Every finding on record at Greenfield Care Center of Fairfield

Based on interview and record review, the facility failed to ensure a comprehensive person-centered care plan was implemented for two of five sampled residents (Resident 1 and Resident 2), when Resident 1's discharge care plan was not updated or revised after fall episodes before discharge, and Resident 2 did not have a discharge care plan initiated or developed. This deficient practice had the potential risk to compromise Resident 1 and Resident 2's highest practicable mental, physical and psychological well-being during the discharge process.Findings: A review of Resident 1's admission Record (AR) indicated Resident 1 was admitted to the facility in 2/25, with diagnoses which included chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), humerus fracture (a break in the upper arm bone), fall, muscle weakness, unsteadiness on feet, and need for assistance with personal care. A review of Resident 2's AR indicated Resident 2 was admitted to the facility in 10/20, with diagnoses which included diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), and removal of the right leg below the knee. A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated [DATE], indicated Resident 1 had minimal difficulty hearing and missed some part/intent of message when communicating with others, and had mild problems with thinking and memory. A review of Resident 1's Care Plan Report (CPR), dated [DATE], indicated a discharge plan was initiated and waiting for approval with no facility updates or interventions documented. A review of Resident 2's MDS, dated [DATE], indicated Resident 2 had no memory impairment. A review of Resident 1's CPR, dated [DATE], indicated Resident 1 was at risk for fall or injury. The CPR did not have any updates or revisions to the discharge care plan to identify Resident 1's discharge goals and interventions. A review of Resident 1's Rehabilitation Notes, dated [DATE], indicated Resident 1 had a fall on [DATE] with a small bump injury to the forehead. During a concurrent interview and record review on [DATE] at 5:30 p.m. with the Administrative Staff (AS, the ADM, the SSD, and the MDS-C), the AS acknowledged Resident 1 and Resident 2 did not have initiated, implemented, updated, or resolved discharge care plans related to their goals and interventions. The AS indicated they did not know that discharge care plan was a requirement for the continuity of care or to ensure the residents' highest level of function. During an interview and record review on [DATE] at 6:15 p.m. with the AS, the ADM indicated the expectation was for AS to be involved in the care plan process to provide safe discharge for Resident 1 and Resident 2. The ADM stated, The [discharge] process is important. We are dealing with people's lives. We want them to have a safe, quality of life. A review of the facility's policy and procedure titled Policy and Procedure - Care plan, revised 09/2009, indicated A care plan is the summation of the resident concerns, goals, approaches and interventions in order to meet the goals and help minimize if not totally eradicate residents' problems. Each individual resident has a comprehensive care plan which is objective, measurable and time-framed. A care plan is accomplished through the interdisciplinary team.The resident care plan.reviewed.as often as needed as there is a change of condition. The evidence of a care plan that has been reviewed should include but not be limited to the new interventions that have been added in addition to the current ones. These interventions should be in chronological order as implemented or carried out.identifying their concerns and developing the highest level of functioning the resident may be expected to attain.

Based on interview and record review, the facility failed to ensure a safe, orderly, and appropriate discharge for one of five sampled residents (Resident 1,) when the facility failed to:Develop, update, and resolve discharge care plans that identified the goals and interventions for Resident 1;Notify Resident 1's Care Navigator (CN - a case manager assigned as an advocate to help residents with community support and resources) at or before Resident 1's transfer/discharge; andDischarge Resident 1 to a setting that met her assessed care needs.These failures resulted in the facility discharging Resident 1 to a Room and Board (R&B) that could not meet her care needs. As a result, Resident 1 fell and had an incontinence episode, which required an ambulance and an emergency room visit on [DATE]. The resident's CN then made an Adult Protective Services (APS) referral on [DATE] because she feared for Resident 1's safety. Findings:A review of Resident 1's admission Record (AR) showed the facility admitted Resident 1 in 2/2025, with diagnoses that included chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), humerus fracture (a break in the upper arm bone), fall, muscle weakness, unsteadiness on feet, and need for assistance with personal care.A review Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated [DATE], showed Resident 1 had minimal difficulty hearing and missed some part/intent of a message when communicating with others. Resident 1's Brief Interview for Mental Status (BIMS - an assessment tool used by facilities to screen and identify the memory, orientation, and judgment status of the resident) summary score was 11, which indicated moderate to mild problems with thinking and memory. The MDS indicated Resident 1 needed a walker or wheelchair for mobility and staff assistance with eating and walking; required moderate assistance getting in and out of bed, going to the bathroom, bathing, and upper body dressing; required maximal assistance moving from sitting to standing and from bed to chair; and depended on staff for lower body dressing and getting in and out of the tub or shower.A review of Resident 1's Care Plan Report (CPR) indicated Resident 1 sustained two unwitnessed falls before the facility discharged her: one on [DATE] with no injury documented, and one on [DATE] that documented a small bump injury to the forehead. On [DATE], the facility initiated a CPR with a focus that identified Resident 1 as at risk for recurrent fall/injury. The CPR showed the discharge plan awaited approval on [DATE], and the facility documented no updates or interventions.Resident 1's Discharge Summary Comprehensive Assessment, dated [DATE], indicated Resident 1 needed assistance with bathing, dressing, eating, personal hygiene (toilet use), transfers, bed mobility, and ambulation (walking).Resident 1's Notice of Proposed Transfer/Discharge, dated [DATE], indicated the facility planned to discharge Resident 1 to the R&B on [DATE], and the facility did not notify Resident 1's CN with this transfer/discharge document.During a telephone interview on [DATE] at 9:20 a.m., the CN stated she did not know the facility transferred Resident 1 to the R&B on [DATE], and that the facility's Social Services Director (SSD) notified her by telephone on [DATE] at 9 a.m. The CN stated she spoke with the R&B Administrator (ADM) within the same hour, and the R&B ADM informed her that Resident 1 needed more care than the R&B staff could provide; Resident 1 had urinated on herself and fallen, which required a hospital emergency room visit, by ambulance, on [DATE]. The CN stated she visited Resident 1 at the R&B on [DATE], and Resident 1 told her she thought she was going to a board and care (B&C - residential housing staffed with individuals who provide 24/7 personal assistance with meals, medications, and daily care needs) home where she could get help; that the R&B had no grab bars; and that she had no means of separating her medications, which were all jumbled together. The CN stated she notified Adult Protective Services on [DATE] and said, I'm afraid for her safety.During a concurrent interview and record review on [DATE] at 5:30 p.m., in the facility's ADM's office, the Minimum Data Set-Coordinator (MDS-C) stated his role was to input the MDS data, that he did not know the specific requirements for residents to discharge, and that he did not know the differences between an R&B and a B&C.During a concurrent interview and record review on [DATE] at 5:30 p.m., in the facility's ADM's office, the Administrative staff (the ADM, the SSD, and the MDS-C) acknowledged that Resident 1 did not have initiated, updated, or resolved discharge care plans related to goals and interventions. The Administrative staff stated they did not know the facility was required to update discharge care plans for continuity of care to ensure the residents' highest level of function.During a concurrent interview and record review on [DATE] at 5:45 p.m., the SSD acknowledged that the CN helped Resident 1 with appointments, transportation, and housing. The SSD stated she notified the CN of Resident 1's discharge to the R&B two to three days after [Resident 1] left. The SSD stated she could not remember the exact date and did not have documentation of the conversation, and said, We [SSD and CN] speak verbally.in person or by phone. The ADM stated Resident 1 called the SSD after being at the R&B and said, [Resident 1] was not sleeping, it's not working, I need to come back there.During an interview and record review on [DATE] at 6:15 p.m., in the facility's ADM's office, the ADM stated she expected staff to have provided safe discharge plans for Resident 1, to have involved the resident in the care plan process, and to have ensured the resident was happy. The ADM stated this process was important and said, We are dealing with people's lives, want it to be a safe, quality of life.During a telephone interview on [DATE] at 10:30 a.m., Resident 1 stated she was not doing well, that the house [the R&B] was not equipped for the handicapped, and that it had no handrails and no elevated toilet seat. Resident 1 stated, I thought this was a [B&C] home, it was not clear, you get handicap services with [B&C].A review of the facility's policy and procedure titled Discharge/Transfer Procedures and Discharge Record Completion, revised 01/2015, indicated, . Allow the Director of Nursing.to review each discharge record to determine the adequacy of the interdisciplinary team's (IDT) discharge: the resident's condition, response, and the events leading to the discharge, transfer. A review of the facility's policy and procedure titled Policy and Procedure - Care Plan, revised 09/09, indicated A care plan is the summation of the resident concerns, goals, approaches and interventions in order to meet the goals and help minimize if not totally eradicate residents' problems. Each individual resident has a comprehensive care plan which is objective, measurable and time-framed.A care plan is accomplished through the interdisciplinary team.The resident care plan.reviewed.as often as needed as there is a change of condition. The evidence of a care plan that has been reviewed should include but not be limited to the new interventions that have been added in addition to the current ones. These interventions should be in chronological order as implemented or carried out.identifying their concerns and developing the highest level of functioning the resident may be expected to attain.

Based on interview, and record review, the facility did not adhere to the resident's rights when they failed to follow their own theft and loss policy and procedures for one out of 17 sampled residents (Resident 27), when Resident 27's cell phone was lost and was not followed up and resolved timely. This failure resulted in Resident 27 experiencing emotional distress and not being able to use her personal property.Findings:A review of Resident 27's clinical record indicated Resident 27 was admitted April of 2025 and had diagnoses that included congestive heart failure (a condition in which the heart cannot pump oxygen-rich blood efficiently to the rest of the body), chronic obstructive pulmonary disease (a group of diseases that causes airflow blockage and breathing-related problems), diabetes (elevated sugar in the blood), muscle weakness, and need for assistance with personal care.A review of Resident 27's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 3/7/26, indicated Resident 27 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated Resident 7 had an intact cognition (mental process of acquiring knowledge and understanding). During an interview on 3/9/26 at 11:08 a.m. with Resident 27, Resident 27 stated her cell phone, which she brought in the facility when she was admitted , went missing. Resident 27 also stated she reported it to the facility staff immediately but up until now, it has not been resolved. Resident 27 further stated she feels annoyed and upset because there has been no resolution about the issue.During an interview on 3/11/26 at 12:46 p.m. with the Social Services Director (SSD), the SSD stated she was aware of Resident 27's report of missing cell phone. The SSD also stated they searched for the item but could not find it, so she advised the resident to contact the carrier of her phone to locate it. The SSD further stated that their process for theft and loss was once it was reported to her, she would initiate searching for the item but would verify first in the resident's inventory sheet. If they could not locate the missing item, they would come up with a resolution and would offer reimbursement of the missing item. The SSD then stated the timeline usually was she would get back to the resident within 2-3 days and would tell them about the result and resolution of the investigation. A review of Resident 27's inventory sheet, signed by Resident 27 and a facility staff on 4/19/25, indicated, .1 cell phone .A review of Resident 27's THEFT AND LOSS RECORD, indicated, .DESCRIPTION OF ARTICLE: iPhone 14 Max .ESTIMATED VALUE .Unknown .DATE/TIME ARTICLE DISCOVERED MISSING: 9/12/25 [at] 23:00 [11 p.m.] .Resident [Resident 27] reported to staff [charge nurse] regarding resident's missing cell phone .A review of an entry on Resident 27's THEFT AND LOSS RECORD, signed by the SSD on 9/17/25, indicated, Searched and asked staff, with resident consent, checked her bedside drawer, closet and under her bed but unfortunately cannot locate her device. Assisted resident checking with her purse .Advised resident to call the [phone] carrier since they have the ability to locate on their end.A review of an entry on Resident 27's THEFT AND LOSS RECORD, signed by the SSD on 10/2/25, indicated, Asked resident family if they called her phone carrier, resident stated to call son, [NAME]. but never called.During a concurrent interview and record review on 3/11/26 at 1:46 p.m. with the SSD, Resident 27's inventory sheet and theft and loss record were reviewed. The SSD confirmed that Resident 27 had 1 cell phone when she was admitted to the facility. The SSD also confirmed that there has been no resolution regarding Resident 27's report of her missing cell phone. The SSD stated she does not know what happened and just stopped following up since the last entry. The SSD further stated the policy should have been followed, and resident 27's report of missing cell phone should have been resolved and should have been reimbursed at this time.During an interview on 3/12/26 at 9:22 a.m. with the Director of Nursing (DON), the DON stated that when a resident complains about theft and loss, staff should follow their policy. The DON also stated staff should follow back to the resident and discuss conclusion of the complaint within 72 hours, including the reimbursement process. The DON further stated the SSD missed to follow back with resident 27's complaint and the complaint was just dropped.A review of the facility's policy and procedures (P&P) titled, Theft and Loss Prevention Policy, undated, indicated, .If you suspect something has been stolen, please notify nursing staff immediately. We will take a full report and investigate the theft of an item worth more than $25. We will report the theft of any item worth more than $100 to local police .Failure to safeguard patient property; reimbursement; citation .A long-term care facility .which fails to make reasonable efforts to safeguard patient property shall reimburse a patient for or replace stolen or lost patient property at its then current value .A review of the facility's P&P titled, GRIEVANCES, dated 12/2017, indicated, 6. The department manager will: .6.2 Investigate the grievance; 6.3 Take corrective actions, as needed; .6.5 Notify the person filing the grievance of resolution within 72 hours by providing a copy of the Grievance Form to the resident/resident representative .

Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 51 when:1. Facility did not have an enhanced barrier precaution (EBP- also known as enhanced standard precaution/ESP, infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs- bacteria that resist treatment with more than one antibiotic] that employs targeted gown and glove use) signage for Resident 1 and Resident 8 who were both on EBP;2. Residents' non-pharmaceutical (not medicinal drug related) personal belongings were found stored in one out of two sampled medication carts with pharmaceutical products; and,3. Kitchen staff was observed not wearing facial hair restraints as required. These failures had the potential to spread germs and cause infection among a vulnerable resident population and staff. Findings: 1a. A review of Resident 1's clinical record indicated Resident 1 was admitted February of 2026 and had diagnoses that included stage 5 chronic kidney disease (severe kidney failure where the kidneys can no longer adequately filter waste or fluid, leading to fatigue, severe swelling, nausea, and little-to-no urine output), and dependence on renal dialysis (the process of removing excess water, particles, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). A review of Resident 1's active physician's order, dated 2/9/26, indicated, On Enhanced Barrier Precautions r/t [related to] Foley Catheter [a flexible, indwelling tube inserted through the urethra into the bladder to continuously drain urine], Hemodialysis [treatment for kidney failure that uses a machine and a filter, the dialyzer, to clean waste and remove excess fluid from the blood] access site, and Wound treatment. [NAME] [wear] PPE on Resident's High Contact Resident Care Activities and Doff [remove] PPE before exiting room. Hand Wash before and after. A review of Resident 1's care plan, dated 2/9/26, indicated, On Enhanced Barrier Precautions r/t Foley Catheter, Hemodialysis access site, and Wound treatment . During a concurrent observation and interview on 3/9/26 at 9:25 a.m. in Resident 1's room, Resident 1 was observed to have a dialysis access site on left chest. Resident 1 stated he has wound on his left foot. There was no observed signage in Resident 1's room that he was on EBP. 1b. A review of Resident 8's clinical record indicated Resident 8 was admitted in December of 2025 and had diagnoses that included obstructive and reflux uropathy (occurs when the urine cannot drain through the urinary tract), muscle weakness, and need for assistance with personal care. A review of Resident 8's active physician's order, dated 12/15/25, indicated, On Enhanced Barrier Precautions r/t Foley Catheter. [NAME] gown and gloves for high contact Resident care activities. Doff PPE before exiting room. A review of Resident 8's care plan, dated 12/15/25, indicated, [resident 8] is on Enhanced Barrier Precautions r/t: Foley Catheter use. During an observation on 3/9/26 at 9:31 a.m. in Resident 8's room, Resident 8 was observed connected to a urinary catheter draining in a urinary bag. There was no observed signage in Resident 8's room that he was on EBP. During a concurrent observation and interview on 3/9/26 at 11:20 a.m. with Certified Nurse Assistant (CNA) 3, in front of Resident 1 and Resident 8's room, there was no observed signage in front of Resident 1 and Resident 8's room indicating that they were on EBP. CNA 3 confirmed the observation. CNA 3 stated Resident 1 usually goes to dialysis three times a week, but she was not sure if Resident 1 was on any kind of infection control precaution. A review of a facility document titled, ENHANCED BARRIER PRECAUTION PROGRAM, dated 3/9/26, indicated Resident 1 was still on EBP due to his dialysis site and Resident 8 was also still EBP due to his foley catheter. During an interview on 3/11/26 at 4:32 p.m. with the Infection Preventionist (IP), the IP stated it was the facility's standard to place EBP signage in front of resident's room if they were on EBP. The IP further stated EBP signage should have been placed in front of Resident 1 and Resident 8's room to indicate and remind staff that they should wear gloves and gown when doing high contact care for the residents. During an interview on 3/12/26 at 9:22 a.m. with the Director of Nursing (DON), the DON stated there should be EBP signage in front of residents' rooms who were on EBP. The DON also stated there would be a risk that staff might not wear gloves and gown when doing high contact care if there was no EBP signage in front of the resident's room. The DON further stated there would be a risk for the residents to get infection if the staff would not wear gloves and gown when caring for them. A review of the facility's policy and procedures titled, Enhanced Barrier Precautions Policy, revised 1/2025, indicated, 3. Enhanced Barrier Precautions are to be implemented .when other Transmission-based precautions do not apply, when facility identifies any resident with: .b. Wounds or skin openings that require dressings .c. Any indwelling medical device, for example: i. Central lines [a tube inserted into a large vein to provide long-term access to the blood supply used for extended treatments like chemotherapy, frequent blood draws, and dialysis] .ii. Urinary catheters .4. Post clear signage on the door/wall outside resident room .a. Type of precautions .iv. Enhanced Barrier Precautions . 2. During a concurrent observation and interview which started on 3/11/26 at 1:48 p.m. with LN 3, of medication cart D wing, two nail clippers were found stored in the top right drawer next to prescribed medications and a black and silver flash drive was found stored next to the controlled medications (medications with high potential for abuse or addiction). LN 3 confirmed the observation. LN 3 stated he does not know who owns those personal items. LN 3 further stated personal items should not be stored inside medication carts because it could contaminate the medications. During a phone interview on 3/12/26 at 8:48 a.m. with the Consultant Pharmacist (CP), the CP stated medications carts should only contain pharmacological products and equipment's necessary for medication administration, and it should not contain personal items. The CP further stated that storing personal items in the medication cart causes risk for contamination of the medications. During an interview on 3/12/26 at 9:22 a.m. with the DON, the DON stated personal items should not be kept inside medication carts because of infection control concerns with medications. A review of the facility's P&P titled, LABELING AND STORING MEDICATIONS, revised 1/2026, indicated, It is the policy of this facility that resident's medication will be properly labeled and stored in the locked medication room/carts. A review of the facility's P&P titled, Administering Medications, revised 1/2026, indicated, 25. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. 3.During an observation on 3/10/26, at 8:48 a.m., Dietary Aide (DA) 1 was observed in the kitchen washing dishes with facial hair above his lips exposed with no covering. During a concurrent observation and interview on 3/10/26 at 8:54 a.m., with the Dietary Supervisor (DS), the DS confirmed DA 1 was not wearing adequate facial hair coverings. DS stated the expectation was for all kitchen staff to wear proper facial hair coverings and if not worn properly, hair could potentially fall into residents' food which would be unsanitary. During a review of the facility's Policy and Procedure (P&P) titled, Infection Prevention and Control Program, undated, the P&P indicated, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to prevent the development and transmission of communicable diseases and infections .based on accepted national infection prevention and control standards.is a facility-wide effort involving all disciplines and individuals.Policies and procedures reflect the current infection prevention and control standards of practice. During a review of the facility's P&P titled, Dress Code, dated 2023, the P&P indicated, Hair net for hair .beards and mustaches (any facial hair) must wear beard restraint. According to the FDA Food Code 2022, Section 2-402.11, Hair Restraints, A. FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.

Based on interview and record review, the facility failed to ensure the Dietary Supervisor (DS) met the required job qualifications of Dietary Supervisor per facility policy and procedures.This failure had the potential for unsafe food handling, and food borne illness in a highly susceptible population of 51 residents. During an interview on 3/9/26, at 9:45 a.m., with the DS, the DS confirmed she had been employed at the facility for one year in the position of Dietary Supervisor. DS stated she did not have a Certified Dietary Manager certification, nor was she currently enrolled in a Dietary Manager training program. The DS further stated she was responsible for all the training, hiring, and scheduling of dietary staff and ordered the food and kitchen supplies. During an interview on 3/10/26, at 3:50 p.m., with the Administrator (ADM), the ADM confirmed the current job description for Dietary Supervisor stated Certified Dietary Manager required. The ADMN acknowledged the current Dietary Supervisor did not possess the Certified Dietary Manager certificate as required by the facility job description. During a review of facility document titled, Job Description and Performance Standards, Position Title Dietary/Food Service Supervisor, revised February 2018, indicated, Qualifications Either a Certified Dietary Manager or Certified Food Protection Professional.

Based on observation, interview, and record review, the facility failed to ensure medications were properly labeled and stored in accordance with the accepted professional principles and current standard of practice for a census of 51 when:1. Multiple DuoNeb (a combination medication containing albuterol sulfate and ipratropium bromide used to treat tightening of the muscles lining the airways) vials (small container) were found stored out of its foil package;2. A total of five loose pills were found in medication cart D wing; and,3. Two expired bottles of Vitamin B12 were found stored in the medication room.These failures had the potential for diversion of the loose medications, and for residents to receive medication that was expired or with unsafe or reduced potency.Findings:1. During a concurrent observation and interview which started on 3/9/26 at 10:35 a.m. with Licensed Nurse (LN) 2 of medication cart C wing, two boxes with multiple DuoNeb vials were found stored out of the foil package. One box was labelled with an opened date of 1/27/26 and the other box was not labelled with its opened date. LN 2 confirmed the observation. LN 2 stated DuoNeb vials should be always stored inside the foil pack because it would expire in 1 week if it was taken out of the foil package. LN 2 further stated there should be an open date label on the medication to know when it was first used.During a phone interview on 3/12/26 at 8:48 a.m. with the Consultant Pharmacist (CP), the CP stated DuoNeb medication is sensitive to light and heat and should be stored inside the foil package. The CP further stated DuoNeb medication could easily expire or the potency could get affected if it was stored outside the foil package causing the medication to not work or it could be defective. During an interview on 3/12/26 at 9:22 a.m. with the Director of Nursing (DON), the DON stated he expects nurses to follow proper storage of medications. The DON further stated DuoNeb vials should be kept inside the foil package because it could get easily be affected by light.A review of a facility's P&P titled, LABELING AND STORING MEDICATIONS, revised 1/2026, indicated, 2. Liquid Medication - Vials .Must be dated and initialed by the Licensed Nurse who first opened the container .A review of a facility document titled, Abridged List of Medications with Shortened Expiration Dates, undated, indicated, Generic Name .Albuterol/Ipratropium .Brand Name .DuoNeb .Beyond Use Date (BUD) Notes .DuoNeb: Store in foil and away from heat and light. Unit-dose vials should remain stored in protective foil pouch at all times. Once removed from the foil pouch, the individual vials should be used within one week .2. During a concurrent observation and interview which started on 3/11/26 at 1:48 p.m. with LN 3, of medication cart D wing, a total of five loose pills were found inside the first and second-right drawer of the medication cart. LN 3 confirmed the observation. LN 3 stated there should not be loose pills inside a medication cart because it could contaminate the medications inside the cart and if the loose pills fall out of the medication cart, a resident might take it.During a phone interview on 3/12/26 at 8:48 a.m. with the CP, the CP stated medications should be secured and labelled. The CP further stated loose pills in a medication cart causes potential medication error and a risk for the loose pills to fall out of the medication cart and a resident might take it.During an interview on 3/12/26 at 9:22 a.m. with the DON, the DON stated that loose pills inside the medication carts are potential cause of medication errors and staff would not know what medication those are anymore.A review of the facility's P&P titled, LABELING AND STORING MEDICATIONS, revised 1/2026, indicated, It is the policy of this facility that resident's medication will be properly labeled and stored in the locked medication room/carts .3. The medications of each resident are kept and stored in their originally received containers.3. During a concurrent observation and interview which started on 3/11/26 at 2:09 p.m. with LN 3, of the medication room, two bottles of Vitamin B12, containing 30 tablets each, and with an expiration date of 12/2025 were found stored in the medication room and ready to be used. LN 3 confirmed the observation. LN 3 stated the expired medications should have been discarded. LN 3 further stated that expired medications can be ineffective or might cause harm to the residents if accidentally administered. During a phone interview on 3/12/26 at 8:48 a.m. with the CP, the CP stated expired medications should not be stored in medication rooms because if it was administered, the medication would not be effective anymore.During an interview on 3/12/26 at 9:22 a.m. with the DON, the DON stated it was not okay to store expired medications in the medication room because it could get administered to residents which could cause undesired effects.A review of the facility's P&P titled, LABELING AND STORING MEDICATIONS, revised 1/2026, indicated, 5. Medications no longer in use or medications which have expired will be disposed of in accordance with Federal and State Laws.

