene completed. Facility Incontinent Care Policy revised 4/26 instructed to wash using front-to-back strokes, rinses, and dry exposed skin surfaces, cleanse perennial/rectal area and apply a new brief. Interview on 7/20/26 at 3:35 PM, the Administrator stated his expectation for incontinence care to be completed thoroughly with perennial area, buttocks, hips included and to use a new wipe for each swipe.

Based on observation, electronic health record review (EHR), resident interviews, staff interviews and policy review the facility failed to provide dignity and respect by not completing personal cares or wound cares in a timely manner, staff raising their voice and talking on the phone during cares to 5 of 10 residents reviewed (Resident #10, #51, #39, #53 and #57). The facility reported a census of 74 residents.Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #10(R10) documented a Brief Interview for Mental Status (BIMS) of 00 indicating severe cognitive impairment. The MDS also documented diagnoses of hemiplegia (condition causing paralysis on one side of the body, affecting the face, arm, and leg) and hemiparesis 9 muscle weakness or partial paralysis affecting one entire side of the body) affecting left non-dominate side and right dominant side. The MDS documented that the resident had a stage 4 pressure ulcer. A Order Summary Report contained a physician's order for R10 with the start date of 6/25/26 which directed staff as follows; coccyx/sacral site (tailbone) to be cleansed to include the wound bed and periwound (skin surrounding the wound) with saline, pat dry, apply skin protective to the periwound, place Hydrofra blue classic foam cut to size of would bed moistened with a few drops of saline, squeeze out excess saline from the foam, and cover with bordered foam dressing as needed for if soiled or dislodged, and also directed staff to complete this order on Monday, Wednesday, and Friday. On 7/12/26 at 3:53 PM Resident #10's Wife stated she went outside with her husband, came back in and found the bed made. Resident #10's Wife stated the bed was made but remained soaked in urine. Resident #10's Wife explained the staff had just pulled the sheet up and not changed or cleaned up the urine. Resident #10's Wife stated she had told the staff that the bed had urine and smelled pretty bad. Resident #10's Wife stated the staff told her the bed was already made. Resident #10's Wife stated the staff member told her that the Certified Nurse Assistant (CNA) had an attitude with her and it was evening shift the day before. Resident #10's Wife stated the CNA said the bed had already been made and was rude with her. On 7/13/26 3:52 PM Resident #10's Wife stated at 3:05 PM a CNA came in and shut the call light off. Resident #10's Wife stated the CNA did this 3 times. Resident #10's Wife said nobody still came in. Resident #10's Wife explained the CNAs came into the room about an hour ago and changed Resident #10's brief. Resident #10's Wife stated the wound dressing on his buttocks was coming off and wanted the nurse to change the dressing. Resident #10's Wife stated the CNA stated she would leave the brief unfastened and could have the nurse come down to the room. Resident #10's Wife said she did not feel as though they were providing her husband with dignity leaving his brief unfastened and the dressing needed replaced for almost an hour. On 7/13/26 at 3:57 PM Staff L, Certified Nurse Assistant (CNA) stated Resident #10 needed to be changed so she changed him. Staff L stated Resident #10's wound dressing needed to be changed. Staff L stated she had told Staff E, Licensed Practical Nurse at least 30 minutes ago Resident #10 needed his wound changed. Staff L explained Staff E could not change the dressing right now because after she told Staff L the dressing needed to be changed she went on break. On 7/13/26 at 4:18 PM the Director of Nursing (DON) stated she would want the resident taken care of immediately. The DON stated she would want the wound dressing changed prior to Staff E leaving for break. The DON stated Staff E should have told someone if she could not complete the task at that time. The DON stated the nurse should have talked to the nurse that took over. The DON stated she should have let management know prior to leaving the dressing needed changed. On 7/13/26 at 4:29 PM Staff C, Licensed Practical Nurse (LPN) stated Staff E had left on lunch break. Staff C stated she was not notified that Resident #10 was waiting for a wound dressing change by Staff E prior to her leaving on break. 2. The MDS dated [DATE] for Resident #51 documented a BIMS of 13 indicating no cognitive impairment. The MDS also documented a diagnosis of acquired absence of left leg below the knee. Review of Electronic Health Records (EHR) titled, Orders documented a physician's order with start date of 7/9/26 that directed staff to cleanse right heel with wound cleanser, apply calcium alginate with silver to wound bed, secure with gauze wrap and tape. Change daily and as needed. On 7/12/26 at 1:28 PM Resident #51 said he wanted his leg dressing rewrapped because it did not feel right and was loose in the morning on Friday and the nurse refused to rewrap the leg. Staff E worked on Friday and told him that she could not wrap the leg appropriately because she did not have the appropriate things to wrap the leg. Resident #51 stated when Staff E came into his room she was frequently on the phone as well. Resident #51 stated Staff E refused to wrap his leg from 9:30 AM till 2:30 PM and then the evening nurse came in and wrapped in around 9:00 PM. On 7/15/26 at 1:19 PM Staff N, LPN stated she had worked 7/10/26 evening 6:00 PM - 6:00 AM. Staff N stated she took over for Staff E that day. Staff N stated she was familiar with Resident #51. Staff N stated she saw him when she first got there that day. Staff N stated a CNA stated he needed to see a nurse. Staff N stated Resident #51 was complaining because his treatment wasn't done right and had requested the treatment completed so he could go to therapy and Staff E did not get there in a timely manner. Staff N stated she had talked to Staff E about it when she came back and she did not respond. Staff N stated she then went down and completed the treatment. Staff N stated she had the discussion before in the past about the same nurse and the same situation with Resident #51. Staff N stated Resident #51 really wanted to go to therapy but couldn't because of his treatment not being completed. On 7/15/26 at 12:30 PM Staff E, LPN stated she told the facility she had an emergency at home with her daughter and said she had to leave. Staff E explained management told her that she could not leave. Staff E stated then the management said she could leave for an hour. Staff E stated the facility started calling and they were upset that she left. Staff E stated Staff C, Licensed Practical Nurse (LPN) took over for her and the DON talked to the administrator about the situation. Staff E stated she had wrapped Resident #51's leg before and it had been changed to night shift. Staff E stated she had worked on 7/10/26 last week. Staff E stated she had worked the morning shift that morning. Staff E stated she thought that Staff N, LPN changed the dressing / wrap right when she first got to the facility. Staff E stated she did not recall if Resident #51 ever asked for her to wrap his leg. Staff E stated that day Resident #51 had behaviors and had refused everything even like going to therapy. Staff E stated she did not know why he refused everything. Staff E stated she was familiar with Resident #10. Staff E stated she did not have any interactions with Resident #10 or his wife that morning. Staff E acknowledged she was working his hall that morning. Staff E stated she left in the morning and came back then left again. Staff E stated the facility was calling her and telling her that the resident needed his dressing changed. Staff E stated she knew when she came back that Staff C was completing the dressing change. Staff E stated Staff L, CNA called and told her that she needed to change Resident #10's dressing. Staff E stated the call was at 4:12 PM according to her phone. Staff E stated she left about 3:30 PM and the DON called right after she had left. Staff E stated Staff L never told her prior to that the dressing needed to be changed. On 7/15/26 at 1:29 PM the DON stated she had received a grievance on the very incident from Resident #51 about Staff E not changing the dressing. The DON explained that the nurse was no longer employed with the facility anymore. The DON stated she would like to have the treatments completed when they are requested if there was not a more pressing matter at the time. 3. The MDS assessment for Resident #39, dated 5/10/26, included diagnosis of Quadriplegia (paralysis form the neck down). The MDS identified the resident was dependent on staff for all all cares, had a indwelling suprapubic urinary catheter, and was always incontinent of bowel. The MDS indicated the resident had a BIMS score of 15, indicating no cognitive impairment. Interview on 7/12/26 at 4:15 PM, Resident #39 stated about a month ago Staff F, Certified Nursing Assistant (CNA)/Shower Aide had taken him to the shower room to receive his shower. The resident stated a nurse always completes his bowel care in the shower room before he receives his shower. Resident #39 stated it took 45 minutes before any staff could find Staff E, Licensed Practical Nurse to come complete his bowel care and when Staff E did come into the shower room she was talking on her personal cell phone with a phone company. Resident #39 stated Staff E ended the phone call after a few minutes and proceeded to perform his bowel care which included Staff E to insert her finger into the resident's rectum to remove any stool that is present, administer an enema, and then remove any remaining stool. Resident #39 stated while Staff E performed the bowel care she received a call on her personal cell phone from her daughter and proceeded to talk on speaker phone while performing his bowel care. Interview on 7/13/26 at 1:45 PM, Staff F stated about 1.5 - 2 months ago she informed Staff E that she was going to give Resident #39 his shower and would need Staff E to perform his bowel care. Staff F stated she proceeded to get Resident #39 ready for his shower and staff were looking for Staff E as she had not came to the shower room yet. Staff F stated it took 45-60 minutes before Staff E was found in the medication room talking on her personal cell phone and when she came into the shower room she was still on her phone with a phone company. Staff F stated she was present during the bowel care as she was going to provide the resident's shower right after. Staff F stated Staff E received a call on her personal cell phone from her daughter and spoke with the daughter on speaker phone while performing the resident's bowel care. 4. Review of Resident #53 MDS dated [DATE] documented a BIMS score of 15 indicating intact mental status. The MDS further documented Resident #53's functional abilities required dependency with cares including toileting hygiene, shower/bathing, dressing upper and lower body and personal hygiene. Review of document titled, Medical Diagnosis documented Resident #53's diagnosis of breakdown (mechanical) of nephrostomy catheter, colostomy and paraplegia. On 7/14/26 at 2:15 PM, Resident #53 was observed in the hallway with his shirt and pants wet from a leaking ostomy. He was self-propelling to his room to activate his call light for assistance. On 7/13/26 at 3:23 PM observation revealed Resident #53 entered his room from the hallway, placed his call light on for assistance as his ileostomy was leaking onto his clothing. At 3:33 PM Staff K, Certified Nurse Assistant (CNA) entered the room, shut off light and stated she needed to find another staff to assist her and left the room. At 3:38 PM Staff K and Staff G, CNA entered the room to assist the resident. Observation revealed Resident #53 with soiled clothing for a total of 15 minutes. On 7/13/26 at 8:46 AM Resident #53 stated staff members raise their voices, yell at him and treat him like a child. Resident #53 further explained when he activates his call light staff silence the alarm, and reports they are busy, and do not return promptly. Resident #53 expressed concerns that his ostomy bags frequently overfill and leak onto his clothing. Resident #53 further explained that this occurrence is embarrassing and leaves him feeling devalued by the facility. On 7/13/26 at 2:00 PM Staff F, CNA/Shower Aide stated Resident #53's ostomy bags are frequently full when she comes onto her shift and that she doesn't feel they are emptied appropriately. Staff F stated both ostomies leak onto Resident #53's clothing frequently and he had expressed to her his concerns with feeling embarrassed when it happens. 5. Review of Resident #57 MDS dated [DATE] documented a BIMS score of 15 indicating intact mental status. The MDS further documented Resident #57's functional abilities as partial to moderate assistance with cares including toileting hygiene and dependent assistance with cares including showering/bathing and dressing upper and lower body. On 7/12/26 at 1:36 PM, Resident #57 stated that staff members wore earbuds and talked on mobile devices while providing care and walking through the hallways. Resident #57 further explained that staff members frequently cited short staffing as a reason for delays in providing assistance. Resident #57 expressed that staff members acted rudely and made her feel like a nuisance when she requested help. On 7/15/26 at 10:38 AM the Director of Nursing (DON) acknowledged concerns with dignity and respect when examples of the resident's statements were shared and observations were revealed. Review of policy provided by the facility dated 4/26 titled, Resident Rights and Responsibilities, Notice Of, directed staff as follows; it is the policy of this facility to inform the resident both orally and in writing of their rights as a resident, as well as the rules and regulations governing the resident's conduct and responsibilities during their stay in the facility. A document titled Resident Rights provided by the facility included the following directives for residents under the sub-category of Respect; *You have the right to be treated with dignity and respect in a manner that promotes or enhances your quality of life *As long as it fits your care plan, you have the right to make your own schedule, including when you go to bed, rise in the morning, and eat your meals *The right to have a choice over preferences that are important to you *You have the right to reasonable accommodation of individual needs and preferences except where your health and safety is at risk or the health and safety of other residents would be endangered

Based on clinical record review, hospital record review, medical provider, staff, resident, and family interviews and facility policy review, the facility failed to accurately reconcile hospital discharge orders for three out of four residents reviewed (Res #2, #4, #6). The facility additionally failed to notify the medical provider of orders requiring follow-up upon a resident's return from a hospitalization. This resulted in harm due to the erroneous discontinuation of Res #4's diabetic medications, resulting in the resident experiencing 14.5 months of no diabetic treatment. Consequently, Resident #4 required hospitalization for a life-threatening blood sugar of 1200 mg/dL (milligrams per deciliter, the unit of measure for blood sugar).On May 12, 2026 at 9:30 am, the State Survey Agency informed the facility the staff's failure to accurately reconcile hospital discharge orders and notify the provider of the need to assess hospital instructions of re-starting diabetic medications created an Immediate Jeopardy situation resulting in a resident hospitalized with a blood sugar of 1200 being admitted to the Intensive Care Unit with potentially life threatening diagnoses which began on February 18, 2025. The facility removed the immediacy on May 13, 2026 at 2:05 pm when the facility staff implemented the following Corrective Actions: Immediate verbal education beginning on 5/12/26 regarding medication transcription expectations, hospital discharge medication reconciliation, and provider notification requirements. Formal in person education with return demonstration and competancy validation beginning on 5/12/26 for nursing staff.Education including monitoring of high risk conditionsRe-education beginning on 5/13/26 with additional focus on clarifying the required process for handling medications on hold or pause status and immediate provider notification for clarification of any discrepancies. Additional education on 5/13/26 to reinforce the education to address inconsistent staff understanding. The scope lowered from a K to a E (harm that is not immediate) at the time of the survey after ensuring the facility implemented their staff education and return demonstration, and competency validation.Findings include: 1. The Discharge Minimum Data Set (MDS) Assessment of Resident #4 dated 2/12/25 identified the resident as having modified independence for decision making, displayed an acute onset of mental status change, and fluctuating inattention. The MDS identified diagnoses which included diabetes, anxiety disorder, major depressive disorder, hyperlipidemia (high cholesterol) and aphasia following cerebral infarction (a communication disorder that affects a person's ability to speak, understand, read, and write following a stroke). The MDS documented the resident was taking medications which included antianxiety, antidepressant and hypoglycemic medications. The MDS documented the discharge was unplanned, and the resident was discharged to a hospital.A Nursing note dated 2/18/25 documented the resident's return to the facility at 3:00 pm.The medication list from the hospital dated 2/18/25 directed that the following medications be held upon the resident's return, pending further orders from the resident's physician or care provider:a. Dapagliflozin propanediol (Farxiga), used for diabetes.b. Lisinopril-hydrochlorothiazide, used for high blood pressure and as a diuretic.c. Metformin, used for diabetes.d. Semaglutide, used for reducing appetite and blood sugars.These hold orders required waiting for the resident's doctor or other care provider to authorize resumption. The resident's Electronic Health Record (EHR) failed to document that the medical director or other provider was at any time notified of these medications needing to be assessed. The medication orders from the hospital also included the following medications to resume upon readmission to the facility:a. Atorvastatin, used for cholesterol.b. Duloxetine, used for depression and/or anxiety.The Medication Administration Record (MAR) for Resident #4 for February of 2025 documented that none of the six above listed medications were given to the resident anytime after the discharge on [DATE].Laboratory results from labs resulted on 2/25/25 documented a Hemoglobin A1c of 5.6 (a blood test that measures average blood sugar levels over the past 2 to 3 months)A Condition Follow-up note dated 2/26/25 at 1:30 am documented the resident had been found on the floor at 8:00 pm the prior evening with injuries including a laceration above his right eyebrow and a broken tooth and had been sent back to the hospital. A Nursing note dated 2/26/25 at 2:37 pm documented the current facility medication list was faxed to the hospital. On 5/12/26 at 1:30 pm, an emergency room nurse at a local hospital was interviewed about the procedure for obtaining an accurate medication list when a resident is sent to the hospital from a nursing facility. She stated the ER staff will reach out to the facility for a current medication list for accuracy. She added that if the ER does not obtain the list then the hospital pharmacist would obtain the list from the facility. When asked if the hospital would look at medications from a prior hospitalization, she stated they would not. She clarified that it was important for the medication list to be the most recent and accurate so therefore, if the resident came from a facility, they would use that list provided by the facility. A Condition Follow-up note dated 2/28/25 at 3:42 pm documented the resident returned back to the facility. The facility Advanced Registered Nurse Practitioner (ARNP) performed a routine visit for Resident #4 on 3/11/2025. The visit summary failed to reflect that the ARNP had been notified of the need to address the held hypertensive and diabetic medications following the first hospitalization.The MDS section of the EHR reflected that the resident remained in the facility from 2/28/25 until 5/5/26. Subsequent laboratory results collected several months later on 12/24/25 documented a significant increase in blood sugar levels. The lab results revealed glucose of 352, compared to the reading from three months earlier of 135, and the Hemoglobin A1c increased from 7.2, up from 6.4 three months prior. Hemoglobin A1c history per facility records (indicating a rising average blood sugar trend):5.6 February of 2025 (average glucose of 114)6.4 September of 2025 (average glucose of 137)7.2 December of 2025 (average glucose of 160)The ARNP noted the 12/24/25 results with her signature on 12/31/25 and documented she would address them on the next visit. The facility was unable to show any documentation of the resident being seen by the ARNP again until 2/12/26. The visit note dated 2/12/26 failed to document the rising trend of the A1c or the glucose reading of 352 (random blood sugars, not fasting, are typically 125-140).A Nursing note dated 5/4/26 at 6:20 pm authored by Staff C, Licensed Practical Nurse (LPN) documented Resident #4's son visited the facility and took the resident outdoors to smoke. The son reported to the nurse the resident was weak, was unable to hold his cigarette properly and had general pain. The note documented Staff C checked the resident's vital signs of blood pressure, pulse, temperature and oxygen. The note failed to document the checking of blood sugar. The note documented Staff C asked the resident of burning sensation, flank pain or back pain with urination with the resident denied. Staff C offered to send Resident #4 to the emergency room (ER) for evaluation. Both Res #4 and his son declined. An SBAR (Situation, Background, Assessment, and Recommendation) note authored by Staff B, Registered Nurse (RN) dated 5/5/26 at 3:43 am documented a change of condition of falls. Blood pressure, pulse, respirations, temperature, weight and oxygen levels were documented on this assessment. No blood sugar level was documented. The note documented an on-call ARNP was notified of the resident being weaker and questioning if the resident had a Urinary Tract Infection (UTI). The resident had refused to have a urine specimen collection completed. A nursing note dated 5/5/26 at 4:36 pm authored by Staff D, LPN documented an order received to obtain a urinalysis with culture and sensitivity and labs.A nursing note dated 5/5/26 at 5:18 pm authored by Staff D, LPN documented the resident was educated on the need to collect a urinalysis sample. Several attempts were made and the resident refused. The family was present and requested to take the resident to the hospital. The ARNP was notified and orders received and the family took the resident to the ER via private vehicle. The History of Present Illness summary from the emergency room physician documented the resident presented at the ER for altered mental status. Increased lethargy, slurred speech, disorientation. The note added he had been repeatedly asking for drinks, expressing increased thirst (a symptom of high blood sugar). The note documented the resident's son was unsure when the symptoms started and that they asked staff how long this had been happening and they were unsure. The ED Course note documented at 5/5/26 Res #4's white blood cell count was 15.75 (normal 4.5-11). At 7:00 pm, it was documented the resident's presentation to be consistent with HHS (Hyperosmolar Hyperglycemic State, a life-threatening complication of type 2 diabetes characterized by extremely high blood sugar (>600 mg/dL) and severe dehydration. It requires immediate emergency medical treatment). The note clarified the resident's blood glucose was 1200 and HHS protocol including insulin infusion was ordered. The resident was being admitted to the Intensive Care Unit (ICU). The resident's Hemoglobin A1c was noted to be 17.3 during this hospitalization (average daily glucose of 450).The Problem List for the hospitalization included the following diagnoses:a. Hyperosmolar hyperglycemic stateb. Severe sepsis, acute cystitis with hematuria (a life-threatening medical emergency. When acute cystitis (bladder infection): bacteria have entered the bloodstream, and caused the body to have a dangerous, systemic response to the infectionc. Acute kidney injury (a sudden episode of kidney failure which happens in a short amount of time)d. Metabolic encephalopathy (brain dysfunction or damage caused by systemic chemical imbalances, organ failure, or toxins)e. Metabolic acidosis (a serious medical condition where your body produces too much acid, or your kidneys fail to remove enough of it, causing your blood pH to drop below normal)On 5/11/26 at 12:20 pm, the ARNP stated she was unaware of Resident #4's diabetic medications being stopped in 2025. She stated she orders routine labs, normally checks A1c twice a year. She stated she did not recall any issues. She was aware he was currently in the hospital and thought he was hospitalized for a UTI (urinary tract infection). She was unaware of the hospital labs or diagnoses. When the State Surveyor showed the ARNP the orders from the February of 2025 hospitalization of the medications being on pause, she stated she had recently been seeing this more often. She added that if she is not notified of this by the facility, then it ends up falling between the cracks. She added that she should have caught it herself at that time. On 5/11/26 at 1:00 pm, the Director of Nursing (DON) stated if a resident comes from the hospital with medications on pause, the facility would address that with the ARNP to follow up on. She stated if it was urgent, they would call her and that the ARNP is in the building every Monday. She stated the process would depend on if it needed to be addressed immediately or could wait for the next visit. The DON described the situation with Resident #4 as a huge med error. She stated she was unaware of Res #4's lab results during the current hospitalization. She stated she would follow up and would also expect the ARNP to review hospital discharge paperwork when she is in the facility. On 5/11/26 at 1:08 pm, Staff C, LPN was asked what she would do if a resident returned from a hospitalization with orders labeled as paused or on hold. She stated she would notify the provider and would call them when the resident arrived. She added that orders for new residents or residents returning from a hospitalization are usually processed by the nurse management and then the floor nurses do a double check. Staff C reported she had been employed at the facility for approximately two years. She stated that while she was familiar with Resident #4, she really did not know what medications he took because the Certified Medication Aides (CMA) are the ones who dispense medications and if there was an issue with the medications, then the CMA would need to report it to the nurse. The nurse would then report it to the provider. She stated for diabetic residents, an as needed blood sugar check can be performed if the resident is not feeling well. She recalled caring for the resident just prior to his hospitalization. She said his son took him out to smoke and reported the resident wasn't feeling well, had low energy. She described how she assessed him and offered for him to go to the ER and asked him about UTI symptoms. They declined the ER and the son asked us to monitor him. She said she gave report to the oncoming shift and he was sent to the ER later. She denied having checked a blood sugar during her assessment. She was not able to recall ever having checked a blood sugar on Res #4. She stated symptoms of high blood sugars are being sweaty, having less energy, being thirsty or being lethargic. When reminded that she earlier in the interview said Res #4 was reported as having less energy, she said she didn't think it was related to blood sugar. She also clarified that most of the diabetic residents in the facility have orders to check blood sugar as needed but that Resident #4 did not have these orders. A record check following this interview verified no blood sugar checks were documented anywhere in the residents chart and he had no orders for blood sugar checks. On 5/12/26 at 1:57 pm, Staff B, RN stated she was passing medications (the night shift prior to the resident being sent to the hospital) and Resident #4 had attempted to transfer himself out of bed and into his wheelchair to go out for a smoke break. He had an unwitnessed fall. She stated she assessed him and found no injuries. She had been told about his change of status from the prior nurse but had not yet been in to see him. When she spoke to him, she felt he was having symptoms of a UTI but said it is very challenging to get urine samples from him. She said she was doing frequent neuro checks on him from the unwitnessed fall so had a lot of interaction with him. She said she did not check a blood sugar because she had never checked a blood sugar on him. She was unaware of him ever taking medications for diabetes. She said she would consider it to be best practice to check blood sugars on diabetic residents but she did not recall ever checking blood sugars on Res #4. She described the resident as being weaker than his baseline and that she spent one on one time with him. She felt he was alert and oriented to his normal baseline. She spoke to both of his sons and had a conversation about how the resident is very hard headed about not wanting to do labs or go to the hospital. He didn't go to the hospital that shift. She reported she pushed a lot of fluids and he took all the fluids fine. She did not feel he took an abnormal amount of water. She said he was a bit disoriented and tired and she had to wake him up a few times (during fall follow up checks). In a follow up interview, the ARNP stated on 5/12/26 at 12:54 pm, that in her professional opinion, the primary cause of Resident #4's blood sugar reaching 1200 was It was that he was not on his medications, obviously. She initially stated she had ordered labs in February and in March and the facility failed to draw them. She then corrected herself and stated the notes she was reading were February and March of 2025. She felt the labs that had been drawn in December of 2025 were unremarkable. On 5/12/26 at 4:00 pm, Staff D, LPN stated when a resident returns from the hospital to check the five rights of medications and to make sure orders are transcribed correctly. She stated to clarify any orders you question and a nurse is never to change orders on their own without a provider order. Staff D stated the family had noticed when Resident #4 had changes, and his transfer status was weak. She said the facility staff felt it was a UTI. She said the resident was not agreeable to giving a urine sample but said the did finally get one but then staff spilled it. She said the ARNP had ordered the urine sample and labs. She had been told about his son coming in and him not being able to hold his cigarette. She said his vitals were stable. The only symptom he had was weakness which normally for this resident meant he was having a UTI. She stated when she checked his vital signs, this did not include a blood sugar. She said she was unaware he was a diabetic. She reported she had been employed at the facility since January of 2026 and nobody had ever advised her he was diabetic. She verified she had access to see the resident's EHR and a list of his diagnoses but felt someone should have told her he was diabetic. She said on the day he went to the hospital, she had called the ARNP several times and kept her advised of his status but she didn't think of it being blood sugar related and she and his family both thought it was a UTI. On 5/12/26 at 4:16, Staff E, Certified Medication Aide (CMA) stated he had worked with Resident #4 for approximately one and a half years. Stated he had never seen him with symptoms of high blood sugar. He did not remember prior medications he was on. He said Res #4 has days of not feeling well, and thought he may have seen him last the day prior to his hospitalization but said he floated between the two floors frequently. He didn't notice any particular symptoms but said he had been working downstairs (Resident #4's room was upstairs) more often the week he was sent to the hospital. On 5/12/26 at 4:20 pm, Staff F, LPN stated the nurse managers are the ones who put orders in. She said the floor nurses do not do anything with any medications until the managers have put the orders in then the floor nurses do another check. She said usually another manager does a second check and the floor nurse does a triple check. She said if medications are paused, then it's held until there is a follow up from the doctor. She said one of them can notify the doctor, and said she would call the doctor who discharged the resident from the hospital but normally it would be the nurse managers who would do that. She said the floor nurses can call or fax the facility providers but would not administer a medication until it was verified. On 5/14/26 at 2:45 pm, Resident #4's son reported learning from the hospital that his father's blood sugar levels had been elevated since December 2025 and that facility staff had failed to notify him of this five-month elevation. He stated that he was only informed after receiving a call from a hospital employee. The son noted his father was initially diagnosed as borderline diabetic and expressed serious concern that the facility had not called him regarding the significant increase in his blood sugars. He said he just wanted to know that staff are performing their duties, specifically citing the correct administration of insulin and medications, and ensuring appropriate hygiene practices given his father's predisposition to UTI's. 2. Clinical records from a local hospital documented Resident #2 had been hospitalized from [DATE] until 2/7/26, having arrived from the facility. The reason for being sent to the ER was shortness of breath with his family expressing concerns of pneumonia. Prior to the hospitalization, the Medication Administration Record (MAR) for Resident #2 for documented medications including the following: Hydralazine, 50 mg, give twice a day (blood pressure medication). The order had a start date of 4/2/25, being on hold during his hospitalization. The order resumed with no changes on the morning of 2/8/26.The MAR additionally documented Metformin, a diabetic medication (1000 mg twice a day, start date 4/2/25), was held during hospitalization. The medication resumed on the morning of 2/8/26 and was given through the morning dose of 2/16/26 when it was then discontinued.The blood sugar administration record for February 2026 reflects the following insulin orders upon the resident's return from the hospital:a. An order for 35 units of long-acting insulin at bedtime was continued after the hospitalization, then discontinued on 2/22/26.b. A new order for 40 units of long-acting insulin each night was ordered with a start date of 2/25/26.c. A new order for short-acting sliding scale insulin, twice a day, start date 2/23/26.The discharge orders from the hospital dated 2/7/26 included these medications:a. Hydralazine: 100 mg total (two 50 mg tablets) by mouth three times dailyb. Insulin Aspart: 0 to 12 unit injected into the skin three times daily after meals. The resident's Metformin was not included as an active medication on the hospital discharge list.The Hospital Course Note in the hospital clinical records (page 41) noted the residents blood pressures and blood sugars were significantly elevated so medication was uptitrated. Correctional insulin was added and metformin was not restarted at discharge given Stage 4 chronic kidney disease. The facility failed to increase the hydralazine as ordered, failed to discontinue the metformin as ordered and failed to begin the short acting sliding scale medication as ordered. On 5/13/26 at 11:57 am the Administrator, via email, stated that upon further review of Res #2's readmission from the hospitalization of 1/29/26 - 2/7/26, it was identified that while the hospital discharge orders were largely consistent with the resident's pre-discharge regimen, there was a frequency adjustment that was not identified during the reconciliation process. He added that at the time of readmission, the nursing staff reconciled medications and re-entered the orders into PCC (EHR software), however, the reconciliation process did not include a sufficiently detailed line-by-line comparison between the hospital discharge MAR and the facility MAR, which contributed to the missed frequency change. The Administrator added the findings were incorporated into process improvement actions.The email did not address the new order for short acting insulin or the discontinuation order of metformin. Review of facility blood pressure documentation reflected the resident had a systolic blood pressure of greater than 180 on:2/9/262/10/262/12/262/13/262/27/263/7/26 (over 200) 3/8/26 (over 200) 3/9/26 (over 200) 3/11/263/17/263/19/26 (over 200) 3/26/26 (over 200) 3/28/263/29/263/30/263/31/264/1/264/7/264/14/264/18/264/20/264/21/265/13/26A progress note dated 2/23/26 documented the ARNP rounded and placed orders to increase Coreg (blood pressure medication), increase long acting insulin and begin sliding scale short acting insulin. 3. The MDS of Resident #6 dated 5/1/26 documented an admission date to the facility of 4/24/26, entering from an acute care hospital. The MDS recorded a Brief Interview for Mental Status score of 15, indicating cognition intact. The MDS recorded diagnoses including necrotizing fasciitis (a rare but severe bacterial infection that destroys the tissue beneath the skin, including fat and the fascia covering muscles) and sepsis. The MDS recorded the presence of a Stage 4 pressure ulcer, which was present at the time of admission to the facility. The Medication List from the hospital, received by the facility upon admission included the following orders:a. Amoxicillin, 500 mg capsule. Take 2 (two) capsules (1,000 mg total) by mouth 3 (three) times daily. b. Hydromorphone 2 mg tablet. Take 0.5 (1 mg total) by mouth 3 (three) times daily as needed for pain. 20 minutes prior to dressing changes. c. Docusate sodium. 100 mg capsule. Take 100 mg by mouth 2(two) times daily. d. Oxycodone 5 mg immediate release tablet. Take 0.5-1 tablets (2.5-5 mg total) by mouth every six (6) hours for 20 days. (Also known as Roxicodone)A review of the Medication Administration Record (MAR) for Res #6 for April of 2026 included the following entries:a. Amoxicillin, 500 mg capsule. Take 1 capsule 3 (three) times daily for sepsis for 10 days, start date 4/24/26. b. Hydromorphone 2 mg tablet. Give 1 tablet by mouth every 8 hours as needed for pain 2-10 and/or 20 minutes prior to dressing changes, start date 4/24/26. c. Docusate sodium. 100 mg. Give 2 capsules by mouth two times a day for constipation, start date 4/24/26. (This error was caught on double check and corrected, the resident did not receive the wrong order) d. Roxicodone 5 mg. Give 0.5 tablet by mouth every 6 hours as needed for pain for 20 days, start date 4/24/26. (This error of being written for as needed rather than scheduled was caught on double check and corrected)In April of 2026, Resident #6 received 10 doses of the incorrect dosage of Hydromorphone (Dilaudid). She did not receive any of the Dilaudid in May, and it was discontinued on 5/11/26.On 5/12/26 at 11:51 am, Staff G, LPN stated Resident #6 had Amoxicillin listed as an allergy and the hospital orders also had no stop date listed. She stated she called the ARNP to obtain orders. When the resident's allergies were reviewed during the interview, it was found that Res #6 had a listed allergy to Piperacillin, not Amoxicillin but the EHR software flagged this as the order was entered as a warning. Staff G stated she did not recall the order stating to take 1000 mg for the Amoxicillin but she thought that the ARNP told her to just give one tab. She stated she was being very careful when she transcribed the orders. Staff G initially stated she thought she had called the ARNP prior to placing the orders in the EHR, but then said she must have called her when she placed the order and it flagged it as a warning due to her allergies. When asked if she documented the phone call anywhere, she stated when there is a medication warning, a box comes up on the screen and she normally documents it there. She was unable to provide this documentation. In a second interview with Staff G on 5/12/26 at 12:38 pm regarding the Dilaudid order, Staff G verified that order was also placed incorrectly. She acknowledged the order from the hospital was for 1 mg and the resident had received multiple doses of 2 mg.On 5/12/26 at 12:54 pm, the ARNP was asked if she recalled Staff G calling her on 4/24/26 regarding the allergy warning for Resident #6 as well as having no end date on the order. The ARNP verified she remembered the phone call and was able to verify the resident had received the medication with no allergic reactions during the hospitalization and ordered an end date of 10 days. She stated she did not change the dosage amount. She added that she was aware of Infectious Disease physicians having extended the end date since that time. She verified she only discussed the allergy listing and the length of the order with Staff G and the dosage was not discussed. Staff A, RN was the nurse who performed the double check of Resident #6's orders after they had been entered into the EHR by Staff G.On 5/12/26 at 1:40 pm, Staff A, RN stated his process is to use the original copies from the hospital and check if the nurse who entered the orders placed the orders correctly. He recalled he did call the hospital to get a clarification on the Oxycodone as it was labeled 0.5 - 1.0 tablets. He stated he also clarified the order for the docusate. He did not recall finding errors with the Amoxicillin or the Hydromorphone/Dilaudid. The facility policy/procedure titled Diabetes Mellitus Resident, Nursing Care of, revision date 11/2007 documented the policy as follows:1. Assist the resident to establish a balance between diet, exercise, and insulin. 2. Restore carbohydrate utilization, correct electrolyte imbalance and prevent recurrence in the resident with diabetic ketoacidosis. 3. Quickly restore normal cerebral function and prevent recurrence of hypoglycemia. 4. Recognize and assist in the treatment of complications commonly associated with diabetes. 5. Individualize teaching according to carefully assessed resident and family needs. The facility policy/procedure titled - Nursing Clinical, reviewed 08/2024 documented the following:It is the policy of this facility to accurately implement orders in addition to medication orders (treatment, procedures) only upon the order of a person duly licensed and authorized to do so in accordance with the resident's plan of care.Point 3: admission orders are reviewed with the physician upon admission based on the discharge instructions from the discharging facility and are transcribed accordingly. Point 6: Medication, treatment or related procedure orders are transcribed in the medical record accordingly.

Based on clinical and hospital record reviews, interviews with staff, residents, family members of residents and a medical provider, the facility failed to ensure nursing competencies were maintained. This resulted in multiple significant medication errors for three of four residents reviewed (residents #2, #4, #6), lack of documentation regarding resident care, and concerns of failing to provide consistent, thorough personal assistance to the residents. Findings include:A review of hospital discharge orders for four residents revealed that three of these residents experienced significant medication errors (Res #2, #4, #6). 1. Following a February 2026 hospitalization, a reconciliation of Resident #2's discharge instructions against the Electronic Health Record (EHR) revealed the staff failed to implement a prescribed dosage increase for a blood pressure medication. Consequently, the resident experienced uncontrolled hypertension over the next three months. The facility additionally failed to process orders for corrective insulin and neglected to discontinue an oral diabetic medication that was noted by the hospital physician and contraindicated due to the resident's kidney function. The Administrator stated on 5/13/26 at 11:57 am via email that a further review was conducted regarding Res #2's readmission to the facility and it was identified that while his hospital discharge orders were largely consistent with his pre-discharge regimen, there was a frequency adjustment that was not identified during the reconciliation process. He added that these findings had been directly incorporated into the facility's process improvement actions. The email did not contain any information regarding the missed orders regarding his diabetic medications. 2. Following a February of 2025 hospitalization, a reconciliation of Resident #4's discharge orders against his EHR documentation revealed facility staff failed to notify the Advanced Registered Nurse Practitioner (ARNP) of hospital orders placing diabetes and other medications on hold pending provider review. Due to the transcription errors, the facility staff inadvertently discontinued three medications the resident took to aid in diabetes health, as well as an antihypertensive medication (blood pressure), an antihyperlipidemia medication (cholesterol) and an antidepressant. Additionally, laboratory results of Res #4 in December of 2025 indicated a significantly elevated blood glucose level of 352. The facility ARNP signed the lab results on 12/31/25 and indicated she would address the labs on her next visit. The facility was unable to provide any documentation of those labs being addressed. The resident experienced another hospitalization in May of 2026. At that time he had a life threatening blood glucose level of 1200. On 5/11/26 at 12:20 pm, the ARNP was interviewed regarding the error with Resident #4's medications. When asked about the monitoring of Res #4's diabetes, she stated she normally checks labs twice a year and more if needed and did not recall any concerns with his labs. She was unaware the resident had a blood sugar of 1200 when hospitalized on [DATE]. The ARNP was asked if she recalled any staff member informing her of his diabetic medications being placed on pause the prior year, and she stated she did not. She added she had been seeing this more often recently and said if staff does not tell her about these circumstances, then they can fall through the cracks but stated she also should have caught it herself. On 5/11/26 at 1:00 pm, the Director of Nursing (DON) was interviewed about Resident #4. She also was unaware of the resident's condition in the hospital and stated she considered the situation to be a huge medication error. On 5/11/26 at 1:08 pm, Staff C, Licensed Practical Nurse (LPN) stated she had worked at the facility for almost two years. She stated she was not aware that his medications had changed after the hospitalization in February of 2025. She stated she does not know what medications the residents take because the Certified Medication Aides administer the medications and she would expect them to report any concerns to her. On 5/12/26 at 1:57 pm, Staff B, Registered Nurse (RN) stated she worked with the resident the night shift prior to him being admitted to the hospital. He experienced an unwitnessed fall and she stated he was weak and she felt he had a Urinary Tract Infection (UTI). She stated she did not think about checking a blood sugar on the resident because she felt his symptoms were related to having a UTI. She stated she did not recall ever having checked his blood sugar during her times of employment working with Resident #4. In a second interview with the ARNP on 5/12/26 at 12:54 pm, the ARNP stated the facility has had an issue with drawing labs in the past and she has had to order lab draws repeatedly before labs are drawn. She stated there have been times labs she orders are never completed. On 5/12/26 at 4:00 pm, Staff D, LPN stated she was unaware that Resident #4 was even diabetic. She stated she had worked at the facility for a few months and nobody had ever told her he was diabetic. Staff D verified she can read the diagnoses of the residents on the EHR but stated she felt someone should have directly informed her he was diabetic. Staff D stated she worked with Resident #4 the day he went to the hospital. He had been resistant to agreeing to provide a urine sample. She reported a urine sample was successfully obtained but staff then spilled it and they were unable to get a second sample. Upon the facility management being informed about the situation with Resident #4's medication errors, they began a plan to provide education to all nursing staff. This included a detailed email being sent to nursing staff who were not on duty that day (5/12/26). On 5/13/26 at 8:20 am, Staff C, LPN verified she had received the email. When asked to describe what was in the email, Staff C was unable to. She stated she would need to open it and read it again. She went through her phone and located the email and showed it to the State Surveyor. On 5/14/26 at 2:45 pm, an interview was conducted with a family member of Resident #4. The family member stated he was concerned because he found out the resident had been having high blood sugars since December and nobody had informed him. He stated he was told about this from a hospital employee. The family member also stated Resident #4 is very prone to having UTIs and every time he visits, he finds him with his pants needing changed and he (the family member) does it himself. The family member reported that he does not feel the facility changes the resident often enough or provides oral care. He reported he had bought personal care supplies several months earlier and they remained unopened including body spray and toothpaste. 3. Upon initial admission to the facility in April of 2026, Resident #6 admitted with diagnoses of necrotizing fasciitis (a rare but severe bacterial infection that destroys the tissue beneath the skin, including fat and the fascia covering muscles) along with sepsis (a life threatening emergency caused by bacteria entering the bloodstream). Staff G, a nurse manager, made four medication transcription errors when entering Res #6's medications into the EHR. Although the resident was stable upon transfer from the hospital to the facility, she required ongoing antibiotic therapy to treat her infections. Staff G erroneously entered orders that halved the prescribed antibiotic and doubled her prescribed narcotic pain medication. While two additional admission transcription errors were identified and corrected during a double-check by a second nurse, the incorrect antibiotic and narcotic orders were processed. On 5/12/26 at 11:51 am, Staff G, LPN stated Resident #6 had amoxicillin listed as an allergy and the hospital orders also had no stop date listed. She stated she called the ARNP to obtain orders. When the resident's allergies were reviewed during the interview, it was found that Res #6 had a listed allergy to piperacillin, not amoxicillin but the EHR software flagged this as the order was entered as a warning. Staff G stated she did not recall the order stating to take 1000 mg (the order read to take two 500 mg capsules) but she thought that the ARNP told her to just give one tab. She stated she was being very careful when she transcribed the orders. Staff G initially stated she thought she had called the ARNP prior to placing the orders in the EHR, but then said she must have called her when she placed the order and it flagged it as a warning due to her allergies. When asked if she documented the phone call anywhere, she stated when there is a medication warning, a box comes up on the screen and she normally documents it there. She was unable to provide this documentation. In a second interview with Staff G on 5/12/26 at 12:38 pm regarding the narcotic order, Staff G verified that order was also placed incorrectly. She acknowledged the order from the hospital was for 1 mg and the resident had received multiple doses of 2 mg.On 5/12/26 at 12:54 pm, the ARNP was asked if she recalled Staff G calling her on 4/24/26 regarding the allergy warning for Resident #6 as well as having no end date on the order. The ARNP verified she remembered the phone call and was able to verify the resident had received the medication with no allergic reactions during the hospitalization and ordered an end date of 10 days. She stated she did not change the dosage amount. She added that she was aware of Infectious Disease physicians having extended the end date since that time. She verified she only discussed the allergy listing and the length of the order with Staff G and the dosage was not discussed. On 5/13/26 at 11:20 am, a joint interview was conducted with Resident #6 and a family member. Both expressed concerns of the known medication error when the antibiotic dosage was incorrectly halved. The family member stated the resident experiences anxiety about her medication administration including the untimeliness of the medications being administered, the error of dosing amount and staff bringing medications in and leaving them at the bedside without speaking to Res #6 about what medications she is receiving or witnessing her taking the medications. The family member reported that on 5/11/26, they had requested a reduction in the overall amount of medications she was receiving alongside an increase in an antidepressant medication. They spoke with the ARNP who agreed to this and placed the order and stated it would start that night. However, the order was not processed to begin until the following night, and then the order was not delivered by the pharmacy. The resident continued to receive the lower dose and had to point out to the staff she was to receive a higher dose. The family member reported that prior to the interview, Staff G, nurse manager had verified the lower, discontinued dosage was still in the medication cart and the higher dose had not been received from the pharmacy. The pharmacy was then called regarding the delivery status of the updated prescription. The family member stated a loss of trust in the facility, rating her confidence in staff competency as zero. The family also discussed when they and the resident requested the resident be sent to the ER regarding her wound care and her medication orders a week or so prior to the interview. It was during this visit to the ER they were informed of Resident #6 only receiving half of her prescribed dose of her antibiotic. The family member stated the nurse assigned to the resident's Infectious disease physician assisted in straightening out the medication errors. The resident and her family member also stated the resident had requested bed baths only due to her wound, as she was unable to sit on a shower chair due to pain from the wound. She stated since admission on [DATE], she could only recall receiving three baths and felt she had body odor. She said staff was stating she was refusing, but she was not. She was refusing a shower due to pain but wanted a bed bath. The resident named additional concerns of her catheter leaking and staff placing tape around the tubing rather than replacing the tubing, not understanding her wound care, and not performing perineal cares when emptying her catheter. The residents family member also showed the State Surveyor a photo of the call light board at the nursing station showing Resident #6's call light being on for 28 minutes earlier in the week. On 5/13/26 at 1:33 pm, Staff H & Staff I, Certified Nurse Aides were observed emptying the catheter of Resident #6. Both performed hand hygiene, donned gloves and isolation gowns and performed the task properly to meet infection control standards. Resident #6 asked the staff repeatedly what this show was all about and remarked this is never how the task is completed. When staff was done with the task, Resident #6 voiced I've never seen them do it like this before. On 5/13/26 via email, the Administrator was asked about documentation and records being accessible in the resident's Electronic Health Records. On 5/13/26 at 11:39 am, he responded, via email, that a Performance Improvement Project had been implemented to address medical record accessibility. He stated this process reinforced expectations to ensure all external documentation is reviewed, reconciled, and uploaded into the EHRs within a defined and consistent time frame. On 5/14/26, three months worth of resident council notes were reviewed as well as grievances filed with the facility over the last three months. Several concerns of staff not being responsive to call lights were noted. The administrator stated the facility does not have the ability to run call light reports and call light times are monitored through oversight by nurse managers.

Based on record review, staff interviews and policy review the facility failed to report an allegation of abuse to the Iowa Department of Inspections, Appeals and Licensing (DIAL) within two (2) hours for one of three residents reviewed for potential abuse (Resident #2). The facility reported a census of 66 residents. Findings include:The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had diagnoses of metabolic encephalopathy (disorder where medical problems such as blood infections or liver or kidney failure cause brain damage), anemia (lack of red blood cells to help transport oxygen from the lungs to the organs) and sepsis (blood poisoning) (the body's response to a life-threatening infection that damages vital organs). The MDS recorded the resident had a Brief Interview for Mental Status score of 13 indicating cognition intact. The Care Plan revised 10/28/25 revealed the resident had a risk for impaired cognitive function/ dementia related to respiratory failure with hypoxia (low oxygen to the body tissues). The Progress Notes revealed: a. On 12/2/25 at 11:45 PM, Resident #2 became agitated and started yelling at the CNA (certified nursing assistant). The CNA left the room and reported that the resident was upset and calling her names. Two CNA's then went down to the resident's room. The resident became angry with both CNA's. The resident called the CNA's bitches and said you guys don't know how to do anything, get the hell outta my room. The CNA's reported that the resident refused to have the CNA's change him. Staff J, Licensed Practical Nurse (LPN), went to the resident's room and asked him what had happened. Resident #2 stated they broke his bed. Staff J pushed the buttons on the remote and showed the resident that the bed was not broken. b. On 12/2/25 at 11:45 PM Resident #2 called 911 to report that he was being attacked. Staff J went to check the resident and asked if he felt safe at the facility. Resident #2 responded no, not with those two girls here. When asked to describe the girls, the resident stated that one was a white, big girl, and the other a black girl with something wrong with the skin on her face. An assessment of the exposed skin on arms and legs revealed no redness, new discolorations developing, no fresh scratches or abrasions observed. The on-call provider was notified and an order was received for a UA (urine specimen) when the resident would allow for a catheter change. c. On 12/3/25 at 12:48 AM, received a call from the police department. The resident had called and stated that he was being attacked and to send help. The police asked if staff could check on the resident and call them back to let them know if the resident was okay. Staff went down to see if resident was okay. The resident allowed staff to change him.Review of a facility Self Report to DIAL on 12/3/25 at 1:06 PM regarding Resident #2 revealed an allegation of abuse with staff to resident. The incident occurred on 12/2/25 at 12:45 AM. The original incident summary was reported to the DIAL hotline number on 12/3/25 at approximately 1:33 AM. In an interview on 4/9/26 at 10:08 AM, Staff J, LPN, reported Resident #2 was always septic due to a UTI (urinary tract infection) from his catheter. She reached out to the on-call physician (Dr) to see if she could send the resident out. The On-call Dr did not want the resident sent out and gave an order to give Ativan (an antianxiety medication). The CNA went to check on the resident and he was resistive or swinging. The CNA came out and told her about it. She told the CNA to go in with two staff. Staff L, CNA, took another CNA (Staff K) in and they came back and told her they could not get him changed. He accused them of being rough with him. He described there was a white fat gal and black gal with something wrong with her face. She called and reported it to Staff I, the former Administrator. She also talked to Staff M, former Director of Nursing (DON). The description of each CNA matched the description of what the resident told her about. In an interview on 4/9/26 at 10:25 AM, Staff K, CNA, recalled Resident #2 said he thought staff were attacking him. She and Staff L went in to change his brief. He became threatening and lashed out at them. He was yelling and screaming and was very confused. She went and reported it to the nurse. Staff K reported she had not seen anybody be rough or unkind to residents. She would report to the nurse right away, let the DON know, write a statement, and call the State if she witnessed any type of abuse. In an interview on 4/9/26 at 10:42 AM, Staff L, CNA, reported she recalled she went to help Resident #2 change his brief. Resident #2 called the police and said that staff were beating him up. She told the nurse about it. The nurse told her not to go in by herself, so Staff L took another CNA in to help her. Staff L reported when she took care of Resident #2 the day before he was not like that, so it surprised her when he started attacking them that night. On 4/9/26 at 11:11 AM, a DIAL Intake Specialist verified the facility called in an allegation of abuse to the DIAL hotline about Resident #2 on 12/3/26 at 1:33 AM by Staff I. In an interview on 4/9/26 at 1:30 PM, the Clinical Resource Nurse reported she expected staff report any kind of allegation of abuse within 2 hours to the facility Administrator. In an interview on 4/9/26 at 1:38 PM, the Administrator reported anytime there was a suspicion of abuse, he expected staff separate the resident and ensure the resident was safe, then contact the Administrator. The Administrator would report the allegation of abuse to DIAL right away or within 2 hours of the allegation. The facility's Freedom from Abuse, Neglect, Exploitation policy revised 8/2024 revealed the facility reported to the appropriate agencies as designated by State and Federal laws if there is an allegation or suspicion of abuse. All allegations of abuse are reported immediately but not later than two hours after the allegation is made if the events that cause the allegation involves abuse.

Based on clinical record review, staff interviews, hospital record review, and facility policy review, the facility failed to administer medication as prescribed and ordered by the physician for 1 of 5 residents (Resident #3) reviewed for medication. Resident #3 required hospitalization due to acute hypoxia (low oxygen saturation in the blood). The facility reported a census of 66 residents. Findings include: The admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 documented a [DATE] admission date to the facility from an acute hospital stay. Her diagnoses included a left humerus fracture (upper arm bone break near the shoulder joint), and a subsequent encounter with routine healing (which indicated the resident had received active care for the fracture and was in the routine healing/recovery phase), acute pulmonary edema (sudden fluid buildup in the lungs), atrial fibrillation (heart rhythm disorder causing an irregular and usually rapid heartbeat), pulmonary hypertension (a type of high blood pressure that specifically affects the lungs), opioid dependence, and edema. The MDS showed the Brief Interview for Mental Status (BIMS) score of 13, which indicated cognition intact. The MDS documented the resident's health conditions included pain management with scheduled pain medications and that the resident had not received PRN (as needed) pain medications or non-medication interventions for pain. Resident #3's Pain Assessment Interview revealed she frequently had experienced pain which made it hard for her to sleep at night and limited her participation in her rehabilitation therapy. The MDS documented the resident's pain rating was 10, which was the highest rating. The MDS further documented the resident had shortness of breath when lying flat and with exertion. The MDS documented the resident's medications included antianxiety, diuretic, and opioid medications. The MDS documented the resident had not received any oxygen therapy. The Care Plan for Resident #3 dated [DATE] indicated the resident had an infection which was not specified, was receiving occupational, physical, and speech therapies, was experiencing pain with interventions that included to administer pain medications as ordered and to follow pain scale (a standard 0-10 tool where 0 is no pain and 10 is the worst imaginable pain) to medicate as ordered, and planned to be discharged after completing her rehabilitation. Resident #3's electronic medical record (EMR) review revealed the following pain medications were prescribed upon her [DATE] admission: a. Tylenol Extra Strength (Acetaminophen) Oral Tablet 500 MG (milligrams) with orders to Give 2 tablets by mouth every 6 hours as needed for pain/fever.The following medications were classified as Opioid Narcotic Controlled drugs:b. Hydrocodone-Acetaminophen Oral Tablet 10-325 MG with orders to Give 1 tablet by mouth every 8 hours as needed for MAX DAILY AMOUNT IS 3 Tablets. c. Oxycodone Oral Tablet 10 MG with orders to Give 1 tablet by mouth every 4 hours as needed for moderate to severe pain. d. Hydromorphone Oral Tablet 2 MG with orders to Give 1 tablet by mouth every 4 hours as needed for SEVERE PAIN THAT IS FOR BREAKTHROUGH WITH PAIN LEVEL OF 10[,] PAIN LEVEL MUST BE A 10 or above to give. The above medications (b, c, and d) contained an ALERT! Black Box Warning! that included: a. Warning: Addiction, abuse, and misuse. Because the use of hydrocodone/acetaminophen - oxycodone - hydromorphone exposes patients and other users to the risks of opioid addiction, abuse, and misuse, which can lead to overdose and death, assess each patient's risk prior to prescribing and reassess all patients regularly for the development of these behaviors and conditions. b. Life-threatening respiratory depression. Serious, life-threatening, or fatal respiratory depression may occur with use of hydrocodone/acetaminophen - oxycodone - hydromorphone. To reduce the risk for respiratory depression, proper dosing and titration of hydrocodone/acetaminophen - oxycodone - hydromorphone are essential. c. Risk from concomitant use [the administration of two or more drugs, such as prescription medications, at the same time] with. other CNS [Central Nervous System] depressants [e.g., opioid pain medications like hydrocodone/acetaminophen, oxycodone, and hydromorphone]. Concomitant use of opioids with other CNS depressants. may result in profound sedation, respiratory depression, coma, and death. Further review of Resident #3's EMR revealed her Medication Administration Records (MAR) for [DATE] documented: a. On [DATE], at 11:22 p.m.; [DATE] at 3:58 a.m. and 8:22 a.m. she received both her Oxycodone and Hydromorphone medications (i.e. concomitant use). Her pain rating at those times were 7, 5, and 6 respectively, which had not met the physician orders for the Hydromorphone medication. b. On [DATE], at 3:52 p.m. she received both her Oxycodone and Hydromorphone medications with her pain rating at 10. c. On [DATE], at 8:31 p.m. she received both her Oxycodone and Hydrocodone-Acetaminophen medications. Her pain rating was 7. Four minutes later, at 8:35 p.m. she received her Hydromorphone medication. Her pain rating was 6, which had not met the physician orders for that Hydromorphone medication. d. On [DATE], at 7:54 p.m. she received her Oxycodone medication.Two minutes later, at 7:56 p.m. she received her Hydrocodone-Acetaminophen medication. Five minutes later, at 8:01 p.m. she received her Hydromorphone medication. Her pain rating for all three opioid medications (i.e., concomitant use) was 7, which had not met the physician orders for the Hydromorphone medication. e. On [DATE], at 3:38 p.m. she received her Hydromorphone medication. Her pain rating was 6, which had not met the physician orders for the Hydromorphone medication. f. On [DATE], at 12:04 a.m. and 7:16 a.m. she received her Hydromorphone medication. Her pain rating was 5 and 6 respectively, which had not met the physician orders for the Hydromorphone medication. g. On [DATE], at 7:19 p.m. she received her Hydromorphone medication. Her pain rating was 5, which had not met the physician orders for the Hydromorphone medication. h. On [DATE], at 12:18 a.m. she received her Hydromorphone medication. Her pain rating was 4, which had not met the physician orders for that Hydromorphone medication. i. On [DATE], at 9:19 p.m. she received her Hydromorphone medication. Her pain rating was 7, which had not met the physician orders for that Hydromorphone medication. Further review of Resident 3's January MAR for her Hydromorphone medication ordered to be given for severe pain that must be at a pain level of 10 revealed that from [DATE] through [DATE] that pain medication was administered 17 times of which four of those times met the physician's orders. 76.5% of those 17 administrations of the Hydromorphone medication had not met the parameters of that order. In a phone interview on [DATE] at 3:17 p.m. with a pharmacist at the facility's preferred pharmacy regarding pain medications prescribed for an individual resident that included Tylenol Extra Strength Oral Tablet 500 MG, Hydrocodone-Acetaminophen Oral Tablet 10-325 MG, Oxycodone Oral Tablet 10 MG for moderate to severe pain, and Hydromorphone Oral Tablet 2 MG for severe pain reported she had rarely seen those three opioid pain medications given at the same time. She stated that taking those opioid medications together could cause excessive sedation, and agreed that a resident should not be receiving those medications at the same time which she agreed would be concomitant use of those opioid pain medications. In reviewing the parameters given for those medications, she stated that the Hydrocodone-Acetaminophen medication should have been given first to address a resident's pain. Followed by the Oxycodone medication for moderate to severe pain at the appropriate time interval if the resident was still experiencing pain at that level. Then the Hydromorphone medication for severe pain at the appropriate time interval if the pain persisted at the pain level of 10. In a phone interview on [DATE] at 10:53 p.m. with Staff P, Certified Nursing Assistant (CNA)/Certified Medication Aide (CMA) stated she had worked for one year at the facility and this was her first job as a CMA. She recalled Resident #3 and stated the resident would take her medications right away and needed no instructions regarding her medications. After reviewing Resident #3's pain medications and physician directions she stated the resident had used her narcotic pain medications one to two times during her 12-hour shift. We discussed her process for giving PRN (as needed) medications and she stated she would go to the resident requesting the medications and ask them if they were requesting anything specific, ask about their pain level, location of pain, and then she would go to the med cart to view the resident's prescribed pain medications. She would then let the resident know of the pain medications available. When asked if she had consulted a licensed nurse regarding the pain medications, she stated she had not with Resident #3. When asked regarding haven given more than one opioid pain medication at the same time to Resident #3, she stated she would have only given multiple pain medications under the direction of a nurse. When asked regarding the nurse, she could not recall the nurse who gave that direction. After reviewing Resident #3's pain medications she had documented on:a. Tuesday, [DATE] at 8:22 a.m. that had included both the Hydromorphone and Oxycodone medications and that she had documented the resident's pain at a level 6.b. Tuesday, [DATE] at 3:52 p.m. that included both the Hydromorphone and Oxycodone medications and that she had documented the resident's pain at a level 10.c. Monday, [DATE] at 12:18 p.m. that included the Hydromorphone medication and that she had documented the resident's pain at a level 4.After discussing the Oxycodone medication was to be given for moderate to severe pain and the Hydromorphone medication for severe pain of 10, she acknowledged she had not followed the physician orders for the Hydromorphone medication with the resident's pain rating of 6 on the morning of [DATE] at 8:22 a.m. and the resident's pain rating of 4 on the afternoon of [DATE] at 12:18 p.m. When asked if she had been provided any guidance on Resident #3's different pain medications and on the difference between moderate pain and severe pain with the pain scale, she stated that no guidance had been provided to her. In an interview on [DATE] at 11:49 a.m. the LPN/MDS Coordinator stated Resident #3 was on a lot of different pain medications, that her pain level was typically high on the pain scale, and the she asked for two pain medications to be given at the same time, but that she was not comfortable administering those opioid pain medications at the same time as individual residents' reactions are different to those pain medications. She stated for Resident #3 she would alternate the resident's pain medications, giving only one pain medication at a time and keep the next pain medication until at least three to four hours later. She stated she would expect the licensed nurses to follow the physician's orders for a resident's PRN pain medication. She acknowledged that a CMA was able to administer PRN pain medications, but a licensed nurse would need to follow-up with the resident to assess the effectiveness of that pain medication. In a phone interview on [DATE] at 12:21 p.m. with Staff Q, Registered Nurse (RN) stated Resident #3 was on a lot of pain medications and she had requested them frequently and that she wanted all three of the pain medications at the same time. Staff Q, RN stated she had tried to convince the resident not to take all those pain medications at one time, but that she insisted the she had been on those same pain medications for years and that was how she took them in the past. Staff Q, RN acknowledged she had reservations and that it was not good to take them all at one time, but had given those three narcotic pain medications at the same time due to the resident's insistence. She recalled discussing Resident #3's reported pain level of 10 with the resident as intractable pain (severe, constant, and incurable pain state that does not respond to conventional medical treatments) and that she may need to be sent to the hospital for that type of pain. Staff Q, RN stated Resident #3 had then replied that her pain level was at a 7, and that Resident #3's pain level was always at a 7 for her after that discussion. In an interview on [DATE] at 12:54 p.m. the Director of Nursing stated she had been in her position since [DATE]. She stated her expectation was that licensed nurses and CMAs would follow the physician orders regarding medication parameters. She was not working at the facility during Resident #3's stay, in [DATE] and hesitated to answer any questions regarding her medication regimen as she was not familiar with that resident. When discussing opioid pain medications in general and the giving of three opioid pain medications at the same time, she stated that would be a lot of opioid pain medications and that individual resident's reactions are different due to their individual diagnoses and she would expect a licensed nurse to contact the resident's medical provider for guidance. The DON was informed and acknowledged the above findings regarding Resident #3's opioid pain medications. Review of the facility's CMA Job Description revealed the CMA administers prescribed medications and treatments as defined by state regulations in accordance with company policy and procedure under the direction of a licensed nurse. It included instructions that a CMA may not administer:a. The first dose of a new medication.b. Any new medication that arrives at the facility. c. As-needed (PRN) medications. Review of the facility's Medication Administration policy, dated [DATE] revealed that medication shall be administered as prescribed by the resident's physician, nurse practitioner, or physician's assistant. The procedure included: a. only licensed medical and nursing personnel or other lawfully authorized staff members may prepare, administer, and record medication administration.b. Medications must be administered in accordance with the written orders of the attending physician. c. When PRN medications are administered, the nurse or medication technician (CMA) must record the date and time administered, and later the results achieved from the PRN medication as appropriate. Review of Resident #3's EMR revealed on [DATE] at approximately 8:00 p.m. Resident #3's daughter came to the facility to visit and called 911 to have Resident #3 transported to the hospital emergency room. Review of the hospital's EMR report for Resident #3's hospitalization from [DATE] through her [DATE] discharge revealed the Emergency Department (ED)'s [DATE] report for Resident #3 documented as follows; Significant lower extremity swelling, tachypneic [rapid, shallow breathing, typically exceeding 20 breaths per minute in adults at rest], hypoxic [a condition characterized by, caused by, or relating to a low level of oxygen in bodily tissues or cells. It indicated inadequate oxygen delivery to tissues, which can be caused by. breathing problems, or cardiovascular issues] requiring supplemental oxygen. Suspect acute heart failure and reviewed previous medications, current med list, and previous hospital notes. Diuretic had been discontinued previously and not restarted which is likely contributory. On anticoagulation. Abnormal chest x-ray with oral effusion. IV diuresis started in ER, medicine consulted for admission for further workup and management.Chief Complaint was Shortness of Breath and History of Present Illness included Patient does not normally wear oxygen, she is on 3 L [Liters] of oxygen and satting [oxygen saturation of] 91 to 92% for EMS [Emergency Medical Services], was satting 77% without oxygen. The ED report documented the Clinical Impression of Resident #3 as follows: 1. Acute Hypoxic Respiratory Failure 2. Acute on chronic congestive heart failure, unspecified heart failure type 3. AKI (acute kidney injury) She was admitted to Adult Critical Care. The Critical Care report, dated [DATE] documented Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: Respiratory failure and cardiac failure. The Hospital Course documented: Patient. admitted on [DATE] with dyspnea [shortness of breath, is defined as uncomfortable, labored breathing often caused by underlying heart or lung conditions like asthma, COPD, pneumonia, or heart failure]. She was originally admitted to hospitalist service in which she began to have lower oxygen saturations. resulting in transfer to the CCU [Critical Care Unit]. She was found to have bilateral pulmonary edema and pleural effusions requiring diuresis. Patient was intubated the morning of 1/26. While on the ventilator she was requiring increased oxygen concentrations leading to continuation of mechanical ventilation. We continued to give pulmonary treatments and diurese to help with her current condition. On the morning of 1/28 patient passed her breathing trial and was able to be extubated and stated that she wanted to be extubated. Upon extubation she did not want to escalate supplemental oxygen therapy further and did have decision-making capacity at this time and understood that this would ultimately lead to respiratory failure and her death. Patient was understanding of these consequences and understood the risks and benefits of treatment and wanted to pursue comfort cares. Patient's family was agreeable to her wishes. Patient underwent comfort cares and was deceased at 11:35 AM on [DATE].

Based on clinical record review, staff interview, hospital record review, and facility policy review, the facility failed to obtain an order for supplemental oxygen for 1 of 1 resident (Resident #3). The facility reported a census of 66 residents. Findings include: The admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 documented diagnoses of acute pulmonary edema (sudden fluid buildup in the lungs), atrial fibrillation (heart rhythm disorder causing an irregular and usually rapid heartbeat), pulmonary hypertension (a type of high blood pressure that specifically affects the lungs), and edema. The MDS showed the Brief Interview for Mental Status (BIMS) score of 13, which indicated cognition intact. The MDS coded the resident had not received oxygen therapy. The Care Plan for Resident #3 dated 1/12/26 indicated the resident had an infection (which was not specified), was receiving occupational, physical, and speech therapies, was experiencing pain, and planned to be discharged after completing her rehabilitation. Her Care Plan had no focus area for respiratory care or any intervention for supplemental oxygen. In a phone interview on 4/9/26 at 1:38 p.m., Staff N, Licensed Practical Nurse (LPN), stated Resident #3 admitted to the facility on [DATE] and he had completed her initial admission Assessment that day and agreed she was not receiving supplemental oxygen at that time. Resident #3's electronic medical record (EMR) revealed her 1/12/26 Initial admission Assessment documented her oxygen saturation (the percentage of oxygen-carrying hemoglobin in the blood, which reflected how well the lungs and circulatory system were functioning) was 95% on room air and indicated shortness of breath, diminished right lung sounds, wheezes in the left lung, productive cough, and that she was not receiving supplemental oxygen. The Daily Skilled Assessments revealed the following: a. On 1/13/26, the resident's oxygen saturation was 95% on room air with no active respiratory symptoms observed and no respiratory treatments provided, including supplemental oxygen. b. On 1/14/26 documented Resident #3 had conditions effecting her respiratory system with her HOB [Head of Bed] elevated due to shortness of breath [when] lying flat and HOB elevated due to COPD [Chronic Obstructive Pulmonary Disease, a progressive incurable lung disease]. Resident #3's diagnoses had not included COPD. c. On 1/14/26, 1/15/26, and 1/16/26 documented the resident's oxygen saturations from 1/13/26, which failed to provide an accurate, daily assessment of the resident's respiratory status. d. On 1/17/26, resident's oxygen saturation was 97% on room air with no active respiratory symptoms observed and no respiratory treatments provided, including supplemental oxygen. e. On 1/18/26, her oxygen saturation dropped to 94% (a normal, healthy reading was between 95% and 100%) and indicated Staff O, LPN, had provided respiratory therapy by initiating supplemental oxygen through a nasal cannula. No physician notification or physician's order for supplemental oxygen administration was documented. f. On 1/19/26, her oxygen saturation dropped to 91% on Continuous Oxygen Use provided at 2 liters per minute through a nasal cannula. Assessment of her respiratory condition documented Shortness of Breath: with exertion, sitting at rest, [and] lying flat. Despite this decline there was no documentation that her physician was notified of the need for oxygen or her worsening respiratory symptoms. g. On 1/20/26, her oxygen saturation was at 95% with supplemental oxygen through a nasal cannula. Assessment of her respiratory condition documented oxygen therapy was provided with continuous oxygen use at 2 liters per minute. Further review of Resident #3's EMR revealed on the evening of 1/19/26 at 6:47 p.m., a Change in Condition was reported to her medical practitioner regarding the resident's cellulitis (a potentially serious bacterial infection of the deep skin layers characterized by red, hot, tender, and swollen skin) to her right lower leg including a wound on that leg that was draining. New physician orders were obtained for her wound care. That night Resident #3's progress notes revealed she was awake all night, putting light on constantly,. several times stating she didn't know what she wanted. and that she was yelling loudly. Resident #3's Weekly Skilled Review on 1/20/26 at 10:51 a.m. documented she was oxygen dependent at 2 liters per minute. The evening of 1/20/26, Resident #3's daughter came to the facility to visit her and called 911 to have Resident #3 transported to the hospital emergency room. Resident #3's Hospital Transfer Form documented the resident was sent to the hospital at 8:00 p.m. During an interview on 4/9/25 at 11:49 a.m. the LPN/MDS Coordinator acknowledged that Resident #3's medical diagnoses had not included COPD. When asked regarding the process for obtaining supplemental oxygen for a resident she revealed that when a resident's oxygen saturation was measured at 90% or below, the nurse should call the physician for an order for supplemental oxygen. She stated the nurse should not wait to obtain the physician's order. During a phone interview on 4/9/26 at 12:35 p.m. with Staff O, LPN, stated she could not recall Resident #3 or her assessments of that resident. When asked about the process for initiating supplemental oxygen for a resident she stated she would call the physician and request an order for oxygen. She agreed that in an emergency situation, staff would administer supplemental oxygen to the resident first, but should call the physician immediately afterwards to obtain the physician order for that oxygen. She could not recall her 1/18/26 Daily Skilled Assessment when she initiated oxygen administration for Resident #3. In an interview on 4/9/26 at 12:54 p.m. the Director of Nursing (DON) revealed she had started her position on 2/6/26 and was not familiar with Resident #3. When asked regarding oxygen administration she stated that a licensed nurse knows when a resident would benefit from supplemental oxygen, but acknowledged they have to get a physician's order for the oxygen administration. Review of the 1/20/26 Hospital Emergency Department (ED)'s report for Resident #3 revealed the Chief Complaint was Shortness of Breath and Patient does not normally wear oxygen, she is on 3 L [Liters] of oxygen and satting [oxygen saturation of] 91 to 92% for EMS [Emergency Medical Services], was satting 77% without oxygen. The ED report documented the Clinical Impression of Resident #3 as follows: 1. Acute Hypoxic Respiratory Failure 2. Acute on chronic congestive heart failure, unspecified heart failure type 3. AKI (acute kidney injury). Review of the facility's policy Change in Condition reviewed April 2025 instructed staff that when the resident's vital signs, including oxygen saturation, have changed the licensed nurse will perform an assessment of the resident and identify the need for additional interventions through communication with the resident's medical provider to obtain new orders. There will be certain circumstances where immediate attention will be warranted,. The nurse shall use his/her clinical judgment and shall contact the physician based on the urgency of the situation. Review of the facility's policy Oxygen Administration reviewed April 2024 documented that oxygen therapy is administered by licensed nurse as ordered by the physician or as a nursing measure and an emergency measure until the [physician] order can be obtained.

Based on clinical record review, observation, staff and resident interviews, and policy review, the facility failed to monitor and supervise a resident with access to a vape for 1 of 10 residents reviewed for smoking and/or vaping (Resident #7). The facility reported a census of 66.Findings include:The Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #7 had diagnoses of traumatic spinal cord dysfunction, quadriplegia C5-C7 complete and Post Traumatic Stress Disorder (PTSD). It also indicated that he had a Brief Interview for Mental Status (BIMS) score of 15 meaning he was cognitively intact.The Electronic Health Record (EHR) indicated on 10/9/25 that management had taken Resident #7's vape from him as he was not following the smoking policy. It also indicated that he had a diagnosis of vaping-related disorder and vapes daily.The Care Plan initiated on 8/1/24 indicated that Resident #7 had a potential for injury related to vaping and directed staff to provide 1:1 observation while smoking cigarettes or vape due to not being able to hold it. It also directed staff to maintain his smoking materials at the nurses' station or other designated area. It indicated that he was often non-compliant with the smoking policy by keeping his vape in his room.The Interdisciplinary Team Care Plan Review dated 10/13/25 lacked documentation on Resident #7 being able to have a vape in his room only to chew on. It indicated that a risk assessment for smoking safety evaluation was discussed and smoking and vaping instructions and expectations with facility protocol and smoking policy were reviewed.During an observation on 4/7/26 at 1:33 PM Resident #7 had a purple vape to the left side of his neck. When asked if it was a vape, he did not say anything for a while. After asking again, he stated that it was a vape and that his mom gets them for him. He stated he usually keeps them in a lock box in his room.During a continuous observation of Resident #7's room on 4/7/26 starting at 2:51 PM:At 2:51 PM Staff C, Assisted Director of Nursing (ADON) did not go into Resident #7's room after the interview with the surveyor but went into the Director of Nursing's (DON) office where the Administrator was at. At 2:57 Resident #7's mother and another woman entered his room with sacks in hand. Mom immediately came back out. At 2:57 Staff D, Certified Nurses Aide (CNA) went into the room and left the room at 3:04 PM. At 2:59 Resident #7's mother returned with utensils and told another resident that she needed to feed Resident #7. At 3:00 PM Resident #7's call light came on. At 3:02 PM Staff D, CNA went in briefly and the light went off. At 3:03 PM Staff C, ADON approached the surveyor in the hall, and then returned to the DON office at 3:10 PM.At 3:30 PM the continuous observation was completed.In an interview on 4/7/26 at 2:30 PM Staff A, Certified Medication Aid (CMA) stated that Resident #7 had a vape in his room and was able to have it. Most of the staff were aware of the vape. She was not aware of where he got them or what kind they were.In an interview on 4/7/26 at 2:32 PM Staff B, CNA stated he had not been in Resident #7's room as he will not allow men to help him. Resident #7 is not supposed to have a vape. He used to have one in his room but not anymore.In an interview on 4/7/26 at 2:42 PM Staff C, ADON stated that Resident #7 was not supposed to have a vape. If he had a vape, staff should ask if they could remove it and let him go out at the designated smoke times. If he won't let them have it they can reach out to his mom. If that doesn't work she didn't know what to do but she would get back to the surveyor. The surveyor informed her that the resident currently had a vape to the left side of his neck. She stated she was not aware that he had a vape but now that she was aware, she would ask him for it after the conversation. If an independent smoker smokes or vapes in their room, they would lose independent smoking privileges if they signed the smoking agreement on admission. She was not sure what they would do if they did not sign the smoking agreement one admission. She was not sure what kind of vape he had. If a family brings in vapes or cigarettes they should bring them to the nurse's station to be locked away. Independent smokers had their own lock box in their room. She was not sure if they have lock boxes yet. She was not sure how he was getting the vape to his neck or who was giving it to him but she would find out.In an interview on 4/7/26 at 2:54 PM Staff D, CNA stated that she saw Resident #7's vape when she was in his room. She did not know how he got the vape to his neck but she did not do it. She stated that the resident had told her in the past that he will do what he wants. She reported to the nurse all the time but nothing changed. She had not reported it today but she would after the conversation.In an interview on 4/7/26 at 3:03 PM Staff C, ADON stated that they don't look at the vapes to see what kind of vapes they are, they just put them in the lock box. If they were to find out about a tetrahydrocannabinol (THC) vape, they would call law enforcement.In an interview on 4/7/26 at 3:40 PM the Administrator stated that Resident #7 was not using his vape currently but did have it in his room so he can chew on it to calm him due to PTSD. When he first arrived, he had it in a lock box but that didn't work. Then his mom was going to keep it and take him out to smoke. That didn't work, so he agreed to get up and go outside during smoking times. That was working then he backed off as he didn't like the times. His mom gives it to him now, not the staff. He doesn't smoke it but puts it in his mouth to chew for PTSD. When asked how he knew Resident #7 was not smoking it, he simply said yes that is true. They can't keep it from him as independent smokers can have smoking supplies in their rooms. They are new to the independent smoker thing and they are trying to figure out what to do with him. The surveyor advised that he is not an independent smoker. He then said they would have to catch him with the smell or smoke noted. When asked if they have tried other things to chew on besides a vape or make sure he could not use the vape, he did not answer the question. He stated they have to believe Resident #7 and his mom have the best intentions. When asked if Resident #7 could actually take a hit of the vape he kept in his room, he said that he could. When the surveyor asked if he knew that none of this information was on the care plan, he did not answer.In an interview on 4/8/26 at 5:56 AM Staff E, Licensed Practical Nursing (LPN) stated that Resident #7 had a vape in his room that he kept in a lock box. His mother comes in daily and gives it to him. She stated he can use his right hand to put it in his mouth. She had not seen him use it.In an interview on 4/8/26 at 6:10 AM Staff F, CNA stated she was aware that Resident #7 had a vape that he keeps locked in a locked drawer. She stated that he would put on his call light to have her get it for him. She had seen him take a hit and saw the smoke. Last time she helped him was 3 weeks ago as she doesn't work in that area often. About 2 weeks ago, other staff told her that he could not vape anymore. Prior to that she did not know he could not vape in his room. Management did not tell her.In an interview on 4/8/26 at 9:15 the Administrator stated Resident #7 can have his vape locked in his room against the current policy since he is not actually using it but is simply chewing on it for PTSD. The decision to be able to have it in his room but not use it was decided in his quarter 3 care conference on 10/13/25. Resident #7 and his mom both agreed he would not use it except to chew on unless he was with mom or in the designated smoking area. In the previous interview the Administrator clarified that when he said the plans did not work, he meant that they could not be sure that the vape was locked up as his mom would forget and he had lots of friends visiting. He had it now as he had agreed not to use it in his room. He can only use it in the designated area at the designated time or when out with his mother. They do not monitor the vape as he is using it when leaving with mom. The vape is now red since mom came yesterday. He has never been able to use the vape in his room. He stated that staff were aware as they are re-educating staff during in-services, huddles and team applications. The education included the night shift.In an interview on 4/8/26 at 5:01 PM Staff G, CNA stated that she did not usually work on the top assignment but there was a guy in room [ROOM NUMBER] that she did not remember his name. He had a vape around his neck. She did not remember if he still had it. She added that at one point, he used to have a THC vape in his locked drawer in his room. She did not remember how long ago and she did not know if he still had it in there.In an interview on 4/9/26 at 8:15 AM Staff H, Activities Supervisor stated that she bought vapes for many of the residents but some families bring them in. They are not always in the original packaging. She stated that the vapes don't have identifiers to say what kind they are but the smoke attendants would be able to tell if they were THC vapes as they have the smell of THC but fruit flavored. When the vapes are empty, they are thrown away in the garbage.According to the National Library of Medicine, in an article titled E-cigarette explosions: patient profiles, injury patterns, clinical management, and outcome, it indicated that recently, there is a growing number of reported cases in which an Electronic Nicotine Delivery System (ENDS) exploded, leading to serious injuries to the user. The lithium-ion batteries are considered the main culprit for these events. Conversely, lithium-ion batteries are inexpensive and easy to produce and use. However, there is a known risk of spontaneous combustion, especially in low quality units. The underlying mechanism seems to be a self-induced rapid overheating of the battery. A specific issue of lithium-ion batteries is the known phenomenon called runaway, which seems to be responsible for the chain reaction, eventually leading to their explosion. The article can be found at: https://pmc.ncbi.nlm.nih.gov/articles/PMC10491958/#:~:text=Recently%2C%20there%20is%20a%20growing,easy%20to%20produce%20and%20use.In an undated document titled Resident Smoking & Vaping Policy it indicated that smoking and vaping are prohibited in all buildings and anywhere on facility grounds except in designated outdoor smoking areas. It also indicated that residents who do not meet criteria for independent smoking must be supervised per their care plan and smoking materials for supervised smokers are maintained by Nursing and Activities. Also, vaping devices are subject to the same rules as combustible smoking and may only be used in designated areas.

Based on clinical record review, staff interview, and policy review, the facility failed to update and revise the care plan to reflect changes in the plan of care for 1 of 10 residents reviewed for smoking and/or vaping (Residents #7). The facility reported a census of 66.Findings include:The Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #7 had diagnoses of traumatic spinal cord dysfunction, quadriplegia C5-C7 complete and Post Traumatic Stress Disorder (PTSD). It also indicated that he had a Brief Interview for Mental Status (BIMS) score of 15 meaning he was cognitively intact.The Electronic Health Record (EHR) indicated on 10/9/25 that management had taken Resident #7's vape from him as he was not following the smoking policy. It also indicated that he had a diagnosis of vaping-related disorder and vaped daily.The Care Plan initiated on 8/1/24 indicated that Resident #7 had a potential for injury related to vaping and directed staff to provide 1:1 observation while smoking cigarettes or vape due to not being able to hold it. It also directed staff to maintain his smoking materials at the nurses' station or other designated area. It indicated that he was often non-compliant with the smoking policy by keeping his vape in his room. It lacked documentation that he could have his vape in a locked box in his room or that he only used it to chew on.During an observation on 4/7/26 at 1:33 PM Resident #7 had a purple vape to the left side of his neck. When asked if it was a vape, he did not say anything for a while. After asking again, he stated that it was a vape and that his mom gets them for him. He stated he usually keeps them in a lock box in his room.In an interview on 4/7/26 at 2:30 PM Staff A, CMA stated that Resident #7 had a vape in his room and was able to have it. Most of the staff were aware of the vape. She was not aware of where he got them or what kind they were.In an interview on 4/8/26 at 9:15 the Administrator stated, Resident #7 could have his vape locked in his room against the current policy since he is not actually using it but is simply chewing on it for PTSD. The decision to be able to have it in his room but, not use it was decided in his quarter 3 care conference on 10/13/25. Resident #7 and his mom both agreed he would not use it except to chew on unless he was with his mom, or in the designated smoking area. The Administrator stated that this change should have been on the care plan.In a document titled Policy/Procedure - Nursing Administration under Section: Care and Treatment and Subject: Care Planning revised 4/2025 it indicated that it was the policy of the facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment. The Care Plan would be revised as needed, and interventions would be implemented. It also indicated that in the event that a resident refused certain services posing a risk to resident's health and safety, the comprehensive care plan would identify care or service declined, the associated risks, IDT's effort to educate the resident and resident representative and any alternate means to address risk.

Based on record review, policy review and staff interviews, the facility failed ensure residents were free from abuse for 2 of 3 residents reviewed (Residents #1 and #3). The facility reported a census of 71 residents. Findings include: 1. The 5-Day Assessment Minimum Data Set (MDS) dated [DATE] for Resident#1 (R#1) revealed a Brief Interview for Mental Status (BIMS) assessment was not conducted as the resident was rarely/never understood. The MDS further revealed the resident did not speak, did not have behavioral symptoms and had diagnoses including quadriplegia (weakness or paralysis leading to partial or total loss of function in the arms, legs, trunk, and pelvis) and profound intellectual disabilities. The Care Plan initiated 8/28/25 for Resident #1 revealed the resident had an activities of daily living (ADL) deficit and required 2 staff with transfers via a mechanical lift. 2. The Quarterly MDS dated [DATE] for R#2 revealed a BIMS assessment was not conducted as the resident was rarely/never understood. The MDS further revealed the resident had mumbled speech, had the ability to express ideas, usually understood others, had physical behavioral symptoms directed towards others and other behavioral symptoms not directed toward others 1 to 3 days during the 7 day look back period. The resident had diagnoses including autistic disorder and profound intellectual disabilities. The Care Plan for R#2 revised 1/17/25 had an ADL self care performance deficit and revealed the resident was able to crawl in and out of his room independently. The Care Plan lacked interventions for sexual behavior prior to 10/19/25. During an interview on 10/21/25 at 10:09 AM Staff H, Certified Nurse Aide (CNA) revealed she was the one who witnessed the incident on 10/14/25 with R#1 and R#2. Reported around supper time she went to get R#1 for supper and found R#2 leaning into R#1's bed which had been in the low position masturbating and rubbing his hand on R#1's face. Staff H reported she observed R#1 who can't speak or move his body trying to cry and move his head away from R#2's hand. Staff H reported R#1's face was wet at the time she intervened. Staff H reported she immediately separated the two residents and reported the incident to Staff I, Licensed Practical Nurse (LPN). Staff H reported she had documented the incident between R#1 and R#2 on a piece of paper, signed and dated it and had Staff I sign and date it as well as she felt the incident was sexual exploitation and that R#1 could not defend himself and she needed to be his voice. Staff H stated when she went to remove R#1 from the situation, R#2 continued to masturbate and laugh. During an interview on 10/21/25 at 1:35 PM, the Administrator revealed she had received a call from Staff I, LPN on 10/14/25 in regards to the incident between R#1 and R#2 and did not feel based on the information she received from Staff I that the incident rose to the level to report it to the Department of Inspections, Appeals and Licensing (DIAL). The Administrator reported she asked Staff I to document the information and she would discuss the incident in the morning meeting the next day. The Administrator stated she felt R#2 did not know what he was doing when he had been touching R#1 while masturbating. The Administrator revealed on the night she received the call from Staff I in regard to the incident, when R#2 started having sexual behaviors staff moved him out of the common area, his behaviors were not intentional, R#1 slept through the incident, he didn't have the ability to speak and R#1 was moved to a different room. The Administrator reported she told Staff I to document the incident, and notify the physician if R#2 was not able to be redirected. The Administrator revealed the next day staff had to again redirect R#2 due to his behavior. Stated Staff J, Nurse Practitioner (NP) was notified, and per R#2's Care Plan he had cycled with sexual behavior and he hadn't exhibited the behaviors in a while. Stated she had physician review R#2's medications and had her review the medications with a psychiatrist. Reported R#2's Care Plan was updated, he was redirected, it was not intentional and R#1 remained sleeping and the resident did not have signs or symptoms of distress following the incident. The Administrator confirmed an incident report and facility investigation had not been completed and DIAL had not been notified of the incident. During an interview on 10/22/25 at 10:08 AM, Staff I, LPN reported R#2 was pretty agitated and masturbating to stimulate himself in the common area on 10/14/25 when staff had gently covered him with a blanket and redirected him. Around 5:00 PM, Staff H, CNA reported to Staff I that she observed R#2 next to R#1's bed and petting R#1's face while masturbating and R#1 was screaming when it happened. Stated R#1 is non-verbal and they decided the two residents should no longer share a room so the CNAs and the oncoming nurse made the decision to move R#1 to a different room. Staff I reported she called the Administrator around 5:30 PM and the Administrator was supportive of keeping R#1 and R#2 separated. Stated she explained the incident to the Administrator like it had been explained to her that R#2 was petting R#1's face while masturbating. Staff I reported she would be upset if that had happened to one of her family members. Staff I reported R#1 is completely dependent on staff. Stated she felt like R#2 had been escalating with the sexual behaviors earlier in the day and she had called the physician to get a one time order for Ativan (sedative) and felt like they were winging it in regard to caring for R#2 and his behaviors. Stated Staff H, CNA documented a statement about the incident and Staff I, LPN signed it verifying what had been told to her in regard to what R#2 had been doing to R#1. During an interview on 10/22/25 at 6:45 PM, Staff D, LPN revealed on 10/14/25 at 6:00 PM she came into work and was getting report from Staff I, LPN when Staff H, CNA reported the concern about the interaction between R#1 and R#2. Staff L reported she directed the CNAs to move R#1 to a different room after R#2 had been found masturbating while touching R#1's face. Staff L reported she instructed one of the CNAs to do a 1:1 with R#2 as he hadn't been very redirectable. Review of facility policy titled, Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment revised 8/2024 revealed it is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, resident representatives, families, friends or other individuals. If there is an allegation or suspicion of abuse, the facility will make a report to the appropriate agencies as designated by State and Federal Law. 1. In response to allegations of abuse, neglect, exploitation, or mistreatment, the Facility will: Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but: a. Not later than two (2) hours after the allegation is made if the events that cause the allegation involves abuse or results in serious bodily injury. b. Not later than twenty-four (24) hours if the events that cause the allegation does not involve abuse and does not result in serious bodily injury. 2. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to: a. The Administrator of the Facility. b. The State Survey Agency. c. Adult Protective Services (as appropriate). 3. Ensure that, after receipt of a report of possible abuse, neglect, mistreatment, exploitation, or misappropriation of resident property, steps are immediately taken to protect the identified resident(s). 4. Ensure that the results of all investigations are reported within five (5) working days of the incident to: The Administrator and The State Survey Agency. Ensure that, if the alleged violation is verified, appropriate corrective action is taken. To assist the facility's staff members in recognizing incidents of abuse, the following definitions are provided: a. Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. b. Alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, another health care provider, or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. c. Mental Abuse includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation. d. Neglect is the failure of the Facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. e. Sexual abuse is non-consensual sexual contact of any type with a resident. Required to report per policy included: A resident who fondles or touches a person's sexual organs and the resident being touched indicates the touching is unwanted through verbal or non-verbal cues. Sexual activities where one resident indicates that the activity is unwanted through verbal or non-verbal cues. Sexual activity or fondling where one of the resident's capacity to consent to sexual activity is unknown. Sexual assault or battery (examples include rape, sodomy, coerced nudity). Forced observation of masturbation, or pornography. Forced, coerced or extorted sexual activity. Other unwanted actions for the purpose of sexual arousal or sexual gratification resulting in degradation or humiliation of another resident. 3. The Minimum Data Set (MDS) for R#3 dated 10/9/25 reflected admission to the facility from the hospital coded as an entry tracking record and documented basic demographics. The Clinical Assessment List for R#3 documented a Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed resident scored 13 out of 15 indicated is cognitively intact. The Electronic file lacked care plan documentation. A facility document titled, Self Report, 5 day summary relayed on 10/13/25 the Administrator received a phone call from R#3 who alleged abuse by Licensed Practical Nurse (LPN) Staff A. Staff A allegedly withheld medication and used profanities towards R#3. Findings noted, after the investigation was determined R#3 experienced poor services. Corrective action included all staff educated on reporting abuse. A statement (not dated) from Staff B, Certified Medication Aide (CMA) documented the following: On 10/10/25 Staff B heard LPN Staff A and R#3 yelling. R#3 said you do not control my medications. Staff A responded she followed the doctors orders so yes does control medications. Staff B reported she heard LPN Staff A verbalize as left the room, the way R#3 is acting, is not getting his fucking oxy, referred to oxycodone pain medication. A statement from CMA, Staff C dated 10/15/25 documented on 10/10/25 relayed Staff C asked by a Therapist, Staff L if R#3 could have pain medication. Replied yes and would be there when the current task finished. Staff L came back and informed R#3 is very upset. CMA, Staff C summoned the LPN, Staff A who entered R#3 room while CMA waited outside. Staff C relayed much yelling back and forth included LPN Staff A said, do not give him shit. CMA, Staff C reported much cussing back and forth, walked away as was instructed to do by Staff A . During an interview on 10/20/25 at 3:40 PM R#3 relayed while at the facility received only one time in the middle of the night pain medication and had a lot of pain, reported on 10/10/25 asked for the Administrator and Staff A responded, what do you want, I am all you got, was screaming back and forth. Staff F said don't give this mother f***r anything and left During an interview with LPN, Staff A on 10/21/25 at 1:50 PM relayed CMA ,Staff C asked for assistance on 10/10/21 sometime after 4:00 PM because CMA, Staff C was afraid of R3# due to his anger. R#3 complained is not getting pain medications. Relayed met with R#3 in his room, voices were raised, tired of R#3 repeated profanities, so just walked out. During an interview on 10/21/25 at 6:11 PM LPN Staff D relayed on 10/9/25 R#3 asked for pain medication, Staff D responded medications had not arrived from the pharmacy. Staff D reported left in the morning of 10/10/25 when the shift ended, still had not received the orders from the hospital. During an interview with the Administrator on 10/27/25 at 2:30 PM was relayed would have expected staff to inform her directly right away of verbal altercation and resident allegations of abuse that transpired on 10/10/25.

Based on clinical record review, staff interview, resident interview and policy, the facility failed to ensure full admission orders for Resident #3 (R#3). The facility lacked medication orders, R#3 did not receive pertinent medication including insulin, cardiac, pain and psychotropic drugs. The facility reported a census of 71 residents. Findings included: The Minimum Data Set (MDS) for R#3 reflected admission to the facility on [DATE] from the hospital and documented basic demographics for R#3 coded as an entry tracking record. The Clinical Assessment List for R#3 documented a Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed resident scored 13 out of 15 indicated is cognitively intact. An admission Record revealed R#3 admitted to the facility on [DATE], primary diagnosis of fracture of the right femur, acute kidney failure and chronic congestive heart failure. Additional diagnoses included leukemia in remission, diabetes, obesity, bipolar, anxiety disorder, high blood pressure, Chronic Obstructive Pulmonary disease (COPD refers to lung disease). An Electronically Mailed (email) statement from Licensed Practical Nurse (LPN) Staff A dated 10/14/25 at 4:02 PM documented on 10/10/25 sometime after 4:00 PM R#3 upset, swearing because did not receive pain medication earlier, said had been dealing with medication issues since arrived at the facility. Reported, R#3 used profanities said was getting the fuck out of here, called family who arrived, police arrived per R#3, requested to retrieve medications. LPN, Staff A relayed could not send medications, R#3 refused to reenter the facility and left with family. A Controlled Drug Receipt, Record, Disposition form documented thirty 5 milligram tabs of oxycodone was received on 10/9/25 directed to give 5-10 milligrams by mouth every four hours as needed for pain. It showed 10 milligrams were given at 4:45 AM on 10/10/25 and 10 milligrams was given at 10:46 AM on 10/10/25. No other medications documented as administered. The Medication/Treatment Administration Record entered by RN, Staff G on 10/10/25 included the following hospital discharge orders:a. Blood sugar check three times a day for diabetes.b. Insulin Glargine 50 units subcutaneously two times a day for diabetes.c. Aspirin 81 milligrams (mg) by mouth (PO) in the morning for heart disease.d. Cyclobenzaprine 10 mg PO three times a day for femur fracture .e. Lamictal 100 mg PO in the morning for bipolar disorder.f. Rosuvastatin Calcium 40 mg PO in the morning for high lipids (fat compound in blood).g. Sertraline 150 mg PO in the morning for bipolar disorder. h. Carvedilol 25 mg PO two times a day for chronic congestive heart failure.i. Pregabalin 50 mg PO two times a day for diabetes.j. Hydralazine 75 mg PO 3 times a day for heart failure.k. Trazodone 150 mg PO at bedtime related to bipolar disorder.l. Albuterol Sulfate, Inhalation, 2 puffs every 6 hours as needed for shortness of breath.m. Lorazepam 0.5 mg PO every 12 hours as needed for anxiety. n. Ondansetron 4 mg PO every 8 hours as needed for nausea.o. Oxycodone 5 mg oral every 4 hours as needed for pain related to femur fracture.p. Acetaminophen 1000 mg PO every 8 hours as needed for pain. During an interview on 10/20/25 at 3:40 PM R#3 relayed while at the facility received only one time in the middle of the night pain medication, did not receive any heart medication, no blood sugar checks, was repeatedly told by staff, you are not in the system and don't have any medications. R#3 relayed should have received insulin in the morning and at bed time and no staff checked his blood sugar or gave his usual medications while at the facility. R#3 relayed about 5:00 PM on Friday 10/10/25 demanded to see the Administrator or Social worker because had a lot of pain, acknowledged had a screaming match with the nurse and felt neglected. R#3 relayed called family and the police so could leave the facility. During an interview on 10/20/25 at 3:45 R#3's family confirmed R#3 left the facility because had not received necessary medications and had increased pain relating to the surgery. During an interview on 10/21/25 at 11:20 AM with LPN, Staff K relayed was working when R#3 arrived to the facility on [DATE]. Staff K was told when the job started, the floor nurses do not do the admission work, was not sure which of management staff was responsible for R#3 admission paperwork. Did not have a diet order but looked at a diagnosis list and decided to give a regular room tray. Staff K relayed shift ended at 7:30 PM and reported to next shift nurse, LPN Staff D of the new admission. During an interview on 10/21/25 at 6:11 PM LPN, Staff D stated the 10/9/25 shift began at 6:00 PM and was informed had a new admit. R#3 asked for pain medication about 6:00 PM, called the Director of Nursing for R#3 orders and was informed, Registered Nurse (RN) Staff G would be entering the orders into the system. Told R#3 the medications had not arrived from the pharmacy. Staff D relayed did have 4 medications that arrived earlier from the pharmacy included oxycodone for pain but did not have the physician orders. Called Staff G who instructed to give the medications that arrived from the pharmacy. Staff D relayed did not feel comfortable with no orders in the system. Staff D stated called the on-call Nurse Practitioner (NP) Staff J who gave an order for 10 milligrams of oxycodone since R#3 was in so much pain. Staff D relayed also called the hospital for orders to be faxed. Staff D reported left in the morning of 10/10/25 when the shift ended, still had not received the orders from the hospital, was not even sure the fax was working. During an interview on 10/23/25 at 9:25 AM Corporate Registered Nurse (RN), Staff G relayed R#3 arrived at the facility between 3-4:00 PM, had agreed to enter the admission orders. Staff G reported received via e-mail the orders from the Assistant Director of Nurses (ADON) that did not include medication orders and could not add orders in the system. Staff G stated Staff D called about 11:00 PM relaying R#3 had no orders and was having pain. Staff G instructed Staff D to give the oxycodone that arrived from the pharmacy and to get all orders from the hospital. Staff G stated discovered the next morning when arrived to the facility that R#3 orders still were not received. Staff G agreed the delay in getting orders caused R#3 unnecessary pain, to not have blood sugar checks (for diabetes monitoring) and R#3 did not get the evening dose of insulin on 10/9/25 or morning insulin on 10/10/25. During an interview with Pharmacist, Staff F on 10/27/25 at 9:56 AM confirmed received admission orders from the facility system on 10/10/25 for R#3 who admitted on [DATE]. Pharmacist, Staff F relayed would have expected a call from the facility if there were any concerns regarding medications. Staff F relayed the facility has an emergency kit of medications to use or could call the pharmacy 24 hour on call option. Staff F relayed a concern with the process was evident regarding R#3 admission. The policy titled Procedure, Nursing Administration, Subject of Admission, last revision 7/2023 included to : Minimize resident stress with transition, provide information and resources for care, comfort and federal and state requirements. Provide safety of possessions, obtain information about the resident to establish baseline data, provide the basis for interdisciplinary assessment, care planning and rehabilitation. Included to:1. Inform physician of admission and verify transfer and admission orders.2. Initiate any required treatments as ordered3. Order medications from pharmacy4. Initiate admission assessments5. Initiate Resident Care Plan.

Based on clinical record review, policy review and staff interviews, the facility failed to complete a thorough investigation in regard to an allegation of sexual abuse in a timely manner for 1 of 3 residents reviewed for abuse (Residents #1). The facility reported a census of 71 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #1 revealed a Brief Interview for Mental Status (BIMS) assessment was not conducted as the resident was rarely/never understood. The MDS further revealed the resident did not speak, did not have behavioral symptoms and had diagnoses including quadriplegia (weakness or paralysis leading to partial or total loss of function in the arms, legs, trunk, and pelvis) and profound intellectual disabilities. The Care Plan initiated 8/28/25 for Resident #1 revealed the resident had an activities of daily living (ADL) deficit and required 2 staff with transfers via a mechanical lift. 2. The MDS dated [DATE] for Resident #2 revealed a BIMS assessment was not conducted as the resident was rarely/never understood. The MDS further revealed the resident had mumbled speech, had the ability to express ideas, usually understood others, had physical behavioral symptoms directed towards others and other behavioral symptoms not directed toward others 1 to 3 days during the 7 day look back period. The resident had diagnoses including autistic disorder and profound intellectual disabilities. The Care Plan for Resident #2 revised 1/17/25 had an ADL self care performance deficit and revealed the resident was able to crawl in and out of his room independently. During an interview on 10/21/25 at 10:09 AM Staff H, Certified Nurse Aide (CNA) revealed she witnessed the incident on 10/14/25 with Resident #1 and Resident #2. Reported when she went to get Resident #1 for supper and found Resident #2 leaning into Resident #1's bed which had been in the low position in the room they shared masturbating and rubbing his hand on Resident #1's face. Staff H reported she observed Resident #1 who can't speak or move his body trying to cry out and move his head away from Resident #2's hand. Staff H reported Resident #1's face was wet at the time she intervened. Staff H reported she immediately separated the two residents and reported the incident to Staff I, Licensed Practical Nurse (LPN). Staff H reported she had documented the incident between Resident #1 and Resident #2 that occurred on 10/14/25 on a piece of paper, signed and dated it and had Staff I sign and date it as well. Staff I reported she felt the incident was sexual exploitation towards Resident #1 who could not defend himself and she needed to be his voice. Staff H stated when she went to remove Resident #1 from the situation, Resident #2 continued to masturbate and laugh. During an interview on 10/22/25 at 10:08 AM, Staff I, LPN reported Resident #2 was pretty agitated and masturbating to stimulate himself in the common area on 10/14/25 when they had gently covered him with a blanket and redirected him. Around 5:00 PM, Staff H, CNA reported to her that she observed Resident #2 next to Resident #1's bed and petting his face while masturbating and Resident #1 was screaming when it happened. Stated Resident #1 is non-verbal and they decided the two residents should no longer share a room so the CNAs and the oncoming nurse made the decision to move Resident #1 to a different room. Staff I reported she called the Administrator around 5:30 PM and the Administrator was supportive of keeping Resident #1 and Resident #2 separated. Stated she explained the incident to the Administrator like it had been explained to her that Resident #2 was petting Resident #1's face while masturbating. Staff I reported she would be upset if that had happened to one of her family members. Staff I reported Resident #1 is completely dependent on staff. Stated she felt like Resident #2 had been escalating with the sexual behaviors earlier in the day and she had called the physician to get a one time order for Ativan (sedative) and felt like they were winging it in regard to caring for Resident #2 and his behaviors. Staff I revealed Staff H, CNA had written out a statement and Staff I stated she signed and dated it verifying what had been told to her by Staff H in regard to the incident. During an interview on 10/21/25 at 1:35 PM, the Administrator confirmed a facility investigation had not been completed in regard to the 10/14/25 incident involving Resident #1 and Resident #2. Review of the clinical record for Resident #1 lacked documentation regarding the 10/14/25 incident with Resident #2 including care plan updates, completion of an incident report and completion of a resident assessment. Review of the clinical record for Resident #2 lacked documentation regarding the 10/14/25 incident with Resident #1 including care plan updates related to hypersexual behavior until 10/19/25, completion of an incident report and completion of a resident assessment. Review of facility policy titled, Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment revised 8/2024 revealed it is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, resident representatives, families, friends or other individuals. If there is an allegation or suspicion of abuse, the facility will make a report to the appropriate agencies as designated by State and Federal Law. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will ensure that after receipt of a report of possible abuse, neglect, mistreatment, exploitation, or misappropriation of resident property, steps are immediately taken to protect the identified resident(s). Ensure that the results of all investigations are reported within five (5) working days of the incident to the Administrator and the State Survey Agency. During an interview on 10/23/25 at 1:45 PM, the Director of Nursing (DON) revealed the expectation in regard to allegations of abuse is to notify the Abuse Coordinator/Administrator, report the incident to DIAL, complete a facility investigation which would include staff interviews and a 5 day summary. The DON further revealed charting, completion of an incident report, documentation of resident to resident interactions, care plan updates with new interventions that are put in place related to the incident, and timely family notification would also take place.

Based on record review, policy review and staff interviews, the facility failed to report allegations of abuse to the Department of Inspections, Appeals and Licensing (DIAL) in a timely manner for 2 of 3 residents reviewed for abuse (Residents #1 and #3). The facility reported a census of 71 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for R#1 revealed a Brief Interview for Mental Status (BIMS) assessment was not conducted as the resident was rarely/never understood. The MDS further revealed the resident did not speak, did not have behavioral symptoms and had diagnoses including quadriplegia (weakness or paralysis leading to partial or total loss of function in the arms, legs, trunk, and pelvis) and profound intellectual disabilities. The Care Plan initiated 8/28/25 for R#1 revealed the resident had an activities of daily living (ADL) deficit and required 2 staff with transfers via a mechanical lift. 2. The MDS dated [DATE] for R#2 revealed a BIMS assessment was not conducted as the resident was rarely/never understood. The MDS further revealed the resident had mumbled speech, had the ability to express ideas, usually understood others, had physical behavioral symptoms directed towards others and other behavioral symptoms not directed toward others 1 to 3 days during the 7 day look back period. The resident had diagnoses including autistic disorder and profound intellectual disabilities. The Care Plan for R#2 revised 1/17/25 had an ADL self care performance deficit and revealed the resident was able to crawl in and out of his room independently. During an interview on 10/21/25 at 10:09 AM Staff H, Certified Nurse Aide (CNA) revealed she witnessed the incident on 10/14/25 between R#1 and R#2. Reported around supper time she went to get R#1 for supper and found R#2 leaning into R#1's bed which had been in the low position masturbating and rubbing his hand on R#1's face. Staff H reported she observed R#1 who can't speak or move his body, trying to cry and move his head away from R#2's hand. Staff H reported R#1's face was wet at the time she intervened. Staff H reported she immediately separated the two residents and reported the incident to Staff I, Licensed Practical Nurse (LPN). Staff H reported she had written out the 10/14/25 incident between R#1 and R#2, signed and dated it and had Staff I sign and date it as well as she felt the incident was sexual exploitation. Staff H reported R#1 could not defend himself and she needed to be his voice and when she went to remove R#1 from the situation, R#2 continued to masturbate and laugh. During an interview on 10/21/25 at 1:35 PM, the Administrator revealed she had received a call from Staff I, LPN on 10/14/25 in regard to the incident between R#1 and R#2 and did not feel based on the information she received from Staff I that it rose to the level to report it to the DIAL. The Administrator reported she asked Staff I to document the information and she would discuss the incident in the morning meeting the next day. The Administrator stated she felt R#2 did not know what he was doing when he touched R#1 while masturbating. Stated the night she received the call from Staff I, R#1 was moved to a different room and when R#2 started to have sexual behaviors, staff moved him out of the common area, his behaviors were not intentional and R#1 was sleeping during the incident and wasn't able to speak. The Administrator confirmed the incident had not been reported to DIAL. During an interview on 10/22/25 at 10:08 AM, Staff I, LPN reported R#2 was pretty agitated and masturbating to stimulate himself in the common area on 10/14/25 when they had gently covered him with a blanket and redirected him. Around 5:00 PM, Staff H, CNA reported to her that she observed R#2 next to R#1's bed and petting his face while masturbating and R#1 was screaming when it happened. Stated R#1 is non-verbal and they decided the two residents should no longer share a room so the CNAs and the oncoming nurse made the decision to move R#1 to a different room. Staff I reported she called the Administrator around 5:30 PM and the Administrator was supportive of keeping R#1 and R#2 separated. Stated she explained the incident to the Administrator like it had been explained to her that R#2 was petting R#1's face while masturbating. Staff I reported she would be upset if that had happened to one of her family members. Staff I reported R#1 is completely dependent on staff. Stated she felt like R#2 had been escalating with the sexual behaviors earlier in the day and she had called the physician to get a one time order for Ativan (sedative) and felt like they were winging it in regard to caring for R#2 and his behaviors. Stated Staff H, CNA wrote out a statement about the incident and Staff I, LPN signed it verifying what had been told to her in regard to the incident. During an interview on 10/22/25 at 6:45 PM, Staff L, LPN revealed on 10/14/25 at 6:00 PM she came into work and was getting report from Staff I, LPN when the Staff H, CNA reported the concern about the interaction between R#1 and R#2. Staff L reported she directed the CNAs to move R#1 to a different room after R#2 had been found masturbating while touching R#1's face. Staff L reported she instructed one of the CNAs to do a 1:1 with R#2 as he hadn't been very redirectable. Review of facility policy titled, Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment revised 8/2024 revealed it is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. 1. In response to allegations of abuse, neglect, exploitation, or mistreatment, the Facility will: Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but: a. Not later than two (2) hours after the allegation is made if the events that cause the allegation involves abuse or results in serious bodily injury. b. Not later than twenty-four (24) hours if the events that cause the allegation does not involve abuse and does not result in serious bodily injury. 2. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to: a. The Administrator of the Facility. b. The State Survey Agency. c. Adult Protective Services (as appropriate). 3. Ensure that, after receipt of a report of possible abuse, neglect, mistreatment, exploitation, or misappropriation of resident property, steps are immediately taken to protect the identified resident(s). 4. Ensure that the results of all investigations are reported within five (5) working days of the incident to the Administrator and the State Survey Agency. During an interview on 10/23/25 at 1:45 PM, the Director of Nursing revealed any allegations of abuse needed to be reported to DIAL. 3. The Minimum Data Set (MDS) dated [DATE] reflected admission to the facility, from the hospital and documented basic demographics for R#3 coded as an entry tracking record. The Clinical Assessment List for R#3 documented a Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed resident scored 13 out of 15 indicated is cognitively intact. The Electronic file lacked care plan documentation. A facility document, Self Report, 5 day summary relayed on 10/13/25 the Administrator received a phone call from R#3 alleging abuse by Licensed Practical Nurse (LPN) Staff A, alleged Staff A withheld medication and used profanities towards him. Findings noted, after the investigation was determined R#3 experienced poor services. Corrective action included all staff educated on reporting abuse. A statement (not dated) from Certified Medication Aide (CMA) Staff B documented on 10/10/25 heard LPN Staff A and R#3 yelling. R#3 said you do not control my medications. Staff A responded, followed the doctors orders so yes does control medications. Staff B heard Staff A verbalize as left the room, the way R#3 is acting, is not getting his fucking oxy , referred to oxycodone pain medication. A statement from CMA, Staff C dated 10/15/25 documented on 10/10/25 relayed Staff C asked by a therapy staff if R#3 could have pain medication. Replied yes and would be there when the current task finished. Therapy staff came back and informed R#3 is upset. CMA Staff C summoned the LPN, Staff A who entered R#3 room while CMA waited outside. Staff C relayed much yelling back and forth included LPN Staff A commented, do not give him shit. CMA Staff C reported much cussing back and forth so walked away. An interview with LPN, Staff A on 10/21/25 at 1:50 PM relayed CMA Staff C summoned her on 10/10/21 sometime after 4:00 PM to assist because Staff A was afraid of R3# who was angry, complaining is not getting pain medications. Relayed met with R#3 in his room yelled profanities in turn Staff A relayed did raise voice, tired of R#3 repeated profanities, so I just walked out. An interview with the Administrator on 10/27/25 at 2:30 PM Administrator relayed would have expected staff to inform her directly right away of verbal altercation and resident allegations on 10/10/25, instead heard from R#3 on 10/13/25. The Administrator relayed understood the obligation to report timely allegations of abuse.