Based on observation, interview, and record review, the facility failed to ensure safe and proper delivery of respiratory care consistent with the facility's policy and procedures (P&P) for one out of 17 sampled residents (Resident 27) when Resident 27's physician's order for oxygen therapy was not followed.This failure had the potential to result in Resident 27's oxygen needs to be not met and for Resident 27 to not achieve her highest practicable well-being.Findings:A review of Resident 27's clinical record indicated Resident 27 was admitted April of 2025 and had diagnoses that included congestive heart failure (CHF- a condition in which the heart cannot pump oxygen-rich blood efficiently to the rest of the body), chronic obstructive pulmonary disease (COPD- a group of diseases that causes airflow blockage and breathing-related problems), diabetes (elevated sugar in the blood), muscle weakness, and need for assistance with personal care.A review of Resident 27's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 3/7/26, indicated Resident 27 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated Resident 27 had an intact cognition (mental process of acquiring knowledge and understanding). A review of Resident 27's MDS Special Treatments, Procedures, and Programs, dated 3/7/26, indicated Resident 27 had received continuous oxygen therapy on admission and while she was a resident in the facility.A review of Resident 27's care plan, revised 4/22/25, indicated, Ineffective Airway clearance r/t [related to] COPD and CHF medical diagnosis. Use Oxygen routine at 3 l/min [liters per minute/lpm- unit of measurement for oxygen administration flow rate] via NC [Nasal cannula- a medical device with two prongs that is connected to an oxygen source used to deliver supplemental oxygen directly into the nostrils] .Administer oxygen at 3 l/min via NC. Observe oxygen precautions .A review of Resident 27's physician's order, dated 2/26/26, indicated, O2 [oxygen] at 3 liter/minute via nasal cannula for SOB [shortness of breath], Wheezing [high-pitched sound caused by narrowed or inflamed airways], Chest Pain .and Notify MD every shift.During a concurrent observation and interview on 3/9/26 at 11:08 a.m. with Resident 27, in Resident 27's room, Resident 27 was lying on bed, awake, and was on oxygen via nasal cannula with the oxygen concentrator (machine) set at 2.5 lpm. Resident 27 stated she uses oxygen all the time and the setting should be at 3 lpm.During a concurrent observation and interview on 3/10/26 at 10:30 a.m. with Resident 27, in Resident 27's room, Resident 27 was sitting on a wheelchair, awake, and was on oxygen via nasal cannula with the oxygen concentrator set at 2 lpm. Resident 27 stated the nurses usually adjust the setting of her oxygen.During a concurrent observation and interview on 3/10/26 at 10:45 a.m. with Certified Nurse Assistant (CNA) 4, in Resident 27's room, CNA 4 confirmed that Resident 27's oxygen was set at 2 lpm.During a concurrent interview and record review on 3/10/26 at 12:18 p.m. with Treatment Nurse (TN) 1, Resident 27's clinical records were reviewed. TN 1 confirmed that Resident 27's physician's order for oxygen therapy was at 3 lpm. TN 1 stated Resident 27's oxygen order should always be followed. TN 1 further stated Resident 27 would be at risk for difficulty breathing or possible hypoxemia (abnormally low concentration of oxygen in the blood) if she was receiving too low oxygen therapy.During an interview on 3/12/26 at 9:15 a.m. with the Director of Staff Development (DSD), the DSD stated oxygen orders should be followed as ordered. The DSD further stated the resident would be at risk for hypoxemia if she would receive oxygen lower than what was ordered.During an interview on 3/12/26 at 9:22 a.m. with the Director of Nursing (DON), the DON stated he would expect nurses to follow doctors order for oxygen administration. The DON further stated the resident would be at risk for shortness of breath and possible hypoxia (a dangerous condition characterized by insufficient oxygen reaching body tissues) if she was given lower than what her oxygen need was.A review of the facility's P&P titled, Oxygen Therapy, revised 1/2025, indicated, It is the policy of this facility that oxygen therapy is administered, as ordered by the physician .PROCEDURES: .5. Adjust oxygen flow, as ordered by physician .

Based on interview and record review, the facility failed to implement a comprehensive person-centered care plan for one out of 17 sampled residents (Resident 3) when Resident 3's care plan interventions for recording and monitoring fluid intake and output were not implemented. This failure had the potential to result in Resident 3 not attaining their highest practicable physical, mental, and psychosocial well-being.Findings:Resident 3 was originally admitted to the facility March 2016 with multiple diagnoses which included type 2 diabetes mellitus (a disease where blood sugar is too high) and gastrostomy (opening made through the abdominal wall into the stomach to insert a feeding tube). A review of Resident 3's Minimum Data Set (MDS, an assessment tool) dated 1/15/26, indicated, Resident 3 had severe problems with thinking and memory.During a review of Resident 3's care plan, date initiated 1/20/26, care plan indicated, MONITOR AND RECORD #CC [metric unit of volume often used for medication dosages or fluid intake and output] FLUID INTAKE & OUTPUT Q [every] SHIFT. Every shift for FOR FLUID DAILY OUTPUT.During an interview and record review on 3/11/26, at 1:13 p.m., with Licensed Nurse (LN) 5, LN 5 reviewed Resident 3's medical record and confirmed the care plan indicated fluid intake and output should be recorded and monitored. LN 4 stated there was no documentation or orders for monitoring fluid intake and output found and confirmed it was not happening. During an interview on 3/11/26, at 1:33 p.m., with the Director of Nursing (DON), the DON stated all nursing staff have access to resident's care plans. DON further stated the expectation was for all nursing staff to follow the care plans and if not followed, residents may potentially have a change of condition and not reach their highest practical well-being. During a review of the facility's policy and procedure (P&P) titled, Policy and Procedure-Care plan, dated 1/26, the P&P indicated, A care plan is the summation of the resident concerns, goals, approaches and interventions in order to meet the goals and help minimize if not totally eradicate residents' problems.The individual comprehensive care plan identifies the professional services and the responsible person that evaluates the concerns and carried out the interventions to prevent or reduce re-occurrences.It further prevents, if feasible, further declines and deterioration of the resident's function or status.

Based on interview, and record review the facility failed to ensure safe and effective pharmaceutical services for a census of 51 residents when Resident 36's controlled drug (drug with potential for abuse) uses and removal signed out from the Controlled Drug Record (CDR- a paper log of controlled drug removal for administration to resident) were not documented in the Medication Administration Record (MAR-a legal document that list administered drugs).This failed practice may contribute to a possible medication administration error for Resident 36, unsafe controlled medication handling, and risk of controlled drug diversion (unlawful channeling of regulated pharmaceuticals from legal sources to the illicit marketplace).Findings:A review of Resident 36's clinical record indicated Resident 36 was admitted May of 2020 and had diagnoses that included hemiplegia (complete loss of the ability to move one side of the body) and hemiparesis (partial weakness of one side of the body) following cerebral infarction (damage to a part in the brain due to a disrupted blood flow) affecting right dominant side, gout (a form of arthritis that causes severe pain, swelling, redness and tenderness in joints), and neuralgia (intense pain caused by damaged or irritated nerves) and neuritis (inflammation of a nerve causing pain).A review of Resident 36's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 1/16/26, indicated Resident 36 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 13 out of 15 which indicated Resident 36 had an intact cognition (mental process of acquiring knowledge and understanding). A review of Resident 36's MDS Health Conditions, dated 1/16/26, indicated Resident 36 received scheduled and as needed pain medications and non-medication intervention for pain. A review of Resident 36's active physician's order, dated 2/6/26, indicated, HYDROcodone-Acetaminophen Oral [Norco] Tablet [a medication for pain which contains a combination of hydrocodone; a controlled pain medication, and Acetaminophen; a potent pain reliever] 5-325 MG [milligrams- unit of measurement] .Give 1 tablet by mouth every 8 hours as needed for pain management moderate to severe 4-10 [numeric pain scale from 1 to 10; 1-3 is mild pain, 4-6 is moderate pain, 7-10 is severe pain] .A random audit of Resident 36's MAR and the CDR for Norco, for February 2026, indicated nursing staff signed out removal of Norco in Resident 36's CDR but did not document Norco administration on the MAR as follows: 1 tablet on 2/20/26 at 12:30 a.m., and 1 tablet on 2/23/26 at 3:20 a.m.During a concurrent interview and record review on 3/11/26 at 4:17 p.m. with Licensed Nurse (LN) 4, Resident 36's CDR and MAR were reviewed. LN 4 confirmed the finding of Norco being signed out of the CDR but was not accurately documented on the MAR on two occasions. LN 4 stated that both the CDR and MAR should be signed when administering Norco to Resident 36.During a phone interview on 3/12/26 at 8:48 a.m. with the Consultant Pharmacist (CP), the CP stated that nurses should always need to sign the CDR and MAR when administering controlled medications. The CP further stated there would be a risk of possible medication error and double dosing if the CDR and MAR are not filled out properly. During an interview on 3/12/26 at 9:22 a.m. with the Director of Nursing (DON), the DON stated that when a nurse administers a controlled drug, the nurse should take out the medication from the pack, sign the CDR, administer the medication, then sign the MAR. The DON further stated that there would be a potential for medication error because other nurses would not see if the resident was given the controlled drug already and also a risk for drug diversion if the MAR is not properly signed.A review of the facility's policy and procedure (P&P) titled, POLICY AND PROCEDURE IN MEDICATION ADMINISTRATION, revised 1/2026, indicated, Medications shall be administered in accordance with our established policies and procedures .12. Medications must be immediately charted following the administration by the license nurse who administered the medication.A review of the facility's P&P titled, Controlled Substances, revised 1/2026, indicated, Dispensing and Reconciling Controlled Substances .1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. 2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records; .

Based on observation, interview and record review, the facility failed to ensure one out of nine sampled residents for medication administration (Resident 60) was free from significant medication error when Resident 60 did not receive prescribed insulin (medication used to manage blood sugar level) in accordance with the physician's order.This failure has the potential to result in Resident 60 experiencing hypoglycemia (too low blood sugar level) and other unnecessary insulin side effects which could negatively affect Resident 60's health.Findings:A review of Resident 60's clinical record indicated Resident 60 was admitted February of 2026 and had diagnoses that included diabetes mellitus (a chronic condition causing too much sugar in the blood), congestive heart failure (a serious condition in which the heart does not pump blood as efficiently as it should), muscle weakness, and need for assistance with personal care.A review of Resident 60's physician's order, dated 2/24/26, indicated, Resident is capable of giving informed consent and/or able to participate in treatment plan.A review of Resident 60's physician's order, dated 2/26/25, indicated, Insulin Lispro [a fast-acting type of insulin used to manage high blood sugar] Injection Solution 100 UNIT/ML [unit/milliliters- unit of measurement] .Inject as per sliding scale [a method of managing blood sugar levels where insulin doses are adjusted based on current blood sugar reading]: .if 140 - 169 = 3 units [unit of insulin measurement] .; 170 - 199 = 4 units; 200 - 249 = 6 units; 250 - 299 = 8 units; 300+ = 10 units .subcutaneously [under the skin] with meals related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS.During a medication administration observation which started on 3/9/26 at 11:38 a.m. with Licensed Nurse (LN) 1, Resident 60 had a finger stick blood sugar (a quick, routine procedure for monitoring blood sugar levels by pricking a finger) reading of 185 milligrams/deciliter (mg/dl- unit of measurement) and LN 1 administered 4 units of insulin lispro to Resident 60.During an observation on 3/9/26 at 12:34 p.m. in Resident 60's room, a staff was observed delivering Resident 60 her lunch meal. Resident 60's lunch meal tray was left on Resident 60's bedside table.During a concurrent observation and interview on 3/9/26 at 12:58 p.m. with Certified Nurse Assistant (CNA) 2, in Resident 60's room, CNA 2 started to assist Resident 60 with her lunch meal. CNA 2 confirmed the observation. CNA 2 stated Resident 60 needs total assistance with eating and needs encouragement and cueing when eating.During an interview on 3/9/26 at 2:55 p.m. with LN 1, LN 1 confirmed that Resident 60's insulin lispro was administered too early if Resident 60 ate at 12:58 p.m. LN 1 stated that Resident 60 should have eaten within 15 minutes after her insulin lispro was administered. LN 1 also stated the facility's lunch mealtime was 11:30 a.m. and she was not sure why Resident 60's lunch meal was late. LN 1 further stated insulin Lispro is a rapid acting insulin and Resident 60 was at risk for hypoglycemia.During a phone interview on 3/12/26 at 8:48 a.m. with the Consultant Pharmacist (CP), the CP stated that the resident should eat within 10-15 minutes after insulin lispro administration because of the risk of hypoglycemia. The CP further stated the physician's order should always be followed.During an interview on 3/12/26 at 9:22 a.m. with the Director of Nursing (DON), the DON stated that nurses should make sure that insulin lispro should be given with food or within 15 minutes after administration. The DON further stated there would be a risk for the resident's blood sugar to rapidly go down if the resident would eat too late after insulin lispro administration.A review of the facility's policy and procedure (P&P) titled, POLICY AND PROCEDURE IN MEDICATION ADMINISTRATION, revised 1/2026, indicated, 1. Drugs must be administered in accordance with the written orders of the attending physician .8. Diabetic resident on insulin should follow MD order .A review of the facility's P&P titled, Insulin Administration, revised 1/2026, indicated, 3. The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order .The three key characteristics of insulin are: a. Onset of action - how quickly the insulin reaches the bloodstream and begins to lower blood glucose .Type .Rapid-acting .Onset* .10-15 min [minutes] .

Based on observation, interview, and record review, the facility failed to provide food in accordance with the physician's prescribed diet for one out of 17 sampled residents (Resident 55) when Resident 55 who was on Renal diet (a diet aimed at keep levels of fluids, electrolytes, and minerals balanced in the body in individuals with kidney disease) received a salt packet during the 3/9/26 lunch meal.This failure had the potential to negatively affect Resident 55's medical condition and for Resident 55 to not achieve his highest practicable well-being.Findings:A review of Resident 55's clinical record indicated Resident 55 was admitted February of 2026 and had diagnoses that included congestive heart failure (a condition in which the heart cannot pump oxygen-rich blood efficiently to the rest of the body), end stage renal disease (occurs when the gradual loss of kidney function reaches an advanced state where kidneys no longer work as they should to meet the body's needs), dependence on renal dialysis (the process of removing excess water, particles, and toxins from the blood in people whose kidneys can no longer perform these functions naturally), hypertension (high blood pressure), and need for assistance with personal care.A review of Resident 55's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 2/16/26, indicated Resident 55 was rarely or never understood. A review of Resident 55's MDS Nutritional Status, dated 2/16/26, indicated Resident 55 had therapeutic diet (specific meal plan prescribed by a doctor and planned by a dietitian to treat or manage a medical condition) while she was a resident in the facility. A review of Resident 55's MDS Functional Abilities, dated 2/16/25, indicated Resident 55 needed setup or clean up assistance with eating.A review of Resident 55's care plan, initiated 2/10/26, indicated, [Resident 55] is at risk for nutritional problem related to diagnosis of .Hypertension, and other medical problems (ESRD .DIALYSIS DEPENDENT) .All staff to be informed of resident's special dietary and safety needs .Diet as per MD order .A review of Resident 55's active physician's order, dated 2/10/26, indicated, CCHO [controlled carbohydrates- a diet used to keep blood sugar stable] /RENAL diet SOFT AND BITE SIZE texture, THIN LIQUIDS consistency.During a concurrent observation and interview on 3/9/26 at 12:25 p.m. with Resident 55, in Resident 55's room, Resident 55 was observed eating his lunch meal and there was a packet of iodized salt observed in Resident 55's meal tray. Resident 55's meal ticket was checked and indicated, Diet: Renal, CCHO. Resident 55 stated she did not want the salt packet, and it was just served together with his meal.During a concurrent observation and interview on 3/9/26 at 12:28 p.m. with Certified Nurse Assistant (CNA) 1, in Resident 55's room, CNA 1 confirmed that Resident 55 was served with a salt packet in his lunch meal. CNA 1 stated Resident 55 was on Renal diet and usually gets the normal meal tray. CNA 1 further stated salt packets are provided to residents on renal diet.During an interview on 3/9/26 at 12:36 p.m. with Licensed Nurse (LN) 1, LN 1 stated residents on renal diet should not get a lot of fluids and salt because it could affect their medical condition. LN 1 further stated staff should not provide salt packets to residents on renal diet. During an interview on 3/11/26 at 4:22 p.m. with the Dietary Supervisor (DS), the DS stated staff should follow the diet order of the residents. The DS also stated salt packets should not be provided to residents with renal diet order because extra salt could affect the salt and fluid balance of the residents. The DS further stated CNAs should know not to provide salt packets to residents on renal diet.During an interview on 3/12/26 at 9:22 a.m. with the Director of Nursing (DON), the DON stated the therapeutic diet order should always be followed. The DON further stated providing extra salt to residents on renal diet could affect their medical condition.A review of the facility's policy and procedures (P&P) titled, Liberal Renal Diet, revised 12/2024, indicated, Liberal Renal Diet, No Salt Packet on Tray (NSPOT) .Procedure .Follow menu guide for regular diet .Avoid .Salt Packet .

Based on interview and record review, the facility failed to adequately assess and initiate timely emergency response for one of three sampled residents (Resident 1) when Licensed Nurse (LN) 3 did not call 911 after Resident 1 had a very low oxygen saturation level (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage) than normal and showed signs of distress and altered level of consciousness.This failure had the potential to delay the initiation of treatment for Resident 1, which could potentially led to respiratory arrest. Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was re-admitted on [DATE] with diagnoses that included pneumonia (an infection/inflammation in the lungs) and acute and chronic respiratory failure (condition where there's not enough oxygen or too much carbon dioxide in the body) with hypoxia (lack of oxygen in tissue).During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/30/25, the MDS indicated Resident 1 had intact cognition.During a review of Resident 1's Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life), dated 6/19/25, the POLST indicated Resident 1 was full code.During a review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 12/22/25, the SBAR indicated, Resident 1 was noted with hypoxia, altered level of consciousness and shortness of breath.During a telephone interview on 1/7/26 at 12:21 p.m. with LN 3, LN 3 stated, on 12/22/25, while administering bedtime medications, LN 3 entered Resident 1's room and attempted to wake him up and observed that something was different about his condition. LN 3 stated, Resident 1 was experiencing difficulty breathing and was on continuous oxygen. LN 3 stated, she increased the oxygen flow rate; however, his O2 sat remained low. LN 3 further stated that although Resident 1 was responsive, his responses were inappropriate, and his behavior was not consistent with his baseline. LN 3 also stated that she contacted the on-call physician, who gave an order to send Resident 1 to the emergency room.During a review of Resident 1's Nurse's Notes (NN), dated 12/22/25, the NN indicated, at approximately 9 p.m. the nurse entered Resident 1's room to administer medications and found him awake, was able to take medication but repeatedly saying the same sentence. The NN indicated, LN 3 asked Resident 1 if he was okay, and he opened his eyes and closed them again. The NN indicated, Resident 1's O2 sat was at 84% (normal values for a healthy adult on room air is 95% to 100% measured by a pulse oximeter [small, clip-on device that non-invasively measures blood oxygen levels] indicating sufficient oxygen in the blood. Levels below 90% suggest significant hypoxemia [ lower-than-normal levels of oxygen in the blood] requiring medical attention), while on 3 liters of oxygen via nasal cannula, the oxygen was increased to 4 liters; however, the O2 sat remained low, around 82-83%. The physician was called at 9:30 p.m., and an order was received to send the resident to the emergency room for hypoxia. A non-emergency transport was called, arrived at 9:45 p.m. and Resident 1 was transferred out of the facility at 10 p.m.; there was no documented evidence that staff changed the the nasal cannula into a non-rebreather mask (a medical device delivering high concentrations [up to 95%] of oxygen in emergencies).During an interview on 1/7/26 at 12:33 p.m. with Director of Nursing (DON), DON stated respiratory distress-including shortness of breath, difficulty of breathing, and O2 sat below 88% accompanied by a decreased level of consciousness-requires activation of the emergency response system which is calling 911. The DON confirmed that Resident 1's condition at that time warranted a 911 transfer due to an O2 sat of 84% and altered mental status.During a concurrent telephone interview and record review on 1/7/26 at 1:06 p.m. with Nurse Practitioner (NP), NP stated, based on her review of Resident 1's case, the resident should have been transferred via 911 (emergency medical transport) due to the clinical indicators of a medical emergency. NP explained that Resident 1 was already hypoxic, not fully responsive, and continued to desaturate despite being on oxygen. NP emphasized that in situations involving low O2 sat and altered mental status, immediate emergency care is required, which skilled nursing facilities (SNFs) are not equipped to manage such acute medical conditions. The NP reviewed the ER records, which indicated Resident 1 had a Glasgow Coma Scale (GCS-scoring system used by doctors to measure decrease in consciousness) score of 7 (severely altered state of consciousness) upon arrival-significantly lower than his baseline of 15 (normal GCS score)-and was intubated due to acute respiratory failure. NP further stated that if care had been delayed longer, Resident'1 clinical progress could have been poorer, and he may have required a prolonged stay in the intensive care unit.During an interview on 1/7/26 at 2:47 p.m. with Resident 1, Resident 1 stated that he did not refuse to go to the hospital, as he was not fully aware of what was happening at that time.During a review of Resident 1's History and Physical (H&P) document from the acute care hospital, dated 12/23/25, H&P indicated that Resident 1 was transferred to acute care hospital for altered mental status and acute respiratory failure. H&P indicated, upon arrival resident (1) had a significantly decreased GCS score and was not protecting his airway, Resident 1 was subsequently intubated.During a review of the facility's policy and procedure (P&P) titled, Emergency Procedures, dated 7/12, the P&P indicated, .to provide immediate medical care to a resident whose condition indicates a need. if the services of a paramedics are needed, activate facility notification system.During a review of the facility's P&P titled, Change of Condition, dated 7/12, the P&P indicated, .licensed nurse will initiate proper first aid measures until emergency response personnel/911 arrive on the scene.According to the California Nursing Practice Act, .The practice of nursing within the meaning of this chapter means those functions, including basic health care, that help people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or the treatment thereof, and that require a substantial amount of scientific knowledge or technical skill, including all of the following. Observation of signs and symptoms of illness, reactions to treatment, general behavior, or general physical condition. (B) implementation, based on observed abnormalities, of appropriate reporting, or referral, or standardized procedures, or changes in treatment regimen in accordance with standardized procedures, or the initiation of emergency procedures .