Based on clinical record review, staff interviews, resident interview and policy, the facility failed to provide appropriate pain medications for 2 of 3 residents reviewed for pain, Resident #3 (R#3) and Resident #4 (R#4).The facility reported a census of 71 residents. Findings included: 1. The Minimum Data Set (MDS) dated [DATE] reflected admission to the facility from the hospital and documented basic demographics for R#3 coded as an entry tracking record. The Clinical Assessment List for R#3 documented a Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed resident scored 13 out of 15 indicated is cognitively intact. The Electronic file lacked care plan documentation. A facility document titled, Self Report, 5 day summary relayed on 10/13/25 the Administrator received a phone call from R#3 alleging abuse by Licensed Practical Nurse (LPN) Staff A, alleged Staff A withheld medication and used profanities towards R#3. Findings noted, after the investigation was determined R#3 experienced poor services. Corrective action included all staff educated on reporting abuse. A statement from (CMA) Staff B undated documented on 10/10/25 heard LPN, Staff A and R#3 yelling. R#3 said you do not control my medications. Staff A responded, followed the doctors orders so yes does control medications. Staff B heard Staff A verbalize as left the room that R#3 is not getting his fucking oxy (referred to oxycodone pain medication). Staff B wrote R#3 family arrived just after and R#3 left the facility. A statement from CMA, Staff C dated 10/15/25 documented on 10/10/25 relayed Staff C asked by a Therapist, Staff L if R#3 could have pain medication. Replied yes and would be there when the current task finished. Staff L came back and informed R#3 is very upset. Staff C summoned the Staff A who entered R#3 room while Staff C waited outside. Staff C relayed much yelling back and forth included Staff A said, do not give him shit. Staff C reported much cussing back and forth, walked away as was instructed to do by Staff A. The Medication/Treatment Administration Record entered by RN, Staff G on 10/10/25 to direct pharmacy to send included the following orders for pain/anxiety: a. Cyclobenzaprine 10 mg PO three times a day for femur fracture. b. Pregabalin 50 mg PO two times a day for diabetes/neuropathy. c. Lorazepam 0.5 mg PO every 12 hours as needed for anxiety. d. Oxycodone 5 mg, 1-2 oral every 4 hours as needed for pain related to femur fracture. e. Acetaminophen 1000 mg PO every 8 hours as needed for pain. A Controlled Drug Receipt, Record, Disposition form documented thirty 5 milligram tabs of oxycodone was received on 10/9/25 directed to give 5-10 milligrams by mouth every four hours as needed for pain. a.10 milligrams were given at 4:45 AM on 10/10/25 b. 10 milligrams was given at 10:46 AM on 10/10/25. No other medications documented as administered. During an interview on 10/20/25 at 3:40 PM R#3 stated while at the facility received only one time in the middle of the night pain medication and had a lot of pain. Stated on 10/10/25 asked for the Administrator and Staff A responded, what do you want, I am all you got, was screaming back and forth. Staff F said don't give this mother f***r anything and left. An interview on 10/21/25 at 11:04 AM with CMA Staff C reported gave R#3 a pain medication at 10:47 AM, R#3 scaled pain at an 8 or 9 out of 10 being most severe. R#3 asked again for pain medication about noon or 1:00 PM, and responded, to come back in two hours. Staff C relayed R#3 did not come back, thought perhaps resident left with family. Staff C relayed next time heard from R#3 was when the therapist reported R#3 was very angry about not getting pain medications, was demanding and yelled profanities at LPN, Staff A. An interview with LPN, Staff A on 10/21/25 at 1:50 PM relayed CMA Staff C was afraid of R3# and summoned her to go to R#3's room. Relayed R#3 screaming the F word. Staff A, stated, tried to explain orders were different from the hospital and were no longer scheduled and had to ask, voices were raised. Staff A relayed R#3 was offered three times to allow CMA to get the medication since it was now time. R#3 continued profanities and Staff A relayed got tired of it and walked out. Staff A reported R#3 went outside, told R#3 if would come back inside could get his pain medication, R#3 refused. Police arrived, Staff A told the police to inform R3# if came back in the building can get the medication, R#3 refused and left with family. An interview on 10/21/25 at 6:11 PM with LPN, Staff D relayed when arrived at about 6:00 PM on 10/9/25 and informed had a new admit, had no other information. R#3 asked for pain medication about 6:00 PM. Staff D responded the medications had not arrived from the pharmacy. Staff D relayed there was no information in the computer and was told RN, Staff G would be entering the orders into the system. About 11:00 PM called RN, Staff G who instructed to give the pain medication that arrived from the pharmacy. Staff D relayed did not have an order so was not comfortable doing that and instead called the on-call Nurse Practitioner (NP) Staff J and obtained an order for 10 milligrams of oxycodone. Confirmed the medication was not given to R#13 until 4:45 AM. Staff D relayed did contact the hospital and requested all orders to be faxed, left at end of shift and was not sure when the orders finally came, stated was not even sure the fax was working. During an interview on 10/23/25 at 9:25 AM the Corporate Registered Nurse (RN), Staff G relayed R#3 arrived at the facility between 3-4:00 PM on 10/9/35 and had agreed to enter the admission orders later and left the facility. Staff G received orders via e-mail from the Assistant Director of Nurses (ADON) Staff E, the orders did not include medication orders. Staff G confirmed Staff D called about 11:00 PM relayed R#3 lacked orders and R#3 requested medications for pain. Staff G instructed Staff D to give the oxycodone that arrived from the pharmacy and to get orders from the hospital. Staff G stated discovered the next morning when arrived to the facility that R#3 medication orders were not sent. Staff G agreed the delay in getting the admitting orders and medications caused R#3 unnecessary frustration. Confirmed R#3 did not receive medications that included pain, muscle relaxant and psychotropic medications. An interview with Pharmacist, Staff F on 10/27/25 at 9:56 AM confirmed received admission orders from the facility system on 10/10/25 for R#3 who admitted on [DATE]. Pharmacist, Staff F relayed would have expected a call from the facility if there were any concerns regarding medications. Staff F relayed the facility has an emergency kit of medications to use or could call the pharmacy 24 hour on call option. Staff F relayed a concern with the process was evident regarding R#3 admission. A Policy titled: Nursing Administration, Subject: Pain documented, The facility assists each resident with pain to maintain or achieve the highest practicable level of well-being and functioning by screening, assessing, identifying circumstances and by developing and implementing a plan, using pharmacologic and/or non-pharmacologic interventions to manage the pain and/or try to prevent the pain consistent with the resident's goals. Staff directed to document, monitor, treat and consult with the physician to evaluate and revise as indicated. 2. The MDS dated [DATE] revealed R#4 had a BIMS of 14 indicating intact cognition. The MDS further revealed the resident had diagnoses including acute osteomyelitis (inflammation of bone) in the right ankle and foot, pain in the right and left knee and required scheduled pain medication regimen in addition to as needed pain medication. The Care Plan initiated 8/24/25 revealed R#4 had acute/chronic pain and directed staff to administer analgesia medication per orders and half an hour before treatments or care. Clinical census for R#4 revealed an admission date of 8/22/25. Review of Encounter Note dated 8/29/25 completed by Staff J, Nurse Practitioner (NP) revealed R#4 reported pain to be 10/10. Staff J documented an order to restart Oxycodone 5 milligrams (mg) every 6 hours as needed. During an interview 10/22/25 at 11:40 AM, Staff J, NP revealed a nurse had called her the week of 9/2/25 reporting they did not have an as needed order for R#4's Oxycodone. Staff J reported she was upset someone had not called her over the weekend as she would have given a verbal order for the Oxycodone. Staff J verified she had originally re-ordered the Oxycodone on 8/29/25 after a visit with R#4 and the information was documented in her notes. Review of Clinical Physician Orders for R#4 revealed the order for Oxycodone 5 mg every 6 hours as needed was initiated 9/4/25. During an interview 10/22/25 at 12:50 PM, R#4 revealed when he first arrived at the facility his hip pain was unbearable and he didn't get much help with pain control except Tylenol. Stated he got an order for more pain medication from the NP and the pain control improved. During an interview 10/22/25 at 3:25 PM, the Director of Nursing (DON) revealed the as needed Oxycodone should have been transcribed when it was received. The DON revealed he was not sure when the breakdown happened but is looking at improving the process.

Based on confidential resident interviews, family interviews, staff interviews, clinical record review, and facility policy review, the facility failed to provide appropriate staffing to meet residents needs. The facility reported a census of 70. Findings include: During a confidential resident interview on 8/25/25 at 11:30 AM, the resident reported he had noticed staff were not getting residents who sat at the assist table up for supper. During the supper meal, only one or two residents were at the assist table, but during the breakfast and lunch meals there were more residents seated at the assist table. The resident reported staff came into the room and shut the call light off, and staff got mad at the resident if he pressed the call light again. The resident reported there had been times when there were only one CNA working upstairs and one CNA working downstairs, which isn't enough to care for all of the residents at the facility. According the the MDS, the resident had a documented BIMS of 15, indicating intact cognition. In an interview 8/25/25 at 8:08 AM, Staff F, LPN, reported the facility only staffed with two CNA's and one nurse downstairs and two CNA's and one nurse upstairs about 50 % of the time. During a confidential interview 8/25/25 at 3:15 PM, a family member expressed concern it took 40-47 minutes for staff to respond to call lights. Staff came in the room, shut the call light off and say they will be back, which took even longer for the resident to get assistance. Staff also brought the resident's food tray in but it took staff 45 minutes to return and feed the resident. In a confidential family interview on 8/27/25 at 11:10 AM, a family member reported the facility was short-handed. The family member expressed concern about the resident not getting changed properly during the night due to the staffing ratio. There were not enough staff to feed the residents that needed assistance with eating. The family member expressed he had concerns about staff coming into the room and shutting the call light off before the resident's needs were addressed. The family member reported residents and family members had expressed concerns about reporting their concerns about call lights and staffing due to they feared retaliation. A confidential resident interview on 08/27/2025 at 09:31 AM with a Resident they stated the facility just does not have enough staff. They stated call lights have been taking a long time, but they was worried about speaking out further for fear of getting in trouble. A review of the Residents Minimum Data Set (MDS) documented they had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. A confidential resident interview on 08/27/2025 at 02:02 PM with a Resident they stated the facility is under staffed. They stated they mostly notice it at night. They stated they have missed wound dressing changes as a result of the low staffing, and are often left in their wheelchair well past their desired 9pm bed time. They stated they have been left up in their wheelchair due to staffing until at least 11pm, with a few occasions having gone even later. They stated they have openly communicated with the facility about this, but worry about reprisal should they continue to self-advocate. A review of the Residents Minimum Data Set (MDS) documented they had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. A confidential resident interview on 08/28/2025 at 01:59 PM with a Resident they said the facility has staffing concerns. They stated call lights, often during the evening shift, can take longer than 25 minutes to get assistance. There are times their call light is answered but their issue is not addressed, their call light is turned off, and they have to press their light again. A review of the Residents MDS documented they had a BIMS score of 15, indicating intact cognition. An interview on 09/02/2025 at 10:27 AM with Staff G, Certified Nurse Aide (CNA), she stated there are only some days she feels they have enough CNAs. She stated she knows the facility has been working on it, but it is still difficult and has led to not everything getting done. An interview on 09/02/2025 at 10:27 AM with Staff H, Licensed Practical Nurse (LPN), he stated that while staffing has gotten better, they can still improve. An interview on 09/02/2025 at 10:32 Am with Staff A, CNA, she stated the facility still struggles with staffing. At least once a week they are so short staffed that it is difficult to get everything done. A review of time card data from 07/28/2025, 08/04/2025, and 08/22/2025 failed to document the required number of CNAs on several shifts. It also documented the Director of Nursing (DON) worked the floor from 10pm-6am on 07/28/2025. Review of Resident Council Notes dated 8/22/25 documented facility call light times were still out of parameters (greater than 15 minutes) and that beds were still not getting made. Review of the Facility Assessment from 2025, it documented there are to be at least 5 CNAs on day and evening shifts, and 4 or more on the overnight shift.

Based on clinical record review, observation, staff interview, and policy review the facility failed to ensure a resident's buttocks was appropriately covered in order to maintain the resident's dignity for one of sixteen residents sampled (Residents #15). The facility reported a census of 70 residents.Findings include:The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had diagnoses of severe intellectual disability and schizoaffective disorder. The MDS recorded the resident had a Brief Interview for Mental Status Score of 9, indicating moderately impaired cognition. The MDS indicated the resident required partial to moderate assistance for lower body dressing. The Care Plan revised 5/22/25 revealed the resident required assistance with Activities of Daily Living (ADL's). The Care Plan directed staff to provide assistance of one for dressing. During observation on 8/25/25 at 12:04 PM, Resident #15 sat in a chair by a table in the upper dining room with her buttocks fully exposed. At the time, nine other residents were in the same dining room. One male resident sat at a table facing Resident #15's backside. At 12:08 PM, four staff were lined up by the kitchen waiting for food to be plated and in order to deliver plates of food to the residents in the upper dining room. Staff walked back and forth between the kitchen and the upper level dining hall, and walked past Resident #15. At 12:12 PM, Staff B, Certified Medication Aide, placed a blanket between Resident 15's back and the chair to cover the resident's exposed buttocks. In an interview 9/2/25 at 4:05 PM, the Administrator reported sometimes a resident would expose their body but he expected the staff to ensure the resident's backside was appropriately covered. A Dignity and Privacy policy revised 10/2024 revealed all residents treated with dignity and privacy. Residents will be appropriately dressed in a manner that maintains the privacy of their body.

Based on observation, clinical record review, staff interview, and policy review the facility failed to administer treatments and perform dressing changes as ordered by the physician for one of four residents reviewed (Resident #11). The facility reported a census of 70 residents.Findings include: The Significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had a Stage 3 pressure ulcer on the left ankle, one Stage 1 pressure ulcer and one unstageable pressure ulcer. The MDS recorded the resident required application of nonsurgical dressings and medications for skin treatments. The Care Plan revised 5/23/25 revealed the resident had impaired skin integrity related to wounds on her left inner ankle and coccyx, and also had a history of infections. The care plan directed staff to administer treatments as ordered. The Care Plan lacked information about a wound to the right foot. The Order Summary Report dated 8/27/25 revealed an order to cleanse the right lateral foot wound with cleanser of choice, apply calcium alginate to the wound bed, cover the wound with a silicone absorbent dressing daily and as needed for wound care with order date of 8/21/25.The Treatment Administration Record dated 8/1/25 to 8/31/25 revealed a wound treatment and dressing change to the right lateral foot documented on the day and the night shift 8/24/25 to 8/26/25.During observation on 8/27/25 at 10:10 AM, Staff D, Licensed Practical Nurse (LPN) and Staff E, Wound Nurse Practitioner, were in the room with Resident #11. Staff D removed the foam boots on the resident's feet while the resident was lying in bed. A dressing was observed to the right lateral foot dated 8/24/25. Staff D removed the dressing over the right lateral foot. Staff E took a scalpel and debrided the wounds to the right lateral foot and left inner ankle. Staff D cleansed the wound areas and applied calcium alginate and a silicone foam dressing. Staff D then placed a piece of tape labeled 8/27 and her initials. In an interview 8/28/25 at 10:15 AM, the Director of Nursing (DON) reported he expected staff date and initial the dressing whenever a resident's dressing had been changed. The DON explained if a treatment or dressing change was ordered more than once a day, the dressing should be labeled with the date and the staff's initials. The DON reported he would be able to tell who completed the dressing change and when the dressing was changed by checking the date and the staff's initials on the dressing. A Physician's Order policy reviewed 8/2024 revealed the facility accurately implemented orders in addition to treatment orders in accordance with the resident's plan of care.

Based on direct observation, clinical record review, staff interview, and facility policy review, the facility failed to provide appropriate infection control practices in the form of enhanced barrier precautions when required for 3 of 5 individual reviewed (Resident's #9, #11, #14). The facility reported a census of 70. Findings include: 1. The Quarterly Minimum Data Set (MDS) for Resident #14, dated 07/17/2025, documented the residents Brief Interview for Mental Status (BIMS) score as 15, indicating intact cognition. It documented the following relevant diagnoses: Septicemia (Blood infection), Hip fracture, Cerebrovascular Accident (Stroke), Paraplegia (Paralysis of the legs), Traumatic Brain Injury, Need for Assistance with personal Cares, Pressure ulcer of the right ankle. The MDS documented that the resident was dependent on staff for toileting hygiene, personal hygiene, lower body dressing, and putting on/taking off footwear.The Care Plan for Resident #14, last revised 08/14/2025, documented the resident's need for assistance with personal cares due to his paraplegia, as well as warned staff that he had alterations to the right lateral lower leg's skin due to trauma. The Care Plan instructed staff to follow Enhanced Barrier Precautions (EBP). During a direct observation on 08/28/2025 at 09:26 AM with Staff I, Licensed Practical Nurse (LPN), and Staff J, Certified Nurse Aide (CNA) where they were performing wound care for Resident #14's ankle pressure wound. During the observation, Staff I, LPN, donned gloves and a disposable gown, but Staff J, CNA, did not wear a gown while assisting with cares and directly handling the resident. Also during the observation, Staff I touched the incontinence pad and the residents skin and buttocks with gloved hands, then used the same gloves to cleanse the wound bed. In an interview on 09/02/2025 at 10:27 AM with Staff G, CNA, she stated staff members are required to wear Personal Protective Equipment (PPE) when they are handling a resident that has a qualifying condition such as open wound or catheters. She stated she has to wear PPE even when she is not directly providing those cares. In an interview on 09/02/2025 at 10:32 AM with Staff A, CNA, she stated PPE has to be worn by all members of the care team when caring for a resident who requires enhanced barrier precautions. She noted PPE consists of a gown and gloves in this case. She stated the PPE should be donned as soon as they enter the room. In an interview on 09/02/2025 at 10:44 AM with Staff K, CNA, she stated everyone in the room who is touching or might touch a resident who requires enhanced barrier precautions requires PPE. In an interview on 09/02/2025 at 10:20 AM with Staff H, LPN, he stated that all people assisting with cares on a resident who requires enhanced barrier precautions should be wearing PPE as you do not know when you will be required to touch a resident. In an interview on 09/02/2025 at 12:20 PM with the Director of Nursing (DON), he stated that all parts of the care team are expected to wear PPE when required by enhanced barrier precautions standards, which include open wounds and catheters. He stated you should never clean a wound bed after touching potentially contaminated surfaces such as an incontinence pad or a residents skin. 2. The Significant Change in Status MDS assessment dated [DATE] revealed Resident #11 had a Stage 3 pressure ulcer on the left ankle, one Stage 1 pressure ulcer and one unstageable pressure ulcer. The MDS recorded the resident had application of nonsurgical dressings and medications for skin treatments. The Care Plan revised 5/23/25 revealed the resident had impaired skin integrity related to wounds on her left inner ankle and coccyx, and had a history of infections. The Care Plan directed staff to administer treatments as ordered. The Care Plan directed staff to use a gown and gloves for Enhanced Barrier Precautions (EBP) during high resident contact care activities due to wounds. The Order Summary Report dated 8/27/25 revealed an order to cleanse the right lateral foot wound with cleanser of choice, apply calcium alginate to the wound bed, cover the wound with a silicone super absorbent dressing daily and as needed for wound care. During observation on 8/27/25 at 10:10 AM, Staff D, LPN, and Staff E, Nurse Practitioner, were in the room with Resident #11. Resident lying in bed. Staff D removed the foam boots on the resident's feet. A dressing was observed to the right lateral foot dated 8/24/25. Staff D removed the dressing over the right lateral foot. Staff E took a scapel and debrided the wounds to the right lateral food and left inner ankle. Staff D cleansed the wound areas and applied calcium alginate and a silicone foam dressing. Staff D placed a piece of table labeled 8/27 and initials KW. Staff did not wear a gown while performing treatment or the dressing change on the resident's wound. 3. The Quarterly MDS assessment dated [DATE] revealed Resident #9 had diagnoses of quadriplegia. The MDS recorded the resident had no skin conditions such as a pressure ulcer present. The Care Plan revised 1/10/25 revealed the resident had impaired skin integrity. The Care Plan directed staff to provide treatments per the physician's orders and use enhanced barrier precautions. The Order Summary Report dated 8/2025 revealed an order for EBP's with start date of 5/14/25. EBP's indicated due to wound and indwelling medical device. Use of a gown and gloves required for high contact care activities. During observation on 8/27/25 at 11:35 AM, Staff D obtained supplies from a treatment cart, then took the supplies to Resident #9's room. Staff D sanitized her hands and donned a pair of gloves. Staff D took a gauze soaked in Vashe wound cleanser and cleansed the resident's left and right heels. Staff D applied betadine, an ABD (large) dressing, and kerlix to each wound. Staff D did not wear a gown during the procedure, and did not change gloves or sanitize hands when going from a dirty to clean task. In an interview 8/28/25 at 11:30 AM, Staff A, Certified Nursing Assistant (CNA) reported EBP used whenever wound care or catheter care performed, or if a resident had an infection. EBP entailed wearing a gown and gloves during high contact activities. In an interview 8/28/25 at 10:15 AM, the Director of Nursing (DON) reported he expected EBP implemented anytime staff took care of a resident who had a catheter or a wound. Staff should wear PPE gown and gloves for EBP. The DON reported he also expected gloves changed whenever staff removed a dressing and anytime going between steps or a clean area. Staff should change gloves and sanitize their hands, then put a clean dressing on. An Infection Control Standard and Transmission-Based Precautions policy reviewed 8/2024 revealed infection control measures implemented to prevent the spread of diseases and conditions. Section 3 revealed EBP's used in conjunction with standard precautions and expanded the use of gown and gloves during high-contact resident care activities (for example when cared for residents with wounds and indwelling medical devices due to the high risk of acquisition and colonization of Mulit-Drug Resistant Organisms (MDRO's). Personal Protective Equipment (PPE) donned upon room entry, then doffed and properly discarded, and hand hygiene performed before exiting the room to contain pathogens.

Based on observations, staff interview, and policy review, the facility failed to ensure the lunch menu and meal met the nutritional needs and preferences for 7 out of 68 resident lunch trays prepared. The facility reported a census of 72. Findings include: During on observation on 6/4/25 at 10:30 AM, Staff L, Cook, pureed 2 pork steaks for lunch service. Staff L confirmed the facility had 2 residents on a puree diet. The puree food was placed in a steamtable pan and into the over for reheat until service. During the observation, Staff L did not measure out the final volume of the puree meat before placing into the steam table pan. A Puree Diet Portion Sizes/Scoops chart was laying on the table where the puree food was prepared. Staff L reported the Diet Spreadsheet listed the use of a #8 scooper size for the puree pork. During a lunch service on 6/4/25 from 11:15 AM to 12:45 PM, the following was observed: a. 1 resident did not receive a Magic Cup supplement which was highlight on the lunch ticket b. 1 resident received a Mighty Shake supplement instead of a Magic Cup which was highlighted on the lunch ticket c. 3 residents did not receive a Mighty Shake supplement which was highlighted on the lunch tickets d. 1 resident did not receive a side dish of cottage cheese which was added to the lunch ticket e. 1 resident did not receive ice cream which was added to the lunch ticket f. 3 residents received approximately three-fourths full #8 scooper serving size of the puree pork steak; 2 residents had puree diet orders; 1 resident had a liquified diet which was prepared by mixing the puree meat with hot water in an 8 oz mug During an interview on 6/10/25 at 10:00 AM, the Certified Dietary Manager (CDM) would expect staff to prepare resident meal trays with items as listed on the meal ticket. The CDM stated they were unsure how Staff L typically prepares the liquefied food for the resident. The CDM did not have a preference if staff prepared liquefied food individually in the Robot Coup, to the correct consistency, or if mixed in a cup with puree food and hot water. During an interview on 6/10/25, Staff L confirmed 2 residents on a puree diet and 1 resident on a liquefied diet. Staff F acknowledged serving 3 residents the puree pork even though 2 intact pork steaks were pureed (representing 2 total servings of puree pork). Sample menus from the facility-provided International Dysphagia Diet Standardization Initiative (IDDSI) Resource packet indicated if 3 total servings of a puree item is needed, 3 servings of the cooked food item should be added to the food processor and processed to the appropriate consistency.

Based on observations, record review, resident and staff interviews, the facility failed to identify a hazard, and the facility did not take action to reduce the risk for further injuries. On 10/28/24, Resident #2 was identified to have a rectangular shaped red mark to the right forearm measuring 10.3cm x 5.6cm, with scattered blisters. Resident #2 reported to the staff that the water in the shower room caused the injury. On 10/31/24 the resident went to the Urgent Care and was found to have a 2nd degree burn on the right arm. The facility continued to give showers in the identified shower room. On 11/5/24, After 3 residents received showers, a Department of Inspection, Appeals and Licensing (DIAL) staff measured the water temperature to be 145.2 degrees Fahrenheit. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of October 28, 2024 on November 5, 2024 at 4:55 p.m. The facility staff removed the Immediate Jeopardy on November 6, 2024 by implementing the following actions: 1. Resident #2 had treatment in place of the area on the right arm. 2. The 3 residents that were given showers on the morning of 11/5/24 had complete head to toe skin assessments completed and were questioned about the temperature of water. 3. Weekly skin assessments are recorded in each resident's chart in Point Click Care (PCC), no residents voiced concerns about shower temperature, or any injuries noted from skin assessments. 4. All showers were put out of use immediately after DIL staff reported water temperature finding of 145.2 degrees. The high temperature had the potential to harm other residents in the facility that receive showers. 5. All showers are regulated to prevent water temperatures above 120 degrees. 6. 1-[NAME] Plumner services contacted on 11/5/24 to assess the current plumbing system with additional monitoring thermometer installed on the water heater. 1-[NAME] Plumber's report isolated an incident of sediment build up that was resolved by maintenance staff with no further interventions required for safe water temperatures. 7. Maintenance will check water temperature in each shower room daily beginning 11/5 for the next 7 days and then on a weekly basis as a part of weekly system checks through TELS. Weekly system checks have no end date. 8. All nursing staff will be educated on how to monitor water temperature with a thermometer placed in the shower room by the end of day 11/6/24. If the water temperature is greater than 120 degrees, they are to cease the shower for the resident, and report to the administrator, maintenance or charge nurse and cease showers until the water temperature has been checked and deemed to be at a safe level. The scope lowered from J to D at the time of the Survey after ensuring the facility implemented staff education and procedures. The facility reported a census of 59 residents. The Minimum Data Set (MDS) for Resident #2 dated 8/9/24 revealed a diagnosis of quadriplegia (partial or complete paralysis of both arms and legs as a result of a spinal cord injury) and was dependent on staff for a shower. Resident had a Brief Interview for Mental Status (BIMS) score of 15 which suggested an intact cognition. The Care Plan for Resident #2 identified the need for total assistance with bathing and directed staff directed staff to offer a bath/shower 2 times a week and as needed. The Nursing progress notes for Resident #2 revealed: a. On 10/28/24 at 4:12 PM The nurse was notified by Physical Therapy (PT) of a skin alteration to resident's right arm. Upon assessment, the resident was noted with a rectangular shaped red mark to right forearm measured 10.3 centimeters (cm) x 5.6 cm with scattered blisters in the middle of the area. The resident stated this may have happened while in the shower earlier in the day. The area was cleansed, skin prep applied and family and provider notified. b. On 10/28/24 at 4:18 PM A change of condition: skin wound. The primary care provider was notified on 10/28/24 at 3 PM and the resident representative was notified at 3 PM. c. On 10/28/24 at 4:22 PM A condition follow-up: redness to right forearm with scattered blisters. An order for skin prep 2 times a day (BID) until healed. d. On 10/29/24 at 9:59 AM A condition follow-up: Staff J, Nurse Practitioner, was here to see the resident. Resident #2 complained of pain and burn on the site, skin looks red on surface. The treatment completed as ordered. No signs or symptoms of infection noted at this time. e. On 10/31/24 at 9:14 A condition follow-up: A new observation noted. The skin is still red, blisters are drained. A clear tape is covering the area. The resident complained of pain to the area. f. On 10/31/24 at 6:42 PM A condition follow-up: The arm was red with raised blisters, no signs or symptoms of infection. g. On 11/1/24 at 12:47 AM A condition follow-up: The area being monitored is from what resident stated was from water and then stating it was from the shower bar. The area is square in shape, has small intact blisters in the middle. The resident was out all day on Saturday and Sunday with friends and family and did not have a long sleeve shirt on when leaving facility. The resident stated it was sore. There was no bleeding or drainage noted. h. 11/1/24 at 7:45 AM Late entry: on 10/31/24 the resident and his friend came back with a note from Urgent care at Mercy. i. 11/1/24 at 6:26 PM Resident was seen by provider. A new order for a topical antibiotic (TAO) to be applied BID (2 times a day) and as needed (PRN), apply a non-adherent dressing and loosely wrap with Kerlix dressing. A voicemail was left for mother. During an interview on 11/5/24 at 1:09 PM, Resident #2 stated on 10/28/24, Staff B, Certified Nursing Assistant (CNA) assisted him to a shower chair and transported him to the upstairs shower room. Resident #2 stated when the water touched his forearm, he could feel the temperature and Staff B put the water on his right forearm. Resident #2 stated, She had to turn it down because it was scalding hot. Resident #2 stated he felt heat on his right (Rt) arm and felt discomfort when it was dried off with a towel. Resident #2 stated the CNA's that dressed him identified the reddened area and the therapist notified Staff D, Licensed Practical Nurse (LPN). Resident #2 stated Staff D assessed his arm and stated to leave it open. Resident #2 stated he notified his mother who came to the facility and was told it was a rash. Resident #2 stated his arm was painful, and was given Oxycodone for back pain but stated that did not relieve the burning pain. Resident #2 stated the facility provider assessed the reddened, blistered area on 12/29/24 who stated she was not sure what it was but the staff told her it was a rash and gave an order for skin prep to be applied. Resident #2 stated the blisters increased in size and he experienced prickly pain. Resident #2 stated he seen at the Urgent Care on 10/31/24 and treated for a 2nd degree burn to the right forearm. During an observation on 11/5/24 at 1:08 PM, Resident #2 had a reddened area to the right upper forearm/elbow area that revealed a dried, open, scared area inside the reddened skin. Resident #2's mother provided a picture of the affected area, verified by Resident #2, that was taken after a shower on 12/28/24 that revealed a reddened area with blisters in the center to the skin on his right forearm. A document titled Mercy One dated 10/31/24 revealed: a. History of present illness: Minor burn, patient notes a burn on right forearm and elbow. He notes that he lives in a home and was in the shower when he was burned. It is a second degree burn on his right arm at the elbow area. b. Assessment/Plan: 2nd degree burn. Keep clean and dry. Cover and use an antibiotic ointment on it, as needed, for the next 3-4 days until it is healing more and feeling better. During an interview on 10/4/24 at 2:58 PM The Director of Nursing (DON) stated Resident #2 was out of the facility over the weekend and received the shower that he said he received the burn on Monday 10/28/24. The DON stated the provider told her that the water in the shower may have exacerbated the area. The DON stated Resident #2 went to a clinic on his own. The DON stated she had followed up with the clinic staff who stated he was to put an antibiotic on the dressing, but they did not have an antibiotic order. The DON stated the facility provider was treating the area with skin prep to toughen up the blisters. The DON stated the maintenance supervisor keeps water logs and had tested water temperatures every day. During an interview on 11/5/24 at 9:52 AM, Staff K, CNA stated Resident #2 told her the shower water was too hot in the upstairs shower room. Staff K stated sometimes that shower room gets hot and they have to check it. Staff K reported giving 3 showers in that shower room this AM without incident. The metal grab bars could get hot if the water was turned all the way up and running straight down on to the bar. Staff K stated the water will get hot if turned all the way up. During an observation on 11/5/24 at 10:02 AM, in the shower room located in 100 Hall (identified as the upstairs shower room) the DIAL surveyor turned water on and tested the water temperature with her hand and the water was too hot to touch. A measurement was conducted with a thermometer that revealed 145.2 Fahrenheit. The Administrator was present for the test. During an observation on 11/5/24 at 10:37 AM, The administrator applied a sign onto the upstairs shower door that read out of order. During an interview on 11/5/24 at 11:25 AM, Staff I, CNA stated the shower room upstairs, if you turn it all the way up, potentially could burn your skin. Staff I stated, I don't turn it all the way up. I don't think anyone would turn it all the way up. During an interview on 11/5/24 at 3:02 PM Staff B, CNA stated she had assisted Resident #2 out of bed on 10/28/24 about 9 AM and into the shower room for the nurse to do bowel care before his shower. Staff B stated the entire time, the water was running, and she had tested the water. Staff B stated this was her first time to give Resident #2 a shower, he had a routine and would give instructions. Staff B stated Resident #2 let her know the water got cold and she had turned it up, then he could tell her if it was too hot. Staff B stated another aide took over after the shower. Staff B stated Staff E, LPN approached her when she was giving another shower, asked if she had seen anything red or raised on his arms and stated she did not see anything on Resident #2's right arm before or during the shower. Staff B stated she had given 4 showers before Resident #2 had his and the water was not overly hot. During an interview on 11/7/24 at 10:04 AM Staff E, LPN stated Resident #2 had lived in the facility about a year and was a typical [AGE] year old with an active social life. Staff E stated she had completed his bowel care and during that time, she did not visualize anything on his skin. Staff E stated after the shower, she was notified by therapy and assessed a red rectangular shape area with blisters to Resident #2's right arm. Staff E stated Resident #2 stated he was burned when the CNA ran water over his arm. Staff E stated she had notified the provider and received an order to apply skin prep and it was not normal to put skin prep on burns. Staff E stated she notified the mother, the DON and the Assistant Director of Nursing (ADON). Staff E stated she had questioned Staff B, CNA who denied having the water over his arm. Staff E stated that Resident #2 did not want to get the CNA into trouble. During an interview on 11/7/24 at 10:31 AM Staff M, CNA stated she had worked with Resident #2 on 10/28/24 and assisted his to undress for the shower. Staff M stated there was nothing, no redness to his arms and he did not have pain. Staff M stated she had assisted Resident #2 to the shower room then left the room. Staff M stated when Resident #2 returned from the shower, he had a red mark the size of her phone, with blisters to his right arm. Staff M stated she did not visualize the redness before the shower, but it was there after the shower. During an interview on 11/6/24 at 1:16 PM Staff L, Occupational Therapist (OT) stated on 10/28/24 he had entered Resident #2's room to assist in dressing after the shower. Resident #2 told Staff L that he had a burn to his right arm from hot water in the shower room upstairs. Staff L stated there was a red rectangular patch of redness to the upper forearm and lower humerus with small blisters in the center. Staff L stated he did not disagree with Resident #2 and notified the nurse. During an interview on 11/6/24 at 1:42 PM Staff C, CNA stated she was aware that the upstairs shower was pretty hot and stated she did not want to burn anyone. Staff C stated she was recently informed that there was a thermometer in the shower room and the staff were to measure the water to ensure it was not to rise above 120 degrees F. During an interview on 11/6/24 at 2:11 PM Staff F, CNA stated the water was too cold in the down stairs shower rooms, therefore Resident #2 would receive showers in the upstairs shower room. Staff F claimed the water was too hot to put her hand underneath it and would have to turn it down and test it before putting it on a resident. During an interview on 11/6/24 at 2:01 PM, Staff G, Certified Medication Aide (CMA) stated the water temperature in the upstairs shower room depended on how long it was on. Staff G stated she received a text message that read not to give showers until the problem was corrected. During an interview on 11/6/24 at 2:28 PM, Staff D, LPN stated Resident #2 told her on 10/29/24 that he received the injury in the shower room. Staff D stated she had not tested the water temperature, was not aware that the water was hot. Staff D stated, No one could figure out what it (the injury) was, I thought it was a spider bite because there was a blister on it. Document provided by the facility titled Test and Log the Hot Water Temperatures revealed: a. Test the water at various locations throughout your facility. b. For burn prevention, federal guidelines advise that you keep domestic water temperatures below 120 degrees Fahrenheit, although this temperature can still cause burns if exposure reaches five minutes. Many states have even stricter standards that can set maximum temperatures lower than 120 degrees Fahrenheit. Although 100 degrees Fahrenheit is considered a safe water temperature for bathing. c. Test temperature in shower areas. d. Check resident rooms at the end of each wing on a rotating basis or per facility policy. e. Note any discrepancies. f. Adjust water heater settings as required. g. Retest as necessary. A document titled Logbook Water Temps revealed: a. Date 10/31/24 8 Room's tested , room numbers not identified temp range 103 to 105F Laundry room and Kitchen 140F. Lacked testing of shower rooms. Signed by Staff H, Maintenance Supervisor. b. Date 10/25/24 room [ROOM NUMBER]- T 104F, room [ROOM NUMBER]- T 104F, room [ROOM NUMBER]- T103, room [ROOM NUMBER]-T104F room [ROOM NUMBER]-T104F, room [ROOM NUMBER]- 104F, room [ROOM NUMBER]- T 103F, room [ROOM NUMBER]-T 104F Laundry room & Kitchen 140F. Lacked testing of shower rooms. Signed by Staff H. A document titled Logbook Documentation revealed: a. Dated Oct. 24-30 (no year) Side 1 shower pass 108.4, Side 2 east shower pass 104, Side 2 west shower pass 103.8. Comments: Side 1 a little higher than normal. Completed by lacking a signature. b. Dated [DATE]-[DATE] (no year) Side 1 shower pass 108.2, Side 2 east shower pass 103.8, Side 2 west shower pass 104. Comments: Side 1 still a little high than normal, still at passing temperature, I will keep checking it. Completed by lacking a signature. A review of the Journal of American Medical Association Studies of Thermal Injury revealed the time for a 3rd degree burn to occur for a water temperature of 148 degrees F. for 2 seconds, water temperature of 140 degrees F for 5 seconds and a safe water temperature for bathing 100 degrees F. Based upon the time of the exposure and the temperature of the water, the severity of the harm to the skin is identified by the degree of burn, as follows: a. First-degree burns involve the top layer of skin (e.g., minor sunburn). These may present as red and painful to touch, and the skin will show mild swelling. b. Second-degree burns involve the first two layers of skin. These may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin. c. Third-degree burns penetrate the entire thickness of the skin and permanently destroy tissue.

Based on clinical record review, staff interviews, and policy review, the facility failed to provide assessment and intervention for the necessary care and services for 4 of 4 residents reviewed (#4, #8, #9, & #10). This resulted in harm to Resident #10 due to delayed interventions and resulted in an emergent transfer to a higher level of care. The facility reported a census of 67 residents. Findings include: 1) The Quarterly Minimum Data Set (MDS) for Resident #10 dated 9/12/24 revealed a Brief Interview for Mental Status (BIMS) score could not be obtained but indicated the resident was rarely or never understood. It included diagnoses of anemia, hyponatremia (low blood sodium), non-Alzheimer's Dementia, Transient Ischemic Attack (TIA-brief blockage of blood flow to the brain), metabolic encephalopathy (brain dysfunction caused by a chemical imbalance in the blood), and electrolyte imbalances. It revealed the resident was usually understood with difficulty communicating some words or finishing thoughts and was dependent for all levels of Activities of Daily Living (ADLs). The Care Plan indicated the resident desired to be a full-code and was dependent on staff for cognitive stimulation. It also directed staff to engage the resident in simple, structured activities and revealed her family preferred her to be included in activities even if she is not participating in them. The Electronic Health Record (EHR) revealed monthly labs were collected on 9/19/24 and sent to the lab. On 9/26/24 at 1:06 pm, the resident's relative stated she entered the resident's room and came back out after noting the resident's continued declined condition and notified the nurse the resident's mouth was dry and reminded them the resident needed to be hospitalized . She stated she informed the nurse every time the resident exhibited these signs, it was due to a urinary tract infection (UTI) and she had to be hospitalized . On 9/26/24 at 3:50 pm, Staff J, Licensed Practical Nurse (LPN) stated Resident #10 appeared more tired than usual on 9/19/24 and her white blood cell (WBC) count was a little high at 20 cells/microliter. She also stated Saturday (9/21/24) was the first recollection she noticed the resident's level of consciousness (LOC) had declined since Thursday (9/19/24). On 9/30/24 at 2:18 pm, Resident #12 stated Resident #10 appeared more sluggish than her normal on Thursday (9/19/24) and Friday (9/20/24). She also stated the staff assigned to the resident said they would have the doctor come look at Resident #10. The MDS for Resident #12 dated 8/28/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of anxiety and depression and revealed her hearing and ability to understand others were intact and she used corrective lenses. On 9/30/24 at 1:23 pm, the resident's relative stated Staff J informed her on 9/21/24 via telephone the resident's vital signs were normal. She added that when she arrived to the facility, she checked the resident's pulse and respiratory rate and had to locate the nurse and notify her of the elevated vital signs. On 9/30/24 at 2:35 pm, Staff J stated she did not work on 9/20/24 but worked on 9/21/24 and 9/22/24. When shown resident documentation she signed on 9/20/24, she stated she forgot she worked that day. She was unable to provide any details of an interaction with the resident's daughter on 9/20/24. She also stated she was made aware on 9/21/24 in report a UA was ordered for the resident but it wasn't collected by the time she began her 9/21/24 AM shift. She stated she was expected to get it if she could but said another nurse said she would get it because she had more time. On 9/30/24 at 3:31 pm, the Assistant Director of Nursing (ADON) stated he received the UA order from the provider via an email on 9/20/24 and was responsible for entering the order into the EHR. He also indicated the Director of Nursing (DON) usually verified his order entries were correct but he didn't believe she had an opportunity to verify it. He also revealed he didn't enter the UA order into the EHR because he thought the resident would need to be straight catheterized. He stated he was waiting to get further clarification because some staff wouldn't think to straight catheterize the resident if they were unsuccessful at collecting a urine sample. On 9/30/24 at 3:48 pm, the DON stated she documented a change of condition on 9/21/24 for Resident #10 because Staff J notified her that the resident's heart rate was elevated at a rate of 110 bpm. She stated the follow-up documented change of condition on 9/21/24 at 11:40 am included dry mouth, increased lethargy (tiredness), and increased WBC count. She stated she did not contact the medical provider about the additional assessment information. The EHR progress notes indicated the resident went unresponsive on 9/22/24 at 10:30 am and staff obtained orders from the medical provider to send the resident to the hospital. On 10/01/24 at 8:50 am, the medical provider stated she was not made aware of the resident's relative's request to send the resident to the hospital nor about the additional change of condition assessment findings on 9/21/24. She also stated she was not notified the UA had not been collected. She added the resident would have been sent to the Emergency Department and would have had more resource options had she been informed of this information. She also stated she felt the resident's outcome would not have changed. A policy titled Resident assessment dated ,d+[DATE] directed staff to complete a nursing assessment with a significant change in the resident's condition. 2) On 9/24/24 at 9:17 am, Resident #4's negative pressure wound therapy (NPWT = wound vac) machine was audibly beeping while the resident slept. At 9:28 am, Staff K, Certified Nurse Aide (CNA) entered the room and removed the breakfast trays for both residents. The resident's wound vac alarm was audibly beeping. At 9:42 am, Staff L, Occupational Therapist (OT) entered the resident's room and to confirm therapy attendance. Resident #4's wound vac alarm was still audibly beeping. At 9:44 am, Staff M, CNA entered the room to fill ice cups and exited at 9:53 am. The wound vac alarm was still audibly beeping. At 10:13 am, Staff K and Staff M entered the resident's room and the wound vac alarm was no longer audible. The wound vac screen was dark and was not plugged in to the power outlet. The Minimum Data Set (MDS) for Resident #4 dated 8/05/24 indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of neurogenic bladder (uncontrolled bladder due to nerve damage), hip and other fractures, traumatic brain injury (TBI), and a pressure ulcer. It also revealed the resident required setup assistance with eating, supervision with oral and personal hygiene, moderate assistance with upper body dressing, and was dependent with all other activities of daily living (ADLs). It further indicated he received nonsurgical dressings. The Care Plan dated 9/08/24 directed staff to change the wound vac to the right ischium (the lower back part of the hip) on Monday, Wednesday, and Friday and as needed (PRN) for contamination or dislodgement. On 10/01/24 at 4:15 pm, the DON stated staff should report alarms to the assigned nurse. On 10/02/24 at 1:16 pm, the Administrator indicated the facility did not have a policy specific to staff responding to alarms as it is a standard of practice. 44972 3) The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 carried diagnoses of chronic obstructive pulmonary disease, acute and chronic respiratory failure, obstructive sleep apnea, schizoaffective disorder, anxiety and morbid obesity. The MDS indicated the resident's Brief Interview for Mental Status (BIMS) score was 10 indicating moderate cognitive impairment. The resident required set up or clean up assistance with eating, toileting, and personal hygiene, moderate staff assistance with bathing and was independent with transfers. Resident #8 experienced shortness of breath with exertion, when sitting at rest and when lying flat and utilized oxygen therapy. The care plan dated 8/1/24 revealed a focus area for Resident #8 having emphysema, and chronic obstructive pulmonary disease related to smoking. Interventions included: to give aerosol or bronchodilators as ordered and to give oxygen therapy as ordered by the physician at 2 liters per nasal cannula continuous. The Medication Administration Record for Resident#8 dated 10/01/24 to 10/31/24 documented the following physician order with start date of 8/02/24; Oxygen at 2 liters via nasal cannula continuous every morning and at bedtime related to acute and chronic respiratory failure with shortness of breath. In an observation on 9/24/24/ at 12:45 PM, Resident #8's oxygen concentrator was noted to be unplugged and against the wall in her room and an oxygen tank was in the corner of the room and not being used. Resident #8 did not have oxygen on at the time. On 9/24/24 at 4:07 PM, Resident #8 was lying in bed with her eyes closed and no oxygen on. On 9/25/24 at 9:56 AM, Resident #8 sat on the side of the bed with no oxygen on at that time. The concentrator was along the wall and unplugged. The oxygen tank was next to it and turned off. Resident #8 stated she had not used the oxygen in several days. She denied being short of breath. She stated the concentrator had been unplugged for several days because the staff had moved the concentrator from under the window to along the wall and never plugged it back in. In an interview on 9/25/24 at 10:59 AM, Resident #8 reported she had not refused or told staff she did not want to wear the oxygen. She stated she was able to put the oxygen on herself but she had been unable to do it for the previous 3-4 days, since staff moved the concentrator and never plugged it in. She stated she had not experienced any shortness of breath during that time but did prefer to wear the oxygen at night for sleeping. On 9/26/24 at 1:25 PM, Resident #8 sat in her room in her wheelchair. She did not have oxygen on at that time. The oxygen concentrator was sitting along the wall and not plugged in. On 9/30/24 at 9:05 AM, Resident #8 sat in her room in her wheelchair and the concentrator was located along the wall and not plugged in. The oxygen tank was sitting next to it and turned off. The resident was not wearing oxygen at that time. On 10/2/24 at 10:20 AM, Resident #8 satin her room in her wheelchair. The oxygen concentrator and oxygen tank were both sitting along her wall and the concentrator was not plugged in. The resident was not using oxygen at that time. In an interview on 10/1/24 at 4:41 PM, the Director of Nursing (DON) stated it was the expectation that if a resident was supposed to be using oxygen and they were checking the oxygen saturations when the resident was not wearing oxygen and the oxygen saturations were normal, they should re-evaluate the need for oxygen and contact the provider. The staff should document the resident was not using the oxygen and then follow up with the provider for further evaluation. In an interview on 10/2/24 at 12:42 PM, the Marketing Director stated the facility did not have a policy relating to following physician orders as it was considered a standard of practice. 50471 4) Observation on 9/26/24 at 2:40 PM revealed the Resident #9 resting in wheelchair in lounge, no date on tubing, portable oxygen tank noted completely empty and on 3 liters. The Staff E, Certified Medication Aide (CMA) assessed the pulse ox-noted 85-89%-oxygen tank is empty, checked the nasal cannula for air flow-none noted, looked at the gauge on the portable oxygen tank, noted the tank is empty, asked staff to get a portable oxygen tank, the Assistant Director of Nursing (ADON) obtained the portable oxygen tank, noted the oxygen tank empty, and proceed to switch the tanks, and assessed the pulse ox-noted 95% on 3 liters. Observation on 9/30/24 at 11:26 AM revealed the Resident #9 sitting in wheelchair with visitor in lounge, noted portable oxygen tank gauge at beginning of red-revealed need for refill tank, and showed the Resident #9 on 2 liters. In an interview on 9/26/24 at 2:23 PM the ADON stated the Resident #9 is to be on 3 liters nasal cannula continuously. The Resident #9 current order for oxygen is 4 liters continuous. In an interview on 9/30/24 at 11:26 AM The ADON stated the nurses look at the orders to verify what liters of oxygen the residents are on. The Resident #9 is on 3 liters of oxygen continuous. The Resident #9 current order is 4 liters continuous. Clinical Physician Orders directed staff as follows; Oxygen at 4 liters via nasal cannula continuously with revision date of 2/9/24. The facility policy titled Physician Orders revised 8/24 instructed the staff that drugs shall be administered only upon the written order of a person duly licensed and authorized to prescribe such drugs, no drugs or biologicals shall be administered except upon the order of a person lawfully authorized to prescribe for and treat human illnesses, and drug and biological orders must be recorded on the physician's order sheet in the resident's chart.