Based on interview, and record review the facility failed to ensure safe and effective pharmaceutical services for a census of 55 residents when Resident 41 and Resident 47's controlled drug (drug with potential for abuse) uses and removal signed out from the Controlled Drug Record (CDR- a paper log of controlled drug removal for administration to resident) were not documented in their Medication Administration Record (MAR-a legal document that list administered drugs).This failed practice may contribute to unsafe controlled medication handling and/or risk of controlled drug diversion (unlawful channeling of regulated pharmaceuticals from legal sources to the illicit marketplace).Findings:1a. A review of Resident 41's clinical record indicated Resident 41 was admitted May of 2020 and had diagnoses that included gout (a form of arthritis that causes severe pain, swelling, redness and tenderness in joints), neuralgia (pain caused by irritation or damage to a nerve), and neuritis (inflammation of a nerve causing pain).A review of Resident 41's active physician's order, dated 4/25/23, indicated, Resident is not capable of giving informed consent and/or able to participate in treatment plan.A review of Resident 41's active physician's order, dated 4/21/25, indicated, Norco Tablet [a medication for pain which contains a combination of hydrocodone; a controlled pain medication, and Acetaminophen; a potent pain reliever] 5-325 MG [milligrams- unit of measurement] .Give 1 tablet by mouth every 6 hoursas needed for moderate-severe pain 4-10 pain scale [numeric pain scale from 1 to 10; 1-3 is mild pain, 4-6 is moderate pain, 7-10 is severe pain] .A random audit of Resident 41's MAR and the CDR for Norco, for August and September 2025, indicated nursing staff did not document Norco administration on the MAR when signed out from CDR on the following times: 1 tablet on 8/18/25 at 1:02 p.m.1 tablet on 8/19/25 at 1:06 a.m. 1 tablet on 9/8/25 at 12:25 p.m.1b. A review of Resident 47's clinical record indicated Resident 47 was admitted May of 2025 and had diagnoses that included dementia (memory loss that interferes with daily functions, muscle weakness, and need for assistance with personal care.A review of Resident 47's active physician's order, dated 5/16/25, indicated, HYDROcodone-Acetaminophen [Norco] Oral Tablet 5-325 MG . Give 1 tablet by mouth every 6 hours as needed for moderate to severe pain 4-10 .A random audit of Resident 47's MAR and the CDR for Norco, for August and September 2025, indicated nursing staff did not document Norco administration on the MAR when signed out from CDR on the following times:1 tablet on 8/25/25 at 9 a.m.1 tablet on 9/4/25 at 7:45 a.m.During a concurrent interview and record review on 9/10/25 at 1:58 p.m. with Licensed Nurse (LN) 2, Resident 41 and Resident 47's's CDR and MAR were reviewed. LN 2 confirmed the finding of Norco being signed out of Resident 41 and Resident 47's CDR but was not accurately documented on the MAR. LN 2 stated that Norco administration should be both signed out in the CDR and signed in the MAR.During an interview on 9/11/25 at 9:52 a.m. with the Consultant Pharmacist (CP), the CP stated he would expect nurses to always sign off the CDR and MAR when administering controlled medications. The CP further stated there would be a risk for controlled drug diversion or issues like unsafe handling of controlled drugs if the CDR and MAR are not both signed.During an interview on 9/11/25 at 10:49 a.m. with the Director of Nursing (DON), the DON stated he would expect the nurse to sign both the CDR and MAR when administering controlled medications. The DON further stated once the nurse pops the controlled medication in the pill cup, they should sign the CDR, then after administering the medication, the nurse should sign the MAR.A review of the facility's policy and procedure (P&P) titled, Documentation of Medication Administration, revised 1/2025, indicated, 1. A nurse or certified medication aide (where applicable) documents all medications administered to eachresident on the resident's medication administration record (MAR). 2. Administration of medication is documented immediately after it is given.A review of the facility's P&P titled, Medication Administration, dated 5/2016, indicated, 1. The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications .5. When PRN [as needed] medications are administered, the following documentation is provided: a. Date and time of administration, dose, route of administration (if other than oral) .d. Signature or initials of person recording administration and signature or initials of person recording effects .A review of the facility's P&P titled, Controlled Substances, dated 1/2025, indicated, Dispensing and Reconciling Controlled Substances .1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. 2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records; c. Declining inventory records .

Based on observation, interview, and record review the facility failed to ensure safe medication administration practices were followed when the facility's medication error rate was more than 5% (percentage- number or ratio that expressed as a fraction of 100) for a resident census of 55. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of three errors out of 36 opportunities which resulted in a facility wide medication error rate of 8.33% in one out of 9 residents (Resident 32) observed for medication administration.These failures had the potential for unsafe and ineffective medication use for Resident 32 and had the potential to negatively affect the residents' medical conditions.Findings:During a medication administration observation which started on 9/8/25 at 10:54 a.m. with Licensed Nurse (LN) 1, LN 1 administered a total of six pills to Resident 32 which included 1 capsule of aspirin-dipyridamole (a medication used to prevent stroke) ER (extended release) 25-200 mg (milligrams- unit of measurement), 1 capsule of docusate sodium (a medication utilized for managing and treating infrequent or difficult bowel movements) 100 mg, and 1 tablet of buspirone (a prescription medication used to treat anxiety and/or depression) 5 mg.A review of Resident 32's active physician's order, dated 6/30/25, indicated, Aspirin-Dipyridamole ER Oral Capsule Extended Release 12 Hour 25-200 MG .Give 1 capsule by mouth two times a day related to UNSPECIFIED SEQUELAE [a condition which is the consequence of a previous disease or injury] OF CEREBRAL INFARCTION [damage to a part in the brain due to a disrupted blood flow].A review of Resident 32's active physician's order, dated 6/10/25, indicated, Docusate Sodium Oral Capsule 100 MG .Give 1 capsule by mouth two times a day for bowel management.A review of Resident 32's active physician's order, dated 7/15/25, indicated, busPIRone HCl Oral Tablet 5 MG .Give 1 tablet by mouth two times a day for manifested by [sic] self isolation related to MAJOR DEPRESSIVE DISORDER, RECURRENT [persistently depressed mood or loss of interest in activities, causing significant impairment in daily life] .A review of Resident 32's medication administration records (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for the month of September 2025 indicated Resident 32's morning dose of aspirin-dipyridamole, docusate sodium, and buspirone were all scheduled at 9 a.m.During a concurrent interview and medication order review on 9/8/25 at 2:32 p.m. with LN 1, LN 1 acknowledged the observed medication administration of aspirin-dipyridamole, docusate sodium, and buspirone to Resident 32 which were two hours after the scheduled time. LN 1 stated she was aware that the medications aware were administered late. LN 1 also stated she was supposed to administer the medications an hour before or after the scheduled time of administration to maintain therapeutic level (concentration of a medication in the body that is high enough to produce the desired medical effect without causing significant side effects) of medication in the resident.During an interview on 9/11/25 at 9:52 a.m. with the Consultant Pharmacist (CP), the CP stated nurses really need to administer medication within that 1-hour before or after scheduled time frame. The CP further stated there would be a risk that residents could not get the full effect of the medication, possible side effect issues, and poor therapeutic level management.During an interview on 9/11/25 at 10:49 a.m. with the Director of Nursing (DON), the DON stated that nurses should always follow the facility's policy in administering scheduled medication which was either 1 hour before or after the scheduled time.Requested the facility's medication administration policies and procedures (P&P) discussing the timing of administering medications but none was providedA review of the facility's policies and procedures titled, Medication Administration, revised 5/2016, indicated, 14. Medications are administered within 60 minutes of scheduled time .Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center .A review of a facility document titled, MEDICATION ADMINISTRATION TIMES, undated, indicated, MEDICATION ADMINISTRATION TIMES .9:00 AM, 12:00 PM, 5:00 PM, 9:00 PM, 6:30 AM.

Based on observation, interview, and record review, the facility failed to ensure pharmaceutical products were properly handled and stored in accordance with the facility's policies and procedures (P&P), and accepted professional principles for a census of 55 when:1. Multiple expired wound dressings (a material applied to a wound to protect it, promote healing, and prevent infection) were stored in the treatment cart;2. An expired medicated shampoo prescribed for a resident was stored in the treatment cart; and,3. An out of the package syringe needle (injection needle) was found in the treatment cart.These failures had the potential for residents to receive pharmaceutical products that were expired or with unsafe or reduced potency, and risk for residents and/or staff injury and/or infection.Findings:1. During a concurrent observation and interview which started on [DATE] at 11:38 a.m. with Treatment Nurse (TN) 2, of the facility's treatment cart, five silicone wound dressing (a type of wound dressing used to manage wounds with discharges while also helping to reduce scarring and provide pain-free dressing changes) with an expiration date of [DATE], and six occlusive petrolatum gauze wound dressing (a type of wound dressings used to treating wounds such as burns, by creating a moist, breathable, non-sticking environment that protects the wound, reduces pain during changes, and promotes healing) with an expiration date of [DATE] were found stored in the treatment cart. TN 2 confirmed the observation. TN 2 stated expired wound dressings should be discarded and not be used because the wound dressings would have less effectiveness in treating wounds.2. During a concurrent observation and interview which started on [DATE] at 11:38 a.m. with TN 2, of the facility's treatment cart, a medicated shampoo prescribed for a resident with an expiration date of [DATE] was found stored in the treatment cart. TN 2 confirmed the observation. TN 2 stated the expired shampoo should have been discarded because the resident would be at risk for side effects and the treatment would not be as effective as desired.3. During a concurrent observation and interview which started on [DATE] at 11:38 a.m. with TN 2, of the facility's treatment cart, an out of the package syringe needle (injection needle) with a needle cap on, was found in the treatment cart. TN 2 confirmed the observation. TN 2 stated they don't use syringe needles in their treatments and was wondering why there was a syringe needle in the treatment cart. TN 2 further stated the out of the package syringe needle should not be in the cart because of safety issues.During an interview on [DATE] at 3:16 p.m. with the Director of Staff Development (DSD), the DSD stated expired wound dressings, and medicated shampoo should not be stored in the treatment cart because the wound dressing and shampoo would not be effective anymore. The DSD further stated the out of the package syringe needle should not be in the treatment cart and they should have been discarded in a sharp container to prevent staff or resident injury. During an interview on [DATE] at 10:49 a.m. with the Director of Nursing (DON), the DON stated all expired wound dressings, and medicated shampoo should be discarded because they would not be effective when used. The DON further stated an opened syringe needle should not be stored in the treatment cart because of the risk for needle prick.A review of the facility's policy and procedures (P&P) titled, Medication Storage, dated 9/2010, indicated, .biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective .administration A review of the facility's P&P titled, Disposal Of Sharps Needles and Syringes, revised 1/2015, indicated, Used sharps, needles and syringes will be disposed of safely and in accordance with applicable laws. Procedures: . 2. Needles are not to be recapped after use to avoid needle-sticks. 3. Syringes and Needles shall be placed into puncture- resistant sharp disposal containers immediately after use. Needles are not to be deliberately bent or broken .

Based on observation, interview, and record review, the facility failed to enrich the caloric content of meals for five of seven residents (Resident 3, Resident 4, Resident10, Resident 37 and Resident 42) with fortified (increased calorie and/or protein content) dietary orders when the cook omitted the scoop of melted butter intended for fortification. This failure had the potential to put these residents at risk for poor nutritional status. Findings:A review of Resident 3's admission record indicated Resident 3 was admitted on [DATE] with the diagnosis of Multiple Sclerosis ( MS-a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord). A review of Resident 3's physician (MD) orders indicated an order, dated 12/4/23, for a fortified diet. A review of Resident 4's admission record indicated Resident 4 was admitted on [DATE] with a diagnosis of a Stage 3 pressure injury (Full thickness loss of skin, dead and black tissue may be visible).A review of Resident 4's physician (MD) orders indicated an order, dated 4/19/21, for a fortified.A review of Resident 10's admission record indicated Resident 10 was admitted on [DATE] with a primary diagnosis of UTI (an infection in the bladder and urinary tract) and severe protein calorie malnutrition.A review of Resident 10's physician orders indicated an order, dated 1/27/25, for a fortified diet.A review of Resident 37's admission record indicated Resident 37 was admitted on [DATE] with a diagnosis of Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movements) and Dysphagia (difficulty swallowing). A review of Resident 37's physician (MD) orders indicated an order, dated 12/25/24, for a fortified diet.A review of Resident 42's admission record indicated Resident 42 was admitted on [DATE] with a diagnosis of Multiple Sclerosis (MS-a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord). A review of Resident 42's physician (MD) records indicated an order, dated 3/21/23, for a fortified diet.During an observation on 9/9/25 beginning at 11:34 a.m. in the kitchen of the lunch tray line, [NAME] 2 was plating resident meals. Several residents were noted to have an indication for a fortified meal on their tray tickets and no additional calories were observed to have been added to meals. At 11:58 a.m. [NAME] 2 looked up at the surveyor and acknowledged the current omission and added a scoop of melted butter to the plate. [NAME] 2 did not check to see if they had missed other fortified diet meals prior to their realization. During an interview on 9/9/25 with the Dietary Supervisor (DS) at 4:00 p.m., the DS confirmed several residents had not received their fortified meals today and explained melted butter was usually added to the meal for extra calories. The DS stated, without the diet fortification the residents were at risk of not getting the extra nutrition they needed. A review of the facility's policy and procedure (P&P) titled, Fortification of Food: Increasing Calories and/or Protein in the Diet, the P&P indicated the enrichment of foods will be done on an individual basis for residents who cannot consume adequate amounts of calories and/or protein to sustain their weight or nutrition status.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, serve food in accordance with professional standards for food service safety when:1. Four steamtable pans were found wet, stacked in the ready to use shelves. 2. One cook failed to follow food safety/sanitation procedures while preparing cooked ready to eat foods.3. One diet aide was observed putting a clean and sanitized dish rack on the kitchen floor.These failures had the potential to lead to food borne illness for the 51 residents eating facility prepared meals.Findings:1) During an observation of the initial kitchen tour on 9/8/25 at 8:57 a.m., four steamtable pans were observed to be stacked wet (wet nesting) on the bottom shelves in the food preparation area, which indicated they were ready to use. During an interview, on 9/8/25 at 9:22 a.m., with the Dietary Supervisor (DS), the DS stated that wet nesting is not desirable. The DS confirmed the observation of the wet trays and instructed the dishwasher to re-wash them. During a review of the facility's policy and procedure (P&P) titled, Sanitation, dated 2023, the P&P indicated, The Food and Nutrition Services Director is responsible for instructing employees in the fundamentals of sanitation in food service and for training employees to use appropriate techniques.The Food and Drug Administration (FDA) Food Code 2022, 4-9 Protection of Clean Items. Drying 4-901.11 -Equipment and Utensils, Air-Drying Required. After cleaning and sanitizing, equipment and utensils: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface sanitizing solutions), before contact with food; and (B) May not be cloth dried except that utensils that have been air-dried may be polished with cloths that are maintained clean and dry. 2.During the initial kitchen tour on 9/8/25 at 9 a.m., a cooked ready to eat beef roast in a bag had been placed in the sink next to the cook.During a concurrent observation and interview, on 9/8/25 at 9:02 a.m. with the cook, the cook stated that the roast was already cooked, and it is in a sealed bag. During an interview with the DS on 9/8/25 at 4 p.m., the DS stated that the cook should have placed the cooked roast package in a bowl on the counter and that the cooked roast had the potential for food borne illness to the residents. During an interview with the Registered Dietician (RD) on 9/9/25 at 10:05 a.m., the RD stated that the DS had stopped by to talk to him about the cooked roast in the sink. The RD confirmed the potential for contamination of wrapped food in the sink risking cross contamination and that cooked/ready to eat food cannot be placed in the sink.During a review of the facility's policy and procedure (P&P) titled, Food Borne Illness Outbreak, dated 2023, the P&P indicated, Important factors which lead to many foodborne illness outbreaks, cross contamination.The Food and Drug Administration (FDA) Food Code 2022, 3-302. Preventing food and ingredient contamination 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. (A) Food shall be protected from cross contamination by: (1) Except as specified in (1)(d) below or when combined as ingredients, separating raw animal foods during storage, preparation, holding, and display from: (a) Raw ready to eat food . (b) Cooked ready-to-eat food . FDA Food Code 2022 Chapter 3. Food Chapter 3 - 11 (2) Except when combined as ingredients, separating types of raw animal foods from each other such as beef, fish, lamb, pork, and poultry during storage, preparation, holding, and display by: (a) Using separate equipment for each type, or in separate areas; .sanitizing as specified under S 4-703.11; (4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the food in packages, covered containers, or wrappings; (5) Cleaning hermetically sealed containers of food of visible soil before opening; 3.During a subsequent kitchen tour on 9/8/25 at 10 a.m., the dietary aide was observed placing a dish rack on the floor after emptying clean glasses. The dishwasher picked it up and loaded dirty dishes on it.During an interview with the DS on 9/8/25 at 4 p.m. the DS acknowledged the dietary aide should not put anything on the floor and that it could contaminate the dish rack. During an interview with the RD on 9/9/25 at 10:05 a.m. he stated that putting the rack on the floor contaminates the rack and should never be placed on the floor.During a review of the facility's policy and procedure (P&P) titled, Food Borne Illness Outbreak, dated 2023, the P&P indicated, Unsanitary dishware, examples: Improperly cleaned and sanitized tableware, utensils and cutting equipment; failure to protect sanitized ware from contamination.According to the 2022 Federal Food and Drug Administration (FDA) Food Code 4-9 Protection of Clean Items. Drying 4-901.11 -Equipment and Utensils, Air-Drying Required. After cleaning and sanitizing, equipment and utensils: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface sanitizing solutions), before contact with food; and (B) May not be cloth dried except that utensils that have been air-dried may be polished with cloths that are maintained clean and dry.

Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 55 when:1. A shared manual blood pressure machine (a device which measures blood pressure), a shared stethoscope (a device used to listen to the body's internal sounds), and a shared pulse oximeter (a medical device that measures the pulse rate and oxygen level in the blood) was not sanitized properly in between use of residents.2. One facility staff did not remove or properly cover a bracelet under personal protective equipment (PPE) while performing wound care for Resident 25.3. Enhanced Barrier Precaution (EBP, an infection control intervention that utilizes the use of gowns and gloves during direct care activities to reduce transmission of multi-drug-resistant organisms) guidelines were not followed for Res 5 and Res 53.These failures had the potential to spread germs and cause infection for a census of 55. Findings: 1. During an observation on 9/8/25 at 10:33 a.m., with Licensed Nurse (LN) 1, LN 1 was observed checking a resident's blood pressure using a manual blood pressure machine and stethoscope, and the resident's pulse rate using a pulse oximeter which were all shared between residents. LN 1 wrapped the manual blood pressure machine on the resident's upper arm and used the stethoscope to check for the resident's blood pressure. LN 1 then placed the pulse oximeter on one of the resident's fingertips and waited for about a minute to read the results. After reading the results, LN 1 went out the room, wiped the shared manual blood pressure machine, stethoscope, and pulse oximeter using a wipe of [Brand name] GERMICIDAL DISPOSABLE WIPE quickly (approximately 5-10 seconds each) to clean the blood pressure machine, stethoscope, and pulse oximeter's outer surfaces, then placed the three items on top of the medication cart to let it dry. During another observation on 9/8/25 at 10:44 a.m., with LN 1, LN 1 was observed checking a resident's blood pressure using a manual blood pressure machine and stethoscope, and the resident's pulse rate using a pulse oximeter which were all shared between residents. LN 1 wrapped the manual blood pressure machine on the resident's upper arm and used the stethoscope to check for the resident's blood pressure. LN 1 then placed the pulse oximeter on one of the resident's pointing fingertips and waited for about a minute to read the results. After reading the results, LN 1 went out the room, wiped the shared manual blood pressure machine, stethoscope, and pulse oximeter using a wipe each of [Brand name] GERMICIDAL DISPOSABLE WIPE quickly (approximately 5-10 seconds each) to clean the blood pressure machine, stethoscope, and pulse oximeter's outer surfaces, then placed the three equipment on top of the medication cart to let it dry. During an interview on 9/8/25 at 2:32 p.m. with LN 1, LN 1 confirmed the two subsequent observations of her cleaning the shared blood pressure machine, stethoscope, and pulse oximeter's outer surfaces quickly (approximately 5-10 seconds each) in between use of residents. LN 1 stated the shared blood pressure machine, stethoscope, and pulse oximeter should have been wiped for two (2) minutes each to disinfect the three pieces of equipment properly and prevent cross contamination between residents. During an interview on 9/11/25 at 9:25 a.m. with the Infection Preventionist (IP), the IP stated that the facility's shared blood pressure machine, stethoscope, and pulse oximeter should be disinfect properly every after each resident's use to prevent the risk of infection. The IP further stated that nurses should follow the manufacturer's guidelines of the purple top wipe (germicidal disposable wipe) when sanitizing a shared equipment which was to wipe it, and it should remain visibly wet for two (2) minutes. During an interview on 9/11/25 at 10:49 a.m. with the Director of Nursing (DON), the DON stated that staff should always properly disinfect shared equipment after use of each resident to prevent the risk of cross-contamination. A review of the facility's policy and procedures (P&P) titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 5/2024, indicated, 6. Reusable resident care equipment is decontaminated and/or sterilized between residents according to manufacturers' instructions. A review of the [Brand name] GERMICIDAL DISPOSABLE WIPE label indicated, TO DISINFECT AND DEODORIZE HARD, NONPOROUS SURFACES: .Unfold a clean wipe and thoroughly wet surface. Allow surface to remain wet for two (2) minutes. Let air dry . 2. A review of Resident 25's clinical record indicated Resident 25 was admitted [DATE] with diagnoses that included surgical aftercare following surgery on the skin and subcutaneous tissue (a layer of loose connective tissue [supports, protects, joins, and provides structure to other tissues and organs, storing fat, and facilitating nutrient transport], located beneath the skin. Hidradenitis Suppurativa (a chronic, inflammatory condition that causes painful, recurring lumps and abscesses), Sick Sinus Syndrome (a condition where the heart's natural pacemaker, known as the sinus node, does not function properly). Cardiac Pacemaker (a small, implantable device that helps regulate the heart's rhythm by sending electrical pulses). Sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection, leading to widespread inflammation and organ damage). A review of Resident 25's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 2/22/24, indicated Resident 25 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated Resident 25 had intact cognition. A review of Resident 25's active order, dated 8/6/25, indicated, Lt buttocks surgical site: Cleanse with Dakin's (a dilute sodium hypochlorite solution used to clean and disinfect wounds such as cuts, burns, and diabetic foot ulcers to prevent or treat infection and promote healing), pat dry, apply Santyl (the brand name for collagenase, a prescription ointment that removes dead tissue from chronic skin ulcers and severely burned areas. It is a debriding (a medical procedure that involves removing dead or infected tissue from a wound) agent that helps clean the wound and facilitate healing) + gauze and cover with abd (Army Battle Dressing) pad and tape. Every day shift for wound healing. During an observation on 9/9/25 at 1:58 p.m. in Resident 25's room, Treatment Nurse (TN) 1 performed Resident 25's daily surgical wound dressing change. TN 1 sanitized hands, applied a gown and non-sterile gloves, set up the bedside table with dressing supplies and trash bag and informed Resident 25 of the dressing change to be performed. TN 1 addressed Resident 25's pain level after medicating Resident 25 before planned wound change. TN 1 washed hands in bathroom sink and re-gloved and placed a chux (a disposable bed pad used for absorbing liquids) under dressing area, removed tape, changed gloves, removed gauze, changed gloves. TN 1 saturated clean gauze with Dakin's solution and wiped the wound, patted dry with clean dry gauze and applied Santyl. TN 1 dressed the wound with dry gauze covered with abd gauze and taped. During the wound cleansing, TN 1's bracelet slipped down arm and was visible on the outside of the glove and gown of right wrist. TN 1's bracelet touched the wound when TN 1 was wiping the wound with the gauze. TN 1continued to dress the wound. TN 1 changed gloves and cleaned the workspace. TN 1 de-gloved and de-gowned in the room and sanitized hands with hand sanitizer. During an Interview on 9/9/25 at 2:10 p.m. with TN 1, TN 1 indicated the expectation for jewelry during a dressing change is to remove the jewelry or tuck the jewelry under the gown to avoid contact with the wound. TN 1 stated the reason is to avoid infection. TN 1 acknowledged the bracelet had dropped down the arm to the wrist during the dressing change. TN 1 indicated no awareness that the bracelet touched the wound. During an interview on 9/9/25 at 2:19 p.m. with IP, the IP confirmed the expectation for jewelry during dressing changes is to remove the jewelry to avoid contact with wound. IP confirmed the reason is to avoid infection. During an interview on 9/11/25 at 9:42 AM with the DON, the DON stated the expectation for jewelry, such as a bracelet, during a dressing change is for the jewelry to be removed to avoid contact with the wound and potential infection. The DON stated if the TN noticed the bracelet became exposed, the TN should have removed gloves and gown, remove the bracelet, re-gowned and gloved and restarted the dressing process. A review of the facility's P&P titled, Infection Control Polices/Practices/Programs, revised June 2012, indicated, It is the policy of this facility that the primary principle of this facility's infection control policies, practices and programs are to establish guidelines to abide by to provide a safe, sanitary and comfortable environment and to assist in preventing the development and transmission of diseases and infections. 2. The objective of our infection control policies, practices and programs are to: a. Investigate, control, and prevent infections in the facility including but not limited to infectious microorganisms for both contacts and droplet types and forms. 3. During a review of the clinical record for Resident 53, the clinical record indicated Resident 53 was admitted to the facility on [DATE], with the diagnoses that included Cellulitis (common bacterial skin infection), and Gastrostomy (GT, feeding tube directly into the stomach). During a concurrent observation and interview with Certified Nurse Assistant (CNA) 4 inside Resident 53's room on 9/9/25 at 9:40 a.m., CNA 4 did not wear a gown when they performed direct nursing care to Resident 53. CNA 4 stated that with the help of CNA 5, they used the Hoyer lift (mechanical device used to assist individuals with mobility) to transfer Resident 53 from bed to recliner. CNA 4 acknowledged she did not wear a gown when they performed the task, and she stated that she should have worn a gown to promote infection control. CNA 4 confirmed there was an EBP signage posted by Resident 53's door, and it indicated when and how to properly wear the gown and gloves for residents with EBP. During an interview with CNA 5 on 9/9/25 at 9:50 a.m., CNA 5 stated they turned Resident 53 to her sides, tucked the Hoyer sling and mechanically lifted Resident 53 and transferred her to the recliner. CNA 4 helped CNA 5 during the transfer. CNA 5 acknowledged that she wore a gown and gloves to promote infection control as Resident 53 is on EBP. CNA 5 confirmed that CNA 4 did not wear a gown when they performed direct care to Resident 53. During an interview with the DON on 9/9/25 at 10:25 a.m., the DON stated the staff should have worn gown and gloves when performing direct nursing care such as transferring residents who are on EBP from the bed to recliner to promote infection prevention. During an interview with IP on 9/10/25 at 12:05 p.m., the IP stated Resident 53 had a GT and was on EBP. The IP continued, the staff should have worn gowns and gloves during direct nursing care to prevent the spread of infection. In a review of the facility's policy and procedure, titled Enhanced Barrier Precaution Policy, revised 1/2025, the P&P indicated, It is the policy of this facility that Enhanced Barrier Precautions, in addition to Standard and Contact Precautions will be implemented during high-contact resident care activities when caring for residents that have an increased risk for acquiring a multidrug-resistant organism (MDRO). 4. A review of Resident 5's admission record indicated that Resident 5 was initially admitted on [DATE] and returned on 8/12/25 after hospitalization for Sepsis (a life-threatening blood infection). Resident 5 was on Dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed) and had a Stage 4 pressure injury (Full thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone). A review of Resident 5's active orders indicated that he was placed on EBP on 8/13/25 for Dialysis Access Site and wound treatment. During an observation on 9/8/25 at 11:35 am, CNA 3 was seen changing Resident 5's pillowcases without wearing a gown. A sign was present outside of Resident 5's room indicating that Resident 5 and his roommate were both on EBP. During an interview on 9/8/25 with CNA 3 at 11:42 am outside of Resident 5's room, CNA 3 confirmed that both Resident 5 and his roommate were on EBP. CNA 3 confirmed she only put on gloves and not a gown because changing pillowcases was not considered direct contact. During an interview on 9/11/25 with the DON, the DON stated, If a resident is on EBP it means staff must wear PPE (personal protective equipment used to prevent the spread of infection) for direct care, gloves, gown and mask if indicated. Changing linens is considered direct care, it's on the sign and the resident has contact with the sheets. Precautions are there to protect both residents and staff. A review of the facility's policy titled, Enhanced Barrier Precautions Policy, last reviewed in 2024, indicated that changing linens is considered a high contact resident care activity, and that a gown and gloves must be worn when changing linens.

Based on interview, and record review, the facility failed to provide appropriate treatment and services to maintain or improve mobility, and prevent decline in range of motion (ROM) for two out of 19 sampled residents (Resident 30 and Resident 23) when:1. Resident 30's restorative nursing program (RNA program- interventions that actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning) frequency was not followed; and,2. An RNA program referral from Physical Therapy (PT) was not implemented for Resident 23.This failure had the potential for Resident 30 and Resident 23 to experience a decline in range of motion and/or function and not achieve their highest practicable physical wellbeing.Findings: 1. A review of Resident 30's clinical record indicated Resident 30 was admitted June of 2023 and had diagnoses that included hemiplegia (complete loss of the ability to move one side of the body) and hemiparesis (partial weakness of one side of the body) following cerebral infarction (damage to a part in the brain due to a disrupted blood flow) and contractures (permanent shortening of muscles, skin, and nearby soft tissue that results in limited range of motion and stiffness) of left hand and right knee. A review of Resident 30's Minimum Data Set (MDS– a federally mandated resident assessment tool) Cognitive Patterns, dated 8/7/25, indicated Resident 30 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 5 out of 15 which indicated Resident 30 had a severely intact cognition (mental process of acquiring knowledge and understanding). A review of Resident 30's MDS Functional Abilities indicated Resident 30 was dependent with eating, oral hygiene, toileting hygiene, shower/bathing self, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. A further review of Resident 30's MDS Functional Abilities indicated Resident 30 was also dependent with rolling left and right, chair/bed-to-chair transfer, and tub/shower transfer. During a phone interview on 9/8/25 at 3:15 p.m. with Resident 30's daughter, Resident 30's daughter stated Resident 30 was not getting his exercises as often as he needed. A review of Resident 30's active physician's order, dated 10/13/23, indicated, RNA to provide PROM [passive range of motion- the movement of a joint by an external force] for BLE's [bilateral lower extremities- both legs] .3x/wk [three times a week] with 1 person assist. every day shift. A review of Resident 30's active physician's order, dated 10/13/23, indicated, RNA to provide PROM for LUE [left upper extremity- left arm] .3x/wk with 1 person assist, as tolerated. every day shift. A review of Resident 30's care plan intervention, revised 1/23/24, indicated, RNA to provide PROM for BLE's .3x/wk with 1 person assist. every day shift .RNA to provide PROM on LUE .3x/wk with 1 person assist, as tolerated. PROVIDE RNA AS ORDERED . During a concurrent interview and record review on 9/10/25 at 2:49 p.m. with Restorative Nurse Assistant (RNA) 1, Resident 30's RNA flowsheet for the August and September 2025 were reviewed. RNA 1 confirmed that Resident 30 only received PROM of BLE and LUE on 8/1, 8/4, 8/7, 8/11, 8/13, 8/15, 8/18, 8/20, 8/22, 8/26, 8/28, 9/1, and 9/4. The RNA 1 confirmed that Resident 30 did not get his exercises in accordance with the ordered RNA program frequencies which were three times a week. RNA 1 stated the RNA frequency order should have been followed. RNA 1 further stated there would be a risk for contracture and decline in function if Resident 30's RNA program frequency was not followed. During an interview on 9/10/25 at 3:16 p.m. with the Director of Staff Development (DSD), the DSD stated RNA program frequency should have been followed and there should have been documentation about why the exercises were not done. The DSD further stated Resident 30 would be a risk for contracture and weakness if the RNA program frequency was not followed. During an interview on 9/11/25 at 10:49 a.m. with the Director of Nursing (DON), the DON stated that he would expect that RNA program frequency would be followed. The DON further stated that the resident would be at risk for decline in function if the RNA program frequency was not followed. A review of the facility's policy and procedures titled, Restorative Program, revised 4/2019, indicated, The Restorative Program focuses on achieving and maintaining optimal physical, mental and psychological functioning of the resident to attain/maintain each resident's highest practicable functioning. The facilityprovides Restorative Programs to promote the resident s ability to adapt andadjust to living as independently and safely as possible .2.Residents who receive restorative services have a care plan with individualized, measurable goals and interventions . Findings: 2. A review of Resident 23's clinical record indicated Resident 23 was admitted [DATE] with diagnoses that included multiple fractures (a medical condition where a bone breaks or cracks) of ribs, traumatic pneumothorax (occurs when air enters the pleural space, the area between the lung and chest wall, due to an injury), muscle weakness, history of falling, abnormalities of gait (gait refers to the pattern of walking, including the sequence, rhythm, and speed of steps) and mobility (the ability to move or be moved freely and easily). A review of Resident 23's MDS Cognitive Patterns, dated 6/23/25, indicated Resident 23 had a BIMS score of 15 out of 15 which indicated Resident 25 had intact cognition. A review of Resident 23's MDS section GG Functional Abilities, dated 6/29/25, indicated Resident 23 was unable to walk ten feet and used a walker (a mobility aid that provides support and stability for people who have difficulty walking due to leg weakness, balance problems, or recovery from injury or surgery) or a wheelchair (a chair fitted with wheels for use as a means of transport by a person who is unable to walk). A review of Resident 23's RNA program referral, dated 7/22/25, written by Physical Therapist (PT) 1, PT 1 recommended, RNA for ambulation using FWW (front wheeled walker) approximately 150 ft or as tolerated, QD (everyday), 3x/wk (3 times a week) with one person assist, to maintain functional levels. A review of Resident 23's orders revealed no order was placed for the RNA program referral dated 7/22/25. A review of Resident 23's care plan revealed no care plan was initiated for the RNA program. During an interview on 9/8/25 at 11 a.m. with Resident 23, Resident 23 stated she did not understand why PT was not happening. Resident 23 stated she was told by PT 1 that insurance coverage for continued PT was denied. Resident 23 stated it was not possible because she had insurance. During an interview on 9/9/25 at 8:58 am with PT 1, PT 1 stated Resident 23 was discharged from the PT program due to insurance coverage on 7/2/2025. PT 1 stated that Resident 23 reached PT goals and was denied by insurance for further PT. PT 1 stated Resident 23 was notified. Resident 23 was referred to the RNA program on 7/22/25. PT 1 stated the referral was placed on the RNA's desk. PT 1 stated the normal process for RNA program referral is to place the referral on the RNA's desk if the RNA is working or put it in the communication binder if the RNA is not working. During an interview on 9/9/25 at 9:51 a.m. Social Service director (SSD), SSD confirmed Resident 23's last day of insurance coverage was 7/3/25. During an Interview on 9/9/25 at 11:55 am with RNA 1, RNA 1 stated they were not aware of the referral and were notified by PT today, 9/9/25. RNA stated the usual process for RNA program referrals begins with PT initiating the referral. PT places the referral on the RNA desk if she is working that day or places it in the communication binder with the referral sticking up to indicate there is a new referral. RNA 1 stated the referral is given to the nurse who is assigned to the resident. The nurse signs off on the referral and returns it to the RNA signed and dated. The RNA implements the plan of care. RNA 1 confirmed the referral was not seen and therefore was not implemented for Resident 23. During an Interview on 9/9/25 at 12:19 PM with PT 1, PT 1 confirmed Resident 23 should have begun the RNA treatment plan on the referral, dated 7/22/25. During an interview on 9/9/25 at 12:48 p.m. with Treatment Nurse (TN) 1, TN 1 stated when an RNA program referral is received, a Licensee Nurse (LN) enters it as an RNA order and then places it in a binder at the nurse's station for the doctor or nurse practitioner (NP) to sign. TN 1 stated the order is immediately available for the RNA to implement. During an interview on 9/9/25 at 1:35 p.m. with the Administrator (Admin), the admin stated when appropriate, residents are referred to the RNA program by PT and the RNA gives a copy of the referral to the Admin and the DON. The administrator indicated they work closely with Resident 23 and was aware of her being discharged from physical therapy and referred to RNA Program. Admin confirmed PT refers residents to the RNA Program. The RNA gives the referral to a nurse to enter the order. Admin confirmed the expectation was for the RNA to implement the plan once the order is entered. Interview on 9/11/25 at 9 a.m. with the DON, the DON stated the process for RNA program referral starts with the Physical Therapist giving the LN who is assigned to the resident the referral. The LN calls the doctor to get the order, and the nurse inputs the order and initiates a care plan. The DON states the RNA has no reason to be involved in the initial referral process and states the RNA is being used as the middle person between the Physical Therapist and the LN. The DON states the RNA should implement the order on the day the order is entered unless it is late in the day, the RNA will implement the following day. The DON states he would attempt to locate the written procedure for this process. A review of the initial Interdisciplinary Team (IDT) Care Conference, dated 6/20/25, revealed no discussion regarding rehabilitation. A review of the IDT notes dated 9/9/25, two months after the referral date of 7/22/25, indicated, IDT met today on a discussion regarding the RNA referral done by PT on 7/22/25. Informed resident by RNA that there is a referral for RNA Program. A review of the facility's policy titled, RNA Referral revised July 2012, indicated it is the policy of the facility to provide rehabilitative services and a restorative program for resident to prevent deterioration and achieve and maintain optimal levels of functioning and independence. 1. Based on assessment result a recommendation will be forwarded to the attending physician. 3. Attending physician will give an order either for skilled rehabilitation therapist or R.N.A. program. 6. Skilled therapist will assess resident if qualified to undergo skilled rehabilitation services or just to be on R.N.A. program. 7. The skilled therapist can also initiate and recommend restorative program active treatment. 8. Restorative Assistant carries out program in according to the written plan of care.

Based on observation, interview, and record review, the facility failed to ensure one out of 19 sampled residents (Resident 2) was provided with appropriate care and services with enteral feeding (also referred to as tube feeding/ feeding tube- the delivery of food and nutrients through a feeding tube directly into the stomach or part of the intestines) when Resident 2's gastrostomy tube (G-tube- a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) was not flushed with water before medication administration and enteral feeding.This failure had the potential for Resident 2 to experience complications of the G-tube such as clogging and for the resident not to attain his highest practicable well-being.Findings:A review of Resident 2's clinical record indicated Resident 2 was admitted November of 2023 and had diagnoses that included encounter of gastrostomy status, dysphagia (swallowing difficulties), and hemiplegia (complete loss of the ability to move one side of the body).A review of Resident 2's active physician's order, dated 11/9/23, indicated, Resident is capable of giving informed consent and/or able to participate in treatment plan.A review of Resident 2's Minimum Data Set (MDS- a federally mandated resident assessment tool) Swallowing/Nutritional Status, dated 8/12/25, indicated Resident 2 has used a feeding tube while a resident in the facility.A review of Resident 2's care plan, initiated 2/24/24, indicated, The resident [Resident 8] requires tube feeding (gtube) r/t [related to] CVA [cerebrovascular accident/stroke- a condition that occurs when a blood vessel in the brain becomes blocked or ruptures, cutting off blood flow to the brain] with Hemiplegia, Dysphagia . A review of Resident 2's care plan intervention, dated 4/25/25, indicated, ENTERAL FEEDING: Flush G-tube with 30cc [cubic centimeter- unit of measurement] of water BEFORE and AFTER feedings .ENTERAL FEEDING: Flush G-tube with 30cc of water BEFORE and AFTER medication administration AND flush with 5cc of water in between EACH medication given for prevention of tube clogging.A review of Resident 2's active physician's order, dated 4/24/25, indicated, ENTERAL FEEDING: Flush G-tube with 30cc of water BEFORE and AFTER medication administration AND flush with 5cc of water in between EACH medication given for prevention of tube clogging every shift.A review of Resident 2's active physician's order, dated 8/11/25, indicated, ENTERAL FEEDING: Flush G-tube with 60ml [milliliter- unit of measurement] of water BEFORE and AFTER feedings every 6 hours.During an observation on 9/9/25 at 12:16 p.m. with Licensed Nurse (LN) 1, in Resident 2's room, LN 1 was observed doing Resident 8's tube feeding. LN 1 positioned Resident 8 properly, checked Resident 8 feeding residual [left feeding formula] amount, and checked the gastrostomy tube placement, but did not flush tube with water before starting medication administration and enteral feeding. The flow of the medication and feeding formula was observed to be sluggish during the procedure.During a subsequent interview on 9/9/25 at 1:03 p.m. with LN 1, LN 1 confirmed that she did not flush Resident 2's G-tube with water before starting medication administration and enteral feeding. LN 1 stated she should have flushed the tube with water before starting medication administration and enteral feeding. LN 1 further stated that it could cause the G-tube to clog if the tube was not flushed with water before medication administration and enteral feeding.During an interview on 9/10/25 at 3:16 p.m. with the Director of Staff Development (DSD), the DSD stated that the G-tube needed to be flushed with water before starting medication administration and enteral feeding to make sure the tube was patent and to prevent clogging.During an interview on 9/11/25 at 10:14 a.m. with the Director of Nursing (DON), the DON stated the nurse was supposed to flush the G-tube with water before starting medication administration and enteral feeding. The DON further stated there would be a risk of clogging if the G-tube was not flushed with the ordered water amount before medication administration and enteral feeding.A review of the facility's policy and procedures titled, Enteral Nutrition: General Guidelines, revised 1/2025, indicated, MEDICATION ADMINISTRATION .15. Tube will be flushed with water before and after medication administration .