Based on record review, observation, resident and staff interviews, police report, and policy review the facility failed to properly secure exit doors and failed to ensure residents were adequately supervised for 1 of 7 residents reviewed for wandering and elopement risk (Resident #1). The facility staff failed to know the whereabouts of a resident who left the facility unattended. Resident #1 was last seen by staff on 8/21/24 at approximately 9:00 PM, and not found until 8/23/24 at approximately 6:45 AM. The resident reported he had walked several blocks from the facility to a retail store, and later admitted himself to the Emergency Department (ED) for an evaluation. On 8/27/24 at 12:00 PM, the Iowa Department of Inspections, Appeals, and Licensing staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy (IJ) situation existed at the facility. The IJ began on 8/21/24, the day Resident #1 left the facility without staff knowledge. Facility staff removed the Immediate Jeopardy on 8/28/24 through the following actions: a. Temporary alarms put in place until a permanent new call light and wander guard system could be installed. b. All staff educated on the presence and use of the alarms, and the need to check/investigate the doors and surrounding area outside whenever a door alarm sounded and prior to deactivating the alarm effective 8/27/24. Staff orientation included the elopement policy. Agency staff required to read and sign the education in the schedule binder prior to their worked shift effective 8/27/24. c. The facility conducted a door alarm drill for staff on the day shift on 8/22/24. d. Current residents were assessed for elopement/wandering risk on 8/22/24. Residents assessed at high risk had a further evaluation completed, their care plan updated with resident-centered information and interventions, and a wander alert device initiated as necessary. e. A facility-wide evaluation of the wander alert system conducted on 8/22/24. f. All residents shall be educated upon admission and during Resident Council quarterly about the facility's voluntary discharge process, leave of absence process, and signing out with the charge nurse whenever the resident left for an outing with family/friends. The scope was lowered from J to a G the time of the survey after ensuring the facility implemented education and their policy and procedure. Findings include: The Census List revealed Resident #1 admitted to the facility on [DATE] to Side 1 (upper level) hallway and then moved to the Side 2 (lower level) hallway on 7/17/24. The Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 admitted to the facility from another long-term care (LTC) facility on 7/11/24 and had diagnoses of debility, diabetes, malnutrition, schizophrenia, and a hip fracture. The MDS recorded the resident had a Brief Interview for Mental Status score of 14 out of 15, which indicated cognition intact. The resident had no behaviors. The MDS indicated the resident used a walker and had independence for toileting, dressing, bed mobility, and transfers. The MDS documented the resident had no wander or elopement alarm. The Care Plan initiated 7/12/24 and revised on 8/7/24, revealed the resident had a self-care deficit in activities of daily living (ADL's) related to a recent left femur fracture. The resident transferred and ambulated independently using a front-wheeled walker, and he was his own responsible party. The Care Plan revealed the resident took medication for schizophrenia and had a risk for falls. The Care Plan lacked any information regarding prior wandering or elopement, or if the resident had a wander guard (a wander alert system). The Care Plan revised on 8/23/24 revealed the resident had impaired safety awareness and at risk for elopement related to a history of attempts to leave the facility unattended at a previous care facility. The staff directives included to monitor the placement of a wander guard on his left ankle. A Nursing Admission Evaluation dated 7/11/24, completed by Staff I, Registered Nurse (RN), revealed Resident #1 admitted from another care facility. Resident alert but confused and deemed an elopement risk. An alarm protocol was initiated and a wander guard applied. The Progress Notes dated 7/11/24 to 7/31/24 revealed the following: a. On 7/11/24 at 2:48 PM, Staff I, RN, documented Resident #1 admitted to the facility from another LTC facility. Resident alert and oriented, and ambulated on his own without difficulty. The resident has a known history of wandering so a wander guard placed on his right ankle. Staff educated on the importance of listening for the wander guard alarms and to monitor the resident. b. On 7/11/24 at 3:54 PM, resident had a history of elopement while at home and attempted to leave a facility without informing staff. Elopement risk score 4, indicating the resident at risk for elopement. The resident met the elopement risk criteria for wandering and verbally expressed a desire to go home, packed up belongings to go home, or stayed near an exit door. He also had admitted to the facility within the past 30 days and had not accepted the situation. c. On 7/12/24 at 4:14 PM, the resident wandered the hallways a few times but had no exit seeking. d. The Progress Notes indicated the resident exhibited behaviors on: 8/1/24 at 12:39 PM 8/2/24 at 9:28 AM 8/2/24 at 4:48 PM 8/4/24 at 8:18 AM The progress notes lacked the behaviors the resident exhibited. e. On 8/8/24 at 12:59 PM, the nurse practitioner (NP) saw the resident. The NP ordered to monitor the resident for insomnia and wandering, Trazadone (an antipsychotic medication) 25 milligrams (mg) at bedtime (HS), and continue psychiatric services. Resident is his own power of attorney (POA) and aware of the new orders. f. On 8/22/24 at 1:10 AM, Certified Nursing Assistant (CMA) reported resident not in bed. Unable to locate the resident after a search of the facility and grounds done. Director of Nursing (DON) and provider on-call informed of the missing resident. Awaiting further instructions from the DON. g. On 8/22/24 at 1:30 AM, DON called back and informed Staff D, Licensed Practical Nurse (LPN) to call the police and report the resident missing. Police called. h. On 8/22/24 at 1:45 AM, police arrived. Resident last seen by staff at approximately 8:30 PM wearing jeans, dark shirt/hoodie, and a red hat. Resident had a wheeled walked and ambulated independently in the facility. The temperature outside was 61 degrees. The resident's roommate reported he saw the resident packed belongings into a black bag before he noted Resident #1 missing. Roommate unable to recall what time he last saw Resident #1. Resident #1 did not say anything to him about leaving the facility. Resident's walker not located at the facility or on the grounds. Police will inform the facility if and when they found the resident. i. On 8/23/24 at 7:03 AM, Social Services (SS) visited Resident #1 upon his return to the building. He stated he wanted to see the world and find his friend to get a painting job. He also stated he went to the hospital due to his knees swelled up and hurt. Hospital paperwork given to the nurse. A provider's Encounter Note dated 8/6/24 revealed Resident #1 had increased agitation and wandering at night (HS), and referred to psychiatric services. Resident alert and oriented to self. The resident reported chronic left hip pain. He had an unsteady walk, and had impaired memory and insight/judgement. Trazadone 25 mg ordered every HS. The Order Summary Report revealed the following: a. Monitor wandering every shift started on 8/8/24. b. Monitor placement and functioning of the wander guard every shift started on 8/25/24. Document a (+) if the wander guard in place on right ankle and functioned correctly, and a (-) if the device not working. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated 7/1/24 to 7/31/24 lacked documentation of a wander guard. The MAR dated 8/1/24 to 8/31/24 revealed to monitor behaviors such as restlessness, agitation, and elopement started on 7/11/24 and discontinued on 8/5/24 at 5:21 PM. An order to monitor placement and functioning of the wander guard was added to the MAR on 8/25/24 at 3:20 PM. The TAR dated 8/1 - 8/31/24 revealed an order to monitor the resident for insomnia and wandering every shift started on 8/8//24 at 12:50 PM. A Police report created 8/22/24 at 2:41 AM revealed a police officer dispatched to the facility for a missing person on 8/22/24 at 1:10 AM. Staff D reported Resident #1 had gone missing from the facility in what they believed was a voluntary basis on 8/21/24 at 9:00 PM. Staff D reported Resident #1 had a history of walking away from the car/home/facilities he had been placed in. Resident #1 left with a silver walker and took his clothes with him. Staff reported the individual was homeless previously and that could be where he headed. Staff were advised to call if he resurfaced on his volition (own will). The ED Physician's Note recorded Resident #1 triaged in the ED on 8/22/24 at 9:11 PM. The resident presented to the ED for complaint of bilateral knee pain rated at 10 out of 10. The resident had a history of a fall and left hip fracture in 4/2024. X-rays of both knees revealed no acute findings. Labs revealed CK (an enzyme found in heart tissue and the muscle) was elevated and believed to be possibly related to him riding a bike for transportation. He was diagnosed with musculoskeletal pain and referred to follow up at a free clinic. He discharged from the ED on 8/23/24 at 5:13 AM. An Elopement/Wandering Evaluation dated 8/23/24 revealed the resident at high risk for elopement due to a history of wandering and an elopement in the past 6 months. A Condition Monitoring assessment dated [DATE] revealed the resident had an elopement on 8/22/24. Staff I documented a head-to-toe assessment completed and no abnormal findings noted. Resident alert and oriented x 4 (person, place, time, situation) and stated he was going out to see the world. Resident denied pain and rated pain 0 on a 0 to 10 pain scale. Resident seen at the ED on 8/22/24. Resident told SS he fell , and told Staff I his knees were bothering him so he went to the ED. Resident spent the night of 8/22/24 in the ED for observation. Resident had discharge paperwork with education about osteoarthritis. The Facility's Investigation File revealed the following written statements: a. A written statement dated 8/21/24 by Staff E, CNA, revealed she started her shift at about 10:14 PM. Staff realized the resident wasn't in his room. We looked everywhere but we did not find him. b. A written statement dated 8/22/24 by Staff F, CNA, revealed she saw Resident #1 a little bit after supper. He walked up the ramp without his walker and the dietary supervisor handed his walker to me. I gave the walker to Resident #1. He then walked toward the smoke door. It was around 6:45 PM when Staff G, RN, and I saw him. He wore a dark top and had a red ball cap on. It's 2:15 AM and it's 61 degrees in Des Moines. I searched all rooms and bathrooms on side one and side two and also checked the courtyard, as at one time you could walk around the building from the courtyard to circle drive. c. A written statement dated 8/22/24 by Staff G, RN, revealed she saw Resident #1 in the upper dining room around 6:30 - 6:45 PM trying to open the gate (by the ramp to access the upper/lower level). He did not use his walker so I went to him and asked Staff F to get his walker. Dietary got the walker for him and he returned to the lower dining room. I did not see him after that. Staff C, CNA, informed me at approximately 12:30 AM, Resident #1 could not be found. I checked the rooms and spoke to staff. I spoke with the resident's roommate (Resident #6). Resident #6 said he observed Resident #1 packing clothes in a black bag. Staff C and I checked for a black bag in the room and could not find it, and no walker found in the room. Around 9:50 PM, I heard the Circle Drive alarm going off and when I checked it, I saw Staff K, CNA, coming in (the door). Staff K said she just threw (out) the trash. d. A written statement dated 8/21/24 by Staff H, CNA, revealed at 7:45 PM I took the residents outside for a smoke and Resident #1 was with us. After smoking, Resident #1 went back inside. I didn't see him getting out of the building at all. e. A written statement dated 8/22/24 by Staff D, LPN, revealed I did not come into work until midnight so I did not see the resident at all. Staff C, CNA, reported about 12:30 AM the resident was not in his room and questioned if anyone had seen him. Resident #1 is independent throughout the facility so all staff informed Resident #1 missing and started searching the premises which include all rooms, bathrooms, and outdoor premises/grounds. A CNA left the facility to search around the facility up to the gas stations/convenience stores. Unable to locate the resident. DON and local law enforcement informed. f. A written statement dated 8/22/24 by Staff C, CNA, revealed on 8/22/24, we (the staff) noticed that no one had seen Resident #1 since around 8:30 PM. We scattered out to search for him around the property but he was not found. The nurse took over matters and took the proper elopement precautions steps after we didn't locate him. During observation on 8/26/24 at 9:47 AM, the lower lever Circle Drive exterior exit door had a rock propped between the door and the doorframe. At 10:15 AM, the rock remained on the floor in the vestibule by the exterior exit door, but the rock no longer propped the door open. On 8/27/24 at 1:05 PM, a rock remained on the floor by the Circle Drive exit door. At the time, the surveyor showed the Corporate DON and the Administrator the rock by the exit door and told them staff had reported they used the rock to prop the door open so staff could get back inside the building. During an interview 8/26/24 at 10:00 AM, Resident #6 reported his roommate went missing last week (the week of 8/21/24). He noticed his roommate wasn't around. His roommate had a black bag on his bed. The bag was about 2 ft tall (gesturing to show the size of the bag). He didn't think much about it. He usually went to bed before his roommate did. His roommate had packed everything and jumped the facility. He was gone for a couple of days. Resident #6 stated he thought that was the only problem the facility had with Resident #1 leaving. Resident #6 thought the facility needed to put an alarm system on Resident #1's ankle or moved him closer to the nurse's station so they could keep better track of him. During an interview 8/26/24 at 10:15 AM, Resident #1 reported he had lived at the facility about a month. He could come and go from his room as he liked. On the evening he left the facility, he was just going to go for a walk. He liked to walk to get exercise. He reported he walked down to the family dollar store. He doesn't know if they were open, he didn't go inside. Resident #1 stated at the crack of dawn though, he got out of there. He didn't want to get in trouble. Resident #1 stated he just wanted freedom. During an interview 8/26/24 at 10:40 AM, Staff A, Certified Medication Assistant (CMA) reported Resident #1 doesn't have any behaviors. He was independent and required some cues and reminders. Resident #1 got out of the facility about 3-4 days ago. She was uncertain what happened or why he left. The resident told staff when he returned to the facility he left because he was in pain and went to the hospital, but he never told staff he was in pain. Staff A reported wander guards are reliable. If a resident had a wander guard, it alarmed whenever the resident got near the doors. Whenever an alarm sounded, she checked the panel by the nurse's station to see which exit door was alarming, checked the door, then called out 'clear and disabled the alarm. The alarm tone sounded different if there was a wander guard in the area. Staff A reported Resident #1 had a wander guard since he came in 7/2024. His wander guard was still assembled. She thinks Resident #1 was small enough and somehow got the device off his wrist or ankle. Resident #1 could dress himself and reach his extremities. On the day of the incident (8/21/24), she administered his medication around 7:45 - 8:00 PM. There was a culture party that night and there were a lot of people and activities going on. Staff didn't have their undivided attention on all of the residents. She left around 9:00 PM, after she gave residents their medications. Staff A reported she thought maybe Resident #1 slipped out of the facility when the partygoers were leaving. Staff A reported she didn't see Resident #1 outside with the smokers at 7:30 PM. Between 8 and 8:30 PM, staff noticed he wasn't around. Resident #1 wasn't found prior to her leaving at 9:00 PM. Staff A reported the nurse who was supposed to work 6 PM - 6 AM didn't come to work until after 10:00 PM. The CNA let Staff G, RN, know they hadn't seen Resident #1. Staff looked for him. She looked in his room. She did not find a wander guard in his drawer, in his bed, or under his pillow. She thinks he had the wander guard on. Staff A reported Resident #1 often sat in a chair by the exit door. Staff A stated she didn't think there were enough eyes and ears to watch all of the residents. There were also a lot of new staff who were not as familiar or knew the residents. Staff A reported staffing on the evening shift consisted of 3 CNA's, 1 CMA, and 1 nurse for 50 residents on Side 2 (lower level). Wednesdays were a heavier shower days because several residents required a Hoyer for transfers, which left only 1 CNA to watch the other residents. Staff A stated the outside door to the Circle Drive didn't lock. Staff had to put a rock in the door in order to get back into the building. Staff A relayed there are no cameras in the building that she knew of to monitor the hallways or exit doors. During an interview 8/26/24 at 11:00 AM, Staff B, Licensed Practical Nurse (LPN), reported he worked the 6 AM to 6 PM shift on the lower level and took care of Resident #1 on the day he left the building. Staff B recalled Resident #1 didn't have any behaviors, complaints, or anything out of the ordinary when he saw him during his worked shift. He normally filled out a change in condition assessment if a resident had a change in condition such as new behaviors. He checked the wander guard on his ankle and it functioned. Resident #1 is very compliant, and he went out to the courtyard to smoke during the smoke time. He had no complaints of wanting to leave, and he attended all three meals. He was not exit seeking. Resident #1 liked to sit in the chair by the vending machine and the SS's office. The chair sat alongside the wall near the exit door to Circle Drive. Staff B thought the resident maybe walked by the exit door, he sat down, and it triggered the alarm. The facility had a Culture night that evening. It was an introduction for the staff and residents to get to know the new company and the people. He didn't know what happened (with Resident #1 missing) because he got his prize and left the facility. He didn't hear any alarms going off, and he didn't notice anybody walking in the area when he left the building. He stated he had not witnessed Resident #1 try to leave before. During an interview 8/26/24 11:20 AM, Social Services reported Resident #1 stayed to himself and liked to go for walks. She had not seen him try to leave the facility before. He sat in the chair by the exit door and watched the cars outside the window. The SS reported she was not in the facility when Resident #1 apparently left the facility. She got a text (message) from the DON the resident had left the building. The text came at 2:30 AM (on 8/22), but she didn't get the text message until she got up that AM. She drove around looking for Resident #1 before she came to the facility for work. She read his PASRR, and called the social worker at another facility to see if they knew a contact for the resident. She found out from staff at another care facility the resident had eloped from their facility, but the SS didn't know that before until this elopement happened. She also called the mission and shelters. The resident went to the ED sometime after he left the facility and was evaluated for knee pain. The Dr told him he had arthritis. He was discharged from the ED. Staff were out looking for him all day. She called the hospitals and shelters three times but still unable to locate him. Staff H, CNA, found Resident #1 sitting on a park bench near 6th (Avenue) and University. Staff H worked the evening/night shift. He went back to get him and he was gone. Someone had picked him up. She asked the resident after staff brought him back to the facility where he was going or why he left the facility. He told her he tried to find his friends and wanted to get a painting job. He wanted to see the world. During an interview 8/27/24 at 8:05 AM, Staff C, CNA, reported he had worked at the facility since 8/8/24 and worked the 10 PM to 6 AM shift. He had two days of orientation to go over exits, fire extinguishers, on-line education, and things like that. Resident #1 was independent but he checked on the resident and made sure he was ok, and helped do whatever he needed. A company had just bought the facility on 8/1/24. They were having a get to know you party, where staff introduced themselves to each other. The facility was pretty crowded inside. Staff C reported he worked the floor and took care of residents during the time. Resident #1 was ok. When the party got over, Resident #1 went out with the other residents to smoke. Staff C took care of residents while another staff person went out and supervised the smoking residents. The surveyor asked Staff C when he noticed Resident #1 missing. Staff C responded he noticed Resident #1 wasn't in his room but that was not unusual because he was independent and could go around the facility. Residents were allowed to go to different parts of the facility, go outdoors to the courtyard, or anywhere in the building at this facility. The residents had freedom to go where they wanted. Staff C reported he was assigned to 14-15 residents. He couldn't watch the residents when they could go all over the place. Staff C stated the facility needed to look at the resident ratio for safety reasons. Staff C stated around 12 or 12:30 AM, he noticed the resident had not been seen, so they checked the premises. They discovered he was not around. Staff C said come to think of it, he had not seen Resident #1 since he went out to smoke, but there was no cause for concern because he had never left the facility before. The resident was quiet and went about his business. He doesn't bother anyone. Staff C reported no interventions on Resident #1's care plan prior to the incident. He just kept an eye on him and kept him safe. Since the incident, he checked on the resident every hour. The facility also provided education about elopement and how to check the exits. During an interview on 8/26/24 at 12:30 PM, Staff D, LPN, reported she normally worked the 6 PM to 6 AM shift but she didn't come into work until 12:00 AM (on 8/22/23). When she arrived, another nurse was doing treatments and the CNA's made rounds. Staff D reported as she sat at the desk on the lower level, Staff C told her Resident #1 not in his room when he made rounds. Staff C had just started working at the facility and was not as familiar with the residents. She told him where to look. He came back and told her he couldn't find Resident #1. She told everyone they needed to look for him. Some staff got in their car and drove around to see if they could find him. They searched upstairs, downstairs, and the courtyard but still didn't see any signs of him. She talked to Resident #1's roommate. His roommate said he saw Resident #1 packing things in a black bag. Resident #1 didn't mention anything to his roommate about leaving. They continued to search for him. Staff D stated she attempted to call the Administrator but he didn't answer, so she called the DON and told her about the resident. She asked the DON if she should call the authority to report him missing. The DON said she needed to check on something first. Staff D reported she called the police around 1:30 AM. Resident #1 wandered at a facility he resided at previously. Staff D stated she was unsure what interventions were in place for Resident #1. She thought Resident #1 had a wander guard on him but he had a history of taking the wander guard off. She doesn't recall if he had a wander guard on prior to the incident. Staff D stated she was unsure if the wander guard was documented on the TAR but the wander guard should be listed on the resident's care plan. During an interview 8/26/24 at 12:10 PM, Staff E, CNA, stated she normally worked the 10 PM to 6 AM shift. Resident #1 didn't require a lot of care. Most of his cares were done when she got there on the night shift. She made sure he was in his room. Resident #1 would be up and wandered. He would go toward the doors. She let the nurse know to keep an eye on him. Sometimes he got a drink from the machine or got a cup of coffee and drank the coffee in the dining area. He also sat by the nurse's station. Resident #1 had a wander guard on when he lived upstairs (Side 1) and also had the wander guard when he moved downstairs (Side 2). He got moved downstairs for safety reasons. Staff E reported she came to work at 10 PM on the day of the incident, the search for Resident #1 was already going on. The nurse that was working had just started back, and didn't know what he looked like. Staff looked in rooms and around the building, under beds, closets, in the bathrooms, and checked other residents' rooms. They searched around the building and on the road. Some aides drove to the gas stations, across the street to the church, and behind the facility. They checked everywhere where he possibly could be. The last time someone saw him, he came in from a smoke break, it was between 8:45 -9 PM. The staff were busy putting residents back to bed, but there had been a gathering before this. Staff E reported it puzzled them that he had went outside of the building, because when an alarm went off, they checked the door and did a count of the residents. Staff E guessed maybe after the party, the wander guard didn't go off. Resident #1 was independent. He usually came out of his room and got something to drink, then returned to his room. He often sat in the area by the exit door. The chairs near the vending area were not in that location previously. The chairs had recently been placed there because the upstairs area was too packed. Someone was supposed to come and get the chairs. Staff E confirmed no cameras in the area by the exit doors but she heard the company planned to install cameras. Staff E stated she felt they had the required staff on duty the evening of the incident. During an interview 8/27/24 at 3:10 PM, Staff F, CNA, stated she only worked on Wednesdays and Saturdays 16-hour shifts. On the evening of Wednesday, 8/21, around 6:45 PM, she saw Resident #1 ambulate from the lower level dining room toward the upper level dining room without his walker. A dietary staff member from downstairs brought his walker to him. After that, she brought residents from the dining room to their room on the upper level and performed cares and helped the residents into bed. The night shift nurse walked down the hallway and asked her if she had seen Resident #1. She said no. She went and searched the resident rooms on the upper level, then the lower level, and the courtyard. She let the nurse know she couldn't find him. She also told another aide who came in at 10:00 PM to look for him. They went room to room and looked for him but still were unable to find him. Resident #1 resided on the upper level a couple days when he first got admitted . She doesn't know if he had a wander guard on when he got admitted or if he had a wander guard on when he resided downstairs. She didn't take care of him. Staff F stated on 8/21/24 evening, a culture night party was going on. The party started at 7:00 PM. There was a lot of activity going on, and people (staff) were coming and going. No alarms went off during this time. No alarms went off during her shift except the smoke door exit alarm. The alarm went off when the residents who smoked and the staff who supervised the residents came back into the building. Staff F reported normally when an alarm went off, she checked the door, went outside and checked the parking lot and looked down the sidewalks to see if she saw anyone. She then came back into the facility and checked the rooms to ensure each resident was accounted for. Staff F reported she entered a code to exit the facility, and she pressed the green button on the wall to enter the building so it doesn't set the alarm off. The alarm may also trip if it took too long for someone to enter or leave the facility. Staff had to go to the Side 1 nurse's station desk and press the button to clear or deactivate the alarm to the exit door. Staff F reported staff not supposed to shut the alarm off until everything was clear. In a follow up interview 8/27/24 at 4:35 PM, Staff F reported the residents' smoke time scheduled at 7:30 PM but it depended on how fast the resident smoked their cigarette and how long they stayed outside. The smoking time varied from 15 minutes to 1/2 hour. During an interview 8/26/24 at 1:35 PM, Staff G, RN, stated she worked the 6 PM to 6 AM shift. She worked on Side 1 and also had responsibility for a few residents on the [NAME] end of Side 2. Whenever an alarm sounded, she checked to see which area alarmed. Staff G reported many times visitors came or left the facility and didn't enter the code, which triggered the alarm to go off. If she didn't see anyone when the alarm sounded, she looked outside to see if she saw someone, and then checked and accounted for the residents. The alarm sounded if a resident with a wander guard, got near the exit door. Staff G reported she checked the wander guards every shift. A list of residents due for wander guard checks showed up on the computer. Wander guard checked for placement and functioning and documented in the EHR. Staff G reported she was uncertain if Resident #1 had a wander guard prior to the incident. She was not normally assigned to Resident #1. On the evening of the incident, Staff C came and told her he had tried to find Resident #1. She told him to check the courtyard. The other nurses were aware and they had done a headcount. She went and checked the public bathrooms. Staff also checked other areas of the building. She went to Resident #1's room. The roommate mentioned Resident #1 had packed things in a black bag but the roommate didn't know what time that occurred. Staff C and Staff G looked for the black bag. Staff G stated she looked in the closet and his half of the closet was empty. A staff person drove around to areas by the facility to see if they could find him outside. Staff G reported she didn't hear any wander guard alarms while she passed meds and when she went in and out of the resident rooms. There was culture party downstairs in the dining room and there were a lot of people coming in and out. The door alarm kept going off so she checked the door and turned the alarm off. The maintenance man from a sister facility also helped her turn off the alarm by the nurse's station. She stood by the medication cart in the hall by the upper dining room, but she saw who came or left from the party. At the time, residents waited to go outside to smoke. She asked the residents to wait until the people from the party left. She did not see Resident #1 leave the facility when she worked that night. She seldom saw Resident #1 upstairs. She saw him by the exit door to the courtyard once, but he liked to sit by by the Circle Drive exit doors. Staff G again reported she was ce [TRUNCATED]

Based on observations, interviews and clinical record review, the facility failed to safely serve the recommended therapeutic meals according to physician orders and speech therapy recommendations for 2 of 2 residents reviewed (Res #4, and Res #26). The facility contains 16 residents on a mechanically altered diet. The facility reported a census of 60. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 07/09/24 at 03:26 PM. The IJ began on 07/08/24. Facility staff removed the Immediate Jeopardy on 07/11/24. The facility staff removed the Immediate Jeopardy by implementing the following actions: 1. 100% Audit of Resident diet orders on 07/09/24 2. 100% Audit of resident diet cards on 07/09/24 3. 100% Care plan audit for all residents to verify diet and texture are accurate on 07/09/24 4. 100% Audit completed of diet type and texture, with any additional diet texture restrictions to follow a triple check process on 07/09/24 5. All staff educated on the signs and symptoms of choking or swallowing issues on 07/09/24 6. All staff were educated on 07/09/24 for competency of providing correct textures in regard to modified diets 7. An in-service was completed in person by the dietician and verbally communicated by nurse management to staff members regarding diet textures on 07/11/24 8. A Quality Assurance and Performance Improvement (QAPI) meeting was held on 07/09/24 to address the IJ. The scope was lowered from a K to an E at the time of the survey after ensuring the facility implemented education. Findings Include: 1. The Quarterly Minimum Data Set (MDS) for Resident #26, dated 06/13/24, documented a Brief interview for mental status (BIMS) score of 04, which indicated severely impaired cognition. It failed to document her relevant diagnoses of dysphagia, oropharyngeal phase, and documented that she did not have trouble swallowing. Resident #26's Care Plan documented her diagnosis of dysphagia, oropharyngeal phase. The Care Plan directed staff to observe the resident for the signs and symptoms of dysphagia, including choking, pocketing, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, and appearing concerned during meals with initiated date of 9/14/18. It documented her diet as mechanical soft texture. Review of Resident #26's doctor's order summary revealed her diet was noted as mechanical soft texture, thin consistency, no bread, no watermelon. In an interview on 07/08/24 at 12:46 PM with Staff A, Speech Language Pathologist, reported that she made the recommendation on 07/01/24 to remove breads from Resident #26's diet, citing coughing while consuming bread products. She made the recommendation to move the resident to one-on-one eating assistance on 05/02/24 due to the resident's risk of aspiration and choking. A direct observation of the lunch service on 07/08/24 at 12:30 PM revealed Resident #26 was served a mechanically soft diet with an unmodified garlic breadstick and slice of unmoistened pound cake. Resident #26 was unobserved by staff members when she was originally served. Resident #26 began to immediately consume the pound cake, coughing heavily while she did so. Shortly after consuming the pound cake, Resident #26 picked up and took a bite of the garlic breadstick. She began to cough again. The Speech Language pathologist intervened after her initial bite of the garlic breadstick, removing it from her and reminding the resident that she couldn't have bread anymore. The Speech Language Pathologist sat with Resident #26 to ensure she was observed during her meal, and provided education to three different staff members about Resident #26's diet. The Speech Language Pathologist summoned Staff B, Licensed Practical Nurse (LPN) to assess Resident #26 by listening to her lungs and checking her pulse oxygen levels due to her strong coughing. In an interview on 07/08/24 at 12:37 PM with Staff C, Registered Nurse (RN), she stated that Resident #26 was supposed to stop getting bread with meals a week ago, but the kitchen has sent her bread on more than one occasion since then. She noted Resident #26 was also supposed to be encouraged to take drinks between bites of food. In an interview on 07/08/24 at 12:46 PM with Staff A, she noted that if she had not intervened she believed the resident would have consumed the entire garlic breadstick. She further noted that bread products, such as pound cake in the format it was served to Resident #26, was also not to be served to the resident due to the risk of choking and aspiration it poses to her. She noted this is not the first issue she has had with the kitchen serving improper diets to the residents. She recalls having to send food back to the kitchen on several occasions. The most recent was when the resident was served large whole chunks of chicken, instead of her prescribed mechanically softened diet. She noted she is often the one to catch these issues and correct them. She noted the facility has often not been assisting the resident one-on-one as recommended. She revealed that she had brought this to the attention of previous facility leadership and nothing had been done about it. She was hopeful that the new facility leadership would take these issues more seriously. A direct observation on 07/09/24 at 12:13 PM of the lunch meal revealed Resident #26 was served her appropriate diet. She was observed coughing only briefly on three occasions during her meal. A direct observation on 07/10/24 at 08:18 AM showed that Resident #26 was again served the appropriate diet. She was observed lighting coughing just twice during this meal. In an interview on 07/10/24 at 11:01 AM with The Regional Director of Nutritional services she noted the facility uses the International Dysphagia Diet Standardization Initiative (IDDSI) to inform dietary choices for residents, but further noted they use a more generic diet order system with only three diet levels. Regular, Mechanically Soft, and Puree. In an interview on 07/11/24 at 11:46 AM with Staff D, Dietary Cook, she revealed that on Monday the kitchen did not have enough blushing pears for everyone and substituted Pound Cake for the residents. She indicated she did not document this in the substitutions log and this change was not approved by the dietician. She indicated she did not know how to conduct the fork test, and indicated there was no pound cake remaining to perform a fork test. Review of IDDSI documentation showed the organization currently recommends items like pound cake undergo the Fork Test if being served unmodified to a resident on a level 5 (Mechanically soft) diet, or a level 4 (Puree) diet. The fork test involves using a fork to gently crush a food item, if the item deforms easily and does not return to its previous shape it can be considered on a case-by-case basis for individuals at risk of aspiration and choking. IDDSI framework further noted crumbly textures, like cake, are a choking risk because they need good tongue control to bring crumbly pieces together and mix with enough saliva to hold together to be moist and safe to swallow. A direct observation on 07/10/24 at 12:02 PM revealed a chaotic kitchen service. Staff D, Dietary Cook, was preparing resident plates before locating their diet slip. After plating the resident's food, Staff D then located their diet slip in her stack of slips and immediately passed it on to the next staff member. During this service she plated an incorrect diet for Resident #24, plating a regular diet instead of a mechanically soft diet. This required the intervention of the Region Director of Nutritional Services to correct. Review of Speech Therapy Encounter Notes dated 07/08/24 documented the resident was served and ate a bite of the garlic breadstick, as well as the need for one-on-one assistance at all times during meal service. It further details the education was provided to three separate Certified Nursing Assistants (CNAs). Review of a facility led interview with the Speech Language pathologist dated 07/08/24 at an unknown time documented the observation above and continued to describe Resident #26's coughing as large/strong coughs. It further details that nursing staff was required to assess the resident for possible aspiration. It continued to detail the Speech Language Pathologist spoke with kitchen staff after the incident and asked if they required a second recommendation to be made regarding bread. The kitchen staff are reported to have indicated to her they did not require an additional recommendation and they would fix the issue for the next meal. Review of a facility document titled Principles and Guidelines Used in Meal Planning from the Long-Term Care Diet Manual with an edition date of 2017 documents under the Pureed Diet section, subsection's D and E, bread and plain-cake product are considered to be of similar texture and require a similar treatment to be included in pureed diets, or diets where bread has been excluded due to risk of aspiration or choking. 2. The Minimum Data Set (MDS) for Resident #4, dated 10/01/23, documented a Brief interview for mental status (BIMS) score of 04, indicating severely impaired cognition. It documented relevant diagnoses of Non-Alzheimer's dementia, dysphagia - unspecified, dysphagia - oropharyngeal phase, cognitive communication deficit. It further documented her ability to eat as requiring supervision or touching assistance. Resident #4's care plan documented the resident's dysphagia, as well as a need to observe the resident during meal service for the signs and symptoms of dysphagia, including pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, and appearing concerned during meals. It revealed her diet to be regular diet with pureed texture with a start date if 07/08/24. Review of Resident #4's Doctor's order summary documented the resident's diet as pureed texture with thin liquids as of 07/08/24. A direct observation on 07/09/24 at 12:16 PM revealed Resident #4 had been served a pureed diet with the addition of Cheeto Puffs and a lettuce salad for lunch. The lettuce salad was turned away at the table, but resident #4 was observed consuming approximately 5 full-sized Cheese Puffs before Staff A observed the resident and intervened. The Cheeto Puffs were removed from Resident #4 by Staff A. In an interview on 07/09/24 at 12:51 PM with Staff A, she noted Resident #4 had been moved to a pureed diet on 07/08/24 and was transitioned during the evening meal. She noted that the resident should not have Cheeto Puffs on a pureed diet, and intervened as soon as she saw to prevent possible choking or aspiration. In an interview on 07/09/24 at 02:54 PM with Staff E, Dietary Cook, she revealed the diet slips had been printed on Sunday for the entire week. She indicated she knew of recent changes to Resident #4's diet, but when she showed me the diet slip for Resident #4 it showed she was still on mechanically soft diet. She indicated the dietary manager is in charge of updating new diet orders, and stated she knows they should not be printing diet slips in advance. She noted it is the dietary cook's job to follow the diet slips, not to change them in the system. In an interview on 07/09/24 at 03:00 PM with Staff F, Dietary Aide, she noted there had been a significant turnover in the kitchen, and indicated staff should be screening to ensure residents are not given items they cannot have. In an interview on 07/09/24 at 03:09 PM with Staff G, Certified Medication Aide (CMA), she revealed it is everyone's job to watch during meal times for signs and symptoms of choking and aspiration, as well as to verify residents are being served the appropriate diets. She noted there is no formal system to notify CMAs and CNAs about what the diets are and if there are only diet changes. They only notice a diet has changed when they see a resident served a new diet, at which time they often verify the change to ensure the resident had been given the correct diet. She acknowledged that based on her understanding of safe diets, she does not believe Cheeto Puffs are acceptable on a pureed diet. She indicated the kitchen has had issues service the appropriate diet, and revealed that on several occasions in the last few months the kitchen has served another resident, Resident #1, graham crackers despite her being on a pureed diet. In an interview on 07/09/24 at 04:36 PM with the Regional Director of Operations, she noted she believed IDDSI classifies Cheeto Puffs as transitional foods. She stated her understanding is that because biting and chewing are not required because they can break down with saliva they could be used on a pureed diet. Review of IDDSI catalogue reveals that Cheeto puffs are classified as transitional foods and can be safe for residents up to dysphagia level 5 diets, which are also known as mechanically soft diets. Resident #4 was on a pureed diet at the time of the incident. It further indicated transitional foods should be broken into smaller pieces of approximately 1.5 x 1.5 cm across if used on any diet lower than level 7, which under IDDSI guideline is a regular, unmodified diet. In an interview on 07/10/24 at 11:01 AM with The Regional Director of Nutritional services she noted residents can have Cheeto Puffs at higher diet levels, and in some cases puree, under IDDSI guidelines. She also noted the expectation is for diet slips to be printed the evening before dining service, not in advance for the entire week. In an interview on 07/10/24 at 02:39 PM with Staff A, she indicated she does not follow IDDSI guidelines. She recommends a more generic three phase diet that includes regular, mechanically soft, and pureed diets. Under the guidelines she believes the facility uses and based on her education as a Speech Language Pathologist she does not believe Cheeto Puffs are an acceptable food on a pureed diet. She further indicated she is not aware of any pureed diet in which whole Cheeto Puffs would be acceptable. Review of facility document titled Therapeutic Diets with a last reviewed date of 08/16/23 documented diet tray cards will be updated to reflect diet and nutritional interventions to unclude but not limited to Low Concentrated Sweets, No Added Salt, Fortified Foods, Double Portions, Double Protein, and Supplements. Review of a facility document titled Menus and Recipes with a last reviewed date of 11/27/23 documented meals should be prepared according to the facility approved menu. The menu shall be approved by the Registered Dietician in the state of practice. It further documented Therapeutic and mechanically altered diets shall be available on a spreadsheet as ordered by a physician, and all changes to a menu or recipe shall be approved by the registered dietician. Review of a facility document titled Nutritional Services Menus with a last reviewed date of 11/27/23 documented changes which must be made following the start-up of the menus shall be provided to the Registered Dietician in a timely manner for approval. Changes which must occur due to shortage of stock, ect. Shall be reviewed for approval with the Registered Dietician. These changes shall be recorded on the menu substitution log and signed off by the Registered Dietician. Review of the Menu Substitution log lacked documentation of the changes to the menu on 07/08/24.

Based on clinical record review, staff interview, Nurse Practitioner (NP ) interview, and Registered Nurse (RN)/Certified Wound Ostomy Continence Nurse (CWOCN) interview, Job Description forms and facility policy review, the facility failed to provide an assessment and interventions for a 2 of 3 residents who presented with a condition change. (Resident #2 and #3) The facility identified a census of 58 residents. On [DATE] at 2:30 p.m. the Iowa Department of Inspections, Appeals and Licensing (DIAL) staff contacted the facility staff to notify them the Department staff dtermined an Immediate Jeopardy (IJ) situation existed at the facility. The facility staff removed the immediacy on [DATE] after the facility staff completed the following: 1. NP/Designee Completed 100% Audit on All Residents; Change of Condition Evaluation in EMR/PCC on [DATE]. 2. 100% Care Plan Audit Completed; Interventions in Place for Residents with a Change in Condition on [DATE]. 3. DON/Designee Completed 100% Education w/Nursing Staff on the Following on [DATE]: Identifying Early Change in Condition; Completing Change in Condition Evaluation Utilizing SBAR/eInteract in EMR/PCC. Implementing Interventions with Change in Condition. Monitoring Change in Condition X72 Hours or Until Condition Improves; Utilizing Shift to Shift Reporting. DON/Designee will Incorporate Education on Change in Condition with New Hires as part of Orientation. 4. Facility will Monitor through Facility Audit Tool (5) Residents, X5/Week for X4 Weeks and then Monthly to ensure ongoing Compliance. Monitored Findings will be Reviewed during Monthly QAPI Meeting. The scope was lowered from and J to a G at the time of the survey. Findings include: 1. A Minimum Data Set (MDS) assessment form dated 3.1.24 indicated Resident #3 had diagnosis that included a cognitive communication deficit, Anemia, Atrial Fibrillation (AF), Hypertension (HTN), Renal Insufficiency, Diabetes Mellitus (DM), Respiratory Failure, morbid obesity, required assistance with personal care and muscle weakness. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 8 (moderately impaired cognitive skills), an impairment of both sides of her lower extremities, dependent on staff with toileting hygiene, required substantial to maximum assistance of staff with rolling/repositioning and as always incontinent of her bowels and bladder. The assessment identified the resident as at risk for pressure ulcers however with no pressure ulcers and not on a turning/repositioning program. A Care Plan revealed the following Focus area and Interventions as dated: a. I/my responsible party requested a full code status. (initiated 2.25.22) 1. Staff to have called for an ambulance. (initiated 2.25.22) 2. Provision of emergency measures as appropriate. (initiated 2.25.22) b. A diagnosis of HTN. (initiated 3.8.22) 1. Staff to have monitored for and document any edema. (initiated 3.8.22) c. Anticoagulant medication use with a risk of abnormal bleeding, hemorrhage and/or increased/easy bruising related to (r/t) anticoagulant use of Coumadin/Warfarin. (initiated 2.16.23) d. The resident had a pressure ulcer to the left heel or potential for pressure ulcer development. (initiated 3.8.22) 1. Monitor/document/report any as needed (PRN) changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size and stage. (initiated 3.8.22) An email from Staff A, Assistant Director of Nursing (ADON) dated 4.5.24 at 9:59 a.m. to a NP revealed the following: Hey, the husband of Resident #3 made us send the resident to the hospital and we had no documentation related to (r/t) you having identified the resident as terminal or about the conversation you had with the resident's husband and etc. She requested a full code/CPR (cardiopulmonary) status so we really needed to be documenting everything on her. An email from the NP dated 4.5.24 at 3:50 p.m. revealed the following response to the above documented email: Sorry I have/had no right to say/write that someone is/was terminal until proven. I referred to Hospice because of the decline in health. I sent her to the hospital and they sent her back and the husband made the decision to refuse Hospice care. If her Husband is/was her Power of Attorney (POA), he had the right of decision to make her a Do Not Resuscitate (DNR) or FULL Code. During an interview 4.10.24 at 3 p.m. the Director of Nursing (DON) confirmed the facility staff failed to properly assess the resident and they should have due to (d/t) her CPR status. Review of the resident's Progress Notes revealed the following as dated: a. 3.25.24 at 1:43 p.m. - A NP addressed the resident's code status as CPR. b. 3.25.24 at 1:49 p.m. - The resident experienced a change of condition r/t skin wounds and pressure ulcers. The blood pressure, pulse, respirations, temperature and pulse oximetry documented on this date revealed documentation from a 1.22.24 assessment. This assessment failed to identify the resident's current vital signs. c. 3.25.24 at 2:01 p.m. - Two (2) small scabbed areas to the resident's right 2nd toe and a small 0.5 centimeter (cm) x 0.5 cm scab to the top of the right end toe. Also noted to have a small scabbed area to her left third toe with no assessment provided. d. 3.26.24 and 3.27.24 - No assessment completed. e. 3.28.24 - The interdisciplinary team met to review the resident's changes in weight and overall decline in her physical health. No assessment completed. f. 3.28.24 at 11:05 a.m. - New order received on 3.27.24 which discontinued the treatment to the resident's right buttock. No assessment completed r/t skin issues and her overall decline in physical health. g. 3.29.24 thru 3.31.24 - No assessments completed r/t skin issues and her overall decline in physical health. h. 3.30.24 at 2:39 a.m. - PT/INR (prothrombin time and international normalized ratio) drawn with a reading of 7.3 (critically high). Order received for administration of 5 milligrams (mg) of Vitamin K and recheck PT/INR in the afternoon of 3.30.24. No further assessment completed. According to an email 4.23.24 at 10:25 a.m. the resident's therapeutic PT/INR range should have been 2.0 - 3.0 i. 3.30.24 at 2:45 a.m. - Order received to discontinue (DC) current Coumadin order with a plan for an establishment of new Coumadin dosing with the providers when the critical PT/INR of 7.3 had been resolved. No further assessment completed. j. 3.30.24 at 6:45 p.m. - Received an order to hold Coumadin for one (1) more day an recheck the PT/INR on 3.31.24 with nofurther assessment completed. k. 3.31.24 at 3:35 p.m. - Attempted to draw PT/INR times (x) 2 attempts and without success. A new Physician's order received to try again in morning. No further assessment completed. l 4.1.24 at 10:45 a.m. - Order received to send the resident the emergency room (ER) d/t edema to her right hand and an elevated PT/ INR. No further assessment completed. m. 4.1.24 at 1:04 p.m. - The NP completed the following assessment: Staff requested the NP to see the Resident for swelling to her right arm. Objective: Edema first observed to right arm on ,d+[DATE] from blood draw and resolved with elevation of extremity. The Resident also had an open areas to her buttocks with treatment orders in place. Staff also reported an elevated INR of 7.3 as they held her Coumadin/Warfarin until the next PT/INR draw. Staff report attempted to redraw blood but failed with multiple trials. Today staff reported an acute change in the resident's health from baseline, with changes in skin color and temperature. The resident demonstrated consciousness to herself, tail bone pain and appetite changes. The resident denied nausea and vomiting, chest pain and shortness of breath. n. 4.1.24 at 1:24 p.m. - The NP received a call from the hospital ER where a PA notified her the resident's INR had improved and down to 4.3 from 7.3. The PA also confirmed the resident's right swollen hand which resulted from the attempted blood draws and no diagnosis identified. The PA reported the resident came to the hospital with a report of right-hand swelling and they planned a transfer back to the facility. The NP discussed with PA that resident required a more diagnostic workup because her health had gradually changed from baseline. The resident had been disoriented during an assessment, staff reported a sore buttock which might have gotten worse and the resident complained of tailbone pain. The NP also mentioned of her lower left extremity swelling. The PA at the hospital promised to take a closer look. Without any significant diagnosis, PA planned to send resident back to facility for routine care. o. 4.1.24 at 8:30 p.m. - Resident returned from the ER with no new orders but rather a follow up with the primary care provider (PCP) for her PT/INR and continued pressure ulcer care to her buttocks. The current PT was 41.1 and INR was . The Resident took medications without difficulty. Blood sugar (BS) 89 at HS (hour of sleep) staff gave the resident a banana and snack. No further assessment completed. A Weekly Wound Observation form dated 4.2.24 at 1:53 p.m. included the following assessment to the resident's worsening right buttock: 4.5 cm x 5.0 cm and 0.1 cm deep. 60% dermis and 40% necrotic (dead) tissue. A small amount of sero-sanguineous drainage and no odor. A Skin Observation tool dated 4.2.24 at 4:46 p.m. provided no assessment. p. A Progress Note entry dated 4.2.24 at 5:41 p.m. included the following: Resident seen by a NP that morning who diagnosed the ulcers on the resident's buttocks as a Kennedy ulcer (an ulcer that occurred as part of the dyeing process) and unavoidable. The wound to the resident's right buttock appeared much larger and now included her left buttock. No further assessment completed. q. 4.3.24 at 1:26 p.m. - No assessments completed by the facility nursing staff throughout the entire day. r. 4.4.24 at 10:54 a.m. - The resident alert without verbal responses to the nurse. The resident had been alert to self only. No further assessment completed. Review of the Hospital's ER report dated 4.5.24 indicated the resident arrived in the ER at 10:31 a.m. and was admitted at 10:35 a.m. A Certificate of Death form filed 4.10.24 indicated the resident passed away 4.5.24 at 3:30 p.m. from Sepsis. During an interview 4.11.24 at 3:54 p.m. Staff C, Certified Nursing Assistant (CNA) confirmed he found the area on the resident's gluteal region which he indicated it looked like a bruised, blistered area the size of a quarter. He reported the area to Staff A who assessed the area and applied a cream. The next time the staff member observed the ulcered area had been about another week and at that time he described the area as the size of an orange, the blister opened up as the skin flapped and drainage present in/on her brief. At that point the resident presented as coherent however the staff member kept saying staff needed to send her to the hospital. When the resident became really weak and made moaning noises the staff member called the resident's husband with a status report and the husband directed him to get her to the hospital Staff C state on 4.1.24 a Physician and Staff A came down to the resident's room and the staff member showed them new ulcered areas on her upper back and her thighs. The staff member offered that he felt like the facility management failed to take the direct care workers word/assessments seriously and they are the ones that saw everything. During an interview 4.11.24 at approximately. 12 p.m. a NP confirmed she observed the area on the resident's gluteal region on 3.25.24 and described it more like an unopened blister but not pressure of which the facility told her they thought the area presented as a [NAME] Ulcer. The NP confirmed once the blistered area presented itself staff should have assessed the area as a means to monitor the status. The NP indicated she had not observed the resident again until 4.1.24 when she was told in a meeting the resident had a swollen right arm. When she reviewed the Progress Notes there had been no assessment present so she had to assess the area herself but she expected staff to have assessed the area prior. Following the assessment she called the resident ' s husband who directed her to send the resident to the ER. The facility transferred the resident to the ER via the ambulance and after the hospital assessed and intervened they called her and told her they planned to send her back to the facility. The NP directed the hospital staff to wait as the resident ' s current condition had not been her baseline. The NP confirmed she expected staff to thoroughly assess a resident with a condition change on a regular basis and/or until resolved. During an interview 4.12.24 at 8:08 a.m. an RN/CWOCN at the hospital confirmed she cared for the resident while hospitalized . The RN, CWOCN voiced several concerns with the 1st having been the resident's full code status and 2nd it had been obvious by the condition of the resident's skin on arrival to the hospital the nursing facility neglected her care and treatment. Based on the location of all of her wounds she laid on her left side most of the time. Staff failed to reposition her and/or treat the resident ' s wounds appropriately. Although the wound on her buttocks turned into a Kennedy ulcer the etiology had been pressure and should have been treated accordingly. When this hospital staff member 1st treated the resident ' s wound on her buttocks she described the smell as horrendous and it was obvious to her no treatment had occurred. The resident should have been treated appropriately again, due to her desire for CPR and all life sustaining measures and she was not. During an interview 4.11.24 at 11:04 a.m. the DON indicated the facility had no policy on what to assess with a condition change but she had been told by a Corporate Nurse the facility charted by exception (a deviation from normal). During an interview 4.11.24 at 2:21 p.m. Staff B, RN indicated he never witnessed the blistered area on the resident's gluteal area, rather he described the area the 1st time her observed it as a darker coloration of the right buttock, oval shaped and open. The staff member had not recalled any depth, drainage, odor or signs of infection to the area. Upon assessment he described the area as a pressure area because she refused to get out of bed. The pressure area got worse and worse and it changed to a Kennedy ulcer as she declined in health. Staff B indicated the facilities standard of practice r/t assessments as a result of a change of condition from baseline had been 72 hours from when the change started. The staff member confirmed he had never been directed to document by exception. During an interview 4.12.24 at 10:42 a.m. Staff D, RN confirmed three (3) staff members attempted to draw blood on 3.29.24 without success because her arm had been swollen but on 3.30.24 they were successful at the blood draw. The staff member confirmed the resident's arm as swollen on 3.29.24 and told Staff E about the status but failed to perform an assessment herself. The staff member confirmed if a resident exhibited a change of condition staff assessed for seven (7) days. Pertaining to this resident the staff member indicated all nurses should have been assessed the resident through her entire decline in her medical condition. During an interview 4.12.24 at 9:44 a.m. the resident's husband verbalized the following concerns: a. The facility staff failed to reposition her every 2 hours as expected. The husband confirmed he visited his wife every day for ,d+[DATE] hours per day and each time no staff member came into her room to reposition her. b. The swelling in/on her arm began Sunday 3.31.24 but the facility staff failed to assess the area. It has not been until 4.1.24 when he insisted staff send her to the ER. The Resident's husband felt the edema in/on her arm resulted when Staff D poked the resident so many times to draw her PT/INR which had been the hospital's conclusion as well. 2. A MDS assessment form dated 3.27.24 indicated Resident #2 had diagnosis that included Cardiorespiratory Conditions/Debility, Pneumonia, Chronic Obstructive Pulmonary Disease (COPD), Interstitial Pulmonary Disease and a mild cognitive impairment. The assessment indicated the resident had a BIMS score of 9 out of 15 (moderately impaired cognitive skills) and required supervision to moderate assistance with his activities of daily living. A Care Plan revealed the following Focus area and Interventions as dated: a. I elected for a full code status. (revised 6.8.21) 1. Provision of all life sustaining measures. (initiated 2.27.21) 2. hospitalization for acute status changes and send for tests/treatments as ordered. (revised 5.27.21) b. The resident with COPD r/t smoking. (revised 7.13.23) 1. Monitor for difficulty breathing on exertion. (initiated 7.13.23) 2. Monitor, report and document signs and symptoms of acute respiratory insufficiency i.e. anxiety, confusion, restlessness, shortness of breath (SOB) at rest cyanosis (blue color) and somnolence (tired). (initiated 6.8.21) 3. Application of oxygen when SOB or SPO2 (saturation of peripheral oxygen) registered below 90%. (initiated 9.7.23) Review of the facilities Progress Notes revealed the following as dated: a. 3.31.24 at 3:34 p.m. - A condition change evaluation form had been completed. b. 4.1.24 and 4.4.24 - No assessment completed. c. 4.5.24 at 5:40 a.m. - The resident had not felt well and suffered from a congested cough. No further assessment completed. d. 4.6.24 - No assessment completed. e. 4.7.24 at 6:05 a.m. - Resident still had not felt well. No further assessment completed f. 4.7.24 at 6:36 p.m. - Resident admitted to the hospital with Acute Respiratory Failure. An ER Hospital Admission form indicated the resident arrived in the ER 4.7.24 at 8:56 a.m. and admitted at 8:57 a.m. with a chief complaint of SOB. The Resident's SPO2 registered at 70 (95% or higher signified a normal range) with room air only when the medics arrived at the nursing facility. The medics placed a CPAP (continuous positive airway pressure) machine which increased his CPO2 to 90%. Active diagnosis in the ED had been Acute Hypoxic Respiratory Failure as his primary diagnosis, Pneumonia due to an infectious organism, Lactic Acidosis and a fever. The Resident had been placed on a ventilator when hospitalized . 3. Review of the facilities Job Description for a Licensed Practical Nurse (LPN) revised 5.2022 the essential functions included the following: a. Assess and document the resident's condition and nursing needs. 4. Review of the facilities Job Description: Director Nursing (DON) form revised 5.2022 the essential functions included the following: a. Provided personal care to residents in a manner conductive to their safety and comfort conistent with the Company Clinical Policies and Procedures as well as the state/federal guidelines and regulations. 5. A Notification of a Change of Condition policy revised 4.26.23 included the following: The attending Physician/Physician Extender (NP, Physician Assistant (PA) or Clinical Nurse Specialist) should have been notified of a change in the resident's condition, per standards of practice and federal and/or state regulations. The change in condition included, but not limited to the following: a. Significant change or unstable vital signs. b. Onset of pressure injuries. c. Signs/symptoms of infection. d. Change in the level of consciousness. Once a change of condition had been identified the policy directed the facility staff to have documented the resident's change of condition in the Interdisciplinary Team Notes (Progress Notes).