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care to attain and maintain their highest practical wellbeing consistent with professional standards of practice and facility's policy and procedure (P&P) for nine out of 31 sampled residents (Resident 265, 60, 267, 264, 266, 160, 262, 263, and 48) when: 1. Resident 265's prescribed pain medication, and Resident 60 and Resident 267's prescribed medications were ordered late; 2. Resident 264's order for pain medication was sent to the pharmacy without a valid prescription order and another prescribed medication was ordered late; 3. Resident 266's order for pain medications were sent to the pharmacy without valid prescription orders and another prescribed medication was returned to the facility for a signature and additional authorization, which caused the delay; 4. Resident 160's order for pain medications and two other medications were authorized late; 5. Resident 262 and Resident 263 did not receive their prescribed medication in a timely manner in accordance with the physician's order; and, 6. When Licensed Nurse (LN) 2 did not safely administer medications via the gastrostomy tube (G Tube -a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) for Resident 48 as per physician's orders and professional standards. These failures resulted in Resident 265, 60, 267, 264, 266, 160, 262, and 263 not receiving their medications on time which subsequently resulted in Resident 265, 264, 266, and 160 experiencing unnecessary pain and emotional distress that had negatively affected the residents' level of comfort, activity and sleep, and risk for Resident 48 to have an unsafe medication administration. Findings: 1a. A review of Resident 265's clinical record indicated Resident 265 was admitted February of 2025 and had diagnoses that included fracture (a break in the continuity of a bone) of left humerus (upper arm bone), neuralgia (pain caused by irritation or damage to a nerve) and neuritis (inflammation of a nerve), and need for assistance with personal care. A review of Resident 265's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns (mental process of acquiring knowledge and understanding)., dated 3/2/25, indicated Resident 265 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 10 out of 15 which indicated Resident 265 had a moderately impaired cognition. A review of Resident 265's MDS Health Conditions, dated 3/2/25, indicated Resident 265 had frequently experienced pain or hurting which frequently made it hard for her to sleep at night, occasionally limited her participation in rehabilitation therapy sessions, and occasionally limited her day-to-day activities. A review of Resident 265's progress notes, dated 2/19/25, indicated Resident 265 arrived at the facility on 2/19/25 at around 11:58 p.m. and has a pain level of 4/10 (numeric pain scale from 1 to 10; 1-3 is mild pain, 4-7 is moderate pain, 8-10 is severe pain). A review of Resident 265's physician's order, dated 2/19/25 at 12:13 p.m., indicated, MS Contin (Morphine Sulfate) [a strong medication used to treat moderate to severe pain] Oral Tablet Extended Release 30 MG [milligrams- unit of measurement] Give 1 tablet by mouth every 8 hours for Pain management. A review of Resident 265's care plan, initiated 2/19/25, indicated, At risk for pain or discomfort related to left humeral fracture due to ground fall at home. A review of Resident 265's care plan intervention, initiated 2/19/25, indicated, Administer pain meds as MD (Medical Doctor) ordered .MS Contin Oral Tablet .for Pain management. A review of Resident 265's Medication Administration Record (MAR- a legal document used to record medications given to the residents), for the month of February 2025, indicated Resident 265's morphine sulfate was scheduled to be administered every 8 a.m., 4 p.m., and 12 midnight, with the first dose scheduled on 2/19/25 at 4 p.m. A further review of the MAR indicated the 4 p.m. of the morphine sulfate on 2/19/25 was marked with a chart code 5, which indicated the medication was held and not given to the resident. A review of Resident 265's Weights and Vitals Summary, dated 2/19/25 at 8:38 p.m., indicated Resident 265 had a pain level of 8 [severe pain]. During an interview on 3/10/25 at 9:42 a.m. with Resident 265, Resident 265 stated she did not receive her morphine medication on the day she was admitted in the facility. Resident 265 also stated her pain was so awful that day, it went to a level of 9 out of 10 (severe pain). Resident 265 further stated, Well, It [sleeping] was hard .I got hard time sleeping .I was in so much pain. During a concurrent interview and record review on 3/11/25 at 4:22 p.m. with LN 6, Resident 265's MAR for February 2025 was reviewed. LN 6 confirmed that Resident 265's morphine sulfate was not given on 2/19/25 at 4 p.m. LN 6 stated there was a risk for Resident 265 to be in so much pain when the morphine sulfate was not given. During a concurrent phone interview and record review on 3/13/25 at 10:54 a.m. with the Pharmacist from the Facility's Pharmacy (PP), Resident 265's medication orders were reviewed. The PP stated they only received Resident 265's medication order for morphine sulfate on 2/19/25 at 7:41 p.m. and had filled and sent it on the next scheduled delivery time which was 10:30 pm. During a concurrent interview and record review on 3/13/25 at 11:46 a.m. with the Admissions Coordinator (AC), Resident 265's medication records were reviewed. The AC showed a fax receipt indicating Resident 265's prescription order of morphine sulfate was sent to their pharmacy on 2/19/25 at 5:53 p.m. The AC confirmed the prescription order was faxed after the scheduled administration. The AC stated that sometimes it would take 4 hours for nurses to transcribe medication orders which causes the delay in faxing medication orders. A review of the Shipping Manifest [receipt] for Resident 265's morphine sulfate indicated the facility received the medication on 2/19/25 at 10:35 p.m. 1b. A review of Resident 60's clinical record indicated Resident 60 was admitted March of 2025 and had diagnoses that included thrombocytosis (a condition characterized by an abnormally high number of clotting components in the blood) and benign prostatic hyperplasia (BPH- the prostate gland grows larger than normal potentially causing urinary problems). A review of Resident 60's admission History and Physical, dated 3/5/25, indicated Resident 60 was oriented to person, place and time, but Does not have the capacity to understand and make medical decisions. A review of Resident 60's progress notes, dated 3/5/25, indicated Resident 60 arrived at the facility on 3/4/25 at 3:05 p.m. A review of Resident 60's physician's order, dated 3/4/25 at 4:40 p.m., indicated, Tamsulosin HCL(Hydrochloride) [a medication used to treat enlarged prostate] Oral Capsule 0.4 MG . Give 1 capsule by mouth at bedtime related to BENIGN PROSTATIC HYPERPLASIA . A review of Resident 60's physician's order, dated 3/4/25 at 4:43 p.m., indicated, Apixaban [a medication used to treat and prevent blood clots and to prevent stroke] Oral Tablet 2.5 MG . Give 1 tablet by mouth two times a day . A review of Resident 60's MAR for the month of March 2025, indicated Resident 60's tamsulosin was scheduled to be administered starting 3/4/25 every 9 p.m. and the apixaban was scheduled every 9 a.m. and 9 p.m., with first dose on 3/4/25 at 9 p.m. A further review of the MAR indicated the 9 p.m. doses for tamsulosin and apixaban on 3/4/25 were marked with a chart code, 5, which indicated the medications were held and not given to the resident. A review of Resident 60's progress notes, dated 3/5/25 at 6:56 a.m., indicated, .f/u [follow up] with pharmacy as medication not delivered.as per pharmacy they did not receive the face sheet and order. Refaxed all the order and face sheet. Requested stat [immediate] delivery of medication. endorsed to next shift . During an interview on 3/11/25 at 4:08 p.m. with Resident 60, Resident 60 stated he could not remember if he got all his medications when he was admitted in the facility. During a concurrent interview and record review on 3/11/25 at 4:22 p.m. with LN 6, Resident 60's MAR was reviewed. LN 6 confirmed that 9 p.m. doses of Resident 60's tamsulosin and apixaban on 3/4/25 were not given. LN 6 stated there was a risk for Resident 60 to develop impaired circulation when the apixaban was not given and a risk to negatively affect Resident 60's health when the tamsulosin was not given. During a concurrent phone interview and record review on 3/12/25 at 11:51 a.m. with the Pharmacy Technician (PPT) from the Facility's Pharmacy, Resident 60's medication orders were reviewed. PPT stated they only received Resident 60's medication orders for tamsulosin and apixaban on 3/5/25 at 4:18 a.m. and had filled and sent it on the next scheduled delivery time. A review of the Shipping Manifest for Resident 60's tamsulosin and apixaban indicated the facility received the medication on 3/5/25 at 10:30 a.m. 1c. A review of Resident 267's clinical record indicated Resident 267 was admitted March of 2025 and had diagnoses that included asthma (a condition in which a person's airways become inflamed, narrow, and swell, and produce extra mucus, which makes it difficult to breathe) and gastro-esophageal reflux disease (GERD- a condition where stomach acid flows back up into the esophagus causing symptoms like heartburn and regurgitation). A review of Resident 267's admission History and Physical, dated 3/5/25, indicated Resident 60 was oriented to person, place and time, and Has the capacity to understand and make medical decisions. A review of Resident 267's progress notes, dated 3/4/25, indicated Resident 267 arrived at the facility at around at 3 p.m. A review of Resident 267's physician's order, dated 3/4/25 at 4:40 p.m., indicated, Fluticasone-Salmeterol Inhalation [a combination medication used to treat asthma] .500-50 MCG/ACT [unit of measurement] .1 puff inhale orally one time a day for asthma . A review of Resident 267's physician's order, dated 3/4/25 at 6:29 p.m., indicated, Pantoprazole Sodium [a medication used to treat GERD] Oral Capsule 100 MG . Give 1 capsule by mouth two times a day for GERD . A review of Resident 267's MAR for the month of March 2025, indicated Resident 267's fluticasone-salmeterol inhalation was scheduled to be administered starting 3/5/25 every 9 a.m. and the pantoprazole was scheduled every 6:30 a.m. and 4:30 p.m., with first dose on 3/5/25 at 6:30 a.m. A further review of the MAR indicated the 9 a.m. dose of fluticasone-salmeterol inhalation and 6:30 a.m. dose of pantoprazole for Resident 267 on 3/5/25 were marked with a chart code, 5, which indicated the medications were held and not given to the resident. A review of Resident 267's progress notes, dated 3/5/25 at 4:19 p.m., indicated, Fluticasone spray unable to give, waiting for pharmacy delivery . During an interview on 3/10/25 at 11:10 a.m. with Resident 267, Resident 267 stated she did not receive some of her medications when she was admitted in the facility. Resident 267 also stated it was upsetting for her to wait that long for her medications. During a concurrent interview and record review on 3/11/25 at 4:22 p.m. with LN 6, Resident 267's MAR was reviewed. LN 6 confirmed the 9 a.m. dose of fluticasone-salmeterol inhalation and 6:30 a.m. dose of pantoprazole for Resident 267 on 3/5/25 were not given. LN 6 stated there was a risk for Resident 267 to develop gastric acidity when the pantoprazole was not given and a risk to develop difficulty breathing when the fluticasone-salmeterol inhalation was not given. During a concurrent phone interview and record review on 3/12/25 at 11:51 a.m. with the PPT, Resident 60's medication orders were reviewed. PPT stated they only received Resident 267's medication orders for fluticasone-salmeterol inhalation and pantoprazole on 3/5/25 at 12:35 p.m. and had filled and sent it on the next scheduled delivery time. A review of the Shipping Manifest for Resident 267's fluticasone-salmeterol inhalation and pantoprazole indicated the medications were received by the facility on 3/5/25 at 3:20 p.m. 2. A review of Resident 264's clinical record indicated Resident 264 was admitted February of 2025 and had diagnoses that included osteoarthritis (OA- a deteriorating disease that causes pain, stiffness, and swelling where two or more bones meet), pain in right hip, diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), neuropathy (a nerve condition that can cause pain, numbness, tingling, or weakness in the body), chronic pain syndrome (condition that involves persistent pain that lasts for weeks to years), and major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 264's MDS Cognitive Patterns, dated 2/26/25, indicated Resident 264 had a BIMS score of 15 out of 15 which indicated Resident 264 had an intact cognition. A review of Resident 264's MDS Health Conditions, dated 2/26/25, indicated Resident 264 had frequently experienced pain or hurting which frequently made it hard for her to sleep at night, frequently limited her participation in rehabilitation therapy sessions, and frequently limited her day-to-day activities. A review of Resident 264's physician's order, dated 2/19/25 at 3:06 p.m., indicated, Pregabalin [a drug used to treat nerve and muscle pain] Oral Capsule 150 MG . Give 1 capsule by mouth two times a day related to PAIN IN RIGHT HIP . A review of Resident 264's MAR, for the month of February 2025, indicated Resident 264's pregabalin was scheduled to be administered every 9 a.m. and 5 p.m., with the first dose on 2/19/25 at 5 p.m. A further review of the MAR indicated that Resident 264's dose of pregabalin on 2/19/25 at 5 p.m., 2/20/25 at 9 a.m. and 5 p.m., and 2/21/25 at 9 a.m. were all marked with a chart code 5, which indicated the medication was held and not given to the resident. A review of Resident 264's physician's order, dated 2/20/25 at 7:48 p.m., indicated, metFORMIN HCl [a medication used to treat high blood sugar levels] Oral Tablet 500 MG . Give 1 tablet by mouth two times a day for DM. A review of Resident 264's MAR, for the month of February 2025, indicated Resident 264's metformin was scheduled to be administered starting 2/21/25 every 9 a.m. and 5 p.m. A further review of the MAR indicated the metformin 9 a.m. dose on 2/21/25 was marked with a chart code, 5, which indicated the medication was held and not given to the resident. A review of Resident 264's care plan, initiated 2/19/25, indicated, At risk for alteration in comfort/pain related to recent fall with right hip pain, chronic back pain .DM . A review of Resident 264's care plan intervention, initiated 2/19/25, indicated, Administer pain meds as MD ordered . A review of Resident 264's progress notes, dated 2/20/25 at 2:19 p.m., indicated, Followed up with [name of facility pharmacy] about Pregabalin; no response from doctor for authorization. Additional message was left for doctor by pharmacy staff. During an interview on 3/10/25 at 9:48 a.m. with Resident 264, Resident 264 stated she did not get all her medications on the first few days when she was admitted in the facility, including her pain medication. Resident 264 also stated her pain level was so bad which she rated at 10 (severe pain). Resident 265 further stated, I was hurting .I cannot move or do anything .so I just stayed here in the room on those days .I was just in bed because I can't do anything .I was not comfortable, I was in a lot of pain .I was so upset to wait that long for it [pain medication] . During a concurrent interview and record review on 3/11/25 at 4:22 p.m. with LN 6, Resident 264's MAR for February 2025 was reviewed. LN 6 confirmed that Resident 264's pregabalin was held and not given on 2/19/25 at 5 p.m., 2/20/25 at 9 a.m. and 5 p.m., and 2/21/25 at 9 a.m. LN 6 stated there was a risk for Resident 264 to have her pain not relieved when the pregabalin was not given for four times. LN 6 also confirmed that Resident 264's metformin was held and not given on 2/21/25 at 9 a.m. LN 6 further stated there was a risk for Resident 264 to have high blood sugar when the metformin was not given. During a concurrent phone interview and record review on 3/12/25 at 11:51 a.m. with PPT, Resident 264's medication orders were reviewed. PPT stated they only received Resident 264's valid prescription order for pregabalin from the doctor on 2/21/25 at 7:32 a.m. and had filled and sent it on the next scheduled delivery time. PPT also stated they only received Resident 264's medication order for metformin on 2/21/25 at 8:06 a.m. and had filled and sent it on the next scheduled delivery time. During a concurrent interview and record review on 3/13/25 at 11:46 a.m. with the AC, Resident 264's medication records were reviewed. The AC stated Resident 264 came from a local hospital that sends medication order to their pharmacy electronically in which they're having problems with. The AC also stated that their nurse would then need to call their facility doctor to get the actual prescription order and fax it the pharmacy. The AC then confirmed that there was no valid prescription order for Resident 264's pregabalin that was faxed to the pharmacy. A review of the Shipping Manifest for Resident 264's pregabalin and metformin indicated the facility received the medication on 2/21/25 at 1:45 p.m. 3. A review of Resident 266's clinical record indicated Resident 266 was admitted March of 2025 and had diagnoses that included neuralgia and neuritis, osteoarthritis, chronic pain, respiratory failure (is a serious condition that develops when the lungs can't get enough oxygen into the blood and makes it difficult for a person to breathe on his/her own) and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). A review of Resident 266's admission History and Physical, dated 3/6/25, indicated Resident 266 was oriented to person, place and time, Has the capacity to understand and make medical decisions, and was a high risk for fall and Activities of Daily Living (ADL- normal daily functions required to meet basic needs) decline. A review of Resident 266's progress notes, dated 3/4/25, indicated Resident 266 arrived at the facility at around 11:30 a.m. A review of Resident 266's physician's order, dated 3/4/25 at 2:33 p.m., indicated, Buprenorphine [a strong medication used to treat moderate to severe pain] HCl Sublingual [below the tongue] Tablet Sublingual 8 MG . Give 1 tablet sublingually two times a day for Chronic pain. A review of Resident 266's physician's order, dated 3/4/25 at 2:33 p.m., indicated, Pregabalin Oral Capsule 25 MG . Give 1 capsule by mouth two times a day related to NEURALGIA AN NEURITIS . A review of Resident 266's physician's order, dated 3/4/25 at 2:33 p.m., indicated, Dulera [a prescription medicine used to control symptoms such as difficulty breathing] Inhalation Aerosol 200-5 MCG/ACT [micrograms/puff] .2 puff inhale orally two times a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE . A review of Resident 266's MAR for the month of March 2025, indicated Resident 266's buprenorphine, pregabalin, and dulera inhalation were scheduled to be administered every 9 a.m. and 5 p.m., with first dose on 3/4/25 at 5 p.m. A further review of the MAR indicated the 5 p.m. dose of buprenorphine on 3/4/25, the pregabalin 5 p.m. dose on 3/4/25 and 9 a.m. dose on 3/5/25, and the dulera inhalation 5 p.m. dose on 3/4/25 and 9 a.m. dose on 3/5/25 were all marked with chart code, 5, which indicated the medications were held and not given to the resident. A review of Resident 266's care plan, initiated 3/4/25, indicated, At risk for pain or discomfort related to: .> NEURALGIA AND NEURITIS .> OA. >Chronic Pain. A review of Resident 266's care plan intervention, initiated 3/4/25, indicated, Administer pain meds as MD ordered .Buprenorphine HCl .Pregabalin Oral Capsule . A review of Resident 266's progress notes, dated 3/5/25 at 12:58 a.m., indicated, .some of the medication still to be delivered from pharmacy . A review of Resident 266's Weights and Vitals Summary, indicated Resident 266 had pain levels as follows: 3/5/25 at 12:39 a.m.- 5 (moderate pain), 3/5/25 at 9:40 a.m.- 5 (moderate pain), 3/5/25 at 4:40 a.m.- 7 (moderate pain). During an interview on 3/10/25 at 10:04 a.m. with Resident 266, Resident 266 stated she did not get all her medications when she was admitted , including her pain medications. Resident 266 also stated she had pain on the days she did not receive her pain medications which she rated at a level of 9 out of 10 (severe pain). Resident 266 further stated, I was in so much pain .I tried to rest but I could not sleep at all that night .It's [pain] so bad. During a concurrent interview and record review on 3/11/25 at 4:22 p.m. with LN 6, Resident 266's MAR was reviewed. LN 6 confirmed that Resident 266's 5 p.m. dose of buprenorphine on 3/4/25, the pregabalin 5 p.m. dose on 3/4/25 and 9 a.m. dose on 3/5/25, and the dulera inhalation dose on 3/4/25 at 5 p.m. and on 3/5/25 at 9 a.m. were not given. LN 6 stated there was a risk for Resident 266 to have uncontrolled pain when the buprenorphine and pregabalin was not administered and there a risk to develop difficulty breathing when the dulera inhalation was not given. During a concurrent phone interview and record review on 3/13/25 at 8:58 a.m. with the PPT, Resident 266's medication orders were reviewed. PPT stated they received Resident 266's medication order for buprenorphine from the facility on 3/4/25 at 3:27 p.m., they had to send the order to the doctor for approval and only received the valid prescription order for buprenorphine on 3/4/25 at 5:55 p.m. then they had filled and sent it on the next scheduled delivery time. PPT also stated they received Resident 266's medication order for dulera inhalation on 3/4/25 at 3:27 p.m., they needed additional authorization for high-cost medications from the Director of Nursing (DON) which they received on 3/4/25 at 11:36 p.m. and had filled and sent it on the next scheduled delivery time. During a concurrent phone interview and record review on 3/13/25 at 10:54 a.m. with the PP, Resident 266's medication orders were reviewed. The PP stated they received Resident 266's medication order for pregabalin on 3/4/25 at 3:27 p.m. but the facility only sent discharge paper, which is not a valid prescription order, so they needed to fax it to the doctor on 3/4/25 at 6:57 p.m. for approval and only received the valid prescription order for pregabalin on 3/5/25 at 10:37 a.m. which then they had filled and sent it on the next scheduled delivery time which was 5:30 pm. During a concurrent interview and record review on 3/13/25 at 11:46 a.m. with the AC, Resident 266's medication records were reviewed. The AC then confirmed that there was no valid prescription order for Resident 266's buprenorphine and pregabalin that was faxed to the pharmacy. The AC stated they're aware that controlled medications (medications with high potential for abuse or addiction) like buprenorphine and pregabalin needs valid prescription order before the pharmacy dispense the medication. A review of the Shipping Manifest for Resident 266's buprenorphine indicated the facility received the medication on 3/5/25 at 1 a.m. A review of the Shipping Manifest for Resident 266's dulera inhalation indicated the facility received the medication on 3/5/25 at 1:20 p.m. A review of the Shipping Manifest for Resident 266's pregabalin indicated the facility received the medication on 3/5/25 at 7:10 p.m. 4. A review of Resident 160's clinical record indicated Resident 160 was admitted March of 2025 and had diagnoses that included migraine (a neurological condition characterized by recurring headaches, often with throbbing pain, sensitivity to light and sound, and sometimes nausea or vomiting), DM with neuropathy, muscle spasm (an involuntary and sudden contraction of a muscle), irritable bowel syndrome (IBS- a gastrointestinal disorder characterized by chronic abdominal pain, bloating, and changes in bowel habits), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). A review of Resident 160's admission History and Physical, dated 3/5/25, indicated Resident 160 Has the capacity to understand and make medical decisions and was a high risk for falls and ADL decline. A review of Resident 160's physician's order, dated 3/3/25 at 12:46 p.m., indicated, Qulipta [a medication used to prevent episodic and chronic migraine headaches] Oral Tablet 60 MG . Give 1 tablet by mouth one time a day for migraine. A review of Resident 160's physician's order, dated 3/3/25 at 1:27 p.m., indicated, LinaCLOtide [a drug used to treat IBS] Oral Capsule 72 MCG [micrograms- unit of measurement] .Give 1 capsule by mouth one time a day for gastrointestinal agent. A review of Resident 160's physician's order, dated 3/3/25 at 2:36 p.m., indicated, Biotin [vitamin B7 supplement] Oral Tablet 10000 MCG .Give 1 tablet by mouth one time a day for supplement. A review of Resident 160's MAR for the month of March 2025, indicated Resident 160's Qulipta, linaclotide, and biotin were scheduled to be administered starting 3/4/25 every 9 a.m. A further review of the MAR indicated the qulipta, linaclotide, and biotin 9 a.m. doses on 3/4/25 was marked with a chart code, 5, which indicated the medications were held and not given to the resident. A review of Resident 160's care plan, initiated 3/4/25, indicated, At risk for pain or discomfort related to: .>migraine .>muscle spasm .>DM w/ neuropathy. A review of Resident 160's care plan intervention, initiated 3/4/25, indicated, Administer pain meds as MD ordered .Qulipta Oral Tablet .for migraine. A review of Resident 160's progress notes, dated 3/4/25 at 2:33 p.m., indicated, .following meds [medications were] not available to be given on time: linaclotide 75mg [sic], Biotin 1000mg, Qulipta 60 mg tabs. Pharmacy contacted and will [be] delivered ASAP [as soon as possible]. A review of Resident 160's Weights and Vitals Summary, indicated Resident 160 had pain levels as follows: 3/3/25 at 8:10 p.m.- 8 (severe pain), 3/3/25 at 10:05 p.m.- 8 (severe pain), 3/4/25 at 7:38 a.m.- 4 (moderate pain), 3/4/25 at 8:45 a.m.- 9 (severe pain), 3/4/25 at 3:47 p.m.- 8 (severe pain), 3/4/25 at 4:36 p.m.- 6 (moderate pain), 3/5/25 at 12:25 a.m.- 4 (moderate pain), 3/5/25 at 12:47 a.m.- 8 (severe pain), 3/5/25 at 5:22 a.m.- 8 (severe pain). During an interview on 3/11/25 at 2:17 p.m. with Resident 160, Resident 160 stated she needed to wait two days to get some of her medications when she was admitted , including her medication for migraines. Resident 160 also stated she had a migraine on those days and was very uncomfortable. Resident 160 further stated, I felt really bad not getting some of it .well, It's upsetting but what can I do .It [missing migraine medication] was not comfortable of course. During a concurrent interview and record review on 3/11/25 at 4:22 p.m. with LN 6, Resident 160's MAR was reviewed. LN 6 confirmed that Resident 160's qulipta, linaclotide, and biotin were not given on 3/4/25 at 9 a.m. LN 6 stated there was a risk for Resident 160 to experience unrelieved migraine or pain when the qulipta was not given. LN 6 also stated there was a risk for Resident 160 to develop constipation when the linaclotide was not given and risk to negatively affect her health when the biotin was not given. During a concurrent phone interview and record review on 3/13/25 at 8:58 a.m. with the PPT, Resident 160's medication orders were reviewed. PPT stated they received Resident 160's medication order for qulipta and linaclotide on 3/3/25 at 4:39 p.m., they needed additional authorization for high-cost medications from DON which they received on 3/4/25 at 9:30 p.m. and had filled and sent it on the next scheduled delivery time. PPT also stated the pharmacy did not send the biotin medication to the facility because they needed additional authorization for high-cost medications from the DON. A review of the Shipping Manifest for Resident 160's Qulipta indicated the facility received the medication on 3/5/25 at 8:33 a.m. A review of the Shipping Manifest for Resident 160's linaclotide indicated the facility received the medication on 3/5/25 at 10:30 a.m. 5a. A review of Resident 262's clinical record indicated Resident 262 was admitted February of 2025 and had diagnoses that included DM with foot ulcer (open sore or wound) and sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection) A review of Resident 262's admission History and Physical, dated 3/2/25, indicated Resident 262 Has the capacity to understand and make medical decisions. A review of Resident 262's progress notes, dated 2/28/25, indicated Resident 262 arrived at the facility at around 11:35 a.m. A review of Resident 262's physician's order, dated 2/26/25 at 3:38 p.m., indicated, Insulin Glargine [a long-acting insulin used to control blood sugar levels] Subcutaneous [under the skin] Solution 100 unit/ML [milliliters- unit of measurement] .Inject 20 unit subcutaneously two times a day for DM. A review of Resident 262's MAR for the month of February 2025, indicated Resident 262's insulin glargine was scheduled to be administered every 9 a.m. and 5 p.m., with first dose on 2/28/25 at 5 p.m. A further review of the MAR indicated the insulin glargine 5 p.m. dose on 2/28/25 was marked with a chart code, 5, which indicated the medication was held and not given to the resident. A review of Resident 262's progress notes, dated 2/28/25 at 5:34 p.m., indicated, .At 1630pm [4:30 p.m.] BS [Blood sugar was] 149 .Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine)Inject 20 unit subcutaneously two times a day for DM, not given, per [Nurse Practitioner- an advanced practice registered nurse with advanced clinical training who provides direct patient care, including diagnosing, treating, and managing health conditions, and can prescribe medications] ok to administer when delivered tonight by pharmacy . During an interview on 3/10/25 at 9:13 a.m. with Resident 262, Resident 262 stated he had to wait for 1-2 days to receive all his medications. Resident 262 further stated, I felt not so good, when asked how he was when he did not receive all his medications. During a concurrent interview and record review on 3/11/25 at 4:22 p.m. with LN 6, Resident 262's MAR was reviewed. LN 6 confirmed that Resident 262's Insulin Glargine was held and not given on 2/28/25 at 5 p.m. LN 6 stated there was a risk for Resident 262 to have high blood sugar when the insulin glargine was not given. During a concurrent phone interview and record review on 3/12/25 at 11:51 a.m. with the PPT, Resident 262's medication orders were reviewed. PPT stated they received Resident 262's medication order for insulin glargine on 2/28/25 at 2:16 p.m. and had filled and sent it on the next scheduled delivery time. A review of the Shipping Manifest for Resident 262's insulin glargine indicated the facility received the medication on 2/28/25 at 8 p.m. 5b. A review of Resident 263's clinical record indicated Resident 263 was admitted March

Based on observation, interview and record review, the facility failed to ensure four out of 31 sampled residents (Resident 265, 264, 160, and 266) were free from significant medication errors when Resident 265, 264, 160, and 266 did not receive prescribed pain medications in accordance with the physician's order. These failures resulted in Resident 265, 264, 160, and 266 experiencing unnecessary pain and emotional distress which had negatively affected the residents' level of comfort, activity and sleep. Findings: 1a. A review of Resident 265's clinical record indicated Resident 265 was admitted February of 2025 and had diagnoses that included fracture (a break in the continuity of a bone) of left humerus (upper arm bone), neuralgia (pain caused by irritation or damage to a nerve) and neuritis (inflammation of a nerve), and the need for assistance with personal care. A review of Resident 265's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 3/2/25, indicated Resident 2665 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 10 out of 15 which indicated Resident 265 had a moderately impaired cognition (mental process of acquiring knowledge and understanding). A review of Resident 265's MDS Health Conditions, dated 3/2/25, indicated Resident 265 had frequently experienced pain or hurting which frequently made it hard for her to sleep at night, occasionally limited her participation in rehabilitation therapy sessions, and occasionally limited her day-to-day activities. A review of Resident 265's progress notes, dated 2/19/25, indicated Resident 265 arrived at the facility on 2/19/25 at around 11:58 p.m. and has a pain level of 4/10 (numeric pain scale from 1 to 10; 1-3 is mild pain, 4-7 is moderate pain, 8-10 is severe pain). A review of Resident 265's physician's order, dated 2/19/25 at 12:13 p.m., indicated, MS Contin [a strong medication used to treat moderate to severe pain] Oral Tablet Extended Release 30 MG [milligrams- unit of measurement] (Morphine Sulfate) Give 1 tablet by mouth every 8 hours for Pain management. A review of Resident 265's care plan, initiated 2/19/25, indicated, At risk for pain or discomfort related to left humeral fracture due to ground fall at home. A review of Resident 265's care plan intervention, initiated 2/19/25, indicated, Administer pain meds as MD (Medical Doctor) ordered .MS Contin Oral Tablet .for Pain management. A review of Resident 265's Medication Administration Record (MAR- a legal document used to record medications given to the residents), for the month of February 2025, indicated Resident 265's morphine sulfate was scheduled to be administered every 8 a.m., 4 p.m., and 12 midnight, with the first dose scheduled on 2/19/25 at 4 p.m. A further review of the MAR indicated the 4 p.m. dose of morphine sulfate on 2/19/25 was marked with a chart code 5, which indicated the medication was held and not given to the resident. A review of Resident 265's Weights and Vitals Summary, dated 2/19/25 at 8:38 p.m., indicated Resident 265 had a pain level of 8 [severe pain]. During an interview on 3/10/25 at 9:42 a.m. with Resident 265, Resident 265 stated she did not receive her morphine medication on the day she was admitted in the facility. Resident 265 also stated her pain was so awful that day, it went to a level of 9 out of 10 (severe pain). Resident 265 further stated, Well, It [sleeping] was hard .I got hard time sleeping .I was in so much pain. During a concurrent interview and record review on 3/11/25 at 4:22 p.m. with Licensed Nurse (LN) 6, Resident 265's MAR for February 2025 was reviewed. LN 6 confirmed that Resident 265's morphine sulfate was not given on 2/19/25 at 4 p.m. LN 6 stated there was a risk for Resident 265 to be in so much pain when the morphine sulfate was not given. During a concurrent observation and interview on 3/11/25 at 4:55 p.m. with LN 6, the facility's Emergency Kit (Ekit- a supply of medication used for urgent needs of residents) was checked. LN 6 confirmed that oral morphine sulfate is not part of the facility's Ekit supplies. During a concurrent phone interview and record review on 3/13/25 at 10:54 a.m. with the Pharmacist from the Facility's Pharmacy (PP), Resident 265's medication orders were reviewed. The PP stated they only received Resident 265's medication order for morphine sulfate on 2/19/25 at 7:41 p.m. and had filled and sent it on the next scheduled delivery time which was 10:30 pm. During a concurrent interview and record review on 3/13/25 at 11:46 a.m. with the Admissions Coordinator (AC), Resident 265's medication records were reviewed. The AC showed a fax receipt indicating Resident 265's prescription order of morphine sulfate was sent to their pharmacy on 2/19/25 at 5:53 p.m. The AC confirmed the prescription order was faxed after the scheduled administration. The AC stated that sometimes it would take 4 hours for nurses to transcribe medication orders which causes the delay in faxing medication orders. A review of the Shipping Manifest [receipt] for Resident 265's morphine sulfate indicated the facility received the medication on 2/19/25 at 10:35 p.m. 1b. A review of Resident 264's clinical record indicated Resident 264 was admitted February of 2025 and had diagnoses that included osteoarthritis (OA- a deteriorating disease that causes pain, stiffness, and swelling where two or more bones meet), pain in right hip, diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), neuropathy (a nerve condition that can cause pain, numbness, tingling, or weakness in the body), chronic pain syndrome (condition that involves persistent pain that lasts for weeks to years), and major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 264's MDS Cognitive Patterns, dated 2/26/25, indicated Resident 264 had a BIMS score of 15 out of 15 which indicated Resident 264 had an intact cognition. A review of Resident 264's MDS Health Conditions, dated 2/26/25, indicated Resident 264 had frequently experienced pain or hurting which frequently made it hard for her to sleep at night, frequently limited her participation in rehabilitation therapy sessions, and frequently limited her day-to-day activities. A review of Resident 264's physician's order, dated 2/19/25 at 3:06 p.m., indicated, Pregabalin [a drug used to treat nerve and muscle pain] Oral Capsule 150 MG [milligrams- unit of measurement] .Give 1 capsule by mouth two times a day related to PAIN IN RIGHT HIP . A review of Resident 264's care plan, initiated 2/19/25, indicated, At risk for alteration in comfort/pain related to: recent fall with right hip pain, chronic back pain .DM . A review of Resident 264's care plan intervention, initiated 2/19/25, indicated, Administer pain meds as MD ordered . A review of Resident 264's MAR, for the month of February 2025, indicated Resident 264's pregabalin was scheduled to be administered every 9 a.m. and 5 p.m., with the first dose on 2/19/25 at 5 p.m. A further review of the MAR indicated that Resident 264's dose of pregabalin on 2/19/25 at 5 p.m., 2/20/25 at 9 a.m. and 5 p.m., and 2/21/25 at 9 a.m. were all marked with a chart code 5, which indicated the medication was held and not given to the resident. A review of Resident 264's progress notes, dated 2/20/25 at 2:19 p.m., indicated, Followed up with [name of facility pharmacy] about Pregabalin; no response from doctor for authorization. Additional message was left for doctor by pharmacy staff. During an interview on 3/10/25 at 9:48 a.m. with Resident 264, Resident 264 stated she did not get all her medications on the first few days when she was admitted in the facility, including her pain medication. Resident 264 also stated her pain level was so bad which she rated at 10 (severe pain). Resident 265 further stated, I was hurting .I cannot move or do anything .so I just stayed here in the room on those days .I was just in bed because I can't do anything .I was not comfortable, I was in a lot of pain .I was so upset to wait that long for it [pain medication] . During a concurrent interview and record review on 3/11/25 at 4:22 p.m. with LN 6, Resident 264's MAR for February 2025 was reviewed. LN 6 confirmed that Resident 264's pregabalin was held and not given on 2/19/25 at 5 p.m., 2/20/25 at 9 a.m. and 5 p.m., and 2/21/25 at 9 a.m. LN 6 stated there was a risk for Resident 264 to have her pain not relieved when the pregabalin was not given for four times. During a concurrent observation and interview on 3/11/25 at 4:55 p.m. with LN 6, the facility's Ekit was checked. LN 6 confirmed that pregabalin is not part of the facility's Ekit supplies. During a concurrent phone interview and record review on 3/12/25 at 11:51 a.m. with the Pharmacy Technician from the Facility's Pharmacy (PPT), Resident 264's medication orders were reviewed. PPT stated they only received Resident 264's valid prescription order for pregabalin from the doctor on 2/21/25 at 7:32 a.m. and had filled and sent it on the next scheduled delivery time. During a concurrent interview and record review on 3/13/25 at 11:46 a.m. with the AC, Resident 264's medication records were reviewed. The AC stated Resident 264 came from a local hospital that sends medication orders to their pharmacy electronically in which they're having problems. The AC also stated that their nurse would then need to call their facility doctor to get the actual prescription order and fax it the pharmacy. The AC then confirmed that there was no valid prescription order for Resident 264's pregabalin that was faxed to the pharmacy on admission. A review of the Shipping Manifest for Resident 264's pregabalin indicated the facility received the medication on 2/21/25 at 1:45 p.m. 1c. A review of Resident 160's clinical record indicated Resident 160 was admitted March of 2025 and had diagnoses that included migraine (a neurological (relating to the nervous system) condition characterized by recurring headaches, often with throbbing pain, sensitivity to light and sound, and sometimes nausea or vomiting), DM with neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet), muscle spasm (an involuntary and sudden contraction of a muscle), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). A review of Resident 160's admission History and Physical, dated 3/5/25, indicated Resident 160 Has the capacity to understand and make medical decisions and was a high risk for falls and Activities of Daily Living (ADL- normal daily functions required to meet basic needs) decline. A review of Resident 160's physician's order, dated 3/3/25 at 12:46 p.m., indicated, Qulipta [a medication used to prevent episodic and chronic migraine headaches] Oral Tablet 60 MG . Give 1 tablet by mouth one time a day for migraine. A review of Resident 160's care plan, initiated 3/4/25, indicated, At risk for pain or discomfort related to: .>migraine .>muscle spasm .>DM w/ neuropathy. A review of Resident 160's care plan intervention, initiated 3/4/25, indicated, Administer pain meds as MD ordered .Qulipta Oral Tablet .for migraine. A review of Resident 160's MAR for the month of March 2025, indicated Resident 160's qulipta were scheduled to be administered starting 3/4/25 every 9 a.m. A further review of the MAR indicated the 9 a.m. dose of qulipta on 3/4/25 was marked with a chart code, 5, which indicated the medications were held and not given to the resident. A review of Resident 160's Weights and Vitals Summary, indicated Resident 160 had pain levels as follows: 3/3/25 at 8:10 p.m.- 8 (severe pain), 3/3/25 at 10:05 p.m.- 8 (severe pain), 3/4/25 at 7:38 a.m.- 4 (moderate pain), 3/4/25 at 8:45 a.m.- 9 (severe pain), 3/4/25 at 3:47 p.m.- 8 (severe pain), 3/4/25 at 4:36 p.m.- 6 (moderate pain), 3/5/25 at 12:25 a.m.- 4 (moderate pain), 3/5/25 at 12:47 a.m.- 8 (severe pain), 3/5/25 at 5:22 a.m.- 8 (severe pain). A review of Resident 160's progress notes, dated 3/4/25 at 2:33 p.m., indicated, .following meds [medications were] not available to be given on time: .Qulipta 60 mg tabs. Pharmacy contacted and will [be] delivered ASAP. During an interview on 3/11/25 at 2:17 p.m. with Resident 160, Resident 160 stated she needed to wait two days to get some of her medications when she was admitted , including her medication for migraines. Resident 160 also stated she had a migraine on those days and was very uncomfortable. Resident 160 further stated, I felt really bad not getting some of it .well, It's upsetting but what can I do .It [missing migraine medication] was not comfortable of course. During a concurrent interview and record review on 3/11/25 at 4:22 p.m. with LN 6, Resident 160's MAR was reviewed. LN 6 confirmed that Resident 160's Qulipta was not given on 3/4/25 at 9 a.m. LN 6 stated there was a risk for Resident 160 to experience unrelieved migraine or pain when the Qulipta was not given. During a concurrent phone interview and record review on 3/13/25 at 8:58 a.m. with the PPT, Resident 160's medication orders were reviewed. PPT stated they received Resident 160's medication order for Qulipta on 3/3/25 at 4:39 p.m., they needed additional authorization for high-cost medications from the (Director of Nurses) DON which they received on 3/4/25 at 9:30 p.m. and had filled and sent it on the next scheduled delivery time. A review of the Shipping Manifest for Resident 160's Qulipta indicated the facility received the medication on 3/5/25 at 8:33 a.m. 1d. A review of Resident 266's clinical record indicated Resident 266 was admitted March of 2025 and had diagnoses that included neuralgia (nerve pain) and neuritis (inflammation of a nerve), osteoarthritis, and chronic pain. A review of Resident 266's admission History and Physical, dated 3/6/25, indicated Resident 266 was oriented to person, place and time, Has the capacity to understand and make medical decisions, and was a high risk for fall and ADL decline. A review of Resident 266's progress notes, dated 3/4/25, indicated Resident 266 arrived at the facility at around 11:30 a.m. A review of Resident 266's physician's order, dated 3/4/25 at 2:33 p.m., indicated, Buprenorphine [a strong medication used to treat moderate to severe pain] HCl (Hydrochloric acid) Sublingual [below the tongue] Tablet Sublingual 8 MG . Give 1 tablet sublingually two times a day for Chronic pain. A review of Resident 266's physician's order, dated 3/4/25 at 2:33 p.m., indicated, Pregabalin Oral Capsule 25 MG . Give 1 capsule by mouth two times a day related to NEURALGIA AN NEURITIS . A review of Resident 266's care plan, initiated 3/4/25, indicated, At risk for pain or discomfort related to: .> NEURALGIA AND NEURITIS .> OA. >Chronic Pain. A review of Resident 160's care plan intervention, initiated 3/4/25, indicated, Administer pain meds as MD ordered .Buprenorphine HCl .Pregabalin Oral Capsule . A review of Resident 266's MAR for the month of March 2025, indicated Resident 266's buprenorphine and pregabalin were both scheduled to be administered every 9 a.m. and 5 p.m., with first dose on 3/4/25 at 5 p.m. A further review of the MAR indicated the 5 p.m. dose of buprenorphine on 3/4/25, and the pregabalin 5 p.m. dose on 3/4/25 and 9 a.m. dose on 3/5/25 were all marked with chart code, 5, which indicated the medications were held and not given to the resident. A review of Resident 266's progress notes, dated 3/5/25 at 12:58 a.m., indicated, .some of the medication still to be delivered from pharmacy . A review of Resident 266's Weights and Vitals Summary, indicated Resident 266 had pain levels as follows: 3/5/25 at 12:39 a.m.- 5 (moderate pain), 3/5/25 at 9:40 a.m.- 5 (moderate pain), 3/5/25 at 4:40 a.m.- 7 (moderate pain). During an interview on 3/10/25 at 10:04 a.m. with Resident 266, Resident 266 stated she did not get all her medications when she was admitted , including her pain medications. Resident 266 also stated she had pain on the days she did not receive her pain medications which she rated at a level of 9 out of 10 (severe pain). Resident 266 further stated, I was in so much pain .I tried to rest but I could not sleep at all that night .It's [pain] so bad. During a concurrent interview and record review on 3/11/25 at 4:22 p.m. with LN 6, Resident 266's MAR was reviewed. LN 6 confirmed that Resident 266's 5 p.m. dose of buprenorphine on 3/4/25, and the pregabalin 5 p.m. dose on 3/4/25 and 9 a.m. dose on 3/5/25 were not given. LN 6 stated there was a risk for Resident 266 to have uncontrolled pain when the buprenorphine and pregabalin was not administered. During a concurrent phone interview and record review on 3/13/25 at 8:58 a.m. with the PPT, Resident 266's medication orders were reviewed. PPT stated they received Resident 266's medication order for buprenorphine from the facility on 3/4/25 at 3:27 p.m., they had to send the order to the doctor for approval and only received the valid prescription order for buprenorphine on 3/4/25 at 5:55 p.m. then they had filled and sent it on the next scheduled delivery time. During a concurrent phone interview and record review on 3/13/25 at 10:54 a.m. with the PP, Resident 266's medication orders were reviewed. The PP stated they received Resident 266's medication order for pregabalin on 3/4/25 at 3:27 p.m. but the facility only sent discharge paper, which is not a valid prescription order, so they needed to fax it to the doctor on 3/4/25 at 6:57 p.m. for approval and only received the valid prescription order for pregabalin on 3/5/25 at 10:37 a.m. which then they had filled and sent it on the next scheduled delivery time which was 5:30 pm. During a concurrent interview and record review on 3/13/25 at 11:46 a.m. with the AC, Resident 266's medication records were reviewed. The AC then confirmed that there was no valid prescription order for Resident 266's buprenorphine and pregabalin that was faxed to the pharmacy. The AC stated they're aware that controlled medications (medications with high potential for abuse or addiction) like buprenorphine and pregabalin needs a valid prescription order before the pharmacy dispense the medication. A review of the Shipping Manifest for Resident 266's buprenorphine indicated the facility received the medication on 3/5/25 at 1 a.m. A review of the Shipping Manifest for Resident 266's pregabalin indicated the facility received the medication on 3/5/25 at 7:10 p.m. During a phone interview on 3/13/25 at 9:15 a.m. with the Pharmacy Consultant (PC), the PC stated he would expect the facility would be able to provide all prescribed medications to newly admitted residents in a timely manner, especially the pain medications which should be provided immediately. The PC also stated he was not aware the facility ' s Ekit did not contain oral morphine sulfate and pregabalin which were common pain medications. During an interview on 3/13/25 at 9:41 a.m. with the DON, the DON stated she would expect staff to fax medication orders to pharmacy immediately or at most an hour after the resident arrived in the facility so the pharmacy could send the medications right away. The DON also stated that she would expect that all medications for newly admitted residents, especially pain medications, are provided timely and in accordance with the physician's order. The DON further stated that resident's pain should be addressed right away. A review of the facility's policies and procedures (P&P) titled, Pain Management, revised 1/2025, indicated, To provide guidelines for consistent .management .of pain, in order to provide the maximum level of comfort and enhanced quality of life for residents having pain or at risk of having pain .2. The physician may order appropriate .medication intervention s to address the resident's pain. A review of the facility's P&P titled, Administering Medications, revised 1/2025, indicated, Medications are administered in a safe and timely manner, and as prescribed .4. Medications are administered in accordance with prescriber orders, including any required time frame. A review of the facility's P&P titled, Admission Assessment, revised 1/2025, indicated, It is the policy of the facility to admit and retain only residents it can adequately meet the needs and provide services to. A review of the facility's P&P titled, Obtaining, Accepting and Delivery of Medications, revised 3/2025, indicated, 6. Orders from New Admissions will be verified with the Attending Physician for reconciliation and will be transcribed as ordered. 7. A copy of the transcribed orders will be faxed to the Pharmacy and the Nurse will call Pharmacy to verify if the faxed orders were received. A review of the facility's P&P titled, Pharmacy Services, revised 1/2025, indicated, The facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications .4. Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner.

Based on observations, interviews and records review, the facility failed to ensure a pain management program was provided to relieve pain and discomfort for four of 23 sampled residents (Resident 33, 35, 21 and 122), when: 1. Resident 33 who had severe contractures (a loss of full active and passive range of motion [ROM - the extent or limit to which a part of the body can be moved around a joint or a fixed point] in a limb, which can result from limitations imposed by the joint, muscle, or soft tissue) on his left lower extremity and had pressure ulcers (also known as bedsores - damage to an area of the skin caused by constant pressure on the area for a long time) on his left foot, was not given pain medication before providing care and treatment. This failure caused Resident 33 to repeatedly experience pain and discomfort when receiving care from facility staff. (Cross-reference F656 and F686). 2. Resident 21 who had above-the-knee amputation (AKA - removing the leg from the body by cutting through both the thigh tissue and femoral (thigh) bone) was not offered pain medication after returning to the facility, after the procedure. This failure had the potential for Resident 21 to experience pain and discomfort. (Cross-reference F684). 3. Resident 35 and Resident 122 were not given pain medication before wound treatment, as ordered by a physician. This failure resulted in Resident 35 and Resident 122 experiencing pain and discomfort during wound treatment. (Cross-reference F686). Findings: RESIDENT 33 During a review of the Face sheet (a one-page summary of important information about a resident) indicated Resident 33 was admitted on [DATE], with diagnoses, including but not limited to Hemiplegia and Hemiparesis (paralysis of one side of the body); Contractures of left hand and left knee; and Peripheral Vascular Disease (PVD - a blood circulation disorder). During a review of the facility document titled, Joint Mobility Assessment, dated 9/16/23, indicated Resident 33 had severe limitation to left hand, left hip and left knee; and moderate to severe limitation to his left ankle. During a review of the Minimum Data Set (MDS -health status screening and assessment tool used for all residents), dated 3/11/24, indicated Resident 33 had a BIMS score of 03 out of 15 points (Brief Interview for Mental Status - a 15-point cognitive (relating to the mental process involved in knowing, learning, and understanding things) screening measure that evaluates memory and orientation. A score of 13 to 15 is cognitively intact, 08 to 12 is moderately impaired, and 00 to 07 is severe impairment). The MDS indicated Resident 33 had functional limitation in range of motion to both upper and lower extremities. The MDS indicated Resident 33 was dependent on staff to roll from lying on back to left and right side. During a review of the March 2024 Physician's Order for Resident 33, a doctor's order was written on 10/05/23, for RNA (Restorative Nursing Assistant - assists patients with long-term treatment and recovery after an accident, surgery, or illness) to perform Range of Motion (ROM) exercises to both upper and lower extremities. During an observation in Resident 33's room on 3/20/24 at 10:33 a.m., and concurrent interview with RNA V, Resident 33 was grimacing when RNA V was stretching Resident 33's finger on his left hand. When RNA V was asked about Resident 33 showing signs of pain when applying the hand roll or when providing PROM (Passive Range of Motion [the ROM that is achieved when an outside force (such as a therapist) exclusively causes movement of a joint and is usually the maximum range of motion that a joint can move]), RNA V stated Resident 33 grimaced and got physically aggressive when touched. RNA V stated she had reported to the nurse that Resident 33 was in pain. During an observation in Resident 33's room on 3/21/24 at 9:05 a.m., Resident 33 was grimacing when the Infection Preventionist (IP) was repositioning Resident 33's left leg after wound treatment. During an observation in Resident 33's room and concurrent interview with Unlicensed Staff C on 03/21/24 at 10:14 a.m., Resident 33 was grimacing with reddened face and teary eyed when Unlicensed Staff C was repositioning his left leg. When Unlicensed Staff C asked Resident 33 if he was in pain, Resident 33 nodded his head. Unlicensed Staff C barely stretched Resident 33's left leg. She stated Resident 33 could not stretch both his left and right legs. When Unlicensed Staff C was asked what she would do if she observed Resident 33 showing signs of pain, Unlicensed Staff C stated she would report it to the nurse. During an interview and concurrent record review with Licensed Staff U on 3/21/24 at 10:23 a.m., when Licensed Staff U was asked if she received a report from Unlicensed Staff C regarding Resident 33 showing signs of pain, Licensed Staff U stated No. Licensed Staff U stated Resident 33 was not on routine pain medications. However, she stated Resident 33 had an order for Tylenol, as needed. After review of the Medication Administration Record (MAR) with Licensed Staff U for Resident 21, Licensed Staff U stated Resident 33 did not have a doctor's order to monitor pain. She stated Resident 33 could not verbally express when he was in pain. She stated she would know if Resident 33 was in pain when grimacing, holding tightly on the bed rail or when combative. When Licensed Staff U was asked how would pain affect Resident 33's quality of life when his pain was not addressed, Licensed Staff U stated it was very important to assess Resident 33 for pain and address it. During an interview and concurrent record review with the Director of Nursing (DON) on 3/22/24 at 10:15 a.m., when the DON was asked about her expectation from Resident 33's direct care staff (CNAs, RNAs, Nurses) when a sign of pain was observed while providing care, the DON stated CNAs and RNAs were expected to report to the nurse any signs of pain observed and expected the nurses to address the pain right away. The DON stated Resident 33 could not verbally express his need for pain medication due to verbal impairment. She stated she expected the staff to monitor for nonverbal indications of pain like facial grimacing, crying, moaning, etc. and to administer pain medications according to the doctor's order. The DON stated Resident 33 had contractures to both upper and lower extremities which could put Resident 33 at risk for pain while receiving care from staff. A Review of the Physician's Order for Resident 33 with the DON, indicated an order written on 10/04/23, to give two tablets of Tylenol (pain reliever and fever reducer) every six hours, as needed for mild pain. The Physician Order did not show a routine order for pain management. The DON stated Resident 33 should have a routine order for pain medication. When the DON was asked how pain would affect Resident 33's quality of life when his pain was not managed, the DON stated unmanaged pain could have physical and psychological impact to Resident 33. She stated Resident 33 could refuse to move or participate with care and could be physically aggressive to staff when in pain. During a review of the facility document titled, Wound Management Review, dated 3/15/24, indicated Resident 33 had a Stage 3 Pressure Ulcer (full thickness skin loss, where the subcutaneous fat [a type of fat that's stored just beneath your skin] may be visible to the naked eye) on his left lateral foot (the little toe side of the foot). During a wound treatment observation in Resident 33's room with Licensed Nurse L on 3/25/24 at 10:48 a.m., Resident 33 had three wounds on his left foot: The wound closest to the left little toe was covered with blackish matter, the wound farthest from the left little toe and left outer aspect of the heel was open. Resident 33 was grimacing, his face was reddened and loudly verbalized, ahhh ., twice and, aray (Filipino word for ouch) during wound treatment. Resident 33 also hit Licensed Nurse L with his right hand, twice. During an interview with Licensed Staff F on 3/25/24 at 3:37 p.m., when Licensed Staff F was asked if Resident 33 received pain medication earlier during her morning shift, Licensed Staff F stated, No. Licensed Staff F stated Resident 33 did not have a scheduled order for pain medication. When Licensed Staff F was asked how she would know if Resident 33 was in pain, she stated she would know if Resident 33 was in pain because she could sometimes hear him scream in his room. Licensed Staff F concurred that Resident 33 could experience pain when receiving care from staff due to contractures and pressure ulcers, and stated Resident 33 could benefit from having a routine pain medication. During an interview with the (NP - registered nurse who has advanced education and clinical training in a health care specialty area) on 3/26/24 at 10:37 a.m., when the NP was asked if she was aware of Resident 33 showing signs of pain/discomfort during care and wound treatment, the NP stated she was made aware of the issue on 3/25/24, and it was addressed. RESIDENT 21 During a review of the Face sheet indicated Resident 21 was admitted on [DATE], with diagnoses, including but not limited to: Diabetes Mellitus (disease that result in too much sugar in the blood); Morbid obesity (resident weighs 100 pounds over his recommended weight); and Hemiplegia and Hemiparesis (paralysis of one side of the body). During a review of the Progress Note, dated 1/25/24 at 10:14 a.m., indicated Resident 21 was sent to the hospital for wound debridement (the removal of damaged tissue or foreign objects from a wound). During a review of the hospital document titled, Wound Document,s dated 1/25/24, indicated Resident 21 had right fibula (the outer and usually smaller of the two bones between the knee and ankle in the hind or lower limbs) osteomyelitis (inflammation or swelling that occurs in the bone), bilateral (both) foot cellulitis (a common, potentially serious bacterial skin infection) and gangrene (a serious condition where a loss of blood supply causes body tissue to die) of toes. During a review of the hospital document titled, Discharge Documents, dated 1/31/24, indicated Resident 1 had right above-the-knee amputation on 1/28/24. During an interview and concurrent record review with the DON on 3/22/24 at 11:27 a.m., the DON stated Resident 21 was sent to the hospital and returned to the facility with right leg amputation. When the DON was asked about her expectations from the nurses to ensure Resident 21 was made comfortable after his right leg amputation, the DON stated she expected the nurses to administer pain medication, according to the doctor's order. After review of the Physician's order, dated 1/31/24, with the DON, the DON concurred there was no schedule pain medication ordered for Resident 21. The Physician's order indicated the following doctors order written on 1/31/24, to give one tablet of Acetaminophen (also known as Tylenol) Extra Strength 500 mg (milligram-a unit of mass), as needed for Pain; and to give one tablet of Norco (used to relieve moderate to severe pain) every four (4) hours, as needed for moderate pain. However, a review of the MAR with the DON, indicated Resident 21 did not receive a dose of Acetaminophen and received one dose of Norco for the whole month of February 2024. The DON stated Resident 21 could have experienced pain after the amputation and should have a routine order of pain medication for pain management. During an interview with Resident 21 on 3/22/24 at 3:13 p.m., when Resident 21 was asked if he was offered pain medication after his right leg was amputated, he stated he did not receive any pain medicine after coming back from the hospital. Resident 21 stated he did not think his right leg was amputated because he could feel his leg was, aching. Resident 21 stated he was scared to ask for pain medicine because he had history of drug use. During an interview with the NP on 3/26/24 at 10:17 a.m., when the NP was asked why Resident 21 did not have a scheduled order for pain medication after his right leg was amputated, the NP stated Resident 21 never complained of pain when he was assessed. However, when this writer shared an interview with Resident 21 stating he did not think his right leg was amputated because he could still feel his leg, the NP stated Resident 21 could be experiencing, phantom limb (an often painful sensation of the presence of a limb that has been amputated). RESIDENT 35 During a review of the Face sheet indicated Resident 35 was admitted on [DATE], with diagnoses, including but not limited to Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities); Chronic Obstructive Pulmonary Disease (COPD - diseases that cause airflow blockage and breathing-related problems) and Pressure Ulcer of Sacral (the triangular bone just below backbone) Region. During a wound treatment observation, record review and concurrent interview with Licensed Staff O on 3/20/24 at 10:16 a.m., Resident 35 was pulling her butt away when Licensed Staff O was applying the dressing to Resident 35's sacral wound and stated, Ouch. When this writer asked Resident 35 if she had pain, she stated, Yes. After wound treatment, when Licensed Staff O was asked if Resident 35 received any pain medication prior to the wound treatment, Licensed Staff O stated Resident 35 received a dose of Methadone (a powerful drug used for pain relief) at 6 a.m. Licensed Staff O concurred the effectiveness of the medication had worn off after four hours. She stated Resident 35 also had an order for Morphine (treats severe pain when other pain medications have not worked), as needed. However, after review of the MAR, Licensed Staff O stated Resident 35 received 0.25 ml (milliliter -a unit of volume) of Morphine on 3/19/24, and no dose of Morphine was given prior to wound treatment. During an interview with the NP on 3/26/24 at 10:11 a.m., when the NP was asked about her expectation from the nurses regarding pain management during wound care, the NP stated pressure ulcers could be painful during wound treatment, and stated residents with pressure ulcers should have a standing order for pain medication. She stated there should be coordination between the wound care nurse and the charge nurse to make sure the resident was pre-medicated prior to wound treatment. 31424 RESIDENT 122 During an observation and concurrent interview 3/18/24 at 4:15 p.m., Resident 122's heel was wrapped (with a dressing). Resident 122 stated he had been admitted to the facility about one and a half weeks earlier. He stated he was in a hospital prior to his facility admission and had a Stage 4 pressure ulcer (Bedsores; injuries to the skin and tissue due to pressure on the skin; Stage 4 extend deeper, exposing underlying muscle, tendon, cartilage or bone) on his right heel that went to the bone; he stated the wound had been debrided (removal of unhealthy tissue from the wound bed to promote wound healing). Resident 122 stated he took Vicodin (narcotic pain medication) for his heel pain but it did not help much. When asked if nursing staff pre-medicated (give pain medication before a potentially painful activity) him prior to his dressing changes, Resident 122 became tearful and stated the nurses did not pre-medicate him. He stated, if it had been three hours since he last took his Vicodin, and it was time for a dressing change, the nurse would just do the dressing change (without giving additional pain medication). (Online review of the Mayo Clinic website revealed a pain scale provides a standardized means of measuring pain intensity and severity. Their pain scale follows: .Pain Free = 0; Mild Pain = 1-3 (nagging or annoying but doesn't interfere with daily activities) .Moderate Pain = 4-6 (interferes with daily activities) . Severe Pain = 7-10 (disabling or unable to carry out normal daily activities) Ranges from 'impacts your social relationships, or sleep' to 'being bedridden or even delirious (disturbed state of mind resulting from illness or intoxication and characterized by restlessness, illusions, and incoherence of thought and speech).' [https://connect.mayoclinic.org/blog/adult-pain-medicine/newsfeed-post/what-to-expect-at-my-pain-medicine-appointment]. Review of Resident 122's medical record on 3/21/24 at 9:41 a.m., revealed March 2024's Medication Administration Report (MAR; nurse documentation of medication and other pertinent information) that indicated Resident 122's pain ranged from #5 to # 8 (moderate to severe) on the pain scale (Pain Scale: a tool health care professionals utilize to help assess a person's pain; the pain scale is from 0 to 10, where 0 is no pain, and 10 is the worst pain imaginable). A Nursing Care Plan (document that contains essential information about a patient's condition, diagnosis, goals, interventions, and outcomes), dated 3/6/2024, indicated, (Resident 122) is at risk for pain or discomfort related to complex medical conditions . The plans goal indicated, (Resident 122) will be relieved of pain or discomfort within 30 mins (minutes) - 1 hour after non-pharmacologic interventions (interventions other than medication) & pain relief measures daily x (for) 90 days . Nursing interventions indicated, Assess for s/s (signs and symptoms) of pain . Administer pain meds as MD (medical doctor) ordered and evaluate effectiveness . Notify MD for any S/S (signs and symptoms) of COC (change of condition) . Review of Resident 122's medical record revealed the following physician order for pain medication, dated 3/5/2024: Hydrocodone-Acetaminophen (Vicodin) oral tablet 5-325 MG (milligrams) . give 1 tablet by mouth every 4 hours as needed (prn) for Severe Pain . During an observation and concurrent interview on 3/21/24 at 10:30 a.m., Resident 122 was sitting on his bed with his legs resting on a wheelchair next to the bed. Resident 122 stated his pain was currently #8 (severe) on his right heel but he also had pain at a #7 on his buttocks. Resident 122 stated he told the nurse about his pain but the Vicodin was not helping. When asked if the physician had been called, he stated he knew of no calls to his doctor. When asked if staff were working with him on pain control, Resident 122 stated, No. During an observation of Resident 122's dressing change by the physician assistant (PA) on 3/21/24 at 12:15 p.m., the PA took the old dressing off and measured the wound. The heel had erythema (redness) over the entire heel. The PA stated the wound looked infected, and she would be starting Resident 122 on antibiotics to treat the infection. During an interview on 3/22/24 at 12:08 p.m., Licensed Staff S (LS S) was asked about Resident 122's pain control. When asked if she pre-medicated him prior to his dressing changes, she stated, No. LS S stated she was told if a medication was prn (given as necessary; the Vicodin was ordered prn), she only gave it if the resident requested it. She stated she was not trained to pre-medicate residents prior to dressing changes, even for a Stage 4 pressure ulcer. During an interview on 3/26/24 at 9:55 a.m., the Nurse Practitioner (NP) stated on the pain scale, #1-3 was mild pain; #4-6 was moderate pain; and #7-10 was severe pain. She stated pressure ulcers could be painful during wound treatment, resident's should be pre-medicated, and a nurse could ask (the doctor/provider) for another order (for medication) if the pain medication was ineffective. During an interview and concurrent medical record review on 3/26/24 at 10:52 a.m., the DSD was asked if Resident 122's pain level ranging from #5-8 was acceptable and he stated, No. The DSD stated pain was not natural, and they should try to get (a resident) pain free. He stated his expectation for residents with complaints of pain was for routine pain medication to be given. He stated residents should be pre-medicated thirty minutes prior to a dressing change, and they should have a prn order for medication for breakthrough (a pain flare-up that, breaks through, regular medication) pain. He stated nursing should call the physician and report (any issues). Review of the Facility policy and procedure titled, pain Management, revised on 1/2024, indicated, To provide guidelines for consistent evaluation, management and documentation of pain, in order to provide the maximum level of comfort and enhanced quality of life for residents having pain or at risk of having pain. Under Procedure of the policy, indicated: - The licensed nurse will evaluate each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. - The licensed nurse and multidisciplinary team will evaluate pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. - The staff will observe the resident (during rest and movement) for evidence of pain; for example, grimacing while being repositioned or having a wound dressing changed. Review of the Facility policy and procedure titled, Prevention of Pressure Ulcers, revised on 1/2024, indicated, If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected.