Based on observations, interviews, and record review the facility failed to administer pain medication as ordered by a physician leaving 4 out of 4 residents reviewed without adequate pain control (Resident #4, #19, #20, and #21). Four residents reviewed were not administered their Controlled II pain medication as ordered for prolonged periods of time. The nurses and CMAs stated the medication was not available to give, therefore they did not give it. Resident #21 went 8 days without receiving his three times a day routine order of Percocet (an oral opioid pain medication). The other 3 residents did not receive their Fentanyl patches (potent opioid pain patch) as ordered every 3 days. In a 22 day period, the 3 residents reviewed did not have their patch applied every 3 days as ordered resulting in Resident #4 going 11 days, Resident #19 going 12 days, and Resident #20 going 7 days without Fentanyl during the 22 day review period. This situation resulted in Immediate Jeopardy to residents health and safety for the facility. The facility was notified of the Immediate Jeopardy on 6/29/23. The facility abated the Immediate Jeopardy situation on 6/29/23 lowering the scope from a K to an E after staff education was complete and the facility ensured all scheduled/ordered pain medications were available for residents. The facility reported a census of 62 residents. Findings include: 1. A Minimum Data Set (MDS) dated [DATE], documented that Resident #4 diagnoses included Multiple Sclerosis (MS), osteomyelitis of the vertebra (infection of the bone), and non-Alzheimer's dementia. A Brief Interview for Mental Status (BIMS) documented a score of 8 out of 15, which indicated moderate cognitive impairment. Resident #4 required total dependence of 2 for transfers, and personal hygiene. The MDS documented that this resident received opioid medication 7 out of the 7 observation period days. The Pain Management section revealed that Resident #4 received pain medication both routine and PRN (as needed) in the 5 prior days. The Pain Assessment revealed that in the prior 5 days this resident rated her pain at a moderate level and documented that she had pain occasionally. A Medication Administration Record (MAR) for the month of June 2023, directed staff to administer a Fentanyl Patch 12 mcg (microgram)/hr(hour) transdermal (absorbed through the skin) application at bedtime every 3 days for chronic pain to Resident #4. The start date was 2/20/23. Review of the record revealed that this resident did not receive the patch as scheduled on 6/2/23, it was applied the following day on 6/3/23. The resident had a patch applied on 5/5/23 and 5/8/23, then this resident did not have a patch applied again until 5/21/23. On 6/21/23 at 4:00 p.m., When asked if she had pain, this resident stated she did. When asked to rate the pain, she stated it was at a 5 on a scale of 0-10 and the pain was on her bottom. Resident lying in bed at the time. On 6/22/23 at 11:20 a.m., it was noted that Resident #4 had a patch on her right chest dated 6/21/23. Resident was asleep. This resident woke up but required some patting on the arm by staff. On all observations of Resident #4 during this survey Resident #4 had been awake, eyes opened, and responsive with exception of this observation. 2. An MDS dated [DATE], documented that Resident #19's diagnoses included MS and chronic pain. The MDS revealed a BIMS score of 15 out of 15, which indicated intact cognition. This resident required total dependence of 2 staff for transfers. She required total dependence of 1 staff for personal hygiene. The MDS documented that this resident received opioid medication 7 out of the 7 observation period days. The Pain Management section revealed that Resident #19 received pain medication both routine and PRN in the 5 prior days. The Pain Assessment revealed that in the prior 5 days this resident rated her pain at a 5 out of 10 (0 is no pain and 10 is the worse pain you can imagine) and documented that she had pain frequently. A Medication Administration Record for the month of June 2023, directed staff to administer a Fentanyl Patch 25 mcg/hr transdermal application at bedtime every 72 hours (3 days) for chronic pain to Resident #19. The start date was 3/4/23. Review of the record revealed that this resident did not receive the patch as scheduled on 6/2/23, it was applied on 6/5/23. It revealed that she was to get a patch placed on 6/8/23 and did not have a patch applied until 6/14/23. She was scheduled to have a patch applied on 6/17/23 and did not have it applied until 6/20/23. It was documented that it was not available on 6/23/23. The MAR also directed staff that Oxycodone (opioid) 5 mg tablet was to be administered orally 4 times a day to Resident #19. The order date was 6/8/23. From 6/8/23 at 5 p.m. when the first dose was to be given to 6/12/23 at 6:00 a.m. the doses were not given. The 6:00 a.m. dose on 6/13/23 and all 4 doses on 6/14/23 and 6/15/23 were not available. The 8:00 p.m. dose on 6/23/23 was also not available. On 6/21/23 at 4:54 p.m., Resident #19 stated she was in pain and rated it at a 9 out of 10. She stated that she needed to lie down. She stated she hurt everywhere. Resident appeared to be in pain. She was pale and did not move during the conversation. On 6/22/23 at 10:30, Resident #19 was observed to have a patch last placed on 6/20/23 on her left chest. Resident #19 rated her pain at a 9 and stated she hurt all over. She added that the medication person is going to give her pain meds now and they will help. She said she went without the patch a few days ago and she became very sick. She stated she was throwing up and everything. She stated once they were able to get a patch the sickness went away. 3. An MDS dated [DATE], documented that Resident #20's diagnoses included anxiety and chronic pain syndrome. The MDS revealed a BIMS score of 15 out of 15, which indicated intact cognition. This resident required extensive assist of 1 for transfers and personal hygiene. The MDS documented that this resident received opioid medication 7 out of the 7 observation period days. The Pain Management section revealed that Resident #20 received pain medication both routine and PRN in the 5 prior days. The Pain Assessment revealed that in the prior 5 days this resident rated her pain at a 4 out of 10 and documented that she had pain frequently. A Medication Administration Record for the month of June 2023, directed staff to administer a Fentanyl Patch 25 mcg/hr transdermal application at bedtime every 72 hours for chronic pain syndrome to Resident #20. The start date was 5/1/23. Review of the record revealed that this resident did not receive the patch as scheduled on 6/3/23. The last patch prior to this was applied on 5/30/23 and 3 days from that was 6/2/23. This resident went 4 days without the absorption of the patch from 6/2/23 when it should have been applied to 6/6/23. She had the patch applied again on 6/9/23, it wasn't applied on 6/12/23 then it was applied again on 6/15/23. On 6/21/23 at 4:55 p.m., Resident #20 stated she was in pain and rated her pain at an 8 out of 10. She stated it hurt in her tailbone and back. The resident appeared to be in pain. The DON (Director of Nursing) was notified of where Resident #19 and Resident #20 were rating their pain. Both residents had been outside to smoke and were sitting beside their respective beds in their wheelchairs in their room. These two residents are roommates. Both residents had facial grimacing. Resident #19 had guarded movements and sat very still. Observation on 6/22/23 at 10:35 a.m., noted Resident #20 had a patch on her right chest. It was not labeled. Resident #20 stated her tailbone pain is at an 8 which is constant, and her stomach pain was at a 5. She stated they were supposed to give her a suppository 2 nights ago and they never did. She stated she was constipated. When asked if they have missed giving her some pain medications, she said yes. She stated the reason she didn't receive her medication was they didn't have the medication to give. When asked if she was given anything to help with her pain she said no, they told me they didn't have anything else to give. 4. A MDS dated [DATE], documented that Resident #21's diagnoses included malignant neoplasm of the larynx (cancer of the voice box) and chronic pain. The BIMS score for Resident #21 was 12 out of 15 which indicated moderate cognitive impairment. This resident required extensive assist of 2 for transfers and extensive assist of 1 for personal hygiene. The Pain Management section revealed that Resident #21 received routine pain medication in the 5 prior days. The Pain Assessment revealed that in the prior 5 days this resident rated his pain at a 6 out of 10 and documented that he had pain frequently. A MAR for the month of June, directed staff to administer Percocet 5-325mg three times a day at 8:00 a.m., 2:00 p.m., and at 8:00 p.m. to Resident #21. The MAR revealed that Resident did not receive his scheduled Percocet from 6/13/23 at 2:00 p.m. through 6/20/23. The MAR documented that he received a dose at 8:00 a.m. on 6/21/23. On 6/27/23 at 10:31 p.m. observed Resident #21 lying in bed. He nodded his head in affirmation that he did know they didn't have the pain meds to give him. When asked if he was in pain during that time, his eyes widened and he nodded a definite yes. When asked if he remembers what level his pain was at during that time and if he could rate it he shook his head no. He affirmed by nodding that he had went about a week without the pain medication and this happened a couple of weeks back. On 6/21/23 at 10:26 a.m., Staff C, Certified Nurse Aide/Certified Medication Aide (CNA/CMA), when asked what the circled initials meant on the MAR/TAR (/Treatment Administration Record) she stated it meant that they didn't have the medication. She stated it happened more than she would like to admit. She said the DON said to just pass the medications that you can. When asked why some residents had Fentanyl patches and another did not, she stated she did not know. She said maybe it had something to do with pharmacy. She said the facility does not want to report these things. Staff C stated she is told not to get so upset about things. On 6/21/23 at 2:45 p.m., the DON stated she was looking into the Fentanyl patches not being given. When asked what she knew about it, she just shook her head no. On 6/21/23 at 3:00 p.m., Staff C, when asked again about the numerous Fentanyl patches that weren't applied, she stated that the night shift which is mainly agency nurses put the patches on. She acknowledged all of the holes with the Fentanyl patches. She stated it meant they did not get the patches put on. She did not think there was drug diversion. She thought it was more laziness, destroyed. On 6/21/23 at 4:07 p.m., Staff D, Register Nurse (RN) traveler with the facility corporation and the Nurse Consultant stated they were aware of this too and looking into it, when they were told there was a concern with the Fentanyl patches and narcotics not being given. On 6/22/23 at 10:30 a.m., Staff A, CMA stated that medications are getting missed and sometimes it's because staff don't understand the different names of Vitamins i.e. ascorbic acid vs Vitamin C and sometimes they just don't look for the medications. Staff A stated that Resident #4 was without Percocet. Staff A stated she had sent the information that he was out of his Percocet and needed more several times but she was not sure if they had gotten it. She stated that Staff E, RN had told her they were getting a script (prescription for a physician) for the Percocet. Staff A said she had sent the tag in about 5 days before he was out of them. Staff A said it was ample time, more than 3 days to get it ordered. Staff A stated they (nurses) had tried to get it out of the e-kit (emergency medication kit) but he needed a new script. She said that he went 8 days without the Percocet. Staff A did not think there was any drug diversion just laziness. She stated that Resident #4 was going through withdrawal symptoms. Stated he was really tired. Staff B, RN, was part of the above conversation. He stated that there normally are medications up front. Staff B stated they can go up and get them. Staff B stated he did not think there was any drug diversion, just sloppy nursing. On 6/22/23 at 4:06 p.m., Staff F, Nurse Practitioner (NP), stated the facility let her know that the 3 ladies did not receive their patches. She stated she took a look at them and discontinued 2 of the 3 ladies patches as she did not feel they needed it. She said the 3rd lady was a different story. She stated she did know about another resident not getting his Percocet. She found out through faxes. She will look for the faxes of the facility notifying her of the pain medication not being given. Staff F stated it was okay to call her back with any further questions. Stated it was recently brought up to her about the Fentanyl patches not being administered, but she had been notified of this before and was notified by fax. No faxes were provided. On 6/22/23 at 2:30 p.m., Staff G, NP stated that no one had notified her of medications not being given. She had not heard about Fentanyl patches not being available. She had not heard about Resident #4 not getting his Percocet. She said there would be no reason for this. If not contacting her they could contact other providers to get a script or to get these medications ordered. She said in Resident #4's case she saw him after a fall and had abdominal x-ray/test done related to pain. She said at that time she reviewed his medications and did not feel he needed anything more for pain as he was on several medications that helped with pain. Staff G looked at Resident #4's MAR. She stated now that she knows he went without Percocet for that many days she will need to go back to Resident #4 and ask him about pain control. She said she came in to see 5 residents on this day and she was still at the facility because she finds things out when she talks with residents and feels she needs to take care of it. She stated a lot of the stuff she ends up doing are things the nurse should be doing but for some reason it is not getting done. She repeated that there is no reason the residents should not be receiving their medication. She stated a provider and pharmacy can be called. On 6/22/23 at 3:05 p.m., Staff E, RN stated that it was reported to her that Resident #4 did not have Percocet. She stated the CMA did not tell her until the last day that she worked. Staff E stated that sometimes she worked 2-3 days in a row. She stated that afternoon she called the pharmacy for it and the pharmacy said they were waiting on a script for it. Staff E stated that the pharmacy calls the care provider to get the script. She stated that the pharmacy was located out of state, so the pharmacy didn't always call the provider for the nurses. Staff E stated that on weekends it depends on who is on call, the provider might not write a script. Staff E didn't think she had called the on call provider the day she found out about needing a Percocet refill. Staff E stated she reported it on to the next shift but did not remember who. Staff E stated she did think it was important for the residents to have their meds. Staff E stated the facility was running bubble packs as well as cards with medications (meds) in them. Staff E stated that she was running meds all the time. Staff E said she did not want to put the facility under the bus or anything, but the nurses are continually getting meds out of this system because the meds are not filled. Staff E stated it was like all day long they were pulling meds from the ekit (emergency kit storage). Staff E stated it was very time consuming. Staff E stated the fax machine was down for a long time. She said she had been there for 6 months and the facility finally got a fax machine this week. She stated they were unable to fax the pharmacy because of it. Staff E stated they had to call the pharmacy or Staff F, LPN and another nurse had been emailing the pharmacy. Staff E stated that she always called the pharmacy and they would get upset when you have a huge list, the pharmacy wanted the list sent instead. She stated the pharmacy also sometimes did not send the meds. Staff E said that every day she pulled medications out of the ekit, even though the meds had been requested from the pharmacy. Staff E stated that the CMAs don't let the nurse know if there is a med missing, they will just circle it. Staff E said that she and another nurse have reported to the DON that the med aides (CMA's) aren't reporting that there are not meds in the carts. Staff E then went into the medication room. The system was hooked up to a computer. Staff E stated the nurses are able to type in the name of a resident and the medication needed and then you can get it out of the ekit. She stated that the nurses run meds for the residents and then deliver them. She said that it happened often that all of the meds are not there. Staff E said that often times with narcotics, the pharmacy will say a script was needed. Staff E stated that it could be difficult to get a script. Staff E said she honestly did not know if there was drug diversion at the facility, it's pretty scary. Staff E said that she had seen that people have signed things off and she had wondered how the CMAs have signed stuff off that the facility did not have. Staff E was unable to give any specific examples of this nor could she give a time frame. Staff E stated that Staff A and Staff C had told Staff E that night shift agency aides are not passing the meds. Staff C was really good about reporting to Staff E but Staff A didn't always report. Staff E said that Staff A would report to Staff B, but he was Staff A's son in law. Staff E stated she reported this to the DON and nothing really happened. Staff E stated that she did not want to be fired or anything but many things needed fixed. Staff E became tearful and said it's hard to work here because it's very busy and many things get missed. On 6/26/23 at 3:13 p.m., Staff I, RN Hospice stated she had brought up concerns regarding Resident #19 going through withdrawals. Staff I said the facility set her up on routine Oxycodone with the Fentanyl patch before related to Resident #19 requesting so much PRN (as needed) Oxycodone. Staff I said that with Resident #19 taking both of the meds she would still rate her pain at an 8 or 9. Staff I said that Resident #19 had a history of MS so it could be hard to tell with her because you don't know if she is masking pain. When asked who she goes through for medications, she stated they go through the facility doctor first. Staff I said that a lot of times they do things without communicating with her. Staff I stated she has to ask for an updated medication list for Resident #19. Staff I said she sees Resident #19 two times a week. When asked if she knew about Resident #19 not receiving her Fentanyl patch, Staff I stated that she would notice it would be dated for 5 days prior or not on her at all. Staff I said she had her hospice aide check the date on the patch and the hospice aide was to let Staff I know if the date was more than 3 days old or if there was no patch. Staff I stated that Resident #19 would ask Staff I if Staff I would go and see when she was due for her next dose of pain medication. Staff I stated that Resident #19 would ask more about the oxycodone and not the patch. Staff I said she had been Resident #19's case manager for almost 2 months now and that Resident #19 had went on hospice on 1/27/23 and there was a different hospice nurse case manager before Staff I. Staff I said that Resident #19 can make her own decisions and Resident #19 did have a son and a daughter that she wants us to update on her care. Staff I had a conversation with Resident #19 about missing Fentanyl patches. Staff I said that back in May she had went in and noticed that Resident #19 hadn't had one (Fentanyl patch) changed and Staff I brought it up to her and they were able to get a new one started. Staff I stated that since then Resident #19 had been able to let Staff I know if it was taken care of or not taken care of. Staff I stated that in June Resident #19 told Staff I that the Fentanyl patch wasn't being taken care. Staff I said that she spoke with the floor nurse and spoke with the ADON (Assistant Director of Nursing) and it seemed like every time Staff I would talk to somebody, they would tell Staff I they'd get the Fentanyl Patch shortly. Staff I stated she did not feel the issue got addressed. Staff I stated that the other hospice nurse spoke with the floor nurse on June 14th when the other hospice nurse noticed that the patch had not been changed and her roommate noticed the patch had not been changed. Staff I stated that she knew she was biased because them discontinuing the patch after the fact is doing her a disservice. On 6/26/23 at 4:20 p.m., Resident #19 stated that she was in pain and rated her pain at a 9 and 1/2. This resident was lying in bed. Stated she was feeling really bad and was going downhill fast. When asked what she meant by that she stated she just wasn't doing good. When asked about the Fentanyl patch, she said they took that off last week and told her that she didn't need it. When asked what she thought about that, she stated it really didn't help her much anyway. This resident had opened her eyes when the door was knocked on but did not open them very far. This resident did not move any extremities nor her head when she talked. When asked if staff check on her and ask her about her pain, she stated sometimes. When asked if they were checking twice a day, she stated no. When asked if she ever has no pain, she said no. When asked what the lowest her pain had been in the past few months, she stated a 6 or 7. The MAR for Resident #19 for the month of June 2023, directed staff to do a twice a day pain assessment with 0 as no pain, 1-3 as mild pain, 4-6 as moderate pain, and 7-10 as severe pain. The documentation of the pain revealed that from June 1st through June 26th this resident had pain rated four times at 7, two times at 8 and one time at a 6, the rest of the documentation revealed 0's or there were times when it wasn't filled out. On 6/26/23 at 4:30 p.m., Resident #4 was lying in bed smiling. Stated she really didn't have any pain. She was feeling pretty good. Resident #4 was wide awake and appeared happy. She asked about what time it was. The MAR for Resident #4 for the month of June 2023, directed staff to record pain on a 0-10 scale twice a day. The documentation of the pain revealed that from June 1st through the first part of June 26th this resident had 40 times the pain was not rated. On 6/27/23 at 9:15 a.m., Staff J, agency RN, stated he thought there was a Fentanyl patch on the 2nd floor downstairs for a day or so that was not put on. Staff J stated he did not put on but he did leave a note and passed it on. Staff J stated there was no way for him to get the patch. He stated he talked to day shift. He said that it was pretty complicated to talk to pharmacy on the weekend. He said he did assessments. When told about the patches that weren't placed and the time frame the residents went without a Fentanyl patch, he stated he did not know that they did not have patches for that long. Staff J stated he worked a lot on the 2nd floor (where all 4 residents resided). Staff J stated he would work a few days and then off but when he would come back he did not recall seeing any resident going a long time without a patch. Staff J stated that the CMAs do not apply Fentanyl. Staff J said that medications being not available happened quite often. Staff J stated that every time something happened when there wasn't a medication, he always left a note. Staff J stated that he would give a verbal report but he also would write the meds on the sheet and then hand it to the next shift. Staff J stated that the pharmacy says that he needs to fax when he did get a hold of the pharmacy. Staff J stated that the facility's fax was not working and on weekends the pharmacy was not available. Staff J stated that if you want to order more than one or two meds the pharmacy would say to fax the list of meds as the pharmacy preferred faxes. Staff J stated that he always made sure he put it on the sheet that they have so the day nurse would know what the situation was and then they could handle it during the day. When asked about the sheet, he stated he was not very sure where the sheet was kept. Staff J stated that they hand over a copy of it to the next nurse. Staff J stated that sometimes he would pass 8:00 p.m. meds but most of the time it's a CMA. Staff J stated he didn't know about Resident #21's Percocet. Staff J stated that he felt the residents received good care and he thought the communication with the pharmacy was the biggest concern. On 6/27/23 at 9:45 a.m., Staff E stated she did not know where the pharmacy book was in the back (2nd floor). She stated she wasn't sure what they did when the nurses and CMAs filled out the sheets with the meds that are needed. Staff E said she didn't see the book and she thought the sheets might just get thrown away. She pulled a couple of sheets out of the box with things that needed to be shredded. On 6/27/23 at 10:25 a.m., Staff E pulled 2 more pharmacy sheets out of the box when asked if there were any more sheets in the box. On 6/27/23 at 9:50 a.m., Staff H, Licensed Practical Nurse (LPN), stated the facility got a new machine and it copies and prints but it doesn't fax. Staff H stated she had developed a process with the pharmacy where you have an encryption code so the emails between Staff H and the pharmacy can go between us without HIPPA violations. Staff H stated that she had been doing this for 2 months. Staff H stated she receives sheets from the CMAs and on Mondays, Tuesdays, and Wednesdays Staff H forwards the sheets on to the pharmacy and then writes emailed to pharmacy and the date and time. Staff H stated she then puts the sheets into the pharmacy book. Staff H stated that she only worked on the 1st floor. Staff H state the process to get medication was the doctor writes out the order for her on a script, then she would take a picture and email to the pharmacy, after that she documented in the electronic health record to make it an active order. Staff H stated she would usually then call the pharmacy and let them know that she had put in an active order and she would pull a couple of doses of the medication so that they could cover the first couple of doses that needed to be given. Staff H stated that not all nurses have access to their medication system. She stated that sometimes they have agency nurses and the agency nurses cannot get into the facility's medication system. Discussed Resident #19's medication and Staff H stated that Resident #19 had been in pain since she has been here. Staff H stated that Resident #19 should not go without her pain medication. Staff H said that Resident #19 was so frail and pale and always looked like she was in pain. When told the pain level had been signed often as no pain for this resident, Staff H stated that was not right. Staff H stated what she thought staff were doing was seeing if Resident #19 was sleeping and marking it 0, they should be asking her. Staff H said that Resident #19 needed her pain medication. Staff H stated that hospice staff could call the pharmacy too and Staff H stated she did not know why agency nurses wouldn't just call the pharmacy. Staff H stated if they are writing down on the sheet that there was not a med available then it should be in the pharmacy book down there. They should be putting those sheets in to the pharmacy book and those papers should not be shredded. Staff H stated that usually on Mondays there are a lot of meds to order. Staff H stated that she just called the pharmacy and asked them how could she get the meds without a fax and they said she could use her own email but she would need to use their encryption. Staff H stated that's what she did. Staff H stated she did not want to put down the company but they had people running to another facility to fax orders because their facility couldn't get the meds. On 6/27/23 at 11:32 a.m., Staff K, CMA/CNA, stated that it did happen when meds were not available. Staff K stated she circled her initials on the MAR's when meds were not available. Staff K stated that she actually asks her nurse if the med is printable, meaning they can get it from the medication system, but if not to circle it and write a note on 24 hour report. When asked how often she thinks this happens, she stated daily. She stated it had gotten better because they had a new ADON who listens. Staff K stated that they tell the resident when we don't have a med for them and most of the time they are not surprised, unless it's a pain med, anti coagulant (blood thinner), anti anxiety, etc. Staff K stated they have one resident who gets upset if he did not get his oxycodone (pain medication), Lyrica (blocks pain signals in nervous system), or Clonazepam (anti-anxiety). Staff K sated that it took time but they were able to get it for him because they would call the pharmacy and the on call physician and get it pulled. Staff K stated that sometimes the on call doctor doesn't answer and sometimes the pharmacy doesn't answer. On 6/27/23 at 12:03 p.m., Staff L, RN stated she passes medications when they need someone. Staff L stated she would just get meds out of their medication system if she needed a med. She stated she has had trouble with the system jamming. Staff L stated she leaves at 10:30 p.m. and asks prior to leaving if anybody needs anything. Staff L stated she worked noon to 10:30 p.m. Staff L stated that they were checking every night now, they check the MARS and TARS they have to sign. Staff L, RN stated she knew that medications not being available was a problem and they had been working on it real hard. Staff L stated that the facility lost a couple of nurses about a month ago and then it wasn't brought to our attention. Staff L stated after that she went to check not too long ago for gaps and that's when she noticed it was a couple weeks ago. Staff L stated she had no clue that Resident #21 went without Percocet. Staff L stated that they could have called the on call providers. Staff L stated that they can get a hold of pharmacy 24 hours a day and they could get a hold of a physician 24 hours a day. Staff L stated that there was always 2 nurses in the facility so any of them can call and get medication. Staff L stated that they had trouble with faxing a while back. Staff L stated that it was routine orders that the facility had trouble with getting. Staff L stated she did not know who would tell Resident #21 they couldn't get the Percocet. Staff L stated they could always get Percocet. When told that Resident #21 said he was in pain during the time he did not receive the Percocet, Staff L nodded understanding and stated that she was somewhat related to Resident #4, and he will always tell you he has pain. Staff L stated that Staff E, Staff H, and Staff B, all know what to do (how to retrieve medications). Staff L stated that no one ever told her that the facility was out of narcotics for residents, until the facility caught it. Staff L stated that Resident #19 had been on narcotics about 7 months. Staff L stated that Resident #19 is in pain now and stated that Resident #19 was addicted. Staff L said that the meds are available. She stated that staff could also call the ADON, the DON, or Staff L and they would come in and get the meds for the staff. Staff L stated that pretty much every day that she works she takes meds out of the facility's medication system. On 6/28/23 at 9:02 a.m., Staff I called and wanted to give an update on Resident #19. She stated she wanted to give an update on Resident #19's pain. Staff I stated that Resident # [TRUNCATED]

Based on observations, resident, staff and family interviews, record review, and policy review, the facility failed to provide safe mechanical lift transfers for 6 of 7 residents reviewed (Residents #4, #7, #14, #16, #17, and #18). The facility failed to transfer residents safely by not following the Hoyer lift recommendations and locking the lift while raising the resident, not having a clear process in place to ensure staff were using the appropriate sling for transfers, and allowing a non-certified staff to assist in the Hoyer transfer. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of January 9, 2023 on April 25, 2023 at 1:44 P.M. The Facility Staff removed the Immediate Jeopardy on April 26, 2023 through the following actions: a. Education of nursing staff on proper use of Hoyer lift and ensuring the brakes are not locked when raising the resident. b. Removing the Invacare Hoyer lift from service until compatible slings can be obtained. c. A new process was implemented to put the size of sling the resident was to use on the Kardex and placed copies at each nurse's station. d. Nursing staff return demonstrations of a Hoyer lift transfer completed by the Director of Nursing (DON) and Nurse Manager. e. Education of nursing staff that all mechanical lift transfers are to be completed with two certified nursing staff. The scope lowered from a K to an E at the time of the survey after ensuring the facility implemented education and made appropriate changes to their processes and procedures. The facility identified a census of 69 residents. Findings include: 1. Resident #4's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. The MDS indicated Resident #4 required extensive assistance of one person for bed mobility, total assistance of two persons for transferring, and total assistance of one person for toilet use. Resident #4 was always incontinent of bowel and bladder and used oxygen therapy. The MDS included diagnoses of diabetes mellitus, anemia, heart failure, multiple sclerosis, non-Alzheimer's dementia, depression, schizophrenia, respiratory failure, and osteomyelitis of the vertebrae. The Care Plan initiated 5/13/16 and a revision date of 2/16/23, had a fall risk focus area, with a goal for the resident to not sustain any preventable serious injury if a fall should occur. Interventions directed staff to be sure the call light was within reach, half side rail in place for ease in bed mobility and safety, encourage participation in activities that promote exercise, physical activity for strengthening and improved mobility, ensure that resident was wearing appropriate footwear when ambulating or in the wheelchair, follow facility fall protocols, and provide the resident a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light. Provide resident with activities that minimize the potential for falls while providing diversion and distraction and have physical therapy (PT) evaluate and treat as ordered and as needed. The Care Plan initiated 3/13/16 also had an activities of daily living (ADL) self-care performance deficit focus area related to activity intolerance, muscle weakness, obesity, and fatigue with a goal that the resident would maintain their current level of function in bed mobility, transfers, eating, dressing, toilet use, and personal hygiene. Interventions directed staff to encourage the resident to utilize half side rails for increased bed mobility, encourage resident to be up in the wheelchair for meals, assistance of one staff person for bed mobility and dressing and the resident required mechanical aid (Hoyer) and assistance of two staff for transfers. A fall Incident Report dated 2/12/23 at 8:34 PM documented the resident was found lying on the floor with her feet facing the bed and a pillow under her head. Blood noted to be coming from the back of the residents head. Per staff the resident was being transferred from the wheelchair to bed by full mechanical lift (Hoyer) and assistance of two staff when she fell sideways out of the lift after the Hoyer sling caught on the wheelchair arm. The Hoyer sling was still on the lift and the bottom straps observed to not be crossed. The resident was assessed and a laceration viewed to the back of the scalp after flushing the area. The ambulance was called to transport to the emergency room for further assessment. Vital signs were stable at (T),Temperature 97.4, (HR) Heart Rate 96, (R) Respirations per minute 20, (BP) Blood Pressure 127/54, and (PO2) pulse oximeter of 94% on room air. Neurological assessment intact and pupils were equal and reactive to light. Resident was oriented to person, place, and situation. Predisposing environmental factors included clutter, poor lighting, food on the floor, and crowding. Predisposing physiological factors included impaired memory. The Physician was notified of the fall at 8:57 PM. A progress note dated 2/12/23 at 8:56 PM, documented the resident was found lying on her back with her feet facing the bed on the floor with a pillow under her head. Blood noted to be coming from the back of the residents head. Per the Certified Nursing Assistant (CNA) the resident was being transferred from the wheelchair to bed by full mechanical lift (Hoyer) and assistance of two staff and fell sideways out of the lift after the Hoyer sling caught on wheelchair arm. The Hoyer sling was still on the lift and the bottom straps observed to not be crossed. Vital signs were stable and neurological assessment intact. Laceration observed to back of the head. The Emergency Medical Technician's (EMT's) were notified of need for transfer of the resident due to a head injury. A progress note dated 2/13/23 at 1:28 AM, documented the resident returned to the facility at 1:10 AM via ambulance from the emergency room . Documents received stated the resident was treated for injuries sustained from a fall earlier. Diagnosis of laceration of the scalp. The resident received 5 staples to the laceration on the back of her head. The computerized tomography (CT) scans of the cervical spine and head without contrast were both negative. Hospice was notified of residents return to the facility and will come to the facility to assess and readmit to hospice. Resident resting in bed with no complaints of pain, call light in reach and vital signs stable. A physician progress note dated 2/13/23 at 11:58 PM, documented the resident was seen to follow up with an injury to resident's posterior head and post hospital visit. Resident returned to the facility with staples in her posterior head laceration. Surrounding skin was red with no drainage. The resident complained of pain rating at 5 out of 10 and her pain was managed by Tylenol. Resident was awake and alert. Lungs were clear to auscultation, respirations were even and unlabored. Pulse oximeter 97%. Posterior head laceration noted to have some swelling, erythema, and staples. Resident was alert, awake, and oriented to self. Plan was to monitor laceration to posterior head for bleeding, use Tylenol for pain, monitor for signs and symptoms of infection, and notify the provider of metal status changes. In an observation on 4/13/23 at 1:50 PM, Staff G, Certified Nursing Assistant (CNA) and Staff H, CNA transferred Resident #4 from her wheelchair into her bed. Staff G, CNA removed resident's oxygen and the liberator (portable oxygen tank) was turned off. They hooked the sling up to the locked Hoyer using the green loops on the top and the purple loops on the bottom. The resident was instructed to cross her arms and hug herself and she complied. Staff H, CNA used the remote to raise the resident out of the chair. Staff H, CNA unlocked the Hoyer and steered the Hoyer so the resident was positioned in the center of the bed and lowered her down. The sling was removed from the Hoyer. Oxygen was applied once laid down in bed. In an observation on 4/18/23 at 9:40 AM, Staff I, CNA and Staff J, CNA completed a Hoyer transfer for Resident #4 from her wheelchair to bed. Oxygen was removed prior to the transfer. Staff J, CNA placed the Hoyer from the side of the chair with legs apart and it was locked. The sling was a bariatric sling and did not have straps that crisscross under the legs. The staff reported this was the same sling that is always used for this resident. The staff hooked the sling up to the Hoyer using the purple loops on the bottom and the green loops on the top. She was raised up out of the chair, the Hoyer was unlocked and the staff guided to the center of the bed and gently lowered onto the center of the bed. She was rolled side to side and the sling was removed from under her. Staff reapplied resident oxygen and covered her up. The call light was given to resident. In an interview on 4/12/23 at 12:21 PM with Resident #4's Power of Attorney (POA), he stated that the facility was not always the best at updating him on changes in Resident'#4's condition. He stated he recalled an incident in February when the resident fell from a Hoyer and was sent to the hospital and the facility never notified him. He stated he was notified by the hospital when she was admitted for the night but not by the facility. He stated he had a long conversation with the Administrator about this and it has been better since. In an interview on 4/18/23 at 12:20 PM, Staff K, CNA reported she did work the evening of 2/12/23 but stated she was not involved with the fall of Resident #4 but remembers hearing about the incident. Staff K, CNA stated she had heard Staff L, CNA was transferring the resident with the Hoyer by herself. She stated it was the expectation that the Hoyer and EZ stand transfers are always completed with two staff. In an interview on 4/18/23 at 12:22 PM, the Assistant Director of Nursing (ADON) stated it is the expectation that all Hoyer and EZ Stand transfers be completed with two staff without exception. In an interview on 4/18/23 at 1:05 PM, the Administrator acknowledged Staff L, CNA was involved in the fall from the Hoyer with Resident #4. Staff L, CNA terminated her position on the night of the fall (2/12/23). The administrator reported per punch detail, Staff L, CNA punched out at 10:19 PM and wrote a note stating that was her last day. He stated she was very upset over the fall and she was not transferring Resident #4 with the Hoyer by herself, she had another staff person with her (Staff M, CNA). The Administrator did report that she had been involved in a fall from a Hoyer a few weeks prior in which she was transferring using the Hoyer by herself. He stated they had done a lot of education with Staff L, CNA on this and she was not doing Hoyer transfers by herself any longer. In an interview on 4/18/23 at 12:25 PM, Staff N, OTA/Therapy Coordinator reported he had heard that Staff L, CNA had transferred a resident with a Hoyer by herself. He reported he did mass education with staff on always using two staff for all Hoyer and EZ Stand transfers. On 4/18/23, the Administrator provided a written statement from Staff M, CNA stating that he worked in the facility on 2/12/23 and he was walking past a room with a resident slid down in her chair on the opposite hall he was working. He reported it to Staff L, CNA and they both entered the resident's room and helped guide Resident #4 to the floor in a lying position. Staff L, CNA then left to get a Hoyer and brought it into the room and they adjusted the sling behind the residents back as the resident was on the floor. They hooked the resident up to the Hoyer lift. As Staff L, CNA was raising the Hoyer, the resident shifted herself to the right. Staff M, CNA told Staff L, CNA to stop but the resident shifted herself so fast Staff L, CNA did not have time to react causing the resident to fall out of the sling onto the floor hitting her head on the back right of the Hoyer lift. Staff L, CNA immediately went and got the nurse and the nurse called 911 because the fall caused injury to the resident's head. The ambulance arrived and took the resident to the hospital. In a phone interview on 4/19/23 at 9:23 AM, Staff O, Registered Nurse (RN) stated Staff L, CNA came and got her to report resident #4 fell and was on the floor and had a head laceration. Staff O, RN was agency and she did not know the resident so was unsure of her baseline. Staff reported to her they were Hoyer transferring the resident from the chair and she fell out the right side of the sling. The resident was on the floor when she entered the room and a pillow was under her head. Resident #4 was covered with a blanket as she reported feeling cold. Staff O, RN reported she completed an assessment, vital signs were taken and a neurological assessment was completed and were intact. Staff O, RN left the room to get the resident's chart and items for the laceration to the back of her head. Upon return she completed another assessment and vital signs, pulse oximeter, and neurological assessment were done. Resident remained on the floor in the same position until the ambulance arrived as she didn't want to move her. Staff O, RN stated neither staff involved mention to her at all that resident had been lowered to the floor and that they were completing a Hoyer transfer off the floor. They stated it was from the wheelchair and the Hoyer sling had caught on the arm of the wheelchair. She questioned if the sling was to be crisscrossed under the resident's leg and she was informed the resident didn't use that type of sling and that the sling was correctly put under the resident and she was correctly hooked up to the lift. In a phone interview on 4/19/23 at 9:55 AM, Staff L, CNA reported she did work on 2/12/23 and was involved with the fall from the Hoyer for Resident #4. She reported she was working with another CNA who was agency and a male (Staff M, CNA). At around 7:40 PM, he notified her that the resident was attempting to get out of her wheelchair or was sliding out of the wheelchair. She entered the room to assist him. She noted the resident was sliding out of the chair and the staff were not able to lift her back up into the chair. They made the decision to lower her to the floor. She was laid on the floor on her back. She then went to find a Hoyer to lift the resident back into her chair but it took her about 5 minutes to locate and get the Hoyer back to the room. She was unsure if a nurse was notified of the resident being on the floor. She stated she did not notify the nurse. They used the sling that had been under her in the wheelchair and tucked it under her so they could hook her up to the Hoyer. Hooked her up to the machine using the black loops on the top and the green loops on the bottom. She was positive the sling was correctly hooked to the lift and they left the sling attached to the machine after the incident. She reported she was running the controls and the other male CNA was located behind the wheelchair with the residents feet pointed towards him. She stated the resident's head was pointed toward her and no one was touching her as they couldn't reach her. The wheelchair was in the way for him and she couldn't reach around Hoyer to touch her while running the control. She stated she got the resident about half way up and the male CNA stated Her arm! She stated she immediately stopped the machine but the resident then slid out the right side of the sling. She reported the residents head, arm, shoulder, and chest area came out the side of the sling and she hit her head on the base of the lift. Staff L, CNA then lowered the lift back down and went and found the nurse on the 100 hall. The nurse came to the resident's room and assessed her. Staff L, CNA reported she did raise the residents head enough to put a pillow under it for comfort. She reported she left the room to go answer a light and assist another resident. She stated they used the sling that had been under her in the wheelchair and she was not aware of a chart for sizing of Hoyer slings. She stated she was not aware of any other residents falling out of a Hoyer and never anyone under her care. In an interview on 4/19/23 at 11:51 AM, the DON stated that Staff M, CNA (agency) was involved in the fall from the Hoyer for Resident #4, and returned to the facility the next morning and talked to them about the incident. He took the DON and Staff N, OTA/Therapy Coordinator to the room and showed them with the Hoyer what had happened. Per an email sent on 4/25/23 at 4:40 PM, Staff P, Regional Director of Operations reported he had interviewed Staff M, CNA and he had reported he had worked one shift at the facility on 2/13/23 and remembered the incident with Resident #4. He reported the resident was sliding from her chair and so she was lowered by staff to the floor. Staff got the mechanical lift to get her up off of the floor. While the resident was in the lift on the floor she began moving around and hit her head on the tan cover at the base of the lift that covers the leg separation bar. There was no malicious intent by the other staff he was with, the resident just hit her own head. In a phone interview 4/26/23 at 9:22 AM, Staff M, CNA reported that he did speak with Staff P, Regional Director of Operations yesterday while he was at work. The email statement that was sent by Staff P, Regional Director of Operations from their interview yesterday and was reviewed with him. Staff M, CNA's original write up regarding the incident was then reviewed with him. He stated he remembers the night as it was Super Bowl Sunday. He stated he felt the place was very short staffed. He reported he was not actually working in the hall that the resident was in but noted her to be sliding out of her chair when he walked by. He immediately got a hold of Staff L, CNA and they went into the room to assist her. The resident was slid all the way down in the chair. So they lowered her to the floor and placed her sling under her. At that point Staff L, CNA went to get a Hoyer to lift her up. He stated once she was back with the lift they hooked the resident up to the Hoyer and Staff L, CNA was running the controls and he was located at the residents feet. He stated he felt that Staff L, CNA may not have been paying the closest attention to what she was doing as she was arguing with the roommate at the same time she was running the lift. He stated he did not feel that she had any malicious intentions but maybe wasn't paying the closest attention to what she was doing. He said Staff L, CNA began to lift the resident using the controller. He said that the resident was maybe a foot or so off the ground and he thought maybe she got scared and jolted herself to the right a bit and her right arm came out and then she jolted to the right one more time before Staff L, CNA could stop the lift and her right arm, then her head and upper body came out of the right side of the sling and fell to the floor and resident struck her head on the base of the Hoyer. He stated her bottom half remained in the sling but her top half came out the side. He stated Staff L, CNA immediately lowered the Hoyer back to the floor. Staff L, CNA then went and got the nurse and he stayed with the resident until the nurse arrived. He could see the back of her head was bleeding. He also reported he asked both Staff L, CNA and the nurse what kind of action needed to be taken with an incident like this and they both said nothing different than any other fall. 2. Resident #7's MDS assessment dated [DATE] identified a BIMS score of 14, indicating intact cognition. The MDS indicated Resident #7 required extensive assistance of one person for bed mobility, total dependence of two people for transfers, and total dependence of one person for toilet use. Resident #7 was wheelchair dependent and always incontinent of bowel and bladder. The MDS included diagnoses of diabetes mellitus, thyroid disorder, Alzheimer's dementia, cerebral palsy, non-Alzheimer's dementia, seizure disorder, depression, schizophrenia and suicidal ideation. The Care Plan initiated on 7/27/18 with a revision date of 4/7/23, revealed a fall risk focus area related to cognition and being unaware of safety needs and cerebral palsy and a goal that the resident will have no unaddressed falls. Interventions directed staff to anticipate and meet resident needs, encourage resident to wear gripper socks, follow therapy recommendations for transfers and mobility - assist of two people for Hoyer lift transfers, place call light in reach, and skid strips next to bed. The Care Plan initiated on 7/27/18 with a revision date of 4/7/23, also had an ADL self-care performance deficit focus area related to cerebral palsy with a goal the resident maintain their current level of function. Interventions directed staff to encourage the resident to utilize half side rails for increased bed mobility, one person assistance with bed mobility and assistance of two staff with transfers - Hoyer lift only. In an observation on 4/12/23 at 2:00 PM, Staff Q, CNA and Staff R, CNA completed a Hoyer transfer for Resident #7. The resident was sitting in her wheelchair and had the Hoyer sling in place under her. They brought the Hoyer in and hooked her up to it using the blue loops on the top and the purple loops on the bottom. The Hoyer legs were spread and the Hoyer machine was locked. Staff Q, CNA then used the remote to raise the resident into the air and then the machine was unlocked and steered around with Staff R, CNA assisting to guide the resident until she was centered over the bed. She was encouraged to give herself a hug during the transfer. Once she was centered over the bed she was lowered onto the bed and unhooked from the machine. The resident tolerated the process well. The sling was removed from under her by rolling her side to side. 3. Resident #14's MDS assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. The MDS indicated Resident #14 required total dependence of one person for bed mobility and toilet use and total dependence of two people for transfers. Resident was always incontinent of bowel and bladder and was wheelchair dependent. The MDS included diagnoses of atrial fibrillation, diabetes mellitus, thyroid disorder, arthritis, anxiety disorder, depression, respiratory failure, and morbid obesity. The Care Plan initiated on 2/28/22 with a revision date of 4/7/23, revealed an ADL self-care performance deficit activity intolerance focus area related to impaired balance and limited mobility and a goal to maintain current level of function with ADL. Interventions directed staff to assist with bed mobility using two people, encourage to discuss feelings about self-care deficit, praise all efforts at self-care, and Hoyer transfers with assistance of two people. In an interview on 4/19/23 at 2:35 PM, Resident #14 stated she had been a Hoyer lift transfer since admitting to the facility. Staff used the same style and size sling for all transfers. They normally use two staff for her transfers but Staff L, CNA had transferred her alone a couple of times but nothing recent. Felt secure most of the time with her transfers except when the transfer was being completed with one staff person. When at the previous nursing home the resident reported she was dropped from the Hoyer and fractured her knee, so if she did not feel secure, she would tell them to stop and reposition her. 4. Resident #16's MDS assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. The MDS indicated Resident #16 required extensive assistance of one person for bed mobility, total dependence of two people for transfers, and total dependence of one person for toilet use. She was wheelchair dependent, used oxygen, and always incontinent of bowel and bladder. The MDS included diagnoses of heart failure, renal insufficiency, cerebrovascular accident, hemiplegia, anxiety disorder, depression, bipolar disorder, schizophrenia, and chronic obstructive pulmonary disease. The Care Plan initiated on 2/10/22 with a revision date of 4/20/22, revealed an ADL self-performance deficit with a goal to maintain current level of function with ADL's. Interventions directed staff to assist resident to turn and reposition in bed, encourage use of enabling bars/side rails to maximize independence with turning and repositioning in bed, allow sufficient time for dressing and undressing, and requires the assistance of two people for Hoyer transfers. A fall Incident Report dated 1/9/23 at 3:04 PM, documented the nurse was alerted to Resident #16's room by a loud noise and yelling coming from the resident's room. The nurse arrived and observed the resident resting with her head and torso supported in the lift sling and her legs in the wheelchair under the armrest. The Hoyer sling was attached to the lift and the Hoyer lift was tipped sideways with the lift portion between the resident's legs and on her groin. The resident was assisted to the floor with the sling and the assistance of six staff. Resident was assess for injury and it was noted the resident had bruising and raised and abraded areas on her inner thigh. Resident had functional range of motion per her baseline but complained of left hip pain. While being assessed, the resident's eyes rolled back and her body began to shake. Her eyes were fixed open and she was not responsive to verbal or physical stimuli. The nurse directed staff to call 911 and the resident was having suspected seizure activity. Paramedics arrived and transported the resident to the hospital for evaluation. Immediate action: Resident was assisted to the floor, assessed for injury and sent to hospital via ambulance. Resident noted to have an abrasion to front of left thigh. Resident oriented to person. Predisposing environmental factors included clutter, furniture, crowding, and equipment malfunction. Physician was notified of incident. A progress note date 1/9/23 at 3:41 PM, documented the nurse was alerted to Resident #16's room by a loud noise and yelling coming from the room. The nurse arrived and observed the resident resting with her head and torso supported in the lift sling and her legs in the wheelchair under the armrest. The Hoyer sling was attached to the lift and the Hoyer lift was tipped sideways with the lift portion between the resident's legs and on her groin. Resident was assisted to the floor with the lift sling and the assistance of six staff. Resident was assessed for injury and it was noted that she had bruising and pinched areas on her inner thigh. Resident had functional range of motion per her baseline but complained of pain. While being assessed, the resident's eyes rolled back and her body began to shake. Her eyes were fixed open and she was not responsive to verbal or physical stimuli. The nurse directed staff to call 911 as the resident was having suspected seizure activity. Paramedics arrived and transported the resident to the emergency room for evaluation. A progress note dated 1/9/23 at 11:24 PM, documented Resident #16 returned to the facility at approximately 10:00 PM via ambulance. Resident was found to have a clear CT scan and x-rays showed no broken bones or fractures. The resident reported her tailbone and bottom were sore. Resident was given her bedtime medications which included pain medication. Vital signs were stable upon arrival back to the facility (T - 97.8, HR - 74, R - 20, BP - 122/86, and oxygen level was 96% on room air). Resident voiced no other concerns at that time. A physician progress note dated 1/11/23 at 6:29 PM, documented resident had a fall on 1/9/23 from a malfunction of the Hoyer and landed on her back. She was transported to the emergency room . A head CT, back and hip x-ray was done. Hip x-ray was negative for fracture but it did show a contusion of the hip. The head CT was unremarkable. Today she complained of occipital headache, onset was after the fall on 1/9/23, describes it as intermittent throbbing and rates the pain at a 5. She was seen for post emergency room visit. No acute distress and oriented x 4. Plan: Celebrex 100 milligrams (mg) by mouth twice daily as needed for headache as previously ordered, utilize Tylenol as previously ordered and notify the provider with any changes. In an interview on 4/19/23 at 11:51 AM, the DON acknowledged the fall from a Hoyer involving Resident #16 had occurred when Staff L, CNA was operating the Hoyer without a second person at the time. She stated she was not aware of other staff operating mechanical lifts independently. In an interview on 4/25/23 at 8:10 AM, Staff N, OTA/Therapy Coordinator reported he held several in-services throughout the week following the incident with the Hoyer tipping and a staff person using the mechanical lift independently. He stated the in-service consisted of them watching a YouTube video and then they worked in groups of two and practiced Hoyer transfers of a person from the bed to the wheelchair and then back to bed. He stated he observed and let them do the transfers unless he saw a concern, then he would educate and correct at the time. He stated Staff L, CNA did attend the in-service and completed the transfer perfectly. He stated that he feels she knew exactly how to complete the transfers but it was a behavior thing that she chose to take short cuts. 5. Resident #17's MDS assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. The MDS indicated Resident #17 required total dependence of one person for bed mobility and total dependence of two people for transfers, and toilet use. Resident was wheelchair dependent and used oxygen. Resident #17 was always incontinent of bowel and bladder. The MDS included diagnoses of heart failure, cerebral palsy, seizure disorder, anxiety disorder, depression, psychotic disorder, respiratory failure, unspecified intellectual disabilities, and disruptive mood dysregulation disorder. The Care Plan initiated on 7/9/18 with a revision date of 4/21/23, revealed a fall risk focus area related to incontinence with a goal of fall related injuries will be minimized. Interventions directed staff to inspect Hoyer slings before use, anticipate and meet the resident's needs, encourage resident to wear appropriate footwear, follow therapy recommendations for transfers and mobility, place call light in residents reach while in room and review information on past falls and attempt to determine cause of falls. The Care Plan initiated on 9/1/13 with a revision date of 4/21/23, revealed an ADL self-care performance deficit focus area related to cerebral palsy with a goal to have no unaddressed/preventable decline in the resident's current level of function in ADL's. Interventions directed staff to ensure foot board is on the residents wheelchair, use two people to assist with Hoyer transfers, use one or two people for toilet use needs, praise all efforts for self-care, skid strips in front of the bed, use two people to assist in repositioning and turning in bed, and use one person to assist with personal hygiene and oral care. A fall Incident Report dated 1/12/23 at 8:00 AM documented CNA's reported they were transferring the resident from the bed to her motorized wheelchair with the Hoyer lift and the lift tipped over. One of the CNA's reported she was able to catch the lift to prevent the resident from falling onto the floor. The resident instead fell into her motorized wheelchair and hit her left leg on the wheelchair arm rest. The resident was repositioned in the motorized wheelchair, vital signs were obtained, and neurological assessment was completed. The provider and family were notified of the incident. No injuries were noted at the time of the incident. The resident was noted to be lethargic. Predisposing physiological factors included resident being confused, incontinent, impaired memory and a gait imbalance. A progress note dated 1/12/23 at 9:15 AM, documented two staff members were transferring the resident from her [TRUNCATED]