Based on observations, interviews and record reviews, the facility failed to develop and implement an effective fall management program for three out of 23 sampled residents(Residents 38, 13 and Resident 26) with Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), when: A. 1. The facility did not follow its fall care plan (CP, a form where you can summarize a person's health conditions, specific care needs, and current treatment) when Resident 38 was not observed frequently and was not placed in a supervised area when out of bed such as when she was ambulating. 2. The facility did not address the causal factors such as poor balance, poor/comprehension leading to Resident 38's fall incident in developing and implementing relevant, consistent, and individualized interventions to prevent future fall incidents. 3. The facility did not revise nor address Resident 38's risks for falls in the plan of care, as needed, to reduce the likelihood of another fall. These failures led to Resident 38's six incidents of falls at the facility between 6/2023 and 1/2024. The fall incident on 1/21/24, resulted in Resident 38's complaints of pain on both legs and lump on the left side of her forehead. This fall incident on 1/21/24, also resulted in Resident 38 being sent out to the Emergency Department (ED) for further evaluation and treatment where she was diagnosed with head contusion (a bruise to the brain itself. A contusion causes bleeding and swelling inside of the brain around the area where the head was struck). B. 1. Follow the Fall Management policy and procedure (P&P), when the facility did not collaborate with the physician to identify pertinent interventions to try and reduce the risks associated with Resident 13's falls on 4/12/23 and 12/2/23. 2. Follow the Fall Management P&P when the facility did not have the pharmacist complete a Medication Regimen Review (MRR, a review of all medications the patient is currently using to identify any potential adverse effects and drug reactions) after Resident 13 fell on [DATE] and 12/2/23. 3. There was no indication the facility reviewed and re evaluated the fall care plan for effectiveness. These failures resulted in Resident 13 sustaining a fall on 12/2/23, that resulted in a hospitalization on [DATE], with a diagnosis of laceration (a cut to the skin) above her right eyebrow, ecchymosis (bruise) and femur fracture (broken thigh bone). C. The facility did not provide one-on-one supervision (intervention aimed to keep patients safe through observation by staff) as part of Resident 26's Fall Care Plan. This failure resulted in Resident 26's repeated falls. Findings: Resident 38 A review of Resident 38's face sheet (demographics) indicated she was initially admitted to the facility on [DATE]. Her diagnoses included Alzheimers disease (AD, a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), Dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities) and Vitamin D deficiency (loss of bone density, which can contribute to osteoporosis and fractures (broken bones). A review of her Minimum Data Sheet Assessment (MDS, a federally-mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes), dated 10/31/23, Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents) score was 3, indicating severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). A review of Resident 38's At Risk for Fall care plan, revised 11/4/23, indicated to observe Resident 38 frequently and place in supervised area when out of bed, to assess and analyze resident's falls to determine pattern/trend. Resident 38's actual Fall CP, dated 1/21/24, indicated Resident 38 had poor balance and poor communication/comprehension. The care plan had no interventions to address root causes of the fall, poor balance and poor communication/comprehension. A review of Resident 1's nursing note, dated 1/21/24 4:48 p.m., indicated that at 3 p.m., Resident 38 was seen ambulating on B wing and at 3:10 p.m., Resident 38 was seen by the door in room [ROOM NUMBER], where she was lying on her left side on the floor. The nursing note further stated Resident 38 was unable to state what happened, due to her dementia . The nursing note indicated 911 (an emergency number for any police, fire or medic) was called at 3:10 p.m., paramedics arrived at 3:15 p.m., and Resident 38 was sent out to the ED at 15:24. The Emergency Discharge instruction indicated Resident 38 had a computerized tomography (CT) scan (a series of X-ray, a type of radiation used to create a picture of the inside of the body, images taken from different angles around your body ) of her cervical spine without contrast, done on 1/21/24, due to neck pain and headache, which indicated Resident 38 had a left frontal scalp tissue (area in front of the head) swelling as indicated in the CT scan note. During an interview on 1/30/24 at 10:14 a.m., Licensed Staff A stated the facility's fall protocol included assessing for residents' fall risk, encouraging resident to use call light, supervising ambulatory residents with high fall risks, impaired safety awareness and impaired cognition. Licensed Staff A stated, if a resident was a high fall risk, these residents could benefit from rehabilitation treatments, close monitoring and supervision by staff when ambulating. Licensed Staff A stated it was important to address fall risks and causal factors when formulating a fall care plan, and the care plan should be followed. When asked what the risks were if the fall care plan was not followed, Licensed Staff A stated the resident could fall. Licensed Staff A stated a lot of the facility residents were confused and had impaired safety awareness, just like Resident 38. Licensed Staff A stated staff could not just ignore them. Licensed Staff A stated these residents should be supervised and monitored closely for safety. Licensed Staff A stated, not following the care plan and not addressing the root cause of a fall could result in further fall incidents which could result in pain, fracture, internal bleeding, bruising and bumps on the head. Licensed Staff A stated Resident 38 was confused, had an unsteady gait (a manner of walking or moving on foot) but loved to walk. Licensed Staff A stated Resident 38 fell mostly because she would walk unassisted, would get tired and will sit down, because she got tired and weak. Licensed Staff A stated Resident 38's falls were mostly due to walking unsupervised. Licensed Staff A stated Resident 38's fall could have been prevented if there were staff supervising and monitoring her since Resident 38 was confused and had an unsteady gait. During an interview on 1/30/24 at 10:42 a.m., Resident 49 stated the facility staff were lazy and did not want to do the work. Resident 49 stated staff did not pay attention to residents and that is why, people here fall all the time. Resident 49 stated, Do you see anyone supervising me or other patients? Resident 49 stated staff at the facility were not always attentive to the residents' needs. During an interview on 1/30/24 at 10:53 a.m., Unlicensed Staff B stated residents with impaired cognition and unsteady gait should be supervised and assisted during transfers and ambulation. When asked what the risks were if a fall care plan was not followed, Unlicensed Staff B stated residents would fall, and their safety would be at risk. Unlicensed Staff B stated, not following a fall care plan could result in further incidents of falls and injuries. Unlicensed Staff B stated Resident 38 was a high fall risk due to unsteady gait, weakness, multiple falls, and confusion. When asked if it was safe for Resident 38 to ambulate unsupervised or unassisted by staff, Unlicensed Staff B stated, No. When asked if Resident 38's fall could have been prevented, Unlicensed Staff B stated Resident 38's fall could have been prevented if staff were supervising or monitoring her during ambulation. Unlicensed Staff B stated Resident 38 was unsafe when ambulating unsupervised or unassisted. Unlicensed Staff B stated, having staff to assist, monitor and supervise her during ambulation would definitely keep Resident 38 from falling. During an interview on 1/30/24 at 11:23 a.m., the Director of Staff Development (DSD) stated residents who were confused should be monitored and supervised as often as possible to prevent falls. The DSD stated care plans were important and should be followed. The DSD stated, if a care plan was not followed, a resident could fall and get injured. The DSD stated fall a care plan was in place and should be followed for residents' safety. When asked if Resident 38's fall could have been avoided, the DSD stated Resident 38's fall could have been prevented if staff were monitoring and supervising her. During a concurrent observation and interview on 1/30/24 at 11:45 a.m., in the dining room, Resident 38 was noted with purplish-brown discoloration on the left side back of the neck, Resident 38 winced and grimaced when asked to touch the area. When asked if it hurt, Resident 38 nodded her head. Resident 38 was also noted with a purplish maroon discoloration on her left eye and a small bump on the left side of her forehead. Resident 38 grimaced and winced when she touched the area. Resident 38 had difficulty answering yes or no to simple questions. Resident 38 would not answer when asked if she remembered falling and the incident surrounding her fall on 1/21/24. During an interview on 1/30/24 at 12:04 p.m., Unlicensed Staff C stated, residents who were confused with unsteady gait should be supervised when ambulating, for safety. Unlicensed Staff C stated a fall care plan was important and should be followed. Unlicensed Staff C stated, if a fall care plan was not followed, residents would suffer, could fall and could result in injury, fracture, bruising and pain. Unlicensed Staff C stated Resident 38 had an unsteady gait, was confused and was a high fall risk. Unlicensed Staff C stated Resident 38 had fallen multiple times at the facility. Unlicensed Staff C stated, even with her confusion and unsteady gait, Resident 38 was allowed to walk unsupervised and unassisted at the facility. When asked if Resident 38 was safe to walk around the facility unsupervised and unassisted, even if she was confused and had unsteady gait, Unlicensed Staff C laughed nervously but did not respond. When asked if Resident 38's fall could have been avoided, Unlicensed Staff C stated Resident 38's fall could have been prevented if staff were supervising and monitoring her for fall and for safety. During an interview on 1/30/24 at 12:30 p.m., the Interim Director of Nursing (DON) stated the Interdisciplinary Team (IDT, a complex process in which different types of staff work together to share expertise, knowledge, and skills to impact on patient care) meeting post-fall and care planning was important to ensure there was a preventive measure geared towards ensuring residents' safety. The interim DON stated, while the IDT determined the root cause of the fall, the fall care plan needed to address risk factors and root causes of the fall. The interim DON stated the fall care plan ensured resident risk for falls were decreased. The interim DON stated fall care plan should be updated after every fall as needed, and should have interventions specific to address the cause of the fall and how the fall could be prevented. When asked what the risks were if the fall care plan was not followed and was not updated to address fall risks, the interim DON stated, not addressing the risk factor, the root cause of the fall and not following the fall care plan increased a resident's risk for falls with injuries. When asked if Resident 1 was safe to ambulate unassisted or unsupervised by staff knowing Resident 38 was a high fall risk, had in fact fell in the facility five times since 6/2023, and one time in 1/2024, had poor safety awareness, had unsteady gait and was confused, the interim DON did not respond. The interim DON stated, moving forward, it would be safer if Resident 38 was supervised closely, when ambulating, for safety and as a fall precautionary measure. During a telephone interview on 1/30/24 at 12:46 p.m., the Rehabilitation Director (RD) stated, for safety purposes and as a fall prevention, he recommended staff supervision for Resident 38 when ambulating, for safety. During an observation on 1/30/24 at 12:55 p.m., Resident 38 was walking around the hallway, unsupervised, with an unsteady and uncoordinated gait. During an interview on 1/30/24 at 1:10 p.m., the MDS Coordinator stated Resident 38 had multiple falls at the facility and the majority of them were during ambulation. The MDS Coordinator stated Resident 38 was unsupervised when ambulating. When asked why, the MDS Coordinator did not respond. When asked if Resident 38's fall could have been prevented, the MDS Coordinator did not respond. When asked if it was safer for Resident 38 to be supervised by staff when ambulating, the MDS Coordinator stated, Yes. During a concurrent interview and fall incidents record review on 1/30/24 at 1:15 p.m., the interim DON verified Resident 38 had fallen a total of six times between 6/26/23 and 1/21/24, on these dates: 6/26/23, 7/3/23, 8/1/23, 11/16/23, 11/21/23, and 1/21/24. Resident 38 fell eight times between 6/18/22 and 1/21/24, on these dates: 6/18/22, 12/29/22, 6/26/23, 7/3/23, 8/1/23, 11/16/23, 11/21/23, and 1/21/24. During an observation on 1/30/24 at 1:35 p.m., Resident 38 was walking in the hallway unsupervised. Resident 38 was noted with an uncoordinated and unsteady gait. During a concurrent telephone interview and fall care plan record review on 1/31/24 at 3 p.m., the interim DON verified Resident 38's Actual Fall care plan, dated 1/21/24, did not address Resident 38's cause of fall on 1/21/24. The interim DON verified the At Risk for Fall care plan, revised 11/4/23, indicated Resident 38 should be supervised when out of bed and was still in effect but was not followed when Resident 38 fell on [DATE]. The interim DON stated Resident 38's fall care plan was generic and not individualized. When asked if Resident 38's fall on 1/21/24, could have been prevented if staff supervised Resident 38 while she was up ambulating, the Interim DON stated, Yes and she understood. During a telephone interview on 2/2/24 at 3:26 p.m., when asked if Resident 38 could have benefited from an in-depth rehabilitation evaluation on why Resident 38 was falling, the interim DON stated she would have the Director of Rehabilitation (DOR) services discuss this with the surveyor. The interim DON confirmed, despite Resident 38's multiple falls, the facility was not able to determine the causative factor on why Resident 38 continued to fall. The interim DON stated Resident 38's fall care plan was generic and did not really provide interventions based on Resident 38's risk and cause of fall. When asked if Resident 38 could have benefited from a rehabilitation evaluation which was focused on gait, balance, strength, fall risk and safe ambulation assessment due to multiple falls, the interim DON stated Resident 38 might benefit from a rehabilitation evaluation instead of rehabilitation screening only. During a telephone interview on 2/2/24 at 3:56 p.m., when asked what the difference between a rehabilitation screening and rehabilitation evaluation was, the DOR stated rehabilitation screening meant they only interview staff and residents, and it was not an in-depth assessment of residents' functional status, while a rehabilitation evaluation meant a rehabilitation therapist would assess residents' balance, gait, muscle strength and safe ambulation. When asked why Resident 38 only had a rehabilitation screening versus a rehabilitation evaluation, wherein the therapist could have assessed Resident 38's gait, fall risk, muscle strength and safe ambulation, the DOR did not answer. A review of the IDT post-fall documentation indicated Resident 38 fell on [DATE], 7/3/23, 8/1/23, 11/16/23, 11/21/23 and 1/21/24. The IDT post-fall review, dated 11/17/23, indicated Resident 38's fall risk assessment, done on 11/16/23 and 11/21/23, score was 13, indicating she was a high risk for falls. During an interview on 2/23/24 at 1:48 p.m., Unlicensed Staff D stated Resident 38 had an unsteady gait sometimes. Unlicensed Staff D stated Resident 38 was also noted with confusion and could be forgetful. Unlicensed Staff D stated Resident 38 needed supervision and assistance when ambulating, for safety. Unlicensed Staff D stated Resident 38 needed staff to monitor her closely during ambulation. During an interview on 2/23/24 at 1:52 p.m., Licensed Staff E stated Resident 38 was a high risk for falls. Licensed Staff E stated Resident 38 was confused and had poor safety awareness. Licensed Staff E stated that although Resident 38 was noted with weakness, the facility allowed her to ambulate by herself. Licensed Staff E stated Resident 38's falls could have been prevented if she was supervised and monitored by staff closely, during ambulation. During a Fall Risk Assessment (an assessment that checks to see how likely it is that you will fall) and Fall forms record review (a study that is based solely on existing data), Resident 38's Fall risk assessment, dated 1/21/24, score was 14, indicating she was a high risk for falls. Among her risks listed were disorientation, falls within the last 180 days, decreased muscle coordination and balance problem while walking. Resident 38's Fall risk assessment, dated 11/16/23 and 11/21/23, score was 13, indicating high risk for fall. Among her risks listed were disorientation, falls within the last 180 days and ambulatory/incontinence (inability to control the flow of urine from the bladder). The fall form # 1472, dated 11/21/23, indicated Resident 38 was oriented to person, confused, had impaired memory, lack of coordination and weakness. The fall form #1436, dated 11/16/23, indicated Resident 38 was confused and had gait imbalance. A review of the facility's policy and procedure (P & P) titled, Fall Risk Intervention and Monitoring, revised 12/2014, the P & P indicated it was the facility's policy to identify interventions related to resident's specific risks and causes to try and prevent resident from falling and try to minimize complications from falling .the multi-disciplinary team including the physician will identify appropriate interventions to reduce the risk of falls .if falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current intervention remains relevant .the multi-disciplinary team will identify and implement relevant interventions to try and minimize serious consequences of falling .if resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. A review of the facility's policy and procedure (P & P) titled, Fall Management, revised 12/2014, stated it was the facility's policy to provide consistent process for evaluating, managing, and reducing falls to minimize risks and improve quality of life, for residents who were at risk for falls .residents gait, balance and current medications associated with dizziness or increased fall risk should be evaluated following a fall . A review of the facility's policy and procedure (P & P) titled, Investigating Resident Related Incidents /Accidents, revised 7/2012, the P & P indicated it was the facility's policy to ensure provision of adequate supervision and assistance devices to residents, based on their specific care needs, to prevent incidents/accidents .incidents/accidents of unknown cause may be related to lack of supervision and or assistive device shall be investigated to ascertain surrounding circumstances that led to such incident/accident .examples of accidents/incidents to be reported included falls that were not witnessed, falls during ambulation, skin tears, abrasions, lacerations (a cut in the skin) bruises = of known or unknown cause . Resident 13 A review of Resident 13's face sheet (demographics) indicated she was admitted to the facility on [DATE]. Her diagnoses included Dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), History of Falls, Muscle Weakness and Restless Leg Syndrome (RLS, a condition that causes a very strong urge to move the legs). A review of her Minimum Data Sheet Assessment (MDS, a federally-mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes), dated 11/1/23, Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) score was 0, indicating severe cognitive impairment. Her MDS also indicated she needed moderate assistance (where staff lift, holds and support residents') from staff during ambulation. During an observation on 2/21/24 at 9:40 a.m., Resident 13 was in the activity room, but she had no activity in place. Only the Activity Director (AD) was in the activity room. There were no staff paying attention to Resident 13. An attempt made to interview, but Resident 13 could not be interviewed, as Resident 13 only provided nonsensical answers to simple questions. During an interview on 2/21/24 at 11:10 a.m., Licensed Staff N stated it was the facility's fall prevention policy to place residents on one-on-one monitoring (1:1) by staff if needed, to monitor residents every two hours or every 30 minutes as needed, for residents who were a high risk for falls, provide incontinence (an involuntary loss of urine) care every two hours and as needed. Licensed Staff N stated residents at risk for falls with history of falls and dementia had to be monitored and supervised closely. Licensed Staff M stated, if these were not done, it could result in accidents and falls. When asked if Resident 13 was a high risk for falls, she stated, Yes. When asked if care planning (CP, a form [where you can summarize a person's health conditions, specific care needs, and current treatments) was important, Licensed Staff M stated, Yes. Licensed Staff M stated, if a resident were risk for falls or had actual falls and CPs were not created or followed, it became a safety issue, and staff would not be able to care for residents adequately and safely. Licensed Staff M stated residents could fall and injure themselves. During an interview on 2/21/24 at 11:38 a.m., Unlicensed Staff C stated it was the facility's fall policy to provide incontinence care every two hours and to monitor residents every two hours or more frequently especially if they were a fall risk. When asked if Resident 13 was a fall risk, she stated, Yes. Unlicensed Staff C stated Resident 13 should be supervised because she was confused and was at risk for falls. Unlicensed Staff C stated residents who were confused or had dementia should be assisted to the bathroom and should not be left alone in their room. When asked if a fall CP was important, Unlicensed Staff C stated, yes, as it provided a map on how to care for residents safely. When asked what could happen if the fall CP was not followed, Unlicensed Staff C stated residents could receive unsafe care and residents would not receive the care that they needed. During an interview on 2/21/24 at 12:06 p.m., the Minimum Data Set (MDS) coordinator stated Resident 13 had a femur fracture because she fell at the facility. The MDS coordinator stated Resident 13 attempted to get out of bed to use the bathroom and lost her balance. The MDS coordinator stated Resident 13 was a high risk for falls. The MDS coordinator stated Resident 13 fell twice last year, and the fall incident last December resulted to a femur fracture. When asked what was the facility's policy in preventing falls, the MDS coordinator stated the facility should develop a fall care plan to address risks and a fall risk assessments should be completed, to frequently check on residents every two hours or more often as needed and to provide incontinence care every two hours or less as needed. The MDS coordinator stated, if these were not followed, it could result in increased incidences of falls. The MDS coordinator stated Resident 13 was occasionally incontinent of bowel (inability to control bowel movements) and incontinent of bladder function (loss of bladder control). The MDS coordinator stated staff should be providing Resident 13 incontinence care every two hours and as needed or offering to bring her to the bathroom every two hours. When asked if care planning was important, the MDS coordinator stated, Yes, because it was the basis to execute care for residents and it was focused on identification of risks and goals and interventions. The MDS coordinator stated the CP provided structure on how to provide safe care to the residents. When asked what could happen if there was no fall CP or if a fall CP was not followed, the MDS coordinator stated, not following the fall CP or the fall policy put residents' safety at risk and could result in accidents, pain and fractures. The MDS coordinator stated, not following the care plan could also lead to residents not receiving the care they needed. During an interview on 2/21/24 at 12:42 p.m., Licensed Staff O stated Resident 13's fracture was due to a fall at the facility. Licensed Staff O stated Resident 13 was a high risk for falls. When asked what the facility's policy was for fall prevention, Licensed Staff O stated to provide incontinence care and turning and repositioning every two hours or more often as needed and to frequently monitor residents every two hours or more often if a resident was at risk for falls. When asked if fall care planning was important, Licensed Staff O stated, Yes, and the fall CP should be followed. Licensed Staff O stated, if the fall CP or the fall policy was not followed, it could be a safety risk for the resident. Licensed Staff O stated residents could fall and result in injury. During an interview on 2/23/24 at 1:26 p.m., Licensed Staff F stated Resident 13's fracture was due to a fall at the facility. When asked what the facility's policy for falls was, Licensed Staff F stated the policy indicated to monitor residents closely, not to leave a resident unattended especially if the resident was a high fall risk or had poor cognition. Licensed Staff F stated the fall policy also indicated to provide incontinence care every two hours and to monitor residents every two hours. Licensed Staff F stated residents should be assisted in the bathroom if they were confused, weak and had poor safety awareness. When asked if a fall care planning was important, Licensed Staff F stated, yes, as risks were addressed in CPs and appropriate intervention could be put in place. When asked what could happen if the fall CP or the fall policy was not implemented or followed, Licensed Staff F stated it put residents' safety at risk, residents could fall again and residents could be at risk for injury. During an interview on 2/23/24 at 1:45 p.m., the interim Director of Nursing (DON) stated Resident 13 went to use the bathroom, unassisted, and fell . The DON stated this fall resulted in a fracture of the femur. The interim DON stated Resident 13 was a high risk for falls and had poor safety awareness. When asked what the facility's policy was to prevent falls, the interim DON stated the policy indicated to complete a Fall Risk Assessment (an assessment that checks to see how likely it is you would fall), medication review from the pharmacist, to monitor residents frequently every two hours and as needed and to provide incontinence care or offer toileting every two hours and as needed. When asked if fall care planning was important, the interim DON stated, Yes. The interim DON stated the CP provided a baseline on what to do as far as patient care went. When asked what could happen if the fall CP or the fall policy was not followed, the interim DON stated it could be a safety risk. The interim DON stated residents could end up falling, skin issues may arise, and residents may not receive safe and adequate care. During a concurrent interview and fall CP, dated 12/7/23, record review on 3/20/24 at 10:35 a.m., the MDS coordinator verified Resident 13 fell twice last year, on 4/12/23 and 12/2/23. The MDS coordinator verified the fall incident on 12/2/23, resulted in a fracture of Resident 13's femur. The MDS coordinator stated the At Risk For Fall CP, which included interventions such as providing frequent staff monitoring, providing toileting assistance two times per shift and at bedtime, observing resident frequently and placing Resident 13 in a supervised area when she was out of bed, dated 12/7/23, was in effect prior to Resident 13's fall incident on 12/2/23. During a concurrent interview and fall CP, dated 12/7/23, record review on 3/20/24 at 12:18 p.m., the MDS coordinator stated MDS coordinator 2 updated the At Risk For Fall CP and merged it with the actual fall CP on 12/2/23, as indicated on the CP, dated 12/7/23. When asked if he could identify which CP was for At Risk or which of the interventions were new, MDS coordinator did not respond. The MDS coordinator stated the CP was important because it provided a blueprint on how to care for the residents' safely. The MDS coordinator stated the CP should be followed to lessen incidences of falls and injury post fall to the resident. The MDS coordinator stated care plans were updated to ensure they still applied to the resident and to identify interventions which were not appropriate, so a different approach could be implemented. When asked if there were documentation's to indicate whether the care plan was reevaluated for effectiveness, the MDS coordinator stated, No. When asked how a staff could identify if a current care plan was effective, the MDS did not answer. When asked whether there was a collaboration with the physician to identify pertinent interventions to try and reduce the risks associated with subsequent falls, the MDS stated, No. The MDS coordinator was not able to identify which CP was for the At Risk For Fall, the actual fall on 4/12/23, and the fall on 12/2/23. The MDS coordinator was not able to identify whether new interventions were created after Resident 13 fell on [DATE]. The MDS coordinator was not able to provide documentation Resident 13 was offered toileting or provided incontinence care before she fell on [DATE]. During a concurrent interview and IDT post-fall follow-up record review, dated 12/4/23, on 3/20/24 at 3:37 p.m., the Administrator stated Resident 13 was in her room when she fell on [DATE]. The Administrator stated Resident 13 was incontinent and would need assistance in toileting as needed. The Administrator was unable to identify when was the last time Resident 13 was offered or provided toileting by staff before her fall on 12/2/23. The Administrator stated Resident 13 fell while trying to go to the bathroom by herself and probably lost her balance. The Administrator verified, per IDT, post-fall follow-up V3 form, dated 12/4/23, Resident 13's score was 13. The Administrator stated this indicated Resident 13 was a high fall risk. During an interview on 3/20/24 at 3:50 p.m., the DON verified there was no MRR completed by the pharmacist, although there should be one completed as per the facility's fall policy and procedure, after Resident 13 fell on [DATE], and 12/2/23. During an interview on 3/21/24 3:28 p.m., Unlicensed Staff P stated she was working with Resident 13 on the night she fell . Unlicensed Staff P stated, on the night of Resident 13's fall incident last 12/2/23, she found Resident 13 on[TRUNCATED]