Based on observations, interviews, and record review the facility failed to administer pain medication as ordered by a physician leaving 4 out of 4 residents reviewed without adequate pain control (Resident #4, #19, #20, and #21). Four residents reviewed were not administered their Controlled II pain medication as ordered for prolonged periods of time. The nurses and CMAs stated the medication was not available to give, therefore they did not give it. Resident #21 went 8 days without receiving his three times a day routine order of Percocet (an oral opioid pain medication). The other 3 residents did not receive their Fentanyl patches (potent opioid pain patch) as ordered every 3 days. In a 22 day period, the 3 residents reviewed did not have their patch applied every 3 days as ordered resulting in Resident #4 going 11 days, Resident #19 going 12 days, and Resident #20 going 7 days without Fentanyl during the 22 day review period. This situation resulted in Immediate Jeopardy to residents health and safety for the facility. The facility was notified of the Immediate Jeopardy on 6/29/23. The facility abated the Immediate Jeopardy situation on 6/29/23 lowering the scope from a K to an E after staff education was complete and the facility ensured all scheduled/ordered pain medications were available for residents. The facility reported a census of 62 residents. Findings include: 1. A Minimum Data Set (MDS) dated [DATE], documented that Resident #4 diagnoses included Multiple Sclerosis (MS), osteomyelitis of the vertebra (infection of the bone), and non-Alzheimer's dementia. A Brief Interview for Mental Status (BIMS) documented a score of 8 out of 15, which indicated moderate cognitive impairment. Resident #4 required total dependence of 2 for transfers, and personal hygiene. The MDS documented that this resident received opioid medication 7 out of the 7 observation period days. The Pain Management section revealed that Resident #4 received pain medication both routine and PRN (as needed) in the 5 prior days. The Pain Assessment revealed that in the prior 5 days this resident rated her pain at a moderate level and documented that she had pain occasionally. A Medication Administration Record (MAR) for the month of June 2023, directed staff to administer a Fentanyl Patch 12 mcg (microgram)/hr(hour) transdermal (absorbed through the skin) application at bedtime every 3 days for chronic pain to Resident #4. The start date was 2/20/23. Review of the record revealed that this resident did not receive the patch as scheduled on 6/2/23, it was applied the following day on 6/3/23. The resident had a patch applied on 5/5/23 and 5/8/23, then this resident did not have a patch applied again until 5/21/23. On 6/21/23 at 4:00 p.m., When asked if she had pain, this resident stated she did. When asked to rate the pain, she stated it was at a 5 on a scale of 0-10 and the pain was on her bottom. Resident lying in bed at the time. On 6/22/23 at 11:20 a.m., it was noted that Resident #4 had a patch on her right chest dated 6/21/23. Resident was asleep. This resident woke up but required some patting on the arm by staff. On all observations of Resident #4 during this survey Resident #4 had been awake, eyes opened, and responsive with exception of this observation. 2. An MDS dated [DATE], documented that Resident #19's diagnoses included MS and chronic pain. The MDS revealed a BIMS score of 15 out of 15, which indicated intact cognition. This resident required total dependence of 2 staff for transfers. She required total dependence of 1 staff for personal hygiene. The MDS documented that this resident received opioid medication 7 out of the 7 observation period days. The Pain Management section revealed that Resident #19 received pain medication both routine and PRN in the 5 prior days. The Pain Assessment revealed that in the prior 5 days this resident rated her pain at a 5 out of 10 (0 is no pain and 10 is the worse pain you can imagine) and documented that she had pain frequently. A Medication Administration Record for the month of June 2023, directed staff to administer a Fentanyl Patch 25 mcg/hr transdermal application at bedtime every 72 hours (3 days) for chronic pain to Resident #19. The start date was 3/4/23. Review of the record revealed that this resident did not receive the patch as scheduled on 6/2/23, it was applied on 6/5/23. It revealed that she was to get a patch placed on 6/8/23 and did not have a patch applied until 6/14/23. She was scheduled to have a patch applied on 6/17/23 and did not have it applied until 6/20/23. It was documented that it was not available on 6/23/23. The MAR also directed staff that Oxycodone (opioid) 5 mg tablet was to be administered orally 4 times a day to Resident #19. The order date was 6/8/23. From 6/8/23 at 5 p.m. when the first dose was to be given to 6/12/23 at 6:00 a.m. the doses were not given. The 6:00 a.m. dose on 6/13/23 and all 4 doses on 6/14/23 and 6/15/23 were not available. The 8:00 p.m. dose on 6/23/23 was also not available. On 6/21/23 at 4:54 p.m., Resident #19 stated she was in pain and rated it at a 9 out of 10. She stated that she needed to lie down. She stated she hurt everywhere. Resident appeared to be in pain. She was pale and did not move during the conversation. On 6/22/23 at 10:30, Resident #19 was observed to have a patch last placed on 6/20/23 on her left chest. Resident #19 rated her pain at a 9 and stated she hurt all over. She added that the medication person is going to give her pain meds now and they will help. She said she went without the patch a few days ago and she became very sick. She stated she was throwing up and everything. She stated once they were able to get a patch the sickness went away. 3. An MDS dated [DATE], documented that Resident #20's diagnoses included anxiety and chronic pain syndrome. The MDS revealed a BIMS score of 15 out of 15, which indicated intact cognition. This resident required extensive assist of 1 for transfers and personal hygiene. The MDS documented that this resident received opioid medication 7 out of the 7 observation period days. The Pain Management section revealed that Resident #20 received pain medication both routine and PRN in the 5 prior days. The Pain Assessment revealed that in the prior 5 days this resident rated her pain at a 4 out of 10 and documented that she had pain frequently. A Medication Administration Record for the month of June 2023, directed staff to administer a Fentanyl Patch 25 mcg/hr transdermal application at bedtime every 72 hours for chronic pain syndrome to Resident #20. The start date was 5/1/23. Review of the record revealed that this resident did not receive the patch as scheduled on 6/3/23. The last patch prior to this was applied on 5/30/23 and 3 days from that was 6/2/23. This resident went 4 days without the absorption of the patch from 6/2/23 when it should have been applied to 6/6/23. She had the patch applied again on 6/9/23, it wasn't applied on 6/12/23 then it was applied again on 6/15/23. On 6/21/23 at 4:55 p.m., Resident #20 stated she was in pain and rated her pain at an 8 out of 10. She stated it hurt in her tailbone and back. The resident appeared to be in pain. The DON (Director of Nursing) was notified of where Resident #19 and Resident #20 were rating their pain. Both residents had been outside to smoke and were sitting beside their respective beds in their wheelchairs in their room. These two residents are roommates. Both residents had facial grimacing. Resident #19 had guarded movements and sat very still. Observation on 6/22/23 at 10:35 a.m., noted Resident #20 had a patch on her right chest. It was not labeled. Resident #20 stated her tailbone pain is at an 8 which is constant, and her stomach pain was at a 5. She stated they were supposed to give her a suppository 2 nights ago and they never did. She stated she was constipated. When asked if they have missed giving her some pain medications, she said yes. She stated the reason she didn't receive her medication was they didn't have the medication to give. When asked if she was given anything to help with her pain she said no, they told me they didn't have anything else to give. 4. A MDS dated [DATE], documented that Resident #21's diagnoses included malignant neoplasm of the larynx (cancer of the voice box) and chronic pain. The BIMS score for Resident #21 was 12 out of 15 which indicated moderate cognitive impairment. This resident required extensive assist of 2 for transfers and extensive assist of 1 for personal hygiene. The Pain Management section revealed that Resident #21 received routine pain medication in the 5 prior days. The Pain Assessment revealed that in the prior 5 days this resident rated his pain at a 6 out of 10 and documented that he had pain frequently. A MAR for the month of June, directed staff to administer Percocet 5-325mg three times a day at 8:00 a.m., 2:00 p.m., and at 8:00 p.m. to Resident #21. The MAR revealed that Resident did not receive his scheduled Percocet from 6/13/23 at 2:00 p.m. through 6/20/23. The MAR documented that he received a dose at 8:00 a.m. on 6/21/23. On 6/27/23 at 10:31 p.m. observed Resident #21 lying in bed. He nodded his head in affirmation that he did know they didn't have the pain meds to give him. When asked if he was in pain during that time, his eyes widened and he nodded a definite yes. When asked if he remembers what level his pain was at during that time and if he could rate it he shook his head no. He affirmed by nodding that he had went about a week without the pain medication and this happened a couple of weeks back. On 6/21/23 at 10:26 a.m., Staff C, Certified Nurse Aide/Certified Medication Aide (CNA/CMA), when asked what the circled initials meant on the MAR/TAR (/Treatment Administration Record) she stated it meant that they didn't have the medication. She stated it happened more than she would like to admit. She said the DON said to just pass the medications that you can. When asked why some residents had Fentanyl patches and another did not, she stated she did not know. She said maybe it had something to do with pharmacy. She said the facility does not want to report these things. Staff C stated she is told not to get so upset about things. On 6/21/23 at 2:45 p.m., the DON stated she was looking into the Fentanyl patches not being given. When asked what she knew about it, she just shook her head no. On 6/21/23 at 3:00 p.m., Staff C, when asked again about the numerous Fentanyl patches that weren't applied, she stated that the night shift which is mainly agency nurses put the patches on. She acknowledged all of the holes with the Fentanyl patches. She stated it meant they did not get the patches put on. She did not think there was drug diversion. She thought it was more laziness, destroyed. On 6/21/23 at 4:07 p.m., Staff D, Register Nurse (RN) traveler with the facility corporation and the Nurse Consultant stated they were aware of this too and looking into it, when they were told there was a concern with the Fentanyl patches and narcotics not being given. On 6/22/23 at 10:30 a.m., Staff A, CMA stated that medications are getting missed and sometimes it's because staff don't understand the different names of Vitamins i.e. ascorbic acid vs Vitamin C and sometimes they just don't look for the medications. Staff A stated that Resident #4 was without Percocet. Staff A stated she had sent the information that he was out of his Percocet and needed more several times but she was not sure if they had gotten it. She stated that Staff E, RN had told her they were getting a script (prescription for a physician) for the Percocet. Staff A said she had sent the tag in about 5 days before he was out of them. Staff A said it was ample time, more than 3 days to get it ordered. Staff A stated they (nurses) had tried to get it out of the e-kit (emergency medication kit) but he needed a new script. She said that he went 8 days without the Percocet. Staff A did not think there was any drug diversion just laziness. She stated that Resident #4 was going through withdrawal symptoms. Stated he was really tired. Staff B, RN, was part of the above conversation. He stated that there normally are medications up front. Staff B stated they can go up and get them. Staff B stated he did not think there was any drug diversion, just sloppy nursing. On 6/22/23 at 4:06 p.m., Staff F, Nurse Practitioner (NP), stated the facility let her know that the 3 ladies did not receive their patches. She stated she took a look at them and discontinued 2 of the 3 ladies patches as she did not feel they needed it. She said the 3rd lady was a different story. She stated she did know about another resident not getting his Percocet. She found out through faxes. She will look for the faxes of the facility notifying her of the pain medication not being given. Staff F stated it was okay to call her back with any further questions. Stated it was recently brought up to her about the Fentanyl patches not being administered, but she had been notified of this before and was notified by fax. No faxes were provided. On 6/22/23 at 2:30 p.m., Staff G, NP stated that no one had notified her of medications not being given. She had not heard about Fentanyl patches not being available. She had not heard about Resident #4 not getting his Percocet. She said there would be no reason for this. If not contacting her they could contact other providers to get a script or to get these medications ordered. She said in Resident #4's case she saw him after a fall and had abdominal x-ray/test done related to pain. She said at that time she reviewed his medications and did not feel he needed anything more for pain as he was on several medications that helped with pain. Staff G looked at Resident #4's MAR. She stated now that she knows he went without Percocet for that many days she will need to go back to Resident #4 and ask him about pain control. She said she came in to see 5 residents on this day and she was still at the facility because she finds things out when she talks with residents and feels she needs to take care of it. She stated a lot of the stuff she ends up doing are things the nurse should be doing but for some reason it is not getting done. She repeated that there is no reason the residents should not be receiving their medication. She stated a provider and pharmacy can be called. On 6/22/23 at 3:05 p.m., Staff E, RN stated that it was reported to her that Resident #4 did not have Percocet. She stated the CMA did not tell her until the last day that she worked. Staff E stated that sometimes she worked 2-3 days in a row. She stated that afternoon she called the pharmacy for it and the pharmacy said they were waiting on a script for it. Staff E stated that the pharmacy calls the care provider to get the script. She stated that the pharmacy was located out of state, so the pharmacy didn't always call the provider for the nurses. Staff E stated that on weekends it depends on who is on call, the provider might not write a script. Staff E didn't think she had called the on call provider the day she found out about needing a Percocet refill. Staff E stated she reported it on to the next shift but did not remember who. Staff E stated she did think it was important for the residents to have their meds. Staff E stated the facility was running bubble packs as well as cards with medications (meds) in them. Staff E stated that she was running meds all the time. Staff E said she did not want to put the facility under the bus or anything, but the nurses are continually getting meds out of this system because the meds are not filled. Staff E stated it was like all day long they were pulling meds from the ekit (emergency kit storage). Staff E stated it was very time consuming. Staff E stated the fax machine was down for a long time. She said she had been there for 6 months and the facility finally got a fax machine this week. She stated they were unable to fax the pharmacy because of it. Staff E stated they had to call the pharmacy or Staff F, LPN and another nurse had been emailing the pharmacy. Staff E stated that she always called the pharmacy and they would get upset when you have a huge list, the pharmacy wanted the list sent instead. She stated the pharmacy also sometimes did not send the meds. Staff E said that every day she pulled medications out of the ekit, even though the meds had been requested from the pharmacy. Staff E stated that the CMAs don't let the nurse know if there is a med missing, they will just circle it. Staff E said that she and another nurse have reported to the DON that the med aides (CMA's) aren't reporting that there are not meds in the carts. Staff E then went into the medication room. The system was hooked up to a computer. Staff E stated the nurses are able to type in the name of a resident and the medication needed and then you can get it out of the ekit. She stated that the nurses run meds for the residents and then deliver them. She said that it happened often that all of the meds are not there. Staff E said that often times with narcotics, the pharmacy will say a script was needed. Staff E stated that it could be difficult to get a script. Staff E said she honestly did not know if there was drug diversion at the facility, it's pretty scary. Staff E said that she had seen that people have signed things off and she had wondered how the CMAs have signed stuff off that the facility did not have. Staff E was unable to give any specific examples of this nor could she give a time frame. Staff E stated that Staff A and Staff C had told Staff E that night shift agency aides are not passing the meds. Staff C was really good about reporting to Staff E but Staff A didn't always report. Staff E said that Staff A would report to Staff B, but he was Staff A's son in law. Staff E stated she reported this to the DON and nothing really happened. Staff E stated that she did not want to be fired or anything but many things needed fixed. Staff E became tearful and said it's hard to work here because it's very busy and many things get missed. On 6/26/23 at 3:13 p.m., Staff I, RN Hospice stated she had brought up concerns regarding Resident #19 going through withdrawals. Staff I said the facility set her up on routine Oxycodone with the Fentanyl patch before related to Resident #19 requesting so much PRN (as needed) Oxycodone. Staff I said that with Resident #19 taking both of the meds she would still rate her pain at an 8 or 9. Staff I said that Resident #19 had a history of MS so it could be hard to tell with her because you don't know if she is masking pain. When asked who she goes through for medications, she stated they go through the facility doctor first. Staff I said that a lot of times they do things without communicating with her. Staff I stated she has to ask for an updated medication list for Resident #19. Staff I said she sees Resident #19 two times a week. When asked if she knew about Resident #19 not receiving her Fentanyl patch, Staff I stated that she would notice it would be dated for 5 days prior or not on her at all. Staff I said she had her hospice aide check the date on the patch and the hospice aide was to let Staff I know if the date was more than 3 days old or if there was no patch. Staff I stated that Resident #19 would ask Staff I if Staff I would go and see when she was due for her next dose of pain medication. Staff I stated that Resident #19 would ask more about the oxycodone and not the patch. Staff I said she had been Resident #19's case manager for almost 2 months now and that Resident #19 had went on hospice on 1/27/23 and there was a different hospice nurse case manager before Staff I. Staff I said that Resident #19 can make her own decisions and Resident #19 did have a son and a daughter that she wants us to update on her care. Staff I had a conversation with Resident #19 about missing Fentanyl patches. Staff I said that back in May she had went in and noticed that Resident #19 hadn't had one (Fentanyl patch) changed and Staff I brought it up to her and they were able to get a new one started. Staff I stated that since then Resident #19 had been able to let Staff I know if it was taken care of or not taken care of. Staff I stated that in June Resident #19 told Staff I that the Fentanyl patch wasn't being taken care. Staff I said that she spoke with the floor nurse and spoke with the ADON (Assistant Director of Nursing) and it seemed like every time Staff I would talk to somebody, they would tell Staff I they'd get the Fentanyl Patch shortly. Staff I stated she did not feel the issue got addressed. Staff I stated that the other hospice nurse spoke with the floor nurse on June 14th when the other hospice nurse noticed that the patch had not been changed and her roommate noticed the patch had not been changed. Staff I stated that she knew she was biased because them discontinuing the patch after the fact is doing her a disservice. On 6/26/23 at 4:20 p.m., Resident #19 stated that she was in pain and rated her pain at a 9 and 1/2. This resident was lying in bed. Stated she was feeling really bad and was going downhill fast. When asked what she meant by that she stated she just wasn't doing good. When asked about the Fentanyl patch, she said they took that off last week and told her that she didn't need it. When asked what she thought about that, she stated it really didn't help her much anyway. This resident had opened her eyes when the door was knocked on but did not open them very far. This resident did not move any extremities nor her head when she talked. When asked if staff check on her and ask her about her pain, she stated sometimes. When asked if they were checking twice a day, she stated no. When asked if she ever has no pain, she said no. When asked what the lowest her pain had been in the past few months, she stated a 6 or 7. The MAR for Resident #19 for the month of June 2023, directed staff to do a twice a day pain assessment with 0 as no pain, 1-3 as mild pain, 4-6 as moderate pain, and 7-10 as severe pain. The documentation of the pain revealed that from June 1st through June 26th this resident had pain rated four times at 7, two times at 8 and one time at a 6, the rest of the documentation revealed 0's or there were times when it wasn't filled out. On 6/26/23 at 4:30 p.m., Resident #4 was lying in bed smiling. Stated she really didn't have any pain. She was feeling pretty good. Resident #4 was wide awake and appeared happy. She asked about what time it was. The MAR for Resident #4 for the month of June 2023, directed staff to record pain on a 0-10 scale twice a day. The documentation of the pain revealed that from June 1st through the first part of June 26th this resident had 40 times the pain was not rated. On 6/27/23 at 9:15 a.m., Staff J, agency RN, stated he thought there was a Fentanyl patch on the 2nd floor downstairs for a day or so that was not put on. Staff J stated he did not put on but he did leave a note and passed it on. Staff J stated there was no way for him to get the patch. He stated he talked to day shift. He said that it was pretty complicated to talk to pharmacy on the weekend. He said he did assessments. When told about the patches that weren't placed and the time frame the residents went without a Fentanyl patch, he stated he did not know that they did not have patches for that long. Staff J stated he worked a lot on the 2nd floor (where all 4 residents resided). Staff J stated he would work a few days and then off but when he would come back he did not recall seeing any resident going a long time without a patch. Staff J stated that the CMAs do not apply Fentanyl. Staff J said that medications being not available happened quite often. Staff J stated that every time something happened when there wasn't a medication, he always left a note. Staff J stated that he would give a verbal report but he also would write the meds on the sheet and then hand it to the next shift. Staff J stated that the pharmacy says that he needs to fax when he did get a hold of the pharmacy. Staff J stated that the facility's fax was not working and on weekends the pharmacy was not available. Staff J stated that if you want to order more than one or two meds the pharmacy would say to fax the list of meds as the pharmacy preferred faxes. Staff J stated that he always made sure he put it on the sheet that they have so the day nurse would know what the situation was and then they could handle it during the day. When asked about the sheet, he stated he was not very sure where the sheet was kept. Staff J stated that they hand over a copy of it to the next nurse. Staff J stated that sometimes he would pass 8:00 p.m. meds but most of the time it's a CMA. Staff J stated he didn't know about Resident #21's Percocet. Staff J stated that he felt the residents received good care and he thought the communication with the pharmacy was the biggest concern. On 6/27/23 at 9:45 a.m., Staff E stated she did not know where the pharmacy book was in the back (2nd floor). She stated she wasn't sure what they did when the nurses and CMAs filled out the sheets with the meds that are needed. Staff E said she didn't see the book and she thought the sheets might just get thrown away. She pulled a couple of sheets out of the box with things that needed to be shredded. On 6/27/23 at 10:25 a.m., Staff E pulled 2 more pharmacy sheets out of the box when asked if there were any more sheets in the box. On 6/27/23 at 9:50 a.m., Staff H, Licensed Practical Nurse (LPN), stated the facility got a new machine and it copies and prints but it doesn't fax. Staff H stated she had developed a process with the pharmacy where you have an encryption code so the emails between Staff H and the pharmacy can go between us without HIPPA violations. Staff H stated that she had been doing this for 2 months. Staff H stated she receives sheets from the CMAs and on Mondays, Tuesdays, and Wednesdays Staff H forwards the sheets on to the pharmacy and then writes emailed to pharmacy and the date and time. Staff H stated she then puts the sheets into the pharmacy book. Staff H stated that she only worked on the 1st floor. Staff H state the process to get medication was the doctor writes out the order for her on a script, then she would take a picture and email to the pharmacy, after that she documented in the electronic health record to make it an active order. Staff H stated she would usually then call the pharmacy and let them know that she had put in an active order and she would pull a couple of doses of the medication so that they could cover the first couple of doses that needed to be given. Staff H stated that not all nurses have access to their medication system. She stated that sometimes they have agency nurses and the agency nurses cannot get into the facility's medication system. Discussed Resident #19's medication and Staff H stated that Resident #19 had been in pain since she has been here. Staff H stated that Resident #19 should not go without her pain medication. Staff H said that Resident #19 was so frail and pale and always looked like she was in pain. When told the pain level had been signed often as no pain for this resident, Staff H stated that was not right. Staff H stated what she thought staff were doing was seeing if Resident #19 was sleeping and marking it 0, they should be asking her. Staff H said that Resident #19 needed her pain medication. Staff H stated that hospice staff could call the pharmacy too and Staff H stated she did not know why agency nurses wouldn't just call the pharmacy. Staff H stated if they are writing down on the sheet that there was not a med available then it should be in the pharmacy book down there. They should be putting those sheets in to the pharmacy book and those papers should not be shredded. Staff H stated that usually on Mondays there are a lot of meds to order. Staff H stated that she just called the pharmacy and asked them how could she get the meds without a fax and they said she could use her own email but she would need to use their encryption. Staff H stated that's what she did. Staff H stated she did not want to put down the company but they had people running to another facility to fax orders because their facility couldn't get the meds. On 6/27/23 at 11:32 a.m., Staff K, CMA/CNA, stated that it did happen when meds were not available. Staff K stated she circled her initials on the MAR's when meds were not available. Staff K stated that she actually asks her nurse if the med is printable, meaning they can get it from the medication system, but if not to circle it and write a note on 24 hour report. When asked how often she thinks this happens, she stated daily. She stated it had gotten better because they had a new ADON who listens. Staff K stated that they tell the resident when we don't have a med for them and most of the time they are not surprised, unless it's a pain med, anti coagulant (blood thinner), anti anxiety, etc. Staff K stated they have one resident who gets upset if he did not get his oxycodone (pain medication), Lyrica (blocks pain signals in nervous system), or Clonazepam (anti-anxiety). Staff K sated that it took time but they were able to get it for him because they would call the pharmacy and the on call physician and get it pulled. Staff K stated that sometimes the on call doctor doesn't answer and sometimes the pharmacy doesn't answer. On 6/27/23 at 12:03 p.m., Staff L, RN stated she passes medications when they need someone. Staff L stated she would just get meds out of their medication system if she needed a med. She stated she has had trouble with the system jamming. Staff L stated she leaves at 10:30 p.m. and asks prior to leaving if anybody needs anything. Staff L stated she worked noon to 10:30 p.m. Staff L stated that they were checking every night now, they check the MARS and TARS they have to sign. Staff L, RN stated she knew that medications not being available was a problem and they had been working on it real hard. Staff L stated that the facility lost a couple of nurses about a month ago and then it wasn't brought to our attention. Staff L stated after that she went to check not too long ago for gaps and that's when she noticed it was a couple weeks ago. Staff L stated she had no clue that Resident #21 went without Percocet. Staff L stated that they could have called the on call providers. Staff L stated that they can get a hold of pharmacy 24 hours a day and they could get a hold of a physician 24 hours a day. Staff L stated that there was always 2 nurses in the facility so any of them can call and get medication. Staff L stated that they had trouble with faxing a while back. Staff L stated that it was routine orders that the facility had trouble with getting. Staff L stated she did not know who would tell Resident #21 they couldn't get the Percocet. Staff L stated they could always get Percocet. When told that Resident #21 said he was in pain during the time he did not receive the Percocet, Staff L nodded understanding and stated that she was somewhat related to Resident #4, and he will always tell you he has pain. Staff L stated that Staff E, Staff H, and Staff B, all know what to do (how to retrieve medications). Staff L stated that no one ever told her that the facility was out of narcotics for residents, until the facility caught it. Staff L stated that Resident #19 had been on narcotics about 7 months. Staff L stated that Resident #19 is in pain now and stated that Resident #19 was addicted. Staff L said that the meds are available. She stated that staff could also call the ADON, the DON, or Staff L and they would come in and get the meds for the staff. Staff L stated that pretty much every day that she works she takes meds out of the facility's medication system. On 6/28/23 at 9:02 a.m., Staff I called and wanted to give an update on Resident #19. She stated she wanted to give an update on Resident #19's pain. Staff I stated that Resident # [TRUNCATED]

Based on observations, interviews, and record review the facility failed to administer pain medication as ordered by a physician leaving 4 out of 4 residents reviewed without adequate pain control (Resident #4, #19, #20, and #21). Four residents reviewed were not administered their Controlled II pain medication as ordered for prolonged periods of time. The nurses and CMAs stated the medication was not available to give, therefore they did not give it. Resident #21 went 8 days without receiving his three times a day routine order of Percocet (an oral opioid pain medication). The other 3 residents did not receive their Fentanyl patches (potent opioid pain patch) as ordered every 3 days. In a 22 day period, the 3 residents reviewed did not have their patch applied every 3 days as ordered resulting in Resident #4 going 11 days, Resident #19 going 12 days, and Resident #20 going 7 days without Fentanyl during the 22 day review period. This situation resulted in Immediate Jeopardy to residents health and safety for the facility. The facility was notified of the Immediate Jeopardy on 6/29/23. The facility abated the Immediate Jeopardy situation on 6/29/23 lowering the scope from a K to an E after staff education was complete and the facility ensured all scheduled/ordered pain medications were available for residents. The facility reported a census of 62 residents. Findings include: 1. A Minimum Data Set (MDS) dated [DATE], documented that Resident #4 diagnoses included Multiple Sclerosis (MS), osteomyelitis of the vertebra (infection of the bone), and non-Alzheimer's dementia. A Brief Interview for Mental Status (BIMS) documented a score of 8 out of 15, which indicated moderate cognitive impairment. Resident #4 required total dependence of 2 for transfers, and personal hygiene. The MDS documented that this resident received opioid medication 7 out of the 7 observation period days. The Pain Management section revealed that Resident #4 received pain medication both routine and PRN (as needed) in the 5 prior days. The Pain Assessment revealed that in the prior 5 days this resident rated her pain at a moderate level and documented that she had pain occasionally. A Medication Administration Record (MAR) for the month of June 2023, directed staff to administer a Fentanyl Patch 12 mcg (microgram)/hr(hour) transdermal (absorbed through the skin) application at bedtime every 3 days for chronic pain to Resident #4. The start date was 2/20/23. Review of the record revealed that this resident did not receive the patch as scheduled on 6/2/23, it was applied the following day on 6/3/23. The resident had a patch applied on 5/5/23 and 5/8/23, then this resident did not have a patch applied again until 5/21/23. On 6/21/23 at 4:00 p.m., When asked if she had pain, this resident stated she did. When asked to rate the pain, she stated it was at a 5 on a scale of 0-10 and the pain was on her bottom. Resident lying in bed at the time. On 6/22/23 at 11:20 a.m., it was noted that Resident #4 had a patch on her right chest dated 6/21/23. Resident was asleep. This resident woke up but required some patting on the arm by staff. On all observations of Resident #4 during this survey Resident #4 had been awake, eyes opened, and responsive with exception of this observation. 2. An MDS dated [DATE], documented that Resident #19's diagnoses included MS and chronic pain. The MDS revealed a BIMS score of 15 out of 15, which indicated intact cognition. This resident required total dependence of 2 staff for transfers. She required total dependence of 1 staff for personal hygiene. The MDS documented that this resident received opioid medication 7 out of the 7 observation period days. The Pain Management section revealed that Resident #19 received pain medication both routine and PRN in the 5 prior days. The Pain Assessment revealed that in the prior 5 days this resident rated her pain at a 5 out of 10 (0 is no pain and 10 is the worse pain you can imagine) and documented that she had pain frequently. A Medication Administration Record for the month of June 2023, directed staff to administer a Fentanyl Patch 25 mcg/hr transdermal application at bedtime every 72 hours (3 days) for chronic pain to Resident #19. The start date was 3/4/23. Review of the record revealed that this resident did not receive the patch as scheduled on 6/2/23, it was applied on 6/5/23. It revealed that she was to get a patch placed on 6/8/23 and did not have a patch applied until 6/14/23. She was scheduled to have a patch applied on 6/17/23 and did not have it applied until 6/20/23. It was documented that it was not available on 6/23/23. The MAR also directed staff that Oxycodone (opioid) 5 mg tablet was to be administered orally 4 times a day to Resident #19. The order date was 6/8/23. From 6/8/23 at 5 p.m. when the first dose was to be given to 6/12/23 at 6:00 a.m. the doses were not given. The 6:00 a.m. dose on 6/13/23 and all 4 doses on 6/14/23 and 6/15/23 were not available. The 8:00 p.m. dose on 6/23/23 was also not available. On 6/21/23 at 4:54 p.m., Resident #19 stated she was in pain and rated it at a 9 out of 10. She stated that she needed to lie down. She stated she hurt everywhere. Resident appeared to be in pain. She was pale and did not move during the conversation. On 6/22/23 at 10:30, Resident #19 was observed to have a patch last placed on 6/20/23 on her left chest. Resident #19 rated her pain at a 9 and stated she hurt all over. She added that the medication person is going to give her pain meds now and they will help. She said she went without the patch a few days ago and she became very sick. She stated she was throwing up and everything. She stated once they were able to get a patch the sickness went away. 3. An MDS dated [DATE], documented that Resident #20's diagnoses included anxiety and chronic pain syndrome. The MDS revealed a BIMS score of 15 out of 15, which indicated intact cognition. This resident required extensive assist of 1 for transfers and personal hygiene. The MDS documented that this resident received opioid medication 7 out of the 7 observation period days. The Pain Management section revealed that Resident #20 received pain medication both routine and PRN in the 5 prior days. The Pain Assessment revealed that in the prior 5 days this resident rated her pain at a 4 out of 10 and documented that she had pain frequently. A Medication Administration Record for the month of June 2023, directed staff to administer a Fentanyl Patch 25 mcg/hr transdermal application at bedtime every 72 hours for chronic pain syndrome to Resident #20. The start date was 5/1/23. Review of the record revealed that this resident did not receive the patch as scheduled on 6/3/23. The last patch prior to this was applied on 5/30/23 and 3 days from that was 6/2/23. This resident went 4 days without the absorption of the patch from 6/2/23 when it should have been applied to 6/6/23. She had the patch applied again on 6/9/23, it wasn't applied on 6/12/23 then it was applied again on 6/15/23. On 6/21/23 at 4:55 p.m., Resident #20 stated she was in pain and rated her pain at an 8 out of 10. She stated it hurt in her tailbone and back. The resident appeared to be in pain. The DON (Director of Nursing) was notified of where Resident #19 and Resident #20 were rating their pain. Both residents had been outside to smoke and were sitting beside their respective beds in their wheelchairs in their room. These two residents are roommates. Both residents had facial grimacing. Resident #19 had guarded movements and sat very still. Observation on 6/22/23 at 10:35 a.m., noted Resident #20 had a patch on her right chest. It was not labeled. Resident #20 stated her tailbone pain is at an 8 which is constant, and her stomach pain was at a 5. She stated they were supposed to give her a suppository 2 nights ago and they never did. She stated she was constipated. When asked if they have missed giving her some pain medications, she said yes. She stated the reason she didn't receive her medication was they didn't have the medication to give. When asked if she was given anything to help with her pain she said no, they told me they didn't have anything else to give. 4. A MDS dated [DATE], documented that Resident #21's diagnoses included malignant neoplasm of the larynx (cancer of the voice box) and chronic pain. The BIMS score for Resident #21 was 12 out of 15 which indicated moderate cognitive impairment. This resident required extensive assist of 2 for transfers and extensive assist of 1 for personal hygiene. The Pain Management section revealed that Resident #21 received routine pain medication in the 5 prior days. The Pain Assessment revealed that in the prior 5 days this resident rated his pain at a 6 out of 10 and documented that he had pain frequently. A MAR for the month of June, directed staff to administer Percocet 5-325mg three times a day at 8:00 a.m., 2:00 p.m., and at 8:00 p.m. to Resident #21. The MAR revealed that Resident did not receive his scheduled Percocet from 6/13/23 at 2:00 p.m. through 6/20/23. The MAR documented that he received a dose at 8:00 a.m. on 6/21/23. On 6/27/23 at 10:31 p.m. observed Resident #21 lying in bed. He nodded his head in affirmation that he did know they didn't have the pain meds to give him. When asked if he was in pain during that time, his eyes widened and he nodded a definite yes. When asked if he remembers what level his pain was at during that time and if he could rate it he shook his head no. He affirmed by nodding that he had went about a week without the pain medication and this happened a couple of weeks back. On 6/21/23 at 10:26 a.m., Staff C, Certified Nurse Aide/Certified Medication Aide (CNA/CMA), when asked what the circled initials meant on the MAR/TAR (/Treatment Administration Record) she stated it meant that they didn't have the medication. She stated it happened more than she would like to admit. She said the DON said to just pass the medications that you can. When asked why some residents had Fentanyl patches and another did not, she stated she did not know. She said maybe it had something to do with pharmacy. She said the facility does not want to report these things. Staff C stated she is told not to get so upset about things. On 6/21/23 at 2:45 p.m., the DON stated she was looking into the Fentanyl patches not being given. When asked what she knew about it, she just shook her head no. On 6/21/23 at 3:00 p.m., Staff C, when asked again about the numerous Fentanyl patches that weren't applied, she stated that the night shift which is mainly agency nurses put the patches on. She acknowledged all of the holes with the Fentanyl patches. She stated it meant they did not get the patches put on. She did not think there was drug diversion. She thought it was more laziness, destroyed. On 6/21/23 at 4:07 p.m., Staff D, Register Nurse (RN) traveler with the facility corporation and the Nurse Consultant stated they were aware of this too and looking into it, when they were told there was a concern with the Fentanyl patches and narcotics not being given. On 6/22/23 at 10:30 a.m., Staff A, CMA stated that medications are getting missed and sometimes it's because staff don't understand the different names of Vitamins i.e. ascorbic acid vs Vitamin C and sometimes they just don't look for the medications. Staff A stated that Resident #4 was without Percocet. Staff A stated she had sent the information that he was out of his Percocet and needed more several times but she was not sure if they had gotten it. She stated that Staff E, RN had told her they were getting a script (prescription for a physician) for the Percocet. Staff A said she had sent the tag in about 5 days before he was out of them. Staff A said it was ample time, more than 3 days to get it ordered. Staff A stated they (nurses) had tried to get it out of the e-kit (emergency medication kit) but he needed a new script. She said that he went 8 days without the Percocet. Staff A did not think there was any drug diversion just laziness. She stated that Resident #4 was going through withdrawal symptoms. Stated he was really tired. Staff B, RN, was part of the above conversation. He stated that there normally are medications up front. Staff B stated they can go up and get them. Staff B stated he did not think there was any drug diversion, just sloppy nursing. On 6/22/23 at 4:06 p.m., Staff F, Nurse Practitioner (NP), stated the facility let her know that the 3 ladies did not receive their patches. She stated she took a look at them and discontinued 2 of the 3 ladies patches as she did not feel they needed it. She said the 3rd lady was a different story. She stated she did know about another resident not getting his Percocet. She found out through faxes. She will look for the faxes of the facility notifying her of the pain medication not being given. Staff F stated it was okay to call her back with any further questions. Stated it was recently brought up to her about the Fentanyl patches not being administered, but she had been notified of this before and was notified by fax. No faxes were provided. On 6/22/23 at 2:30 p.m., Staff G, NP stated that no one had notified her of medications not being given. She had not heard about Fentanyl patches not being available. She had not heard about Resident #4 not getting his Percocet. She said there would be no reason for this. If not contacting her they could contact other providers to get a script or to get these medications ordered. She said in Resident #4's case she saw him after a fall and had abdominal x-ray/test done related to pain. She said at that time she reviewed his medications and did not feel he needed anything more for pain as he was on several medications that helped with pain. Staff G looked at Resident #4's MAR. She stated now that she knows he went without Percocet for that many days she will need to go back to Resident #4 and ask him about pain control. She said she came in to see 5 residents on this day and she was still at the facility because she finds things out when she talks with residents and feels she needs to take care of it. She stated a lot of the stuff she ends up doing are things the nurse should be doing but for some reason it is not getting done. She repeated that there is no reason the residents should not be receiving their medication. She stated a provider and pharmacy can be called. On 6/22/23 at 3:05 p.m., Staff E, RN stated that it was reported to her that Resident #4 did not have Percocet. She stated the CMA did not tell her until the last day that she worked. Staff E stated that sometimes she worked 2-3 days in a row. She stated that afternoon she called the pharmacy for it and the pharmacy said they were waiting on a script for it. Staff E stated that the pharmacy calls the care provider to get the script. She stated that the pharmacy was located out of state, so the pharmacy didn't always call the provider for the nurses. Staff E stated that on weekends it depends on who is on call, the provider might not write a script. Staff E didn't think she had called the on call provider the day she found out about needing a Percocet refill. Staff E stated she reported it on to the next shift but did not remember who. Staff E stated she did think it was important for the residents to have their meds. Staff E stated the facility was running bubble packs as well as cards with medications (meds) in them. Staff E stated that she was running meds all the time. Staff E said she did not want to put the facility under the bus or anything, but the nurses are continually getting meds out of this system because the meds are not filled. Staff E stated it was like all day long they were pulling meds from the ekit (emergency kit storage). Staff E stated it was very time consuming. Staff E stated the fax machine was down for a long time. She said she had been there for 6 months and the facility finally got a fax machine this week. She stated they were unable to fax the pharmacy because of it. Staff E stated they had to call the pharmacy or Staff F, LPN and another nurse had been emailing the pharmacy. Staff E stated that she always called the pharmacy and they would get upset when you have a huge list, the pharmacy wanted the list sent instead. She stated the pharmacy also sometimes did not send the meds. Staff E said that every day she pulled medications out of the ekit, even though the meds had been requested from the pharmacy. Staff E stated that the CMAs don't let the nurse know if there is a med missing, they will just circle it. Staff E said that she and another nurse have reported to the DON that the med aides (CMA's) aren't reporting that there are not meds in the carts. Staff E then went into the medication room. The system was hooked up to a computer. Staff E stated the nurses are able to type in the name of a resident and the medication needed and then you can get it out of the ekit. She stated that the nurses run meds for the residents and then deliver them. She said that it happened often that all of the meds are not there. Staff E said that often times with narcotics, the pharmacy will say a script was needed. Staff E stated that it could be difficult to get a script. Staff E said she honestly did not know if there was drug diversion at the facility, it's pretty scary. Staff E said that she had seen that people have signed things off and she had wondered how the CMAs have signed stuff off that the facility did not have. Staff E was unable to give any specific examples of this nor could she give a time frame. Staff E stated that Staff A and Staff C had told Staff E that night shift agency aides are not passing the meds. Staff C was really good about reporting to Staff E but Staff A didn't always report. Staff E said that Staff A would report to Staff B, but he was Staff A's son in law. Staff E stated she reported this to the DON and nothing really happened. Staff E stated that she did not want to be fired or anything but many things needed fixed. Staff E became tearful and said it's hard to work here because it's very busy and many things get missed. On 6/26/23 at 3:13 p.m., Staff I, RN Hospice stated she had brought up concerns regarding Resident #19 going through withdrawals. Staff I said the facility set her up on routine Oxycodone with the Fentanyl patch before related to Resident #19 requesting so much PRN (as needed) Oxycodone. Staff I said that with Resident #19 taking both of the meds she would still rate her pain at an 8 or 9. Staff I said that Resident #19 had a history of MS so it could be hard to tell with her because you don't know if she is masking pain. When asked who she goes through for medications, she stated they go through the facility doctor first. Staff I said that a lot of times they do things without communicating with her. Staff I stated she has to ask for an updated medication list for Resident #19. Staff I said she sees Resident #19 two times a week. When asked if she knew about Resident #19 not receiving her Fentanyl patch, Staff I stated that she would notice it would be dated for 5 days prior or not on her at all. Staff I said she had her hospice aide check the date on the patch and the hospice aide was to let Staff I know if the date was more than 3 days old or if there was no patch. Staff I stated that Resident #19 would ask Staff I if Staff I would go and see when she was due for her next dose of pain medication. Staff I stated that Resident #19 would ask more about the oxycodone and not the patch. Staff I said she had been Resident #19's case manager for almost 2 months now and that Resident #19 had went on hospice on 1/27/23 and there was a different hospice nurse case manager before Staff I. Staff I said that Resident #19 can make her own decisions and Resident #19 did have a son and a daughter that she wants us to update on her care. Staff I had a conversation with Resident #19 about missing Fentanyl patches. Staff I said that back in May she had went in and noticed that Resident #19 hadn't had one (Fentanyl patch) changed and Staff I brought it up to her and they were able to get a new one started. Staff I stated that since then Resident #19 had been able to let Staff I know if it was taken care of or not taken care of. Staff I stated that in June Resident #19 told Staff I that the Fentanyl patch wasn't being taken care. Staff I said that she spoke with the floor nurse and spoke with the ADON (Assistant Director of Nursing) and it seemed like every time Staff I would talk to somebody, they would tell Staff I they'd get the Fentanyl Patch shortly. Staff I stated she did not feel the issue got addressed. Staff I stated that the other hospice nurse spoke with the floor nurse on June 14th when the other hospice nurse noticed that the patch had not been changed and her roommate noticed the patch had not been changed. Staff I stated that she knew she was biased because them discontinuing the patch after the fact is doing her a disservice. On 6/26/23 at 4:20 p.m., Resident #19 stated that she was in pain and rated her pain at a 9 and ½. This resident was lying in bed. Stated she was feeling really bad and was going downhill fast. When asked what she meant by that she stated she just wasn't doing good. When asked about the Fentanyl patch, she said they took that off last week and told her that she didn't need it. When asked what she thought about that, she stated it really didn't help her much anyway. This resident had opened her eyes when the door was knocked on but did not open them very far. This resident did not move any extremities nor her head when she talked. When asked if staff check on her and ask her about her pain, she stated sometimes. When asked if they were checking twice a day, she stated no. When asked if she ever has no pain, she said no. When asked what the lowest her pain had been in the past few months, she stated a 6 or 7. The MAR for Resident #19 for the month of June 2023, directed staff to do a twice a day pain assessment with 0 as no pain, 1-3 as mild pain, 4-6 as moderate pain, and 7-10 as severe pain. The documentation of the pain revealed that from June 1st through June 26th this resident had pain rated four times at 7, two times at 8 and one time at a 6, the rest of the documentation revealed 0's or there were times when it wasn't filled out. On 6/26/23 at 4:30 p.m., Resident #4 was lying in bed smiling. Stated she really didn't have any pain. She was feeling pretty good. Resident #4 was wide awake and appeared happy. She asked about what time it was. The MAR for Resident #4 for the month of June 2023, directed staff to record pain on a 0-10 scale twice a day. The documentation of the pain revealed that from June 1st through the first part of June 26th this resident had 40 times the pain was not rated. On 6/27/23 at 9:15 a.m., Staff J, agency RN, stated he thought there was a Fentanyl patch on the 2nd floor downstairs for a day or so that was not put on. Staff J stated he did not put on but he did leave a note and passed it on. Staff J stated there was no way for him to get the patch. He stated he talked to day shift. He said that it was pretty complicated to talk to pharmacy on the weekend. He said he did assessments. When told about the patches that weren't placed and the time frame the residents went without a Fentanyl patch, he stated he did not know that they did not have patches for that long. Staff J stated he worked a lot on the 2nd floor (where all 4 residents resided). Staff J stated he would work a few days and then off but when he would come back he did not recall seeing any resident going a long time without a patch. Staff J stated that the CMAs do not apply Fentanyl. Staff J said that medications being not available happened quite often. Staff J stated that every time something happened when there wasn't a medication, he always left a note. Staff J stated that he would give a verbal report but he also would write the meds on the sheet and then hand it to the next shift. Staff J stated that the pharmacy says that he needs to fax when he did get a hold of the pharmacy. Staff J stated that the facility's fax was not working and on weekends the pharmacy was not available. Staff J stated that if you want to order more than one or two meds the pharmacy would say to fax the list of meds as the pharmacy preferred faxes. Staff J stated that he always made sure he put it on the sheet that they have so the day nurse would know what the situation was and then they could handle it during the day. When asked about the sheet, he stated he was not very sure where the sheet was kept. Staff J stated that they hand over a copy of it to the next nurse. Staff J stated that sometimes he would pass 8:00 p.m. meds but most of the time it's a CMA. Staff J stated he didn't know about Resident #21's Percocet. Staff J stated that he felt the residents received good care and he thought the communication with the pharmacy was the biggest concern. On 6/27/23 at 9:45 a.m., Staff E stated she did not know where the pharmacy book was in the back (2nd floor). She stated she wasn't sure what they did when the nurses and CMAs filled out the sheets with the meds that are needed. Staff E said she didn't see the book and she thought the sheets might just get thrown away. She pulled a couple of sheets out of the box with things that needed to be shredded. On 6/27/23 at 10:25 a.m., Staff E pulled 2 more pharmacy sheets out of the box when asked if there were any more sheets in the box. On 6/27/23 at 9:50 a.m., Staff H, Licensed Practical Nurse (LPN), stated the facility got a new machine and it copies and prints but it doesn't fax. Staff H stated she had developed a process with the pharmacy where you have an encryption code so the emails between Staff H and the pharmacy can go between us without HIPPA violations. Staff H stated that she had been doing this for 2 months. Staff H stated she receives sheets from the CMAs and on Mondays, Tuesdays, and Wednesdays Staff H forwards the sheets on to the pharmacy and then writes emailed to pharmacy and the date and time. Staff H stated she then puts the sheets into the pharmacy book. Staff H stated that she only worked on the 1st floor. Staff H state the process to get medication was the doctor writes out the order for her on a script, then she would take a picture and email to the pharmacy, after that she documented in the electronic health record to make it an active order. Staff H stated she would usually then call the pharmacy and let them know that she had put in an active order and she would pull a couple of doses of the medication so that they could cover the first couple of doses that needed to be given. Staff H stated that not all nurses have access to their medication system. She stated that sometimes they have agency nurses and the agency nurses cannot get into the facility's medication system. Discussed Resident #19's medication and Staff H stated that Resident #19 had been in pain since she has been here. Staff H stated that Resident #19 should not go without her pain medication. Staff H said that Resident #19 was so frail and pale and always looked like she was in pain. When told the pain level had been signed often as no pain for this resident, Staff H stated that was not right. Staff H stated what she thought staff were doing was seeing if Resident #19 was sleeping and marking it 0, they should be asking her. Staff H said that Resident #19 needed her pain medication. Staff H stated that hospice staff could call the pharmacy too and Staff H stated she did not know why agency nurses wouldn't just call the pharmacy. Staff H stated if they are writing down on the sheet that there was not a med available then it should be in the pharmacy book down there. They should be putting those sheets in to the pharmacy book and those papers should not be shredded. Staff H stated that usually on Mondays there are a lot of meds to order. Staff H stated that she just called the pharmacy and asked them how could she get the meds without a fax and they said she could use her own email but she would need to use their encryption. Staff H stated that's what she did. Staff H stated she did not want to put down the company but they had people running to another facility to fax orders because their facility couldn't get the meds. On 6/27/23 at 11:32 a.m., Staff K, CMA/CNA, stated that it did happen when meds were not available. Staff K stated she circled her initials on the MAR's when meds were not available. Staff K stated that she actually asks her nurse if the med is printable, meaning they can get it from the medication system, but if not to circle it and write a note on 24 hour report. When asked how often she thinks this happens, she stated daily. She stated it had gotten better because they had a new ADON who listens. Staff K stated that they tell the resident when we don't have a med for them and most of the time they are not surprised, unless it's a pain med, anti coagulant (blood thinner), anti anxiety, etc. Staff K stated they have one resident who gets upset if he did not get his oxycodone (pain medication), Lyrica (blocks pain signals in nervous system), or Clonazepam (anti-anxiety). Staff K sated that it took time but they were able to get it for him because they would call the pharmacy and the on call physician and get it pulled. Staff K stated that sometimes the on call doctor doesn't answer and sometimes the pharmacy doesn't answer. On 6/27/23 at 12:03 p.m., Staff L, RN stated she passes medications when they need someone. Staff L stated she would just get meds out of their medication system if she needed a med. She stated she has had trouble with the system jamming. Staff L stated she leaves at 10:30 p.m. and asks prior to leaving if anybody needs anything. Staff L stated she worked noon to 10:30 p.m. Staff L stated that they were checking every night now, they check the MARS and TARS they have to sign. Staff L, RN stated she knew that medications not being available was a problem and they had been working on it real hard. Staff L stated that the facility lost a couple of nurses about a month ago and then it wasn't brought to our attention. Staff L stated after that she went to check not too long ago for gaps and that's when she noticed it was a couple weeks ago. Staff L stated she had no clue that Resident #21 went without Percocet. Staff L stated that they could have called the on call providers. Staff L stated that they can get a hold of pharmacy 24 hours a day and they could get a hold of a physician 24 hours a day. Staff L stated that there was always 2 nurses in the facility so any of them can call and get medication. Staff L stated that they had trouble with faxing a while back. Staff L stated that it was routine orders that the facility had trouble with getting. Staff L stated she did not know who would tell Resident #21 they couldn't get the Percocet. Staff L stated they could always get Percocet. When told that Resident #21 said he was in pain during the time he did not receive the Percocet, Staff L nodded understanding and stated that she was somewhat related to Resident #4, and he will always tell you he has pain. Staff L stated that Staff E, Staff H, and Staff B, all know what to do (how to retrieve medications). Staff L stated that no one ever told her that the facility was out of narcotics for residents, until the facility caught it. Staff L stated that Resident #19 had been on narcotics about 7 months. Staff L stated that Resident #19 is in pain now and stated that Resident #19 was addicted. Staff L said that the meds are available. She stated that staff could also call the ADON, the DON, or Staff L and they would come in and get the meds for the staff. Staff L stated that pretty much every day that she works she takes meds out of the facility's medication system. On 6/28/23 at 9:02 a.m., Staff I called and wanted to give an update on Resident #19. She stated she wanted to give an update on Resident #19's pain. Staff I stated that Resident #19 was rating her pain at a 9 out of 10 and described it as sharp and throbbing. Staff I stated that Resident #19's roommate had piped up and said that Resident #19's moaning and groaning through out the night. Staff I stated she felt Resident #19's pain

Based on clinical record review, family, physician, and staff interviews, and policy review, the facility failed to ensure a resident's pressure ulcer did not worsen through following physician orders and accurately assessing the need for further medical intervention for 1 of 1 residents reviewed (Resident #3). This resulted in harm to the resident due to a boggy heel worsening to a Stage 4 pressure ulcer with bone infection and a prolonged hospitalization . Findings include: The Minimum Data Set (MDS) assessment dated [DATE] of Resident #3 identified a Brief Interview of Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment. The MDS revealed the resident was independent with no setup help needed for bed mobility. The MDS revealed the resident required limited assistance with help of 1 staff member for transfers. The MDS documented diagnoses that included diabetes, heart failure, non Alzheimer's dementia, and malnutrition. The current Comprehensive Care Plan of Resident #3 with a Target Date of 5/18/2023 failed to reveal any documentation of the resident being at risk of skin impairment or having any wounds. The Care Plan failed to document any interventions for skin integrity or treatment of any skin wounds. Determining the Stage of Pressure Injury MDS Skin Assessment Tool: Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. On 11/30/22 at 4:59 PM, the MDS Coordinator documented an open area to Resident #3's right heel which was draining. Orders were received on 12/1/22 for daily wound care with dressing changes to the wound. On 12/9/22 at 1:11 AM, Staff E, Registered Nurse, documented in a Skin Observation Tool note she removed a dressing from the resident's wound dated 12/1/22. The note documented the wound had purulent, foul smelling drainage and the resident's skin going up the back of her calf was red and warm (signs of infection). This was the only Skin Assessment documented on the resident during her time at the facility. On 12/9/22 at 12:24 PM Staff A, ARNP, documented Resident #3 was seen for assessment of a right heel wound which was reported to have odor and pus discharge. On 12/9/22 at 5:41 PM the Assistant Director of Nursing (ADON) documented new orders had been received for an antibiotic related to the foot wound for Resident #3. On 1/23/23 at 9:53 PM the Director of Nursing (DON) documented she called Resident #3's daughter and informed her the resident had tested positive for COVID. She also discussed the resident's wound with her at this time, need for antibiotic and a wound culture. On 1/24/23 at 5:19 PM, Staff C documented she informed Resident #3's daughter, the Resident was now on two antibiotics, was weak and shaking. On 1/24/23 at 5:24 PM, Staff C documented Resident #3's daughter requested the Resident be sent to the hospital. On 1/25/23 at 4:50 PM, Staff C documented Resident #3 was admitted to the hospital, had one surgery on her right heel and was scheduled for a second surgery the next morning. The facility wound care physician had an initial visit with the resident on 12/14/22. She noted the size of the wound to be 8 cm 8 x cm by a non measurable depth. At that time, the wound was 30% necrotic (non viable, dead tissue) and 70% eschar (dried necrotic tissue). The wound care physician assessed the wound weekly and gave orders for daily wound care treatments to be completed by the facility staff. Each week the wound notes reflected the wound to be a non measurable depth. Recommendations were made to float her heel when in bed, to wear a prevalon boot, and reposition per facility protocol. On the weekly visit on 1/20/23, the wound was noted to have deteriorated. On 4/10/23 at 12:45 PM, a family member of Resident #3 stated the resident was still hospitalized from being sent to the hospital on 1/24/23 from the facility and the wound on her heel was the reason for the prolonged hospitalization . On 4/12/23 at 2:14 PM a family member of Resident #3 stated the resident had 4 surgeries so far during the prolonged hospitalization including bone grafts. She stated more surgeries were likely going to be needed in the future and the resident currently had a wound vac on the wound. She also stated the facility had never contacted her regarding this wound until a few days prior to the hospitalization . On 4/13/23 at 8:05 AM the Director of Nursing (DON) stated her expectation if a wound is found on a resident is to report that to the Assistant Director of Nursing (ADON) who also acts as the facility skin/wound nurse. Further her expectation is to notify the nurse practitioner or physician and get orders and interventions in place. At the time of a new wound being found, she stated her expectation to be the wound to be measured and documented using a Skin Assessment and documented weekly. On 4:13/23 at 9:45 AM the ADON stated the nurse who was first aware of a wound is expected to measure and document the wound and to notify the physician and obtain orders and to initiate for the wound physician to begin weekly visits. On 4/13/23 at 10:30 AM the MDS Coordinator stated she was working the floor on 11/30/22 when one of the Certified Nurse Aides told her about the heel wound on Resident #3. She stated she remembered looking at the wound and telling the ADON about it. She also said the normal procedure if a new wound was found is to note the location and measurements of the wound and give that information to the ADON. The ADON would then notify the facility medical director or wound doctor and get orders and notify the family. On 4/13/23 at 2:50 PM, Staff A, ARNP stated she recalled one of the staff nurses informing her initially the heel was boggy. She ordered a wound culture and initiated antibiotics. She stated she initiated the wound doctor to begin seeing the Resident. On 4/13/23 at 4:05 PM Staff E, Registered Nurse (former employee) stated she worked the overnight shift at the facility. She stated she was unaware of the resident's wound until 12/9/22 and had never been told about it in report. She said one of the CNA's mentioned it to her and asked her to assess it. She stated she could smell it when she entered the room and it smelled like gangrene. She removed a the dressing which was dated 12/1/22. It had a horrid odor and slough was present. She stated she sent faxes to the wound physician and the primary care physician and reported to the day shift the Resident needed to be seen immediately and notified the DON. Staff E said the lack of care the residents in the facility get is why she is no longer an employee. She described the care as horrific. She said when she would arrive to work the night shift, multiple day shift medications were often not given. She noted the resident was a night owl and often would not go to bed until the middle of the night and normally had a sock and a shoe on her foot. Her other leg was amputated and she used that foot to self propel in her wheelchair. She stated she did not have any heel protectors or any preventatives in place for the wound until she initiated them the early morning hours of 12/9/22. On 4/14/23 at 2:11 PM Staff C, LPN stated the first time she saw the heel wound on the Resident it was just boggy and had treatments for betadine. She said for the next several weeks she was scheduled on the other side of the building and did not care for the resident during that time period. When she was next scheduled on the hall the Resident resided on, the wound had significantly worsened and the smell from the wound was present in the hallway. This was on 1/24/23 and she then sent the resident to the hospital. She stated the normal protocol for a new wound is to get orders for a dressing and treatment and place and note in the box for the physician to assess on next rounds to the facility. A skin assessment should be placed in the Electronic Health Record. On 4/14/23 at 3:08 PM, Staff F, ARNP stated she was aware of the resident but did not know her well. She stated the resident had comorbidities of diabetes and poor nutrition and heart failure and often refused cares. She stated she felt the development of the wound was not avoidable due to comorbidities and behaviors. On 4/14/23 at 3:52 PM the Wound Care Physician state the wound was very advanced upon her initial assessment of the Resident. She stated during her visits she provided education to the resident to elevate the heel. She was aware the resident did refuse treatments at times. She stated with the resident's diabetes and history of a similar wound leading to amputation on her other leg that complications were likely for the Resident. On 4/18/23 at 9:10 AM, a hospital physician who has cared for the resident throughout the hospitalization stated upon admission to the hospital the wound was a Stage IV pressure ulcer with bone being visible. She stated it may have started out as a diabetic foot ulcer and progressed to a Stage IV pressure wound. She stated she would consider Resident #3 to be a high risk for development of wounds due to her history of this type of wound, her diabetes, and her behaviors. She stated in her medical opinion, Resident #3 should have been hospitalized earlier than she was and surgical intervention was needed earlier. She felt the initial development of the wound was likely not avoidable but a higher level of treatment should have been sought earlier than it was. On 4/18/23 at 10:50 AM, the DON stated the facility has weekly Risk meetings and skin issues are discussed. She stated the facility has no policy regarding doing regular foot checks on diabetic patients. She stated her expectation if a resident refuses cares is to re-approach the resident later in the shift. If the resident continues to refuse cares the Nurse Practitioner should be notified and follow up with the resident. On 4/18/23 at 11:10 AM, the Registered Dietitian stated she was only aware the resident had a wound on her foot which required antibiotics. She stated she was not aware it was a pressure wound or that it was severe. She stated during the time frame Resident #3 admitted to the facility weekly skin assessments were not being done which is against corporate policy. She stated this is something the DON has been working on but while it's improving it's still a work in progress. She stated wounds are discussed in weekly meetings but she normally attends via telephone and the discussion is normally very brief and not detailed. On 4/18/23 at 12:45 PM, the Therapy Coordinator stated Resident #3 was very non compliant. She frequently refused therapy due to the pain from the wound. He stated he has seen dressings on residents dated several days old and seen residents not wearing pressure relieving boots as they are supposed to. He further stated he has had conversations with multiple staff regarding these issues. The policy Skin Evaluation dated 12/28/22 included the following points: Residents will have a head to toe skin evaluation performed and documented on a routine basis. Any skin abnormalities identified through this evaluation may be documented in Interdisciplinary Notes. The Unit Manager/Wound Nurse will review and sign the Skin Observation Tool if documented manually. The signature indicated follow up, documentation and care plan interventions have been implemented. 46873

Based on clinical record review, observations, and resident and staff interviews, and policy review, the facility failed to consistently provide and document skin and other assessments, failed to consistently provide and document physician ordered treatments (including dressing changes) and medications (including but not limited to diuretics, heart medications, insulin, and antibiotics), and obtain and document daily weights. Due to these failures Resident #101 underwent three hospital admissions for such conditions as [CONDITION(S)], congestive heart failure, maggots in his wounds, [CONDITION(S)], urinary tract infection, and [CONDITION(S)]. The resident passed away in the hospital after the emergent transfer on 9/24/21. These factors constituted an Immediate Jeopardy to resident health and safety. The facility reported a census of 50 residents. Findings include: 1. The admission Minimum Data Set (MDS) assessment tool dated 7/19/21 revealed Resident #101 admitted to the facility on [DATE] from the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident scored 13 of 15 possible points on the Brief Interview for Mental Status (BIMS) test, which meant the resident demonstrated intact cognitive abilities. The MDS revealed the resident required extensive assistance of one staff for transfers, ambulation (walking), dressing, personal hygiene, toilet use, and bathing. The MDS documented Resident #101 as at risk for pressure ulcers although he had no skin conditions or issues during the 7 day lookback period (07/13/21 - 7/19/21). The MDS also documented the resident experienced shortness of breath (SOB) upon exertion, when lying flat and at rest, used oxygen, and took no medications such as diuretics. The 5 day MDS assessment dated [DATE] revealed the resident admitted from the hospital 8/9/21 and had difficulty walking and weakness. The MDS documented the resident had no skin conditions and took no medications such as diuretics or antibiotics during the 7 day lookback period (8/10/21 - 8/16/21). The MDS assessment dated [DATE] revealed the resident readmitted to the facility on [DATE] from the hospital. The resident had a BIMS of 11 (moderately impaired cognitive abilities). The MDS documented the resident required extensive assist of 1 staff for bed mobility and extensive assist of 2 staff for transfers, toilet use, and bathing. The MDS revealed the resident had open [CONDITION(S)] other than ulcers, and took a diuretic during all 7 days of the lookback period. The care plan initiated on 7/23/21 revealed the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The staff directives included give cardiac and antihypertensive medications as ordered, monitor vital signs, and notify the physician of significant abnormalities. Other interventions included monitor/document/report as needed (PRN) any signs or symptoms of CHF such as dependent [CONDITION(S)] of legs and feet, SOB upon exertion, weight gain unrelated to intake, crackles and wheezes upon auscultation of the lungs, increased heart rate, lethargy, and disorientation. The care plan also documented the resident had potential/actual impaired skin integrity related to fragile skin. The staff directives included encourage good nutrition and hydration in order to promote healthier skin, and follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The staff directives included to weigh resident weekly for 4 weeks, then monthly unless ordered otherwise, and monitor and report significant weight loss of 3 pounds (lbs.) in one week. The electronic health record (EHR) census list revealed Resident #101 admitted to the facility on [DATE], admitted to the hospital 8/4/21, readmitted to the facility 8/9/21, admitted to the hospital 8/21/21, readmitted to the facility 8/26/21, and admitted to the hospital 9/24/21. Review of hospital discharge orders dated 7/12/21 revealed Resident #101 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Discharge orders directed staff to weigh Resident #101 daily, complete vital signs per facility guidelines, give medications as prescribed, and call the physician if the resident gained 3 lbs., or exhibited SOB, or any other symptoms. The document included the following education regarding heart failure: -Heart failure means the heart muscle doesn't pump as much blood as the body needs. -Fluids start to build up in the lungs and other parts of the body and cause SOB at rest, swelling/[CONDITION(S)] in the legs, ankles, and feet, weight gain over a day or two, and feeling bloated. -treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nursing Admission Screening assessment dated [DATE] revealed the resident admitted to the facility for therapy with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment documented the resident weighed 171.5 lbs., had normal lung sounds, and had no pitting [CONDITION(S)]. Staff had left blank the assessment area under Section L. A Pressure Injury Risk assessment dated [DATE] documented a score of 13, which meant the resident had a moderate risk for developing a pressure ulcer. The medication administration record (MAR) dated 7/1 - 7/31/21 lacked documentation of the following: -No diuretic listed on the MAR. -No daily weights from 7/13 - 7/31/21 -No [MEDICATION(S)] (medication for cholesterol) administered on 7/14-7/16, and 7/30/21 -No [MEDICATION(S)] (for [CONDITION(S)]) administered on 7/30/21 x 1 dose -No [MEDICATION(S)] nebulizer treatment administered on 7/12/21 x 2 doses, 7/13/21 x 2 doses, and 7/31/21 x 1 dose. In addition, staff had circled their initials 8 times with regard to the scheduled [MEDICATION(S)] medication, but failed to document the description or reason why they held or did not give the medication as ordered on the reverse side of the MAR or in the medical records. The MARS dated 8/1 -8/31/21 had admitted s 7/12/21, 8/9/21, and 8/26/21. The MARS lacked documentation for the following: No daily weights 8/1, 8/2, 8/11-8/21/21, 8/27, 8/29, 8/30/21 No [MEDICATION(S)] (antibiotic) twice a day (BID) for [CONDITION(S)] on 8/14/21 x 1 dose ([MEDICATION(S)] ordered on 8/13/21) No sulfa for infection on 8/27/21 x 2 doses (sulfa ordered on 8/27/21 but NA (not available) circled on [DATE]/27/21) No [MEDICATION(S)] for [CONDITION(S)] on 8/1- 8/4/21, and 8/27/21 No [MEDICATION(S)] on 8/1 - 8/4/21 No [MEDICATION(S)] (diuretic) 20 milligrams (mg) on 8/19/21 No [MEDICATION(S)] nebulizer treatment administered 8/14/21 x 2 doses, 8/19/21 x 2 doses. The MAR dated 9/1- 9/30/21 lacked documentation for the following: No daily weights - 9/8/21, 9/11/21, 9/14/21, 9/19/21, 9/22/21 No [MEDICATION(S)] on 9/19/21 No potassium chloride on 9/14/21 and 9/19/21. No [MEDICATION(S)] given 9/19/21 (AM dose) and 9/22/21 (PM dose) No [MEDICATION(S)] 40 mg given on 9/19/21 No [MEDICATION(S)] nebulizer treatments 9/11/21 x 1 dose, 9/19/21 x 3 doses, 9/20/21 x 2 doses, 9/22/21 x 1 dose, 9/23/21 x 3 doses The treatment administration record (TAR) dated 7/1 - 7/31/21, 8/1-8/31/21, and 9/1-9/20/21 lacked documentation for the following: No entry for oxygen tubing change 7/13/21-7/31/21 No oxygen tubing change on Wednesdays 8/11/21, 8/18/21 No [MEDICATION(S)]/[MEDICATION(S)] ointment to left eye 7/12-7/15, 7/19/21, 8/3, 8/10, 8/11, 8/13-8/16, 8/18, 8/27/21 (total of 18 of 40 doses not administered). In addition, staff initials circled 6 times but no description or reason documented on reverse side of MAR or in the medical records why medication not administered. Treatment to cleanse bilateral lower extremities (BLE) and cover with Kerlix daily for [CONDITION(S)] (started 8/14/21) left blank /not done on 8/14, 8/17, 8/27, 8/30, 8/31/21, 9/1, 9/3/21 Treatment to cleanse BLE with soap and water, apply ABD pads to absorb drainage from legs, Kerlix, and secure with [MEDICATION(S)] BID- left blank/not done on 9/11, 9/12, 9/16, 9/17, 9/18, 9/19, 9/20, 9/22, 9/23/21 = total of 9 of 34 times not documented/done Assess left arm for sign/symptoms of infection and note appearance BID and change dressing PRN -left blank /not done 6 out of 20 times on 9/16, 9/18. 9/19, 9/22, 9/23, 9/24/21 Staff B wrote on TAR new order to cleanse BLE daily and apply A & D ointment, cover with ABD pads, wrap with Kerlix and ace wraps per nursing order, but entry not dated and had no initials for dates when the treatment completed. The MAR and TAR lacked documentation for weekly skin assessments. The EHR lacked documentation for skin observations or weekly wound assessments. The monthly bath/shower schedule revealed Resident #101 admitted on [DATE] and scheduled for shower on Wednesdays and Saturdays on the 6-2 shift. The schedule revealed no bath or shower given 7/12 - 7/20/21, or 8/7/21. The Shower Day Skin Audit forms documented no skin abnormalities, open areas, unusual skin conditions, or reddened areas 7/24/21, 7/28/21, 9/6/21, 9/13/21, 9/16/21, and 9/23/21. The shower skin audit form 9/11/21 documented the resident had an abrasion, skin tear, and unusual redness but no nurse signature listed as reviewed the report and looked at the skin issues noted by the certified nursing assistant (CNA). The records lacked shower day skin audit forms for the month of 8/2021. The EHR revealed the following weights recorded: 7/12/21 at 4:11 PM 171.5 lbs. 7/20/21 at 12:22 PM 171.0 lbs. 7/27/21 at 10:53 AM 192.5 lbs. 7/28/21 at 4:04 PM 179.5 lbs. 8/12/21 at 11:25 AM 176.6 lbs. 8/20/21 at 2:07 PM 176.0 lbs. 9/3/21 at 3:33 PM 184.6 lbs. 9/5/21 at 2:10 PM 189.2 lbs. A chest x-ray (CXR) report dated 7/18/21 revealed the resident had SOB and low oxygen saturations. The findings revealed hyper expanded lungs that could be seen in [CONDITION(S)], a small right pleural effusion, and evidence of pulmonary congestion. The CXR also showed scattered bilateral opacities compatible with pulmonary [CONDITION(S)] versus atypical infection. Daily skilled summary notes included the following: On 8/2/21 temperature (T) 98.3, pulse (P) 64, respirations (R) 20, blood pressure (B/P) 138/74, pulse oximeter (PO) 95%. The resident had generalized scabs (no location listed) but no open areas, and pitting [CONDITION(S)] to BLE's. Weight stable. On 8/3/21 - same vital signs listed from 8/2/21. Resident had generalized scabs, no open areas, and pitting [CONDITION(S)] to BLE's. Weight stable. On 8/4/21 - same vital signs listed from 8/2/21. Resident had open areas, generalized scabs, and pedal [CONDITION(S)]. Weight stable. An Emergency Department (ED) provider note dated 8/4/21 revealed the resident presented to the ED with bilateral leg swelling and leakage, and the swelling had spread to his abdomen. The resident denied chest pain, SOB, or chills. Weight 189 lbs. The resident had 3+ [CONDITION(S)] to lower legs extending to his abdomen. The resident previously hospitalized ,d+[DATE] - 7/12/21 for CHF exacerbation and [CONDITION(S)]. Ejection fraction 30 %. No diuretic listed on patient medication list although there is reference he was on [MEDICATION(S)] (diuretic) in the discharge summary. A chest x-ray showed worsening CHF with pulmonary [CONDITION(S)] vs. superimposed pneumonia and probable small right pleural effusion. Treatment included IV [MEDICATION(S)] drip. An After Visit Summary dated 8/9/21 revealed an order to start taking [MEDICATION(S)] ([MEDICATION(S)]) 40 mg BID and potassium chloride 20 milliequivalents (meq) daily. A medication list included the medications to start and the medications to continue, except no [MEDICATION(S)] listed. Care instructions included to take medications as prescribed, weigh daily, and call physician if resident had weight gain 2-3 lbs. in a day or 5 lbs. in a week. The Nursing Admission Screening assessment dated [DATE] revealed the resident admitted to the facility from the hospital with heart failure. The assessment indicated the resident had normal lung sounds, slight pitting [CONDITION(S)], lower extremity swelling, and scabs to his upper and lower extremities. Weight 179.5 lbs. A physician order dated 8/13/21 revealed to start [MEDICATION(S)] 40 mg for 5 days, then [MEDICATION(S)] 20 mg daily, start [MEDICATION(S)] 500 mg BID for 10 days for [CONDITION(S)], cover open areas on BLE's, and wrap with Kerlix daily until healed. The progress notes revealed the following: a. On 7/13/21 at 3:12 PM, nurse practitioner (ARNP) saw resident on 7/12/21 after resident admitted to the facility from the hospital. Resident seen in the ED on 7/5/21 for weakness and falls. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident had history of diabetes type 2, [CONDITION(S)], and coronary artery bypass graft (CABG). No lymphadenopathy or bruising noted. Lungs clear to auscultation. Plan included to perform skin checks per protocol. b. On 7/17/21 at 3:33 AM, resident awake most of the night and needed encouragement to lay down and wear oxygen as his oxygen level dropped whenever he got up without oxygen. c. On 7/17/21 at 10:54 AM, staff found resident on floor lying on his right side with a large amount of blood from his right forehead. Assessment done. Sent to the ED. d. On 7/18/21 at 10:15 AM, resident complained of SOB and feeling trapped in his body. B/P 112/58, T 97.7, P 53, R 24, PO 87% on oxygen at 3 liters per nasal cannula (L/NC). Resident refused to go to the ED. ARNP notified and ordered a stat CXR. e. On 7/18/21 at 12:00 PM, ARNP notified of CXR report and ordered [MEDICATION(S)] 40 mg for 5 days. f. On 7/19/21 at 7:47 PM, seen by ARNP due to SOB and [CONDITION(S)]. CXR on 7/18/21 showed [CONDITION(S)] exacerbation, scattered opacities, and a small right pleural effusion. Order to continue [MEDICATION(S)]. g. On 7/27/21 at 4:15 AM, antibiotic arrived early this AM and will start on day shift 7/27/21. Drainage continues at this time. h. On 8/2/21 at 3:37 AM, has BLE [CONDITION(S)] 1+. Resident encouraged to elevate extremities. i. On 8/4/21 at 5:50 PM, resident admitted to hospital for exacerbation of CHF. j. On 8/5/21 at 11:20 AM (late entry), certified medication aide (CMA) brought to nurse's attention the resident appeared to be filling up with fluid. Resident had [CONDITION(S)] up past abdominal area. ARNP notified and order received to send resident to the ED for evaluation. K. On 8/10/21 at 5:41 AM, resident on oxygen at 3 L/NC. Pulse ox 92 %, lungs sound clear. On nebulizer treatment every 4 hours. Has 2-3+ pitting [CONDITION(S)] and redness to lower legs. l. On 8/11/21 at 5:45 AM, resident encouraged to elevate BLE but noncompliant. BLE reddened, has 2-3 + pitting [CONDITION(S)], and legs draining serous fluid. j. On 8/13/21 at 8:22 PM, seen by ARNP for increased [CONDITION(S)] to BLE and weeping from open areas. Has pitting [CONDITION(S)] 3+ to BLE. Weeping clear fluid to the point his socks are saturated. Skin around open area had redness and warmth. diagnosed with [CONDITION(S)] to bilateral lower limbs. New orders included: [MEDICATION(S)] 40 mg daily for 5 days, then [MEDICATION(S)] 20 mg daily. [MEDICATION(S)] 500 mg BID for 10 days for [CONDITION(S)]. Cover open areas to BLE and wrap with Kerlix daily until area healed, monitor [CONDITION(S)], vital signs per protocol, and skin checks per protocol. k. On 8/20/21 at 8:29 AM, seen by ARNP. New order for [MEDICATION(S)] 40 mg BID. l. On 8/21/21 at 11:29 AM, Staff B, Licensed Practical Nurse (LPN), called to the shower room. Resident #101 sat in a shower chair, dressing from lower legs and feet lying on floor. Dressing saturated with yellow fluid and smelled strongly of ammonia, and covered with maggots. Maggots observed in various stages of growth on resident legs and heels bilaterally. The dressing removed had date 8/17/21. Corporate Nurse and ARNP notified. Order received to send to the ED for evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Sent to the ED. m. On 8/22/21 at 11:40 AM, resident admitted to hospital for wound care. On IV [MEDICATION(S)] and [MEDICATION(S)] (antibiotics for bacterial infections), and wound care consulted. n. On 8/29/21 at 8:39 PM, seen by ARNP on 8/27/21 for readmission to facility. Resident sent to ED on 8/21/21 after staff reported a strong ammonia smell and maggots to BLE. Treated with IV antibiotics and returned to the facility. Plan included orders to continue [MEDICATION(S)], wound cares as ordered, [MEDICATION(S)] as ordered, and skin checks per protocol. o. On 9/2/21 at 3:20 PM, attempted to place bilateral foam boots on resident to offload due to feet on pedals and he requested a blanket under his feet. p. On 9/3/21 at 6:48 AM, left heel wound 3 centimeters (cm) x 3 cm open area and behind right great (toe) a 1.4 cm x 1 cm superficial area. q. On 9/5/21 at 2:12 PM, BLE weeping secondary to [CONDITION(S)]. BLE cleansed with wound cleanser, A & D ointment applied to BLE's and ABD pads wrapped around calves, then rolled gauze and ace bandages applied to aide with [CONDITION(S)]. Resident encouraged to elevate his legs but he reported it is painful. r. On 9/14/21 at 2:00 PM, resident has bilateral [CONDITION(S)] in lower extremities. Lower legs weeping and treated BID. s. On 9/20/21 at 6:55 PM, seen by ARNP for [CONDITION(S)] and CHF. [CONDITION(S)] worsened. Staff reported resident drinks fluids constantly and not always compliant with keeping legs elevated. Has 3+ pitting [CONDITION(S)] to BLE and weeping clear fluid. Lung sounds clear. Plan included: start 1500 ml fluid restriction, [MEDICATION(S)] as ordered, vital signs per protocol, and monitor [CONDITION(S)]. t. On 9/24/21 2:40 AM, resident had notable change in status. Complained of nausea, respiratory effort increased, increased fluid retention, and had decreased level of consciousness. Vital Signs included T 96.6, P 42, R 24, B/P 90/58; ARNP notified via phone and message left. Family notified. Transferred to the hospital. Daily skilled summary included the following: a. On 8/19/21, resident had open areas but no pressure ulcers. NA (not applicable) documented under section 4b for wound assessment. Resident had pedal [CONDITION(S)] but weight stable. The assessment lacked lung sounds and location of open areas. b. On 8/20/21, resident had open areas with generalized scabs, and pitting [CONDITION(S)] to BLE's. The bilateral lung bases had wheezing on expiration. The EHR/paper chart lacked a daily skilled summary assessment on 8/21/21. A physician order dated 8/21/21 directed staff to send resident to the ED for evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] An ED provider note dated 8/21/21 revealed the resident presented to the ED for evaluation of lower extremity pain from his feet to his upper lower legs, wounds, and increased drainage to his lower legs. A few open areas had purulent drainage, and had macerated areas between his toes on bilateral feet. Resident reported uncertain how long he had wounds but had increased redness and pain to his lower extremities. The resident reported his legs had only been wrapped once at the nursing facility. EMS reported concern for maggots to his lower extremities. Resident admitted to hospital for BLE [CONDITION(S)] with open wounds. IV antibiotics [MEDICATION(S)] and [MEDICATION(S)] administered, and a wound nurse consulted. A hospital history and physical dated 8/21/21 revealed the resident sent to the ED with lower extremity wounds. The resident complained his legs were very painful the past couple of days. The resident told the physician his legs had only been wrapped once at the nursing facility. EMS brought the resident to the ED, and reported maggots but no maggots observed by ED staff. BLE's had [CONDITION(S)] with open wounds, maceration around the toes, and purulent drainage. Weight 185 lbs. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Treatment included IV [MEDICATION(S)] and [MEDICATION(S)], [MEDICATION(S)] 40 mg BID, oxygen at 2 L/NC, and wound consult. The resident was previously hospitalized ,d+[DATE] - 8/9/21 for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's verbal order dated 9/7/21 included to cleanse bilateral legs with soap and water, paint left great toe and bilateral heels with [MEDICATION(S)], and apply ABD pads to absorb drainage from legs from shin to knees, apply Kerlix, and [MEDICATION(S)]. Specialty Wound Physician notes documented the following: a. On 7/22/21, resident had a bruise/contusion to right upper arm and a wound (2 cm x 1 cm x 0.2 cm) to the side of his nose due to eye glasses. No [CONDITION(S)] to LE's. b. On 8/12/21, resident status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Right distal elbow wound resolved. c. On 8/19/21, resident asked about swelling in his legs. BLE's had severe [CONDITION(S)], heavy weeping, and the dressings on his legs soaked. No evidence of any open areas. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Treatment recommendations included elevation of legs, utilize absorbent pads with Kerlix wrap dressings, monitor for moisture associated wounds given the large amount of weeping, and consider compression with [MEDICATION(S)] to LE's BID. d. On 9/2/21, resident had a left posterior ankle wound 2 cm x 3 cm x immeasurable. The wound had heavy serous drainage and black necrotic tissue to the wound bed. He also had an unstageable pressure wound to his right lateral first toe 1.5 cm x 1.5 cm with 90 % necrotic tissue. Recommendations included to float heels, elevate BLE's, and apply [MEDICATION(S)] socks every AM. e. On 9/9/21, BLE's had moderate [CONDITION(S)] and stasis [CONDITION(S)]. Wounds and moderate [CONDITION(S)] present. Right lateral first toe wound resolved. The left posterior heel wound measured 2 cm x 3 cm and had 50 % black necrotic tissue. Right anterior knee wound measured 2 cm x 1.5 cm x 0.1 cm and had moderate serous drainage. Right proximal medial shin wound measured 1 cm x 2 cm x 0.1 cm and had moderate serous drainage. Left anterior knee wound measured 1.5 x 1.5 x 0.1 cm and had moderate serous drainage. Daily skilled summary assessment notes dated 9/20/21 and 9/23/21 revealed resident had fragile skin and open areas. The assessment included under Section 4-2b regarding skin condition to see skin sheets. BLE had arterial ulcers and [CONDITION(S)]. An ED provider note dated 9/24/21 revealed resident brought to the ED by EMS for wet lungs and 4+ pitting [CONDITION(S)]. The resident had diminished lung sounds bilaterally, and chronic bilateral leg wounds. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A hospital history and physical note dated 9/24/21 revealed the resident presented to the ED (on 9/21/21) for complaint of SOB, [CONDITION(S)] (heart rate 40-50's), and [CONDITION(S)]. The resident had wounds on bilateral leg and pitting [CONDITION(S)] from his abdomen to his extremities. Weight 187 lbs. CXR showed a small pleural effusion and mild pulmonary [CONDITION(S)] or atypical infection. A hospital discharge summary dated 9/30/21 revealed Resident #101 passed away on 9/30/21. In an interview 10/28/21 at 10:45 AM, Staff L, agency CMA, stated she had worked at the facility 3 months. Staff L reported Resident #101 had a lot of wounds all over his hands, face, and arms. The resident had a hard time breathing and incoherent at times. Some weeks he barely would eat food or drink fluids, then other times he would [NAME] himself with food and fluids. Staff L stated she assisted the nurse whenever a treatment and bandages applied to his legs. The resident had [CONDITION(S)] in his buttocks and legs, and his legs had fluids that seeped out. In an interview 11/01/21 at 10:25 AM, the Director of Nursing (DON) reported skin assessments documented weekly on the TAR if a resident had no skin issues. The DON stated she expected staff document in the EHR a weekly wound assessment or use the skin observation tool if resident had a skin concern noted. In an interview 11/1/21 at 2:35 PM Staff B, Licensed Practical Nurse (LPN) reported she had worked at the facility since 7/2019. Staff B stated each resident supposed to have a skin assessment performed at least weekly, and skin assessment typically performed during resident cares or on their shower day. Staff B reported skin assessments documented in the treatment book by initialing the TAR if no areas of concern identified. If a skin issue or concern noted, then the nurse documented a skin note in the nursing progress notes on the EHR. Staff B stated if a resident had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff B stated obtaining weights considered a nursing intervention, and no physician order needed for weights. Staff B stated the CNA's wrote weights on paper and the nurse recorded the weights on the TAR, but the nurse had to remind staff to obtain weights on residents. If a resident took a medication such as [MEDICATION(S)] prior to going to the hospital, and returned to the facility not on a diuretic medication, it would be a red flag, and the nurse needed to call the physician and check if he/she wanted [MEDICATION(S)] or a diuretic continued or discontinued. Staff B stated a number of agency staff worked at the facility, and not as familiar with residents or realized a resident took a diuretic or other medication or the treatments prior to hospitalization and thus it would not be a red flag or as obvious to agency staff. Staff B reported changes for care plan not always communicated. Staff B reported Resident #101 had [CONDITION(S)] so bad, fluid leaked out of his legs. They applied A & D ointment, a nonstick dressing, ABD dressing, Kerlix, and ace wraps on his legs. However, she thought the treatment and dressing changes not done as often as it should've been. On the day Resident #101 went to the hospital, one of the CNA's requested Staff B to come to the shower room right away. When Staff B arrived to the shower room, the resident's dressing from his legs lay on the floor covered with maggots. Staff B reported she saw the maggots crawling on his leg, and feet in-between his toes. Staff B reported she rinsed his legs off then applied a Kerlix dressing to his legs, and sent him to the hospital. Both of his legs appeared red and macerated, and looked like hamburger, and his heels and calves looked macerated and wet. Staff B reported 8/21/21 as the date of the incident. The date listed on the dressing was 4 days old (8/17/21). The resident's treatment should've been on the paper MAR for staff to perform the treatment but doesn't think it was listed on his TAR or MAR. His legs got progressively worse, and nobody was [NAME] enough to call the physician or follow up and get his treatment changed. In an interview 11/02/21 at 10:35 AM Staff J, agency CNA, reported they had a bath/shower book for the CNA to document whenever they gave a resident a shower/bath. Staff J showed the surveyor the bath/shower book that also included a schedule in the front of the book for days/shift when a resident scheduled for a bath/shower. In an interview 11/02/21 at 10:40 AM, Staff C, LPN, reported shower sheets filled out with a skin assessment. The completed paper shower/bath sheets located in medical records. In an interview 11/02/21 at 11:44 AM, Staff C, LPN, reported skin assessments documented under the assessment tab in the EHR. Staff C reported no other areas where staff documented skin assessments other than the bath audit sheets. Staff C stated she also documented skin check in the MDS section M whenever a MDS assessments completed. In an interview 11/03/21 at 11:20 AM, Staff F, CNA, reported she had worked at the facility since 10/2020 and assigned as shower aide and CNA. Staff F stated she notified the nurse whenever a resident had a change in condition or had a skin issue. Staff F reported she filled out a shower skin audit form whenever she gave a resident a shower, and marked on the body map if she noticed any kind of skin issue. She gave the shower sheet to the nurse, and initialed the shower book whenever a shower completed. Staff F reported Resident #101 had very fragile skin and always had fluid leaking from his legs. During his shower, she used disposable wipes on his legs because the washcloths were rough and tore the skin on his legs. The nurses wrapped his legs with gauze. In an interview on 11/3/21 at 1:45 PM, an ED nurse stated when Resident #101 came to the ED on 8/21/21, his legs were extremely weepy, and stuck to the blankets. His legs were supposed to be wrapped at the care facility but looked like they hadn't been changed in weeks. The ED nurse stated no date listed on the dressings when he came to the ED. She asked the resident if someone at the care facility was supposed to help him get ready and the resident said yes. The ED nurse reported if staff at the care center helped him put his pants on they would've seen his soiled and wet dressings. The ED nurse reported when they removed the dressings on Resident #101's legs, his legs were very edematous, had blisters, pitting [CONDITION(S)], and his legs were weeping. EMS reported there were maggots in the wound but she did not see any maggots. Resident #101 admitted to the hospital with [CONDITION(S)] to both legs and a urinary tract infection ([CONDITION(S)]), and received IV antibiotics. The ED nurse reported the resident discharged [DATE] and sent back to the care facility, but then came back to the ED on 9/24/21. He later went into arrest and passed away. On 11/04/21 at 09:50 AM, the administrator reported no other shower or bath sheets were found for Resident #101. In an interview 11/4/21 at 11:10 AM, Staff V, agency LPN, reported weekly skin check documented on the TAR. Staff V stated if a resident had any open areas or skin issues, document under assessment tab on the skin observation tool in the EHR. If a resident had no skin issues, then documented a note on the skin observation tool no skin issues. The MDS nurse entered orders in the EHR whenever a resident came from the hospital. Staff V stated the admission assessment usually done by the MDS nurse. In an interview 11/4/21 at 1:20 PM, Staff I, agency CNA, reported she had worked at the facility for 3 months. Staff I stated whenever a resident had a change in condition or a skin issue, she let the nurse know right away. Staff I reported she had a horrible experience one day when she took Resident #101 to the shower room. She gave Resident #101 a shower on his previous shower day before 8/21/21, and a nurse put bandages on his legs after she gave him his shower. The resident was supposed to have dressing changed on his legs every shift, but she noticed the date on the dressing she saw on 8/21/21 was over 3 days old. Resident #101's legs were usually wet from his knees down. On 8/21/21, the nurse told her to remove the bandages on his legs in the shower. When she removed the bandages, they were dripping with fluid and there were what appeared

DESCRIPTION: Based on clinical record and policy review, observations, and staff, resident, and family interviews, the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person- centered care plan, and the residents' goals and preferences for 1 of 2 residents reviewed (Resident #50). The facility reported a census of 50 residents. Findings: 1. The Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #50 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident scored 15 of 15 possible points on the Brief Interview for Mental Status (BIMS) test, which meant she demonstrated intact cognitive abilities. The MDS also documented Resident #50 required assist of 1 staff with bed mobility, transfers, and toilet use, and set-up assist for eating. Resident #50 had moisture related skin damage and ointments applied during the lookback period. Review of the resident's Care Plan revealed a lack of information, planning, interventions, and staff directives related to management of the resident's pain. In an observation on 10/25/21 at 3:42 p.m., Resident #50 sat in her recliner. The resident reported she often had to wait a long period for staff to bring her pain medication for gastric tube (GT) site pain. She stated she had a scheduled a pain pill at 8 a.m. today but did not receive a pain pill until noon, and described her current pain level as 8 out of 10 (0=Nothing. 10=the worst pain ever felt). The resident appeared to be in pain with facial grimacing observed whenever she moved. On 10/27/21 at 1:11 p.m., Resident #50 reported her current pain level as 5 out of 10. The resident stated she received a pill at noon and commented the nurses do not try to keep my pain controlled and not all nurses apply Dermaceptin as ordered twice per day. She added when staff needed to change her dressing, her pain increased and she now required a [MEDICATION(S)] patch plus the [MEDICATION(S)] for pain. Resident #50 stated since the physician started the [MEDICATION(S)] patch, the nurses do not seem to think she needed the [MEDICATION(S)] and took longer to medicate her. On 11/1/21 at 11:00 a.m., the resident's tube feeding (TF) infused through her GT. Observation revealed the resident in visible pain and alternating her position while she sat. Resident #50 reported she had a rough weekend; the facility ran out of her pain medicine and the nurse did not change her dressings as ordered. She specified that the primary source of her pain is her GT and abdominal wounds when not treated with ointment. During an interview on 10/27/21 at 2:34 p.m., Staff C, LPN, explained the nurses documented skin assessments in the electronic health (EHR), under the assessments tab tilted Skin Observation Tool. In a subsequent interview on 11/01/21 at 11:30 a.m., Staff C, Licensed Practical Nurse (LPN) reported the facility did not have a process for reordering medication, but usually when a medication runs low, the certified medication aide (CMA) or LPN will place a sticker on the reorder form and fax it to the pharmacy. During an interview on 11/1/21 at 11:35 a.m., the Administrator (ADM) reported the facility had no specified process for reordering medication; it is not one person's responsibility to reorder narcotics or other frequently used medications. During an interview on 11/1/21 at 1:15 p.m., the Director of Nursing (DON) stated Staff C, LPN gave Resident #50 [MEDICATION(S)] at 7:00 a.m. on 11/1/21. At 2:50 p.m., the DON added the resident received a [MEDICATION(S)] at 7:30 a.m. today, but she failed to sign out the narcotic and Staff C gave the resident Tylenol at noon. During an interview on 11/1/21 at 3:30 p.m., Staff C, LPN reported the DON had removed [MEDICATION(S)] from the facility Emergency Kit (E-kit) 11/1/21 and administered the medication to Resident #50. Staff C stated the facility ran out of [MEDICATION(S)] for Resident #50 over the weekend and since the facility pharmacy is located in Minnesota, the refill will not arrive until 11/2/21 at approximately 2 a.m. On 11/01/21 at 3:30 p.m., the resident reported an improvement of pain from 10 out of 10, to 9 out of 10 after Staff C, LPN changed her abdominal dressing. Resident #50 stated the dressing change decreased her pain level more than the pain medicine did. On 11/1/21 at 3:40 p.m., Staff C, LPN, stated she gave the resident Tylenol at noon today, but did not sign the medication record. She also said she was not aware the resident did not have a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] On 11/1/21 at 3:45 p.m., the DON reported she placed a call to the facility physician to obtain [MEDICATION(S)] from the E-Kit for Resident #50. On interview on 11/2/21 at 9:39 a.m., Staff C, LPN said nursing staff are to document the effects of pain medicine in the progress notes. During an interview on 11/4/21 at 9:09 a.m., Staff C, LPN, stated the facility wound physician would visit Resident #50 11/4/21. She explained the physician visits the facility every week and had not seen Resident #50 prior to 11/4/21, as she had not needed a wound doctor. Staff C stated she updated the Care Plan for each resident quarterly or PRN and added that wound cares would be on a Care Plan if ordered. Staff C reported she looked at Activities of Daily Living (ADL) sheet, History & Physical (H&P), and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/03/21 at 9:50 a.m., the DON stated she expected Staff C, PLN to update the residents' Care Plan within 24-48 hours. During an interview on 11/3/21 at 12:00 p.m., the DON revealed the Certified Nurse Assistants (CNA's) Shower Day Skin Audit is where staff document the resident skin on shower days. DON stated the Certified Nurse Assistants (CNA's) would have been aware of Resident #50's abdominal wounds and therefore did not make mention of them on the tools. DON stated the expectation would be for staff to draw on the body diagram Resident #50's abdominal wounds. During an interview on 11/04/21 at 2:23 p.m., Staff C, LPN stated she could not locate prior documentation of Resident #50's abdominal wounds in her medical records. During an interview on 11/22/21 at 5:45 p.m., Wound Physician stated she has been rounding on residents at the facility since September 2021. Wound Physician made an initial round on Resident #50 on 11/11/21. During an interview on 12/6/21 at 10:00 a.m., Power of Attorney (POA) stated Resident #50 admitted to the facility with abdominal wounds present. POA stated the wounds have gotten worse and she had asked for a wound doctor to see Resident #50 in September. The DON told the POA that Staff C, LPN was a wound nurse. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The Individual Residents Controlled Substance Record for [MEDICATION(S)]-Acetaminophen (APAP) 5/325 mg, 1 tablet by mouth every 4 hours as needed for pain, revealed the documentation on 10/25/21 appeared altered from 12:00 p.m. to 8:00 a.m.; documentation dated 10/31/21 revealed 1 remaining [MEDICATION(S)] at 3 p.m. A MAR, dated 10/1/21-10/31/21 lacked documentation to show staff administered the resident's [MEDICATION(S)] patch on 10/19/21 and 10/22/21. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] a. [MEDICATION(S)]-Acetaminophen tablet 5-325 mg, give 1 tablet via GT every 4 hours as needed for pain. b. [MEDICATION(S)] patch 72 hour 25 microgram (MCG)/hour, apply transdermally every 72 hours related to acute ischemia of intestine. Review of the MAR, dated 11/1/21-11/3/21 revealed no documentation to indicate staff administered [MEDICATION(S)] as needed for pain on 11/1/21-11/3/21. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] The Individual Residents Controlled Substance Record, dated 11/1/21 revealed: a. 6:03 p.m.: Zero [MEDICATION(S)] on hand, 1 received from E-kit, 1 given, 0 remaining b. 10:05 p.m.: Zero [MEDICATION(S)] on hand, 2 received from E-kit, 1 given, 1 remaining c. 11/2/21 2:00 a.m.: 1 [MEDICATION(S)] on hand, 0 received, 1 given, 0 remaining The MAR, dated 11/1/21-11/30/21 lacked documentation of staff administration of [MEDICATION(S)] patch on 11/1/21. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] a. [MEDICATION(S)]-Acetaminophen tablet 5-325 mg, give 1 tablet via GT every 4 hours as needed for pain. b. [MEDICATION(S)]-Acetaminophen tablet 5-325 mg, give 1 tablet by mouth two times per day for pain b. [MEDICATION(S)] patch 72 hour 25 microgram (MCG)/hour, apply transdermally every 72 hours related to acute ischemia of intestine. The Baseline care plan dated 6/9/21 lacked documentation of current or past skin integrity issues. The resident's Care Plan lacked staff directives related to cares and interventions from skin breakdown. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Skin Assessment Tool, dated 10/14/21 in the EHR revealed Resident #50 had one excoriated area around the GT site only. The resident's record did not have any other Skin Assessment Tools documented. The facility documents in the EHR titled Weekly Wound Observation, dated 10/28/21, revealed blank documentation. The resident's record did not have any other Weekly Wound Observations. The facility policy titled Medication Ordering and Receiving from Pharmacy, dated 12/2017 directed: a. Reorder medication five days in advance of need, as directed by the pharmacy order and delivery schedule, to assure an adequate supply is on hand. b. The refill order is called in, faxed, sent electronically or otherwise transmitted to the pharmacy. The pharmacy label is pulled and transmitted to the pharmacy. Resident #50 chart lacked a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] A Shower Day skin audit form for 10/1-10/29/21 revealed Resident #50 did not have any open areas noted six times by three different staff members. Facility document titled Medication Administration -Preparation and General Guidelines, dated 12/2017 revealed: Documentation: the individual who administers the medication dose records the administration. At the end of each medication pass, the person administering the medications reviews the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . When PRN meds are administered: Date, time of administration, dose, route of administration; complaints or symptoms for which the med was given; results achieved from giving the dose and the time results were noted; signature or initials of person recording administration and signature or initials of person recording effects, if different from the person administering the medications. Resident #50 Progress Note, from date range of 6/21/21 through 11/20/21 revealed: a. 6/21/21 Nurse Practitioner (NP) requested to see resident for increased pain at GT site with redness and irritation, green/yellow drainage from insertion site on gauze and around tube. Plan to start on [MEDICATION(S)] 500 milligrams (MG) x 7 days. Resident #50 stated Tylenol has not controlled pain. b. 6/21/21 NP documented to start [MEDICATION(S)] 500 MG twice per day (BID) x 7; monitor GT site; monitor pain; skin checks per protocol c. 6/22/21 Staff DD, Registered Nurse documented she received nurse order to start [MEDICATION(S)] 500 MG BID for x 7 days for skin infection and to start [MEDICATION(S)]-Tylenol (APAP) 1 tablet every 6 hours as needed (PRN) for pain. Faxed to Pharmacy at 2:15 a.m. d. 6/27/21 Staff Z, RN documented she changed GT dressing and noted 3 centimeter (CM) by 2 CM open abrasion approximately 1 inch above the left side of GT, no drainage from wound, Resident #50 stated tender to touch and pain med given e. 6/27/21 Staff EE, LPN documented open, red areas remain on abdominal creases f. 6/29/21 Staff FF, LPN documented Resident #50 on antibiotics for skin infection surrounding GT, red and raw in some areas, painful per Resident. 7/4/21 NP ordered Dermaceptin BID to GT site BID 7/19/21 NP documented Resident #50 reported increased pain localized to GT site. Wound culture showed no growth. Resident evaluated in emergency department. 7/20/21 Staff CC, RN documented to start [MEDICATION(S)]-APAP 1 tablet every 4 hours for GT pain. 8/31/21 NP documented to see Resident #50 for increased pain. 9/6/21 Director of Nursing (DON) documented to start [MEDICATION(S)] (antifungal) BID for 10 days 9/10/21 Staff GG, LPN documented Resident #50 cried in pain during the night from pain at GT site. 9/17/21 Staff GG documented on physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] 9/26/21 Staff D, LPN documented GT site raw and extremely painful. Resident needs seen for pain management. 9/28/21 NP documented Resident #50 with increased pain at GT site, staff state red with odor, started [MEDICATION(S)] 150 MG x 3 days. 10/13/21 Staff HH, RN documented Resident #50 upset that the nurse had to call the pharmacy for more pain medicine. 11/4/21 Staff V, LPN documented Resident #50 [MEDICATION(S)] patch increased, resident taking scheduled and PRN [MEDICATION(S)] with continued complaints of pain. 11/11/21 Wound Physician rounded on Resident #50 11/13/21 Staff B, LPN documented GT skin dark pink and draining, continued to be tender and Resident appeared to be in pain. 11/20/21 Staff D, LPN documented GT site very red, raw, and painful. Facility policy titled Interdisciplinary Care Plan Meeting, dated 1/24/2019 directed: The initial Interdisciplinary Care Plan Meeting will be scheduled post completion of the initial Resident Assessment Instrument (RAI). Subsequent meetings will take place quarterly, upon significant changes, and as needed. Facility policy titled Comprehensive Person Centered Care Plan, dated 1/24/2019 directed: a. Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. b. For each problem, need, or strength a resident-centered measurable goal is developed. c. Upon change in condition, the Comprehensive Person Centered Care Plan or baseline Care Plan will be updated if: to reduce the risk/occurrences with a problem area, including goals and interventions to reduce the risk/occurrence.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure the residents were free from significant medication errors for two of eight residents reviewed with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The failure resulted in Resident #16's decline in condition and required admission to a higher level of care. The facility reported a census of 50 residents. Findings include: 1. The annual Minimum Data Set (MDS) assessment tool dated 11/5/21 revealed Resident #16 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed the resident had impaired short and long-term memory, poor appetite for 12-14 days during the 14 day look-back period, and was totally dependent on one staff for eating and activities of daily living (ADL's). The care plan revised 11/11/21 revealed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan documented the resident as at risk of contracting COVID-19 due to nursing facility and community living and had a risk of fatal complications of infection due to her advanced age and a compromised immune system. The care plan showed the resident moved to a transitional private room on 10/25/21 due to exposure to a COVID-19 positive resident. On 11/1/21, the resident tested positive for COVID-19 and moved to the COVID unit, and on 11/11/21, the facility deemed the resident recovered from COVID-19. Staff directives included administer medications as ordered and monitor for elevated temperature, respiratory symptoms such as cough, sore throat, and shortness of breath. The physician's progress notes dated 11/8/21 and entered on 11/9/21, revealed Resident #16 tested positive for COVID-19 on 11/1/21. The treatment plan included start vitamin C 500 milligrams (mg) daily (qd) for 30 days, vitamin D 5,000 international units (IU) qd for 30 days, zinc 220 mg qd for 30 days, and aspirin 325 mg qd for 30 days. The physician's progress notes dated 11/12/21 and entered on 11/14/21, documented the facility moved the resident was removed from isolation on 11/11/2021. The treatment plan included continue the vitamin D, vitamin C, aspirin, and zinc medications as ordered. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The progress notes revealed the following: a. On 10/26/21 at 11:26 AM, resident moved to transitional hall due to roommate tested positive for COVID-19. Resident #16 tested negative for COVID-19. b. On 10/30/21 at 6:58 PM, resident seen by provider due to 14 residents and 3 staff at the facility tested positive for COVID-19. Resident #16 at high risk for COVID-19 due to history of [CONDITION(S)], PE, [CONDITION(S)], heart disease, dementia, diabetes, and [CONDITION(S)]. c. On 11/1/21 at 7:19 AM, The resident's COVID point of care test is positive - resident moved to COVID unit. d. On 11/2/21 at 7:54 AM, Resident's PCR test (used to detect genetic material from a specific organism, such as a virus) results positive for COVID. e. On 11/9/21 at 10:35 PM, resident on droplet and contact precautions due to positive COVID-19 test. The resident had poor appetite and didn't want to eat supper, and not drinking fluids when offered - respiration easy and unlabored. No cough observed. Pulse oximeter 94% on room air. f. On 11/12/21 at 7:46 AM isolation discontinued on 11/11/21. g. On 11/13/21 at 11:34 AM, lungs sound diminished bilaterally in bases and transient wheezes audible. h. On 11/17/2021 at 4:55 PM, resident up for breakfast but would not stay awake and refused to eat. Resident asked to lie down. Staff returned resident to bed. Blood Pressure (B/P) 98/69, temperature (T) 97.9, pulse (P) 103, respirations (R) 13. Resident also refused lunch and asked to be left alone. i. On 11/18/2021 01:48 resident up for evening meal and had a fair appetite. Resident assisted to lie down after dinner. j. On 11/18/2021 at 04:00, resident has not voided this shift. Gave resident 240 cubic centimeters (cc) water. Resident skin pale white and bluish in color on hip and in between knees and skin blanched poorly. Resident repositioned off of her right side. j. On 11/18/2021 at 11:53 AM nurse summoned to resident's room. Resident less responsive and had significant change in her condition. B/P 106/56, P 94, R 23. Provider notified and attempted to notify family. Resident sent to the emergency department (ED). k. On 11/19/2021 at 05:33, nurse from hospital contacted facility and advised Resident #16 passed away. In an interview 11/23/21 at 09:31 AM, Staff D, Licensed Practical Nurse (LPN), reported usually the nurse that received the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview 11/23/21 at 09:46 AM, Staff Z, Registered Nurse (RN), reported the nurses entered physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] In an interview 11/23/21 at 11:35 AM, Staff JJ, RN, reported the nurses entered orders whenever they received new physician orders. In an interview 11/23/21 at 12:50 PM, the Director of Nursing (DON) reported the facility had no policy for physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON reported the order summary report dated 10/11/21 were the most current orders for Resident #16. The DON provided a report of orders entered into the EHR after 10/3/21 for Resident #16; the report revealed only an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview 11/23/21 at 01:15 PM, the nurse practitioner (NP) confirmed she ordered the following for Resident #16 on 11/9/21: Start vitamin C 500 mg qd for 30 days, Start vitamin D 5,000 IU qd for 30 days Start zinc 220 mg qd for 30 days Start aspirin 325 mg qd for 30 days The NP reported these medications were the standard cocktail of medications prescribed whenever a resident had COVID-19. The NP confirmed no staff contacted her about orders staff failed to order or administer as prescribed for Resident #16. The NP stated the resident didn't have many signs or symptoms of COVID-19 but had tested positive for COVID-19. The resident then stopped eating and had a decline in health, and was sent to the hospital. A facility policy for Medication Administration Preparation and General Guidelines dated 12/17, directed staff to administer medication as prescribed in accordance with the prescriber's orders. 2. The annual MDS assessment dated [DATE] revealed Resident #34 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed the resident had impaired short and long-term memory and was totally dependent on one staff for ADL's. The care plan revised 11/9/21 revealed the resident had a risk of contracting COVID-19 due to nursing facility community living and at risk of fatal complications of infection due to her advanced age and a compromised immune system. The care plan revealed the resident moved to a COVID unit on 10/25/21 due to positive COVID-19 and symptoms of fatigue and malaise. The care plan documented the resident deemed recovered from COVID on 11/4/21 and directed staff to administer medications as ordered and monitor for elevated temperature, respiratory symptoms such as cough, sore throat, and shortness of breath. A physician's progress note dated 10/30/21 for date of service 10/29/21 revealed resident tested positive for COVID-19 on 10/26/21 but had no symptoms. The treatment plan included to: start vitamin C 500 mg qd for 30 days, vitamin D 5,000 IU qd for 30 days, zinc 220 mg qd for 30 days, and aspirin 325 mg qd for 30 days. The order summary report revealed aspirin 325 mg qd, vitamin C 500 mg qd, vitamin D 5,000 IU qd, zinc 220 mg qd had an order date 10/26/21 and an end date 11/26/21. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] In an interview 11/23/21 at 09:31 AM, Staff D, LPN, reported the nurse who received the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview 11/23/21 09:46 AM Staff Z, RN, reported the nurses usually entered orders in the EHR. In an interview 11/23/21 at 12:50 PM, the DON reported the facility had no policy for physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview 11/23/21 at 01:15 PM, the NP confirmed she ordered to start vitamin C 500 mg qd for 30 days, vitamin D 5,000 IU qd for 30 days, zinc 220 mg qd for 30 days, and aspirin 325 mg qd for 30 days on 10/29/21. The NP reported the medications were a standard cocktail she prescribed whenever a resident had COVID-19. The NP confirmed no staff contacted her about orders not implemented or medication not administered as prescribed.

Based on clinical record review, observation, facility policy review and staff interviews the facility failed to a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for 1 of 2 residents reviewed for pressure ulcers (Resident #53). The facility failed to assess Resident #53's sacrum wound after first identifying the area upon admission on 10/8/21 and failed to treat the area to aid in healing and prevent further deterioration of the wound. The facility reported a census of 50 residents. Findings include: The Minimum Data Set (MDS) assessment tool identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue), may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. Review of Resident #53's hospital record revealed he admitted to the facility on [DATE] from the hospital. He had reported to the emergency department on 10/1/21 for weakness and failure to thrive. Resident's family decided he required increased assistance with activities of daily living (ADL) and opted for long term care placement. The MDS dated [DATE] revealed Resident #53 had a Brief Interview for Mental Status (BIMS) score of 5, indicating he demonstrated severe cognitive impairment. The MDS documented Resident #53 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed the resident experienced bladder and bowel incontinence; although the resident admitted to the facility with an indwelling catheter, the MDS did not reflect its use. The MDS revealed the resident required extensive assist of one person for bed mobility, transfers, dressing, toilet use and personal hygiene and total assist of one person for bathing. The MDS revealed the resident had a risk for development of pressure ulcer/injuries and had moisture associated skin damage (MASD). The MDS documented the resident had a pressure reducing device for his chair and bed. The MDS coded the resident took an anticoagulant. The MDS Care Area Assessment (CAA) Summary triggered concerns for cognitive loss, ADL functional/rehabilitation potential, urinary incontinence and indwelling catheter, falls, nutritional status, and pressure ulcer. The CAA's revealed staff planned to develop care plans for these areas. The care plan dated 10/21/21 lacked documentation of a focus area, goals or interventions for ADL functional/rehabilitation potential, urinary incontinence and indwelling catheter, falls or pressure ulcer. Pressure Injury Risk form dated 10/8/21 completed by Staff Z, Registered Nurse (RN) revealed a Braden score of 14, which assessed Resident #53 as at moderate risk for pressure injuries. Pressure Injury Risk form dated 10/10/21 completed by Staff Z, RN revealed a Braden score of 15, which assessed Resident #53 as at moderate risk for pressure injuries. Pressure Injury Risk form dated 10/17/21 completed by Staff C, Licensed Practical Nurse (LPN) and MDS nurse revealed a Braden score of 12, placing Resident #53 at high risk for pressure injuries. A Nursing Admission Screening/History form dated 10/8/32 at 12:00 PM completed by Staff C, LPN and MDS nurse documented Resident #53's height as 67 inches and weight as 100.5 pounds. Staff C documented an open area on the resident's sacrum measuring 1 centimeter (cm) in length, 1 cm in width, and 0.1 cm in depth. The note defined it as a moisture related breakdown to the sacrum area and revealed staff applied house barrier to the area. When the resident arrived from the hospital, staff found the area covered with an undated patch, which they removed and identified a foul odor emanating from the area. A Skin Observation Tool dated 10/9/21 at 4:40 PM by Staff D, LPN, documented a Stage III pressure wound to the coccyx area measuring 3 cm in length, 5 cm in width, and 0.2 cm in depth. The documentation on the tool identified the resident admitted to the facility with a pressure ulcer that contained slough and a small amount of drainage was noted. A Daily Skilled Summary form dated 10/10/21 revealed Resident #53 had an open area to his coccyx staff documented as a pressure ulcer. The October 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The electronic health records (EHR) lacked any physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The nursing progress notes in the electronic health records revealed the following: a. On 10/9/21 at 3:13 AM, the resident was admitted to facility with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff assessed the resident's skin as warm and dry with areas of dirt on his skin and the skin on his lower extremities very dry. b. On 10/10/21 at 4:11 AM, skin very dry, lotion applied liberally over entire body. Area noted on coccyx - moisture barrier applied - see wound sheet. c. On 11/3/21 at 11:20 AM, during his shower, the resident complained that his bottom hurt, and his skin burned when staff changed his brief. Staff noted 1.3 cm by 0.3 cm open area with a pale red wound base. Call placed to provider to notify of area, then utilized wound formula - Dermaview 11 applied to coccyx. d. On 11/3/21 at 4:53 PM, the social worker notified the resident's son of a small wound found on his coccyx. e. On 11/5/21 at 1:01 AM, staff completed a dressing change as ordered to the resident's coccyx and he voiced no complaints. f. On 11/5/21 at 9:07 AM, the dressing to the resident's coccyx remained intact with no redness or swelling noted to surrounding area and the dressing remained clean and dry. g. On 11/5/21 at 3:52 PM, Resident #53 seen by wound physician and received orders to change wound treatment to collagen pad to wound bed, cover with bordered gauze and apply house barrier to surrounding area. Staff documented they updated the TAR, faxed pharmacy and communicated the new orders to Resident #53. h. On 11/6/21 at 12:18 AM, staff noted the dressing applied by wound physician remained intact to coccyx. i. On 11/7/21 at 12:29 AM, staff documented they applied the dressing to coccyx wound as ordered and saw no drainage on the old dressing - the resident voiced no complaints j. On 11/7/21 at 9:52 AM, staff found the dressing to resident's coccyx clean, dry and intact. Resident #53 denied pain or discomfort. k. On 11/8/21 at 4:38 AM, staff changed coccyx dressing due to the dressing peeling and coming off skin. Area cleaned with normal saline, collagen applied and staff dressed the wound. Staff documented the wound as negative for drainage or odor, healing well, and pink. l. On 11/8/21 at 2:00 PM, staff noted the dressing to coccyx remained clean, dry and intact and the resident denied any pain or discomfort. m. On 11/9/21 at 4:09 AM, staff noted dressing intact to coccyx and the resident denied any pain or discomfort to the area - will continue to monitor. n. On 11/9/21 at 2:27 PM, the dressing to coccyx remained clean, dry and intact and the resident denied any pain or discomfort. o. On 11/10/21 at 4:22 AM staff documented the coccyx dressing remained intact and the resident denied pain or discomfort to the area - will continue to monitor. Clinical record review revealed the resident's EHR and hard or paper chart lacked assessments, treatment, and documentation of Resident #53's coccyx area pressure wound from 10/10/21 to 11/3/21. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Change daily at bedtime and as needed. Another physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/3/21 at 12:36 PM, the DON completed an Initial Wound Assessment tool that documented the facility identified the wound on 11/3/21 and deemed it a facility acquired Stage II pressure wound on the sacrum that measured 1.3 cm (length) x 0.3 cm (width) with an immeasurable depth. She assessed the wound as 95% granulation tissue and 5% epithelial tissue with no exudate noted. The form reflected the resident had predisposing factors of bowel incontinence and pendulous buttocks. The DON recorded the ulcer had a treatment ordered and the resident's bed and chair contained pressure reduction devices. The DON identified the resident reported burning when staff provided incontinence care. The form showed the facility notified the physician on 11/3/21 at 11:45 AM, the son at 11/3/21 at 3:00 PM, and also notified the dietician. On 11/3/21 Staff T, Certified Nursing Assistant (CNA) completed a Shower Day Skin Audit that showed Resident #53 had an open area on the coccyx/sacrum area and noted she reported her finding to the nurse. Observation on 11/3/21 at 11:17 AM, revealed Staff T, CNA, gave Resident #53 a shower while he sat on a shower chair. The resident flinched when staff washed his bottom, and he kept saying his bottom hurt and was tender to the touch. The resident, Staff T, CNA and the DON were unaware of any open areas on resident's bottom. Once back in his room, staff transferred him to the bed and the DON assessed his bottom. When the resident's buttocks were separated an open area was noted on the coccyx. The wound bed was red and had depth. The resident stated the area burned and was painful whenever he had a soiled brief and staff provided incontinence care. In an interview on 11/4/21 at 8:39 AM, Resident #53 stated his bottom felt better. He reported he had a bandage on the area. Observation revealed an approximately 1 inch cushion in his wheelchair seat, but nothing extra noted on the mattress for pressure relief. In an interview on 11/4/21 at 8:44 AM, Staff C, LPN and MDS nurse, reported all of the mattresses at the facility were pressure reducing mattresses and that is why she coded the resident's MDS to reflect a pressure relieving device for his bed. In an interview on 11/10/21 at 8:43 AM, the DON stated she expected staff to conduct a weekly skin assessment including a head-to-toe assessment of every resident in the facility set up on the TAR. If staff identified an area of concern they should initiate a Skin Observation tool if was a skin tear, shearing or moisture related issue. If the areas identified were a pressure related, vascular, arterial or any stageable wound, staff should complete a Wound Assessment. The DON added the CNA would notify the nurse if they identified a wound and she expected the nurse to complete a wound assessment, notify the physician, and initiate a treatment in accordance with the wound care protocol. The physician would then review the plan and set up a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . They would then contact the wound nurse regarding the issue. Staff C, LPN was the facilities certified wound nurse and she completed rounds with the wound physician weekly or every other week to follow the wounds in the facility. The DON stated it was her expectation that all wounds would be assessed and documented weekly. A Wound Assessment should be completed on all arterial, venous or pressure areas weekly and Skin Observation tool completed for all other wounds. The physician would be notified initially and with any changes of concern in the wound. The physician would then determine if further intervention or a change in treatment was indicated. The physician/nurse practitioner reviewed notes in the electronic health system and reviewed the notes entered by the facility wound physician. The DON stated the staff get education and training on-line through Health Care Academy, including wound care training annually. She added the facility had specific training related to wound care for the licensed staff and more general skin care information for the non-licensed staff. She stated staff should complete Braden Scales for each resident upon admission and then at least quarterly thereafter. The Skin Management Guidelines dated 7/2017, revealed upon admission, all residents are assessed for skin integrity by completing an assessment and documenting in the electronic health record. Following admission; the Braden Scale is completed quarterly, annually and with a change of condition, for their risk for development of pressure injury. Nurse aides complete body audits. The body audits are given to the licensed nurse to review for changes in skin condition post shower. Appropriate preventative measures implemented on all resident identified at risk, and interventions documented on the care plan. Residents admitted with skin impairments will have appropriate interventions implemented to promote healing, a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan is developed upon admission, identifying the contributing risks for breakdown, including history of skin impairment and the interventions implemented to promote healing and prevent further breakdown. At-Risk Review Meetings will be conducted to review/discuss: new admission with wounds present, resident identified at risk or with compromise, treatment modalities and interventions, recommendations based on interdisciplinary evaluation and weights will be monitored and dietary consumption reviewed. According to the Skin Management Guidelines dated 7/2017, residents who are at risk or with wounds and/or pressure injury and those at risk for skin compromise are identified, assessed and provided appropriate treatment to encourage healing and/or integrity. A pressure injury is defined as any lesion caused by unrelieved pressure resulting in damage of underlying tissue. Pressure injuries are usually over bony prominences and are staged to classify the degree of tissue damage observed. Per education provided to the facility staff on 5/21/21, each resident was to have a skin assessment/observation completed weekly. The measurements and assessments were being done weekly by wound care but staff were to look at the rest of their skin to make sure they do not have other open areas. This did not include things like skin tears and bruises as they show up on the Skin Observation Tool. The manufacturer's guidelines for the Therapeutic 5 Zone Support Mattress documented the mattress provided pressure redistribution and shear/friction reduction. The deluxe horizontal, cross cut foam mattress provided comfort, support and pressure redistribution over 5 therapeutic pressure zones.