Based on observations, interviews and record reviews, the facility failed to accurately assess, monitor, and provide wound care treatment to prevent development of facility acquired pressure ulcer (PU, a damage to an area of the skin caused by constant pressure on the area for a long time) and to prevent the worsening of an existing pressure ulcer for three of 23 sampled residents (Resident 21, Resident 33, and Resident 122), when: 1. a. The facility did not monitor Resident 21's right heel when he was wearing a Pressure Relief Ankle Foot Orthosis (PRAFO, an orthosis with an aluminum heel connecting bar that helps to hold the ankle in a neutral (90 degree) position. b. The facility was not able to provide documentation Resident 21 was being turned from side-to-side at least every two hours, per facility policy and per care plan (CP, a road map for the care of a patient). c. The facility did not identify Resident 21's pressure ulcer on his coccyx (tail bone) until 2/2/24, although Resident 21 had a PU on his coccyx from 12/2023, as stated by the Director of Nursing (DON). d. The facility did not request a physician order to treat Resident 21's PU on his coccyx, from 12/2023 up to 1/2024. e. The facility did not accurately identify the location of Resident 21's PU on his back, when staff documented on the weekly Skin Integrity Assessment for Pressure Sore/Post-Op [NAME] V2, Resident 21 had a PU on his sacrum (a large, triangle-shaped bone in the lower spine that forms part of the pelvis), instead of the coccyx, on these dates: 2/2/24, 2/10/24, 2/17/24, 2/24/24, 3/2/24 and 3/9/24. The Weekly Skin Integrity Assessment for Pressure Sore/Post-Op [NAME] V2 indicated Resident 21 had a PU on his sacrococcyx (fused sacrum and coccyx). f. The facility did not have a valid treatment order from the physician and did not provide consistent treatment to Resident 21's PU on his coccyx, from 12/2023 up to 1/2024. g. The facility did not complete a Weekly Skin Integrity Assessment for PU on Resident 21's coccyx from, 12/2023 up to 1/2024. h. The facility did not inspect Resident 21's skin daily, when they were providing care. i. The facility did not ensure Resident 21's low air loss mattress (LAL, a mattress designed to prevent and treat pressure wounds) setting was accurate and based on the manufacturer's recommendation, to prevent the development or worsening of pressure ulcers. These failures resulted in Resident 1 developing a Deep Tissue Injury (DTI, a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) to his right heel and a Stage 2 pressure ulcer (a shallow open ulcer with a red or pink wound bed, caused when an area of skin is placed under pressure) on his coccyx, which had now progressed to Stage 4 pressure ulcer (a full thickness tissue loss with exposed bone, tendon, or muscle with slough- the yellow/white material in the wound bed; or eschar- a dead tissue that sheds or falls off from the skin). 2. The facility did not identify Resident 33's left heel pressure ulcer and did not have a doctor's order to treat the wound. This failure cause Resident 33 to experience pain / discomfort and had the potential for the wound worsening due to lack of monitoring and treatment; and, 3. The facility nurses did not implement treatment orders for Resident 122, per facility physician orders and nursing standards of practice, when his wound dressing changes were not performed per orders, his heels were not floated (position heel to remove all contact between the heel and the bed), and an appropriate pressure-reducing surface was not placed on his bed. This failure contributed to Resident 122's wound infection and potentially prevented wound healing, when staff did not ensure his heel was pressure-free. Findings: Resident 21 A review of Resident 21's face sheet (demographics) indicated he was readmitted on [DATE], with diagnoses of Hyperlipidemia (HLP, an elevated level of lipids like cholesterol and triglycerides in your blood), Type 2 Diabetes Mellitus (DM, a disease that occurs when your blood glucose, also called blood sugar, is too high), Depression (a constant feeling of sadness and loss of interest,) and Muscle Weakness. A review of Resident 21's hospital discharge note, dated 1/31/24, indicated he had a right Above-Knee Amputation (AKA, removal of the leg from the body by cutting through both the thigh tissue and femur- thigh bone) on his right lower extremity due to severe ischemia (lack of blood supply to a part of the body) and non-healing wound on his right lower extremity. His Minimum Data Sheet Assessment (MDS, a federally-mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes), dated 3/10/24, Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) condition of residents, score was 15, indicating Resident 21 had an intact cognition. His MDS assessment also indicated he had an impairment on his upper and lower extremities and needed staff assistance when performing his Activities of Daily Living (ADL, activities related to personal care such as bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet). During an observation on 3/19/24 at 10:51 a.m., Resident 21 was in bed, lying on his back. During an observation on 3/19/24 at 2:40 p.m., Resident 21 was still in bed, lying on his back. During an observation on 3/19/24 at 4:42 p.m., Resident 21 was still in bed lying on his back. During an observation on 3/20/24 at 9:55 p.m., Resident 21 was in bed, lying on his back. During an observation on 3/20/24 at 11:55 p.m., Resident 21 was still in bed, awake, still lying on his back. During an observation on 3/20/24 at 2:55 p.m., Resident 21 was still in bed, asleep, lying on his back. During a concurrent observation and interview on 3/20/24 at 4:29 p.m., Resident 21 was lying on his back on a, Dynarex air mattress. The machine pump indicated the bed was programmed at 350 pounds (lbs, a unit of weight) and the lock key was turned on. When the DON was asked how the air loss mattress was programmed, she stated the bed had its, auto weight control feature, however she stated she was not sure how it was programmed. A review of the electronic health record for Resident 21 under the, Weight and Vitals Summary tab, indicated Resident 21's weight on 3/05/24, was 215.8 lbs. During a concurrent observation and interview with the DSD on 3/20/24 at 4:35 p.m., Resident 21 was on a low air loss mattress programmed at 320 lbs. When the DSD was asked if the bed was programmed according to Resident 21's weight, he stated he was not familiar on how to program the mattress and was not sure if the mattress was programmed correctly. He stated he would have to find out how to program the mattress and would have to provide training to the nurses. During an observation on 3/20/24 at 4:56 p.m., Resident 21 was still in bed, lying on his back. During an interview on 3/20/24 at 4:57 p.m., Unlicensed Staff I stated residents should be checked, changed, turned and repositioned every two hours for PU care. During an interview on 3/20/24 at 4:58 p.m., Licensed Staff F stated residents should be checked and changed every two hours and turned and repositioned every two hours for PU care. Licensed Staff F stated residents still needed to be turned and repositioned every two hours even though they were on a LAL mattress. During record review of the turning and repositioning (T&R, to reduce or eliminate pressure, thereby maintaining circulation to areas of the body at risk for pressure ulcers) documentation, dated 12/2023, and interview on 3/20/24 at 5:27 p.m., the Director of Staff Development (DSD) stated Resident 21 was a high risk for developing pressure ulcers. The DSD stated, per facility policy, residents should be turned and repositioned (T&R, turning people to change their body position to relieve or redistribute pressure) every two hours and incontinence care provided every two hours and as needed. The DSD confirmed the turning and repositioning documentation did not indicate which position Resident 21 was on when he was repositioned. The DSD stated the documentation was incomplete and was not acceptable. The DSD stated, to ensure resident 21 was being turned and repositioned, the documentation should include Resident 21's position prior to and after being repositioned. The DSD stated the documentation did not prove Resident 21 was turned and repositioned from side-to-side every two hours. The DSD also verified there was no T&R documentation for 12/2023, 1/2024, 2/2024, to indicate Resident 21 was being turned and repositioned every two hours. During a concurrent observation and interview on 3/21/24 at 11 a.m., Resident 21 was lying on his back. Resident 21 stated he was feeling pain on his back due to the PU on his buttocks. Resident 21 also stated the pain was due to him being on his back all the time and sitting on his urine for long periods of time. Resident 21 stated staff told him he developed the pressure ulcer on his buttocks because he did not like to get up from bed. Resident 21 stated the facility did not provide him with interventions or alternative when he would not get up from bed. Resident 21 stated he was not being turned and repositioned by staff every two hours, and staff were not providing him incontinent care every two hours. Resident 21 stated he developed his PU on his buttocks and right heel at the facility. Resident 21 stated he had the PU on his buttocks even before he went to the hospital last January. Resident 21 stated he did not receive regular treatment on the pressure sore on his buttocks. Resident 21 stated he received different treatments for the pressure sore on his buttocks. Resident 21 stated it depended on who was scheduled as a treatment nurse. Resident 21 stated until today, his LAL mattress was so hard, it was uncomfortable. During an interview on 3/21/24 at 11:50 a.m., the DON verified it was the facility's policy to ensure an Interdisciplinary Team (IDT, a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological and spiritual needs of the patient) meeting was done within 72 hours after a new PU was identified or if a PU had worsened, on top of the weekly skin assessment that needed to be completed. The DON also stated a new Braden Scale (an assessment tool used to identify patients at-risk for pressure ulcers) skin assessment would need to be completed when a new PU was identified or if a PU had worsened. The DON also verified there would be a new Weekly Skin Integrity skin assessment triggered once a new wound/PU was identified. The DON stated the Weekly Skin Integrity Assessment was done weekly to track residents' PU's, to determine if the PU was getting better or worse or if the treatment was effective or ineffective. During an interview on 3/21/24 at 12:15 p.m., the DON stated Resident 21 was a high risk for developing pressure ulcers. The DON stated it was the facility's policy to ensure residents were turned, repositioned, offered toileting or incontinence care provided every two hours. The DON stated, if these were not done, these could be a contributing factor in residents acquiring a PU. When asked if Resident 21's PU on his right heel and coccyx was acquired at the facility, the DON stated, Yes. When asked if Resident 21 being left soaked in urine for a long period of time and not being repositioned every two hours could have contributed to Resident 21 developing PU's on his right heel and coccyx, the DON stated, Yes. The DON stated Resident 21's right heel PU was caused by a medical device. During a concurrent interview and T&R documentation for 3/2024, record review on 3/21/24 at 2:09 p.m., the DON verified the T&R documentation did not indicate what position Resident 21 was on before and after being repositioned. The DON stated the document did not include information on a residents' position before and after being repositioned. The DON stated this was important to track and ensure residents were being repositioned by the staff. When asked if these documents proved Resident 21 was being turned and repositioned by staff every two hours, the DON did not answer. During a concurrent observation and interview with the wound specialist Physician Assistant (PA) and Family Nurse Practitioner (FNP) on 3/21/24 at 2:36 p.m., the PA stated she only started seeing Resident 21 last week. The PA stated Resident 21 had a Stage 4 PU on his coccyx and was currently being treated with Santyl, Calcium Alginate then covered with dry dressing. The PA stated the current measurement of Resident 21's PU on his coccyx was 4.2 centimeter (cm, a unit of length) by 2.5 cm by 1.5 cm. The PA stated the PU was macerated (occurs when skin has been exposed to moisture for too long. A telltale sign of maceration is skin that looks soggy, feels soft, or appears whiter than usual) and had 30% slough. During a concurrent interview and electronic Treatment Administration Record for 12/2023 and 1/2024 (ETAR, a part of a patient's electronic health record that keeps track of when treatments are rendered to the patient), review on 3/21/24 at 4:45 p.m., Licensed Staff K verified these ETARs did not indicate a treatment was rendered on Resident 21's PU on his coccyx. Licensed K stated, if a treatment was not rendered, it could result in further skin issues, development or worsening of PU's and infection. During a concurrent interview and ETAR record review for 12/2023 and 1/2024, on 3/21/24 at 4:47 p.m., the Infection Preventionist (IP) verified the ETARs did not indicate a treatment was rendered to Resident 21's coccyx. The IP stated, if treatment was not rendered, it could lead to development or worsening of PU's. During a concurrent interview and ETAR record review, dated 12/2023 and 1/2024, on 3/21/24 at 5:01 p.m., the DON verified the ETARs did not indicate a treatment was rendered on Resident 21's PU on his coccyx. The DON stated Resident 21's PU on his coccyx was acquired at the facility. The DON stated, not providing treatment on Resident 21's PU on his coccyx could result in further skin issues, worsening of pressure sores and decline in wound status. When asked to provide the IDT notes for Resident 21's PU on his heel and coccyx, the DON stated she could not find any. The DON stated the IDT would meet to ensure root cause analysis was identified and appropriate interventions were kept in place to address risk factors and prevent acquiring further PU's and to prevent existing PU's from worsening. The DON stated, if an IDT was not completed, risk factors would not be identified, new PU's could develop and residents' PU's could worsen or get infected. During a concurrent interview and ETAR record review from 9/2023 up to 12/2023, on 3/22/24 at 9:15 a.m., the Minimum Data Set coordinator (MDS) stated the PRAFO was ordered on 1/11/22, to be worn on the bilateral lower extremity four to six hours daily, five times a week to prevent foot drop and pressure sores. The MDS coordinator stated the PRAFO boots was discontinued (DC'd) on 12/24/23, due to Resident 21 acquiring a DTI on his right heel. The MDS coordinator stated the DTI on Resident 21's right heel was facility acquired and was due to the PRAFO boots that was why it was DC'd on 12/24/23. The MDS coordinator stated the TARs for the months of 9/2023 up to 12/2023, indicated there were no order for staff to monitor Resident 21's skin while using the PRAFO boots on the bilateral foot. When asked if staff should be monitoring Resident 21's skin while using the PRAFO boots, the MDS coordinator did not answer. During an interview on 3/22/24 at 9:25 a.m., Licensed Staff F stated, residents who used PRAFO boots should have an order for skin monitoring to ensure residents did not develop pressure ulcers due to medical devices. Licensed Staff F stated it was important to monitor the skin for early identification of potential of skin issues. Licensed Staff F stated, if there was no skin monitoring, especially of the of heels when a resident was on PRAFO boots, this could result in the development of PU. During a concurrent interview, ETAR's for 11/2023 and 12/2023, PRAFO order for 11/2023 and 12/2023, record review on 3/22/24 at 10:34 a.m., the IP verified the ETAR's did not indicate whether staff were monitoring Resident 21's skin while he was on PRAFO boots. The IP stated the order for the PRAFO boots was vague and did not state clearly how long Resident 21 should wear the PRAFO boots. The IP stated it would have been beneficial for Resident 21 if there was documentation to indicate what time Resident 21 was on PRAFO boots and when staff removed the PRAFO boots. The IP also stated residents on medical devices such as PRAFO should have a skin assessment every shift to ensure early identification of potential skin issues and for prevention of pressure sore development. The IP stated Resident 21's DTI on his right heel could have been prevented if staff were monitoring his skin while he was on PRAFO boots. During a concurrent interview and Weekly Skin Integrity Assessment for Pressure Sore/Post Op forms, dated 2/2/24, with the MDS Coordinator, the assessment indicated Resident 21 had a pressure sore on his sacrum, unstageable, measuring 5 cm x 6 cm x 0 cm, with 40% of the wound bed covered with brown dead tissue. When asked if the nurse assessing Resident 21's PU on his sacrum staged his pressure sore appropriately since only 40% of the wound bed was covered with slough, the MDS Coordinator stated he would not comment but that he stood by the nurse's documentation. During a concurrent interview, review of Weekly Skin Integrity Assessment for Pressure Sore/Post Op [NAME] V2 record review, dated 2/2/24, 2/10/24, 2/17/24, 2/24/24, 3/2/24 and 3/9/24, on 3/22/24 at 12:55 p.m., the DON stated a PU that was partially covered with 40% slough should be staged. The DON stated the Weekly Skin Integrity Assessment for Pressure Sore/Post Op [NAME] V2, completed on 2/2/24, was inaccurate since it indicated Resident 21's PU was located at the sacrum; it was unstageable and was acquired at the hospital. The DON stated Resident 21 had a pressure ulcer on his coccyx and not on his sacrum, and it was acquired at the facility. The DON stated the Weekly Skin Integrity Assessment for Pressure Sore/Post Op [NAME] V2, dated 2/2/2024, 2/10/24, 2/17/24, 2/24/24, 3/2/24 and 3/9/24, were inaccurate since the nurse was documenting Resident 21 had a PU on his sacrum and not on his coccyx. The DON verified the PA's documentation on Resident 21's PU location on 3/21/24, was accurate since it indicated Resident 21 had a stage 4 PU on his coccyx. The DON stated accurate documentation was required for the physician to prescribe an appropriate treatment. The DON stated inaccurate documentations could lead to mis-identification, mis-staging of PU's and inaccurate treatments which could lead to worsening of PU's, infection, or non-healing wounds. During an observation on 3/25/24 at 8:40 a.m., Resident 21 was on his bed, lying on his back. During an interview on 3/25/24 at 8:45 a.m., the Administrator verified she could not locate the Wound Specialist wound care notes, from 12/2023 up to 3/9/24. During an interview on 3/25/24 at 8:52 a.m., Licensed Staff L stated it was important to ensure location of the pressure sore was documented accurately to ensure accurate documentation and to ensure the physician gave an accurate treatment. Licensed Staff L stated inaccurate reports of PU location would not help the resident and could cause the PU to worsen and get infected. When asked what the facility policy was in preventing a PU from developing or from getting worse, she stated, turning, and repositioning every two hours, incontinent care every two hours or more often, as needed, and provision of appropriate treatment. Licensed Staff L verified Resident 21's pressure ulcer on his coccyx and his right heel DTI were facility acquired. When asked if the pressure ulcer on Resident 21's coccyx and right heel DTI could have been prevented, she stated, Yes. When asked if Resident 21's skin should have been monitored while on PRAFO boots, she stated, Yes. When asked if Resident 21 not being turned and repositioned every two hours or residents being left soaked in urine for extended periods of time could lead to pressure ulcer to develop or worsening, Licensed Staff L stated, Yes. Licensed Staff L stated, prior to Resident 21 being sent out to the hospital January of this year, she was already treating Resident