Based on record review, and staff, resident family member and physician interviews, the facility failed to provide adequate supervision and assistance to prevent hazards for 2 of 9 residents reviewed (Residents #7 and #9). On [DATE], a nurse left Resident #7 unsupervised on the commode in his room in order to enter the resident's adjoining bathroom to obtain his wheelchair. When the nurse returned with the wheelchair, she found Resident #7 on the floor; he had fallen and sustained a laceration to the head due to striking his head on the floor when he fell . The facility sent the resident to the hospital emergency room (ER) and computed tomography (CT) scans showed bilateral (both sides of brain) subarachnoid hemorrhage (bleeding on the brain) and a subdural hematoma (bruising with concussion) of the left frontal lobe. Resident #7 died on [DATE] as a result of injuries sustained in the fall on [DATE]. The facility reported a census of 50 residents. Findings include: 1. The [DATE] Minimum Data Set (MDS) Assessment tool revealed Resident #7 admitted to the facility [DATE] with diagnoses that included [CONDITION(S)] (paralysis on 1 side of the body), [CONDITION(S)] (a stroke), [CONDITION(S)] (speech inability or difficulty) and [CONDITION(S)] (irregular heart beat). The MDS documented the resident displayed moderate cognitive impairment without symptoms of [CONDITION(S)], moderate difficultly hearing without hearing aid used, had unclear speech, usually understood others and could sometimes make themselves understood. The MDS also documented Resident #7 required extensive assist of 2 staff for surface-to-surface transfers, bed mobility, dressing, eating, toilet use, bathing and personal hygiene, was always incontinent of bowel and frequently incontinent of bladder. The MDS revealed the resident could not stand or ambulate (walk), and the assessment revealed he had fallen within 1 month prior to the admission and also since the admission without a sustained injury. A risk for falls related to history of falls care plan initiated [DATE] directed staff to: [DATE] - Anticipate resident needs and educate/remind him to call for assistance as needed. [DATE] - Educate, provide supervision, and remind the resident to wear appropriate footwear. [DATE] - Scoop mattress to bed. Review of the incident reports revealed the following falls: On [DATE] at 8:10 a.m., staff observed the resident transferring themselves from their wheel-chair to the bed in room and during the attempt to stand, the resident slid onto floor with his legs extending outward, and landed on his buttocks. The resident sustained a 3.5 centimeter (cm) U shaped skin tear on the upper right elbow that required a dressing. Staff then applied a scoop mattress to the bed. On [DATE] at 3:15 a.m., a certified nursing assistant (CNA) answered the resident's bathroom call light and noted the resident sat on the floor in front of the toilet. The resident stated he took himself to the restroom, lost his balance, and slid to the floor. Staff identified no injuries and did not implement any new interventions. The record showed post fall vital signs and neurological assessments were initiated by Staff H, registered nurse (RN) and former assistant director of nursing (ADON) on [DATE] at 7:15 a.m. On [DATE] at 4:45 p.m., Staff H, RN and former ADON described the resident found lying on floor on right side with wheel chair tipped over him, the fall was unwitnessed. Noted blood on floor by resident's right arm. There was no documentation of post fall vital signs or neurological assessments in the resident's record. On [DATE] at 8:30 a.m., Staff I, licensed practical nurse (LPN), went into the room to check on Resident #7, assisted the resident to the commode, went to grab the wheel-chair from the bathroom, and when the nurse returned the resident lay on the floor bleeding from a laceration on the right side of the head. Staff then sent the resident to the hospital emergency room (ER) and called 911 for ambulance transport. Physical therapy notes transcribed between [DATE] and [DATE] revealed the resident had a static sitting balance (position held in a position for up to 45 seconds) that ranged from did not tolerate to fair, and a dynamic sitting balance (controlled repetitive movements of muscles and ligaments) that ranged from did not tolerate to fair. The notes revealed the resident had a fair static and dynamic sitting balance on [DATE], and a poor static and dynamic sitting balance on [DATE]. The hospital records revealed staff evaluated the resident in the ER after a fall at the nursing home that resulted in head trauma with a laceration to right temple and below the right eye. Computed tomography (CT) scans revealed acute bilateral (both sides of brain) subarachnoid hemorrhage (bleeding on the brain) and a subacute subdural hematoma (bruising with concussion) of the left frontal lobe. The facility's self-assessment submitted with their self-reported incident related to the resident's [DATE] fall revealed the following: On [DATE] at 8:00 a.m., Staff found the resident on his left side near his bed. The resident stated he attempted to transfer himself from the bed, lost his balance, and hit his head on the bed frame. The facility noted a laceration to the left side of the head and applied and maintained pressure until transport arrived. The facility concluded the resident's injury was caused by a fall and documented the resident passed away on [DATE]. A progress note transcribed [DATE] at 3:17 p.m. by Staff N, facility social worker documented the hospital called and reported the resident admitted to the hospital and had orders for a neurological physician consult and palliative care. Staff interviews revealed: [DATE] at 10:40 a.m., Staff I, LPN, stated she was currently employed by a sister-facility, no longer worked at the facility, the last day she worked at the facility was on [DATE]. Staff I reported on the morning of [DATE], she received phone calls from Staff A, RN, and the facility's corporate nurse Staff G, RN, with requests for her to work at the facility that day due to staff call-ins. Staff I stated she arrived to the Side 2 unit of the facility at approximately 8:15 a.m., staff B, LPN was there, she didn't receive report on any of the residents and none of the morning medications had been administered to the residents she was responsible for. Shortly after she arrived, she was notified that the resident was scheduled for a family visit at 9:00 a.m. so she went to the resident's room to get him up and ready for the visit. When she entered his room the resident was awake and tried to climb out of the bed, she called for assistance, Staff B helped her transfer him from the bed to the commode, she got the resident's wheel-chair, called out for Staff B to assist with the transfer and when she turned around the resident was on the floor. It appeared he had fallen forward out of the commode and struck his head on the floor, she didn't think he had attempted to self-transfer. The resident bled from a laceration on his head, she notified the medical provider immediately for orders to transfer to the hospital and called 911 for an ambulance. On [DATE] at 10:15 a.m., Staff B, LPN, stated on the morning of [DATE], she helped Staff I, LPN transfer the resident to the commode because he required assist of 2 staff for transfers. Staff I remained in the room, and Staff B left the room and walked approximately 30 feet toward the nurse's station. Staff B stated in less than a minute, Staff I called for help because the resident was on the floor. On [DATE] at 1:20 p.m., Staff A, registered nurse (RN) stated the resident behaved impulsively, attempted to transfer independently, would self-transfer and was a high fall risk. Due to the resident's impulsiveness, he should not have been left alone unless he was in bed or safely positioned in a chair. [DATE] at 12:09 p.m., Staff D, RN and former interim director of nursing (DON), stated the resident was a high fall risk, he was always incontinent of bowel and bladder and did not use the commode, she didn't know why staff would have transferred the resident to the commode but should not have left him alone when he was positioned on the commode due to his balance problems and impulsiveness. During another interview on [DATE] at 9:25 a.m., Staff D stated after a resident falls, the nurse should always initiate the protocol for post fall vital signs and neurological assessments if the fall was unwitnessed or the resident hit their head when they fell . [DATE] at 10:47 a.m., Staff F, CNA, stated on [DATE], the resident was assigned to her and she saw the resident in bed between 6:30 a.m. and 7:00 a.m. when she checked on him. Staff F stated the resident had a tendency to lean forward when he sat up so staff had to put his feet up in the recliner when he was seated in his room. [DATE] at 10:42 a.m., Staff W, hospitalist physician stated she examined the resident in theER on [DATE] for his head injury associated with a fall at the facility, he was extremely thin and dehydrated, appeared cachectic, his mouth was very dry and he had not received adequate oral hygiene care. In addition to emergent care for the resident's head injury, the resident also required emergent intravenous therapy to treat his dehydration. [DATE] at 12:45 p.m., Staff X, radiologist physician stated the small acute bilateral subarachnoid hemorrhage was consistent with the injury on [DATE], and the subacute left frontal lobe subdural hematoma did not occur from the fall on [DATE], but it possibly could be consistent with the unwitnessed falls that occurred 2 weeks prior. The left frontal lobe subdural hematoma was not present on a head CT scan completed in February, 2021 at the hospital, and likely developed from a fall after February as it was consistent with 1 or more weeks old. During an interview on [DATE] at 4:10 p.m., the resident's family member and responsible party (RP) stated the resident had a stroke that led to right side paralysis and problems with sitting balance. She stated they had seen him lean forward or to his right in the wheelchair sometimes when they saw him at scheduled facility visits. The RP stated the facility did not notify her of the [DATE] fall and on [DATE] the facility notified them the resident's wheel-chair had fallen over on top of him when he transferred himself in the bathroom. On [DATE], they had just left their home at approximately 8:40 a.m. en route to the scheduled facility visit when they received a call from the nurse who said the resident had an X-ray and the doctor had ordered a medication due to the results. Before they hung up they told her the resident had leaned forward when he reached for his oxygen tubing, fell out of his chair, and cut his head when it hit the floor so they were sending him to the ER. The RP stated they met the resident at the hospital and stayed with him, the nurses at the hospital and the ER doctor were very concerned about his injuries from the fall. The RP stated since the resident's death on [DATE], they had contacted the facility 3 different times to request copies of his records, and as of the time of the interview they still had not received them. The RP reported family elected for hospice care because the physician's explained he probably wouldn't have survived the surgery to relieve the bleeding on his brain, and so that meant the resident died as a result of the injuries from the fall. 2. Facility records revealed Resident #9 had diagnoses that included dementia with behavioral disturbance, anxiety, [CONDITION(S)] and pneumonia due to inhalation of food/vomit, the resident admitted at 4:00 p.m. on [DATE], discharged to family at 4:16 p.m. on [DATE], admitted for short-term Respite care at 12:36 p.m. on [DATE], and discharged to family care at 6:00 p.m. on [DATE]. Progress note entries revealed: [DATE] at 6:26 p.m., resident confused, spoke only Italian language, non-compliant with remaining in bed and undressed self frequently. [DATE] at 6:26 a.m., resident removed clothing and attempted self-transfers from bed, Staff P, CNA, assigned to the resident for 1 to 1 supervision/care for resident safety. [DATE] at 12:00 p.m., Oxycodone (strong narcotic [MEDICATION(S)]) 5 milligrams given per order for pain and restlessness, 1 to 1 staff assignment continued. [DATE] at 1:32 p.m., resident encouraged to nap until family arrived to take the resident home, Oxycodone effective to reduce pain symptoms and restlessness, 1 to 1 staff assignment for resident safety continued. [DATE] at 12:36 p.m., arrived by personal vehicle accompanied by spouse, admitted for short Respite stay, resident believed he was at the facility for a doctor appointment. [DATE] at 3:40 p.m., Wandergard transponder bracelet (an electronic device that alerts facility when resident near an exit door) placed on resident's ankle due to wandering. [DATE] at 12:00 p.m., nurse practitioner (NP) at facility and authorized [MEDICATION(S)] (an anti-anxiety medication) 0.5 milligrams administered oral 3 times a day for anxiousness. Resident does not want to remain in his room, ambulating with cane outside of the transitional hallway (restricted due to COVID-19 infection control precautions in place at that time at the facility) and ambulated towards the front door. Has been redirected away from the front door several times by staff, hitting staff with his cane, punched at staff and pulled the activity director's hair because he wanted to leave the facility and go home with his spouse. [DATE] at 12:30 p.m., [MEDICATION(S)] 0.5 mg administered for anxiety and aggressive behavior. [DATE] at 5:00 p.m., resident fell in facility foyer as he attempted to leave, sustained a 2.0 centimeter (cm) abrasion on his right cheek and a 0.2 cm abrasion on the bridge of his nose. Ambulated resident back to his room and assisted into bed. Vital signs and neurological assessment completed (per fall assessment protocol). [DATE] at 5:03 p.m., resident got out of bed and fell again, 3 cm by 3 cm hematoma (bruise) with scant bleeding noted at mid-occipital area (back of the head). [DATE] at 6:00 p.m., discharged home with family per their request. An incident report related to the [DATE] falls revealed: [DATE] at 5:00 p.m., completed by Staff A, registered nurse (RN), stated resident was found on floor in foyer with abrasion to right cheek and across bridge of nose, the resident fell when he tried to leave the facility. He had been wearing glasses, appeared he hit the door frame. At 5:03 p.m. resident fell immediately following the 5:00 p.m. fall, found in doorway of room with a 3 cm by 3 cm mid-occipital abrasion. The staffing schedule for Side 1, where the resident was located, on [DATE] revealed: Staff A, RN, scheduled from 6:00 a.m. to 6:00 p.m., 2 CNA's were scheduled for the 6:00 a.m. to 2:00 p.m. shift (usually 3 CNA's), 2 CNA's were scheduled for the 2:00 p.m. to 10:00 p.m. shift (usually 3 CNA's). The staffing schedule for Side 2 on [DATE] revealed the nurse assigned from 6:00 a.m. to 6:00 p.m. had not reported to work. Per staff interviews, the facility had a nurse from another facility come in at 8:15 a.m. and work until relieved by an agency nurse that arrived at 11:30 a.m., 3 CNA's were scheduled from 6:00 a.m. to 2:00 p.m., and 1 CNA scheduled from 2:00 p.m. to 4:30 p.m. was relieved by another CNA scheduled at 4:00 p.m. (leaving 1 CNA for the area when there were usually 3). Staff interviews revealed: [DATE] at 9:50 a.m., Staff A, RN, stated the resident had advanced dementia and didn't speak English. Even before his family left when he was admitted he was restless and tried to get up without assistance. He continued to try to get up on his own, he was disrobing, and they didn't have the staff to make him a 1 to 1 which is what he needed. The resident was looking for his family, tried to go out exit doors, he hit staff when they tried to redirect him away from the doors. Staff A was on the phone to notify the physician of the fall at 5:00 p.m. when the resident had another unwitnessed fall in his room, again looking for his family. His family came and picked him up after that. [DATE] at 9:00 a.m., the facility administrator stated decisions about resident's accepted for admission were made by their management team that included herself, the director of nursing, social worker, activity director, dietary manager and maintenance supervisor (their inter-disciplinary team). During an interview on [DATE] at 2:11 p.m., the resident's family member stated they had contacted different staff at the facility at different times after the [DATE] discharge in attempts to get more information about the resident's falls and injuries, but the facility would not provide the information. They noticed bruising on the right side of his face, both knees, his right hand and left forearm, and a lump on his head when he was discharged on [DATE]. The family member stated the resident had dementia which had impacted his memory and judgement, but he had not had physical behaviors when at home and had a calm demeanor prior to his admission to the facility. The family member expressed serious concern for the resident's injuries and the facility's refusal to explain how they had occurred.

Based on observation, clinical record review, staff, resident and physician interview, the facility failed to ensure a resident did not develop a pressure sore unless their clinical condition demonstrates it was unavoidable for one of four residents reviewed. (Resident #5) Resident #5 was left on the bed pan causing a Stage III pressure sore. The facility census was 59 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #5 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident was dependent on staff for toilet use, personal hygiene needs, bed mobility, transfers and dressing and was non-ambulatory and occasionally incontinent of bowel and bladder. The assessment documented the resident was at risk for pressure ulcers, but had no pressure ulcers present and was not on a turning and repositioning program. Current weight was 217 pounds. A Care Plan with a focus area initiated on 3/15/18 and updated 6/13/18 and 10/29/18 indicated the resident had skin impairment related to mobility and range of motion (ROM) deficits and a focus area revised 8/3/17 which indicated the resident had an activities of daily living (ADL's) self care performance deficit related to ROM and mobility deficits and was noncompliant with working with therapy. Interventions include: a. Staff to educate the resident on not taking out the bed pan on own and to ask for assistance. (dated 3/15/18) b. Bariatric bed pan. (revised 8/9/18) c. After the certified nurse aides (CNA's) get the resident off the bed pan the resident liked to wipe themselves and the resident liked to take the bed pan out themselves as at times it rubbed on the residents coccyx and caused more irritation. (dated 7/10/18). d. Bed from home with a mattress protector cover. (dated 7/28/17) e. Required assistance from one (1) staff member with the bed pan. (dated 7/28/17) f. Required assistance from 1 staff member with personal hygiene. (dated 6/16/17) During an interview on 11/20/18 at 3:13 p.m., the resident stated she was left on the bed pan for an extended period of time which caused her current pressure ulcer. During an interview on 11/28/18 at 11:47 a.m., the resident stated the area on her buttock was caused because staff left her positioned on a bed pan for a long time. The resident stated she felt the bed pan was positioned under her perineal area and she used the call light for assistance, however staff only answered the light when they wanted. The Progress Notes dated 10/29/18 through 12/22/18, failed to have an assessment of an open area on the resident's right buttock. During an interview on 11/21/18 at 1:32 p.m., the Assistant Director of Nursing (ADON) stated on 10/25/18 one of the 2:00 p.m. to 10:00 p.m., certified nurse aides, (CNA) placed the resident on the bed pan sometime during the shift and the bed pan was not found until after 4:00 a.m., when the night CNA noticed the bed pan was not hanging up per usual. When the bed pan was found and removed staff identified shearing and a perfect ring of bruising from the bed pan. The ADON confirmed staff failed to perform an initial nursing assessment, wound assessment and/or incident report. The ADON indicated the issue as not brought to her attention until 10/30/18 when she performed the first assessment to the area. During an interview on 11/28/18 at 12:07 p.m., Staff C, CNA confirmed she worked on 10/25/18 on the 2 p.m. to 10:00 p.m. shift, however she could not recall having positioned the resident on the bed pan because it was a long time ago. During an interview on 11/28/18 at 1:21 p.m., Staff E, CNA indicated she could not recall if she assisted Staff C with placing the resident on the bed pan as the incident occurred a long time ago. During an interview on 11/28/18 at 2:32 p.m., Staff D, Certified Medication Aide (CMA) confirmed she worked 10/25/18 from 6:00 p.m. until 5:00 a.m. and somewhere between 7:00 p.m. and 8:00 p.m. she administered medications and applied creams as prescribed by the physician. Staff D stated somewhere before midnight she answered the resident's call light but all she wanted was Doritos and a type of butter. Staff D confirmed she observed Staff F, CNA as she performed resident rounds however she was not in the resident's room as she had been unable to assist due to a broken foot and elbow at the time and she had already left the building when the bed pan was found under the resident. During an interview on 11/28/18 at 3:15 p.m., Staff F, CNA indicated when she arrived to work on 10/25/18 for the 10:00 p.m. until 6:00 a.m., shift all of the 2:00 p.m. until 10:00 p.m., staff just left so there was no indication of any resident changes. Staff F indicated at 12:00 a.m. she refilled the resident's water pitcher. At 2:00 a.m. she checked on the resident, however she was sleeping so she did not disturb her. Staff F stated somewhere between 4:00 a.m. and 6:00 a.m., when she performed her last rounds for the residents she noted the resident's bed pan was missing because it had not been hanging it the normal place. As the resident rolled over, Staff F found the bed pan around the resident's left hip area, not where the pressure ulcer had been noted and in an area that gave Staff F the impression the resident attempted removal of the bed pan herself which she had been known to do. Staff F indicated she applied [MEDICATION NAME] to the affected area to enable protection to the resident's skin. During an interview on 12/6/18 at 9:28 a.m., the ADON confirmed the area was actually one and the same and located on the resident's right buttock/gluteal region. A Progress Note entry dated 12/7/18 at 8:19 a.m., indicated a correction was made to the wound progress notes with the clarification the wound involved the resident's right buttock. A physician progress notes [REDACTED]. Review of the Weekly Wound Observation forms revealed: On 10/30/18 at 10:25 a.m., first observation of an abrasion on the resident's left buttock measured 10 cm by 2 cm with no depth, beefy red granulation tissue present with a scant amount of serosangineous drainage and no odor. On 11/6/18 at 7:40 a.m., the abrasion measured 18 cm by 4 cm with no depth, beefy red granulation tissue present with a scant amount of serosangineous drainage and no odor. On 11/14/18 at 3:47 p.m., the abrasion measured 16 cm by 4.5 cm with 0.2 cm in depth, beefy red granulation tissue with a scant amount of serosangineous drainage and no odor. On 11/20/18 at 12:07 p.m., the area now changed to a Stage III pressure ulcer measuring 13.4 cm by 4.8 cm with 0.2 cm in depth, beefy red granulation tissue present with a scant amount of serosangineous drainage and no odor. A Progress Note from the Wound Treatment Center dated 11/20/18 at 4:18 p.m., documented the area was linear/angular in shape, wound under the resident's right buttock suggested a pressure injury from an object such as a bed pan. On 11/27/18 at 10:48 a.m., the Stage III pressure ulcer measured 17 cm by 3.5 cm with 1.0 cm in depth, beefy red granulation tissue present with a scant amount of sanguineous drainage and no odor. Observation on 11/28/18 at 11:22 a.m., revealed the resident repositioned on the left side while the ADON and Staff B, Licensed Practical Nurse (LPN) performed a treatment to the resident's Stage III pressure ulcer. The Stage III pressure ulcer was packed and covered when it was pointed out the resident had another area. The ADON stated the new area was not present on 11/27/18. The new area measured 2 cm by 1 cm and 0.4 cm deep. During an interview on 12/5/18 at 3:50 p.m. , the Physician confirmed the pressure ulcer was avoidable and he felt the area could have increased in size after the initial observation.

Based on clinical record review, resident, staff, home health agency staff, a case manager and homeless shelter staff interviews, the facility failed to ensure a safe and orderly transfer or discharge from the facility for 2 of 4 residents reviewed (Resident #14 and Resident #9). The facility identified a census of 74 residents. Findings include: 1. Review of Resident #14 ' s Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicated intact cognition. The MDS identified Resident #14 as independent with Activities of Daily Living (ADL ' s) and only required supervision/set up help for bathing. The MDS revealed Resident #14 not stable but able to stabilize without staff assistance when moving from a seated to standing position, walking, turning around and facing the opposite direction while walking, moving on and off the toilet and any surface-to-surface transfer, with an impairment on one side of Resident #14 ' s lower extremities. The MDS identified Resident #14 used a walker and wheelchair for mobility. The MDS listed Resident #14 as occasionally incontinent of urine. The MDS of Resident #14 listed [DIAGNOSES REDACTED]. The MDS listed Resident #14 height at 65 inches and weight of 291 pounds. Resident #14 ' s at risk for pressure ulcer development according to the MDS. The MDS revealed Resident #14 suffered an infection of the foot, skin tears and one venous/arterial ulcer. A Care Plan dated 8/12/15, indicated Resident #14 ' s focus areas included: Oxygen therapy related to [MEDICAL CONDITION], DM, [MEDICAL CONDITION], hypertension (HTN), Antidepressant medications related to depression, acute and chronic pain related to toe ulcer, [MEDICAL CONDITION], arthritis and Falls: Resident #14 ' s Care plan identified a moderate risk for potential falls related to [MEDICAL CONDITION], walked with a walker and a wheeled walker and oxygen dependent. A potential for and actual impairment to skin integrity related to [MEDICAL CONDITIONS], DM with a venous stasis ulceration of the right 3rd toe. Resident #14 required assistance with discharge planning. The interventions included the following: a. Resident #14 received oxygen via nasal prongs/mask per physician orders, continuously and humidified as needed (PRN) initiated on 8/31/15. b. Administer anti-hypertensive medications as ordered. Observe for side effects such as low blood pressure and elevated heart rate. Observe for [MEDICAL CONDITION]. c. Diabetes medication as order by the physician. Monitor and document for side effects and effectiveness. d. Fasting serum blood sugar as ordered by the physician. e. Elastic stockings/ Ace Wraps as ordered by the physician. f. Encourage Resident #14 to change position frequently, not sitting in one position for long periods of time. g. Encourage Resident #14 PRN to elevate legs while seated and sleeping. h. Needed pressure relieving/reducing mattress to protect the skin while in bed. i. Anticipate need for pain relief and respond to complaints of pain. Pain is controlled by medication. j. Involve as able in plan of care, update PRN regarding changes. Explain options. Allow time for Resident #14 to express opinions and preferences for care treatment and discharge disposition. k. Consult with the physician, therapy and other disciplines regarding progress toward discharge goals. Make arrangements for appropriate placement and update. l. Upon discharge to the community, provide for continuity of care after discharge. Provide a medication list and information on scheduled appointments and on-going treatments. Provide information on reaching physician(s) involved in my care. According to a Doctor's Progress Notes form dated 8/26/15 for Resident #14 listed Physician's documentation that included, the patient had severe [MEDICAL CONDITION] with 4 plus [MEDICAL CONDITION] and gangrene of the toe. Resident #14 required contact monitoring until resolved and needed to stay in a skilled nursing facility. Review of the physician orders [REDACTED]. During an interview 9/2/15, Resident #14 indicated the facilities Social Worker (SW) threatened him/her for 3 weeks to take Resident #14 to a homeless shelter but it actually came to a head the previous Friday when the SW came to Resident#14's room around noon and boxed his/her belongings up and stated Resident #14 was going to the shelter that day. Resident #14 stated he/she started crying because it scared him/her. The SW packed up his/her belongings. Resident #14 said good-bye to everyone and the Activity Director drove Resident #14 to the homeless shelter in her car around 2:00 p.m. Resident #14 stated the Social Worker and Activities Director got him/her out of the car, into the shelter, sat him/her down in a chair and the Social Worker took a box of medications to the counter which included his/her narcotics. At which time the Social Worker was informed by the shelter staff Resident #14 only allowed 2 bags so she rearranged his/her belongings and brought some of the extra items back to the facility. The SW and Activity Director then left Resident #14 at the homeless shelter. Resident #14 stated he/she sat in the same chair from 2:00 p.m. until 6:00 p.m. when a Home Care Nurse arrived at the shelter and identified no room available in the shelter for Resident #14 specifically since he/she required a specials room due to the oxygen therapy needs. Because Resident #14 not assigned a room the agency was unable to add him/her on the case load so the Home Care Nurse attempted to locate placement for Resident #14, including speaking more with the homeless shelter staff who stated Resident #14 could stay but he/she needed to sit/sleep in a chair for 5-6 days until a bed became available. After many failed attempts for placement the decision was made to send Resident #14 back to the facility. The transfer back to the facility occurred when the facility Social Worker arrived at the homeless shelter at approximately 9:30 p.m. and transferred Resident #14 back to the nursing facility. Review of the Home Health Care Agency Notes from the nurse revealed the following information as dated: a. 8/28/15 at 4:00 p.m. - This Registered Nurse (RN) received a message when at the office the Social Worker from the facility planned to take Resident #14 to the Homeless Shelter in the next hour and his/her manager wanted Resident #14 admitted that night. The RN informed the manager she could not arrive at the shelter until 6:30 p.m. b. 8/28/15 at 6:25 p.m. - The RN arrived at the Homeless Shelter and found Resident #14 was dropped off with 2 small suitcase an oxygen concentrator, a walker and a box of medications in blister packs. The only paperwork available included insurance care information, face sheet and discharge orders with dressing change orders. The RN spoke with the Homeless shelter staff and confirmed no beds available that night and possibly nothing available for 5 to 7 days. Resident #14 located sitting in a straight back chair and according to the shelter staff that was the only space available until a bed opened up. On 8/28/15 at 6:31 p.m. the RN contacted the managerial staff for direction and was told to call Resident #14's daughter and have him/her taken to the emergency room as Resident #14 unable to stay at the homeless shelter due to a lack of appropriate accommodations. c. 8/28/15 at 6:38 p.m. - The RN spoke to Resident #14 who appeared to be crying and stated he/she was cold and scared. Resident #14 stated the facility left him/her at the shelter with only a few possessions. Resident #14 stated no family members cared about him/her except a sister-in-law that lived about an hour away but Resident #14 not able to stay with the sister in law or expect the sister-in-law to pick Resident #14 up and transport to the hospital. d. 8/28/15 at 6:53 p.m. - 6:55 p.m. - The RN called her manager back and again was directed to call 911 and take Resident #14 to the hospital emergency room (ER). e. 8/28/15 at 6:56 p.m. - The RN spoke to Resident #14 to determine the hospital he/she wished to transfer to. Resident #14 requested the RN call his/her physician to see which hospital he wanted him/her to go to. Resident #14 stated he/she saw the physician on 8/26/15 and the physician wanted Resident #14 to stay at the facility in skilled care if able. The physician stated OK to have Resident #14 transferred only if he/she had a room, assistance with medications and procedures and the areas was safe. Also stated the staff are directed to complete the dressing changes to the toe wound on the right middle toe and wrap the bilateral lower extremities with Ace Wraps in the morning and remove in the evening. f. 7:03p.m. - 7:07 p.m. - A returned call provided direction for the RN to transfer Resident #14 to a hospital because the homeless shelters beds are unavailable for 5-7 nights. g. 7:08 p.m. - The RN spoke with the homeless shelter staff who informed her the facility staff failed to contact the homeless shelter about bed availability for Resident #14 as they would have informed the facility there was a waiting list for admissions. h. 7:20 p.m. - Resident #14 ' s physician called the Home Care RN and stated the issue was a situation of leaving Resident #14 without adequate housing and services. i. 7:33 p.m. - The RN spoke with another RN from an outside agency who informed her a hospital would not admit Resident #14 if taken to the ER. The RN then examined Resident #14 ' s medications and found the medication list included the following: An insulin pen that Resident #14 was unsure how to use, blood sugar checks two times a day (BID).Resident #14 was told the home health agency would have provided him/her with a glucometer and ointment to have been applied to his/her feet BID which the client could not reach. The homeless shelter staff can only administer medications set up in separate time and date bottles or planners. The homeless shelter staff can ' t administer unscheduled medication or perform dressing changes or administer insulin injections. j. 8:01 p.m. - The Social Worker (SW) from Genesis called the RN and stated she dropped Resident #14 off at the homeless shelter with the understanding a bed was available. The SW stated the facility failed to receive payment for care of Resident #14 at the facility. The RN explained to the SW nobody at the homeless shelter available to assist Resident #14 to the bathroom, perform the leg wraps, wound care or administer the PRN medications as ordered. k. 8:11 p.m. - The RN spoke with Resident #14 who stated afraid to stay at the homeless shelter, not educated on how to use the insulin pen and unable to reach his/her feet for BID treatments. l. 8:16 p.m. - The facilities SW returned call and acknowledge she failed to assist Resident #14 with Medicaid reinstatement paperwork. The SW offered to return Resident #14 to the facility if needed. m. 8:30 p.m. - The RN spoke with Resident #14 who stated he/she wanted to return to the facility. n. 8:38 p.m. - The RN called the facility SW and arranged for Resident #14 ' s return to the facility. o. 8:42 p.m. - According to a statement Resident #14 informed the RN he/she experienced pain. p. 8:55 p.m. - The RN administered Resident #14 a pain medication with a glass of water. Due to not having a glucometer the RN had not given the scheduled 40 units of [MEDICATION NAME]. q. 9:10 p.m. - The facility SW arrived at the homeless shelter and transferred Resident #14 and belongings back to the facility. During an interview 9/2/15 at 9:00 a.m., Staff A, Licensed Practical Nurse (LPN) confirmed Resident#14 discharged because allegedly medically stable per report. Staff A commented Resident #14 able to administer his/her own medications and perform treatments. Staff A confirmed the facility sent the oxygen, medications and treatment supplies with Resident #14 to the homeless shelter. During an interview 9/2/15 at approximately 12:15 p.m., the Director of Nursing (DON) confirmed Resident #14 as not Medicaid appropriate because he/she failed to meet level of care as mostly independent with cares and could have administered own medications and perform own treatments. During an interview 9/9/15 at 12:55 p.m., the RN for the home care agency confirmed she entered the homeless shelter and identified Resident #14 sitting in the chair crying because he/she was scared. The home care agency RN stated Resident #14 complained of swollen legs but noted he/she had the oxygen running. During an interview 9/9/15 at 1:38 p.m., the Activity Director (AD) stated she assisted the SW with the transfer of Resident #14 and she could tell Resident #14 was scared and teary confirmed during the transfer. Upon arrival at the shelter the AD assisted Resident #14 into the shelter, retrieved a chair and sat Resident #14 down while the SW brought in Resident #14's supplies and went to the counter and spoke with the homeless shelter staff. The AD stayed with Resident #14 and he/she kept saying he/she was scared and not comfortable there. At that point the SW turned around and told the AD she could leave the shelter. Resident #14 began crying at that point so the AD reassured him/her and left at 4:50 p.m. The AD confirmed during the interviewing process that her personal feelings had been that she would never have left Resident #14 at the homeless shelter but she did not know what arrangements the SW had made. During an interview on 9/10/15 at 9:53 a.m., the Manager of the homeless shelter indicated the shelter failed to have a medications management program. The shelter can store the drugs locked behind the desk. The Manager stated she failed to recall a phone call from the facility but that had not meant it had not occurred. The Manager confirmed the shelter never turned anyone away and if there had not been a bed available people can sleep in a chair. The Manager shared the shelters intake record for the day of the 28th which confirmed Resident #14 as present but no intake was completed or bed assigned. During an interview 9/10/15 at 1:19 p.m., the Physician stated he had strong feeling about the identified concerns related to Resident #14.The Physician stated the Nurse Practitioner that wrote orders for discharge from the facility never saw Resident #14 at all prior to the discharge. The Physician stated Resident #14 required home health services, a skilled nursing facility and/or an assisted living facility. The Physician confirmed it had not been safe to discharge and leave Resident #14 at a homeless shelter as his/her current status resulted in a need for nursing services 1-2 hours per day. During an interview 9/10/15 at 1:27 p.m., the facility SW confirmed the facility failed to receive payment for care and services provided to Resident #14. The SW tried to place Resident #14 in alternative housing and the last resort was the homeless shelter. The SW stated she called the homeless shelter and spoke with an unknown person that identified the homeless shelter could place Resident #14 and the oxygen concentrator. The SW stated when she arrived at the shelter with Resident #14 and the Activities Director they brought Resident #14 into the facility and sat him/he down in a chair in the lobby area and brought his/her belongings to the counter where 2 young girls stated the shelter could take Resident #14 but not all of his/her belongings so the SW downsized his/her items and took the medications to the lady behind the desk who said she would lock them up until the home health agency arrived. The SW indicated she counted on the home health agency nurses to administer Resident #14 ' s needed medications. The SW confirmed she left Resident #14 in the lobby at that point but his/her case manager from an outside agency was also present. The SW indicated about 9:30 p.m. that night she received a call from the nurse from the Home Care Agency who stated the SW needed to go back to the homeless shelter and pick up Resident #14 because no bed was available for Resident #14 and he/she had to sit in a chair for 5-6 days until a bed became available. The SW confirmed the nurse had been very upset because Resident #14 ' s leg wraps failed to be in place. Resident #14 failed to have a glucometer or any lamb wool for his/her toe treatment. The SW arrived at the homeless shelter and found Resident #14 sitting in the same place she left him/her previously and returned Resident #14 to the facility. Upon return to the facility the SW confirmed staff members gave Resident #14, 2 sandwiches, pudding, apple crisp dessert and milk. The SW confirmed she felt the situation had not been handled correctly but she followed her directives to get Resident #14 out of the facility due to lack of payment. The SW also confirmed when she left Resident #14 at the facility she was scared herself and wanted out of there because a person at the shelter chased her down and tried to open her car door. During an interview on 9/23/15 at approximately 10:00 a.m. Resident #14's case manager from an outside agency confirmed not present when Resident #14 was transferred and left at the homeless shelter but he/she did arrive later that evening when the Home Care agency nurse arrived. 2. Review of a Minimum Data Set (MDS) assessment form dated 5/27/15 revealed Resident #9 ' s Brief Interview for Mental Status (BIMS) score of 15, identified intact cognition. The MDS indicated Resident #9, required extensive assistance of staff 2 staff members for transfers and bathing, required extensive assistance of 1 staff member with locomotion on and off the unit, dressing, toilet use and personal hygiene. The MDS listed Resident #9 as unable to move from a seated to standing position, unsteady and only able to stabilize with staff assistance when moving on and off the toilet and any surface-to-surface transfers and with impairments on one side of the upper and lower extremities. The MDS indicated Resident #9 utilized a wheel chair for mobility. Resident #9 occasionally experience bowel incontinence. According to the MDS Resident #9 ' s [DIAGNOSES REDACTED]. The MDS identified Resident #9 ' s pain was frequent. Resident #9 weighed 241 pounds. An Immediate Plan of Care dated 5/27/15, indicated Resident #9 at risk for falls, self-care deficit related to a fall in the past 30 days, the use of anti-depressants, neuromuscular/functional deficit related to a fractured tibia and fractured humerus. Listed as non-weight bearing. The interventions included the following: a. Ensure balance in the wheelchair. Specify positioning device per therapy. b. Assistance of 1 to 2 staff with all transfers, bed mobility, toileting, grooming, dressing and bathing. c. Assistance of 1 for locomotion on and off the unit and eating. c. Gait belt with transfers. During an interview 9/17/15 at 8:54 a.m., the Physical Therapist (PT) confirmed when Resident #9 had been discharged he/she remained non-weight bearing on both of his/her upper and lower extremities on one side. The Occupational Therapist (OT) indicated Resident #9 had range of motion (ROM) to his/her arm but still listed as non-weight bearing to the leg. During an interview 9/17/15 at 9:11 a.m., the facilities Social Worker (SW) indicated Resident #9 transferred home with a wheelchair and had someone available to assist him/her into the house but the person proved not been big enough to assist so the SW contacted the maintenance man at the facility who came to Resident #9's house and the friend and maintenance man lifted him/her into the house in the wheelchair. Once in the house Resident #9 was asked if he/she wanted transferred into the recliner but declined. The SW indicated she asked Resident #9 about supper and he/she stated the friend would get him/her something to eat so they visited a bit and the SW left the house. The SW also stated Resident #9 discharged home with home health agency (HHA) services and the expectation involved the HHA being available at Resident #9's home upon discharge. The SW stated, she contacted Resident #9 several times that day and the HHA agency failed to arrive. When the SW contacted the HHA, the agency indicated they are unable to admit Resident #9 as they could not care for her/him and that he/she should not be at home as the environment was very poorly kept and he/she only had a recliner and davenport in the home. The SW indicated she called Resident #9 the next day and asked what he/she needed and Resident #9 stated he/she had no medications so the SW went to Resident #9's house, picked up the medication scripts and located Resident #9 still positioned in the wheelchair in the same position as the night before. The SW then went to the hospital picked up Resident #9's medications and brought them to him/her. The next day the SW returned to Resident #9's house and found him/her on the couch and the friend was present. The SW stated she called an adult protective agency and reported Resident #9 as not safe in the home but unable to recall who she spoke too. During an interview 9/17/15 at 10:43 a.m., the maintenance man confirmed he went to Resident #9's house and found Resident #9 positioned in a chair outside the house so he and another individual transferred Resident #9 from the chair to a wheelchair, turned the wheelchair around and pulled Resident #9 up the stairs and into the house to the kitchen area. Once in the house he did nothing because the house had been so filthy, disgusting and smelled of animals. He further described the floors looked like dirt floors related to the amount of dirt piled up. He indicated he had not wanted to stick around so he left the house and waited outside for the SW who remained in the house for approximately 2-3 minutes. Once both of the staff members exited the house they both left Resident #9 ' s home. During an interview 9/17/15 at 10:15 a.m., the HHA manager confirmed he/she sent a therapist to Resident #9's home the day after arrival and found him/her alone in an unsafe environment in urine soiled clothing positioned in a chair as Resident #9 unable to toilet independently. Because the environment was unsafe, the therapist called the physician who directed them to call the emergency room of a hospital however Resident #9 refused. The HHA manager confirmed the agency did not say they would be present when Resident #9 arrived home the day prior to this visit. During an interview 9/17/15 at 10:05 a.m., a transport agency staff member confirmed Resident #9 was picked up at the nursing facility on 6/2/15 at1:26 p.m. and arrived at his/her home at 1:33 p.m. According to the transport driver family and/or friends present but no one able to assist in transferring Resident #9 up the stairs and into the house. The transport driver confirmed no HHA staff present. The driver waited a bit and a family member and/or friend transferred Resident #9 from the driver's wheelchair into a folding chair with a plan for them to wait for the HHA staff to arrive. At 2:00 p.m. the driver left Resident #9's home as it had been Resident #9's responsibility to make arrangements for care once the transfer was completed. Review of the Nurse's Notes entry dated 6/2/15 at 1:30 p.m., included the following documentation: Resident #9 left via a transport agency for discharge home. All belongings taken with him/her. A call to the HHA and update given related to Resident #9 ' s status. Resident #9 voiced several times concerns related to insecurity about the ability for independent care on his/her own. Instructed Resident #9 that if she/he felt overwhelmed or needed increased care to call the HHA and talk to them related to care needs. During an interview 9/16/15 at 3:11 p.m., Resident #9 confirmed the following: a. The HHA planned to visit his/her house to see if environment was safe. b. The transportation agency escorted Resident #9 home from the nursing facility. c. Resident #9 commented the transport agency left him/her in a folding chair on the lawn for 3 hours. d. Resident #9 called the SW at the nursing facility and she came to Resident #9 ' s house and contacted the maintenance man at the facility and requested he bring a wheelchair to Resident #9 ' s house. f. According to Resident #9 the maintenance man arrived and assisted him/her into the house with the assistance of a friend of Resident #9 ' s. g. Resident #9 confirmed he/she remained non-weight bearing on the right side when transferred home. h. Resident #9 required a wheelchair and commode at home. According to Resident #9 these items are not available in the home. Resident #9 ' s interview dated 9/16/15 at approximately 4:30 p.m., confirmed a male friend present when he/she arrived home but the friend left. Resident #9 confirmed he/she transferred independently from the wheelchair to the easy chair however unable to toilet independently. The HHA agency arrived the next day and identified Resident #9 ' s incontinent of urine. Resident #9 confirmed a lack of medications present upon transfer and discharge home. Resident #9 commented the next day the SW from the facility brought him/her the ordered medications. According to Resident #9 ' s May 2015 Medication Administration Record [REDACTED] 5-325mg 1-2 tablets orally for pain. According to Resident #9 ' s interview the facility failed to coordinate and assure Resident #9 received medications as needed. Note: At the time of the onsite investigation the deficiency was coded at a J level for immediate and serious jeopardy. By September 17, 2015 the facility had implemented measures that adequately addressed the jeopardy issue and the grid placement was lowered to an D level. The facility provided staff training regarding discharges and communication.

Based on observation, record review, interviews with staff and resident, the facility failed to provide adequate supervision for Resident #1 and Resident #3. An incident of inappropriate touching occurred on 2/24/12 between Resident #1 and Resident #3 and the facility did not document or implement care plan directives to meet residents need. The record lacked evidence of increased supervision after 2/24/12 to prevent further incidents. Staff interviews identified other situations between the 2 residents with the last documented incident on 2/29/12. Facility census was seventy-three (73) residents. Findings include: 1.A Minimum Data Set (MDS) assessment with observation end date of 1/27/12 assessed Resident #1 with a brief interview for mental status score of 11 (moderate cognitive impairment). The MDS did not identify any mood or behavior concerns. The MDS identified the resident as independent with bed mobility, transfers, ambulation, toileting and personal hygiene. The assessment determined the resident used a walker when ambulating. The resident had [DIAGNOSES REDACTED]. Observation showed, on 4/11/12 at 2:35 p.m. Resident #1 independently ambulatory with a walker. The resident attended an activity in the dining room. A physician encounter form, dated 3/2/12 revealed staff reported the resident had been sexually inappropriate with touching other women. The resident did not recall doing this and became upset when questioned. The resident ambulated independently with a walker and seeks out different women. The physician offered Medroxyprogesterone (hormone) 100 milligrams (mg.) intramuscularly monthly to control the sexual behaviors. A physician encounter form dated 4/5/12 stated the facility relocated some female residents to another floor and dining room. The resident continued to pursue females. Review of focus nursing notes, care plans and behavior records available on 4/11/12 did not contain any information regarding the resident's sexual behaviors as the physician documented. Before leaving the facility, on 4/11/12, the surveyor questioned the lack of facility documentation regarding the incidents. On 4/12/12, the facility provided the surveyor with additional nurse ' s notes and behavior records that identified sexual behaviors. On 4/12/12 at 9:15 a.m., the surveyor asked Staff F why the sexual behavior sheets were not available for viewing on 4/11/12. Staff F stated the medical records person located them in filed information after the surveyor left on 4/11/12. The surveyor also received a page of focused nursing notes with 2 entries on the page dated 2/27/12 and 2/29/12 (also located in filing). The entry dated 2/27/12 at 11:30 a.m. and written by Staff F (Assistant Director of Nursing) documented staff called Staff F to the dining room related to Resident #1 attempting to touch female residents and staff. The resident made inappropriate comments and gesturing at staff. The entry dated 2/29/12 at 2:30 p.m. and written by Staff J (licensed practical nurse) stated staff observed Resident #1 attempting to grab at female residents in a sexual way. Staff redirected Resident #1 after several attempts and staff removed the female from the dining room. Behavior sheets identified the facility began monitoring Resident #1 for sexual behaviors on 2/27/12. The following dates identified Resident #1 with sexually inappropriate behavior: 2/27/12, 2/29/12, 3/1/12, 3/3/12, 3/4/12, 3/9/12. The following dates identified Resident #1 with "touching of residents, staff, or attempts to touch/grab": 2/27/12, 2/28/12, 2/29/12, 3/3/12, 3/4/12, 3/9/12, 3/12/12, 3/13/12, 3/26/12. Resident #1's care plan dated 2/8/12 did not contain any problems/interventions that identified sexual behaviors. At exit conference, on 4/23/12 at 4:43 p.m. the Director of Nursing submitted the cognitive loss/dementia component of the resident's care plan which contained an addendum dated 3/13/12 that stated, "If staff finds me (Resident #1) making sexual remarks or overtures to staff or my peers, please redirect me and if need be remove me from the situation". This addendum was not present on the care plans obtained on 4/11/12. When questioned, on 4/25/12 at 9:49 a.m., the care plan nurse, Staff U stated she had been gone and did not know about the sexual incident until she returned to work and then she added the addendum to the care plan. She stated the addendum date should be 4/13/12, and not 3/13/12. On 4/12/12 at 1:19 p.m. Staff I (registered nurse) stated she was aware of incidents between Resident #1 and Resident #3. In a written statement prepared on 4/23/12, Staff I documented on 2/24/12 staff called her to a room because staff needed assistance. Observation showed Resident #1 and Resident #3 in a room with the door closed. Upon entering the room Staff I observed Resident #1 standing with his/her pants unzipped and belt open with nothing exposed and Resident #3 with his/her shirt pulled up to the breasts. Staff I separated and redirected the residents. Review of Resident #1 and Resident #3's records did not identify an incident occurring on 2/24/12. On 4/12/12 at 10:30 a.m. Staff J (licensed practical nurse) stated on 2/29/12 she observed Resident #1 and Resident #3 in the dining room. Resident #1 rubbed and touched Resident #3's side up towards the arm pit and called Resident #3 "baby". Staff J also identified self as initialing the dates 3/3/12 and 3/4/12 on behavior records. She stated those incidents involved staff. On 4/12/12 at 9:55 a.m. Staff F (assistant director of nursing) stated she initialed the behavior sheet on 2/27/12. That incident involved Resident #1 attempting to grab at people when they walked by. Resident #1 made sexually and socially inappropriate comments. According to Staff F, Resident #1 directed the comments at females but no one in particular. On 4/12/12 at 12:28 p.m. Staff K (nurse aide) stated she saw Resident #1 hug Resident #3 and one day staff found Resident #3 in Resident #1's room. Resident #1's pants appeared unzipped and Resident #3's shirt was up. Staff K stated nothing was exposed during this incident. She stated she informed the nurse. Not long after that, the facility moved Resident #3 to another level (area) of the facility. On 4/12/12 at 3:12 p.m., Staff G (admissions) stated Resident #1 had his/her hand under Resident #3's blouse and felt around. She asked Resident #3's family about moving Resident #3 and they agreed. Staff G stated everything had been fine since the move with no inappropriate behaviors identified. Staff G stated a couple months ago she observed Resident #1 with his/her hand on Resident #3's shirt. Staff G did not document the incident because she did not see anything occur. After staff observed Resident #1 with the hands under and in Resident #3's shirt, they moved Resident #3. On 4/23/12 at 11:43 a.m. Staff P (nurse aide) stated Resident #3 tends to have boyfriends. On 4/23/12 at 11:50 a.m. Staff Q (nurse aide) stated she observed Resident #1 and Resident #3 hold hands but she did not see anything else. Before Resident #3 was moved, staff had resident stay by them. Staff Q stated Resident #3 would "go crazy" without Resident #1 saying "I love" him/her. On 4/23/12 at 12:05 p.m. Staff O (nurse aide) stated she only saw Resident #1 with his/her hands on top of Resident #3's clothing prior to the move. On 4/23/12 at 2:27 p.m. Staff A (registered nurse), who initialed the behavior records for sexual touching stated it was all towards staff. She never witnessed any resident to resident incidents with Resident #1. On 4/23/12 at 12:42 p.m. Staff B (licensed practical nurse) stated she observed Resident #1 with his/her hand kind of high on Resident #3's thigh before the move. Otherwise Resident #1's actions were directed at staff. A Minimum Data Set (MDS) with assessment reference date of 12/23/11 assessed Resident #3 with a brief interview for mental status score of "3" (severe impairment). The MDS assessment identified Resident #3 with Alzheimer ' s Disease. Review Resident #3's focused nursing notes did not identify any incidents of inappropriate behaviors. The care plan dated 1/4/12 and 4/4/12 did not identify inappropriate behaviors. On 4/12/12 at 9:18 a.m. observation showed Resident #3 in a wheelchair. The resident stated "yes" when asked if he/she had been touched inappropriately. The resident refused to elaborate further. The resident appeared very confused and could not identify the year, month, or town. Review of documentation identified the facility moved Resident #3 to another level (area) of the facility on 3/1/12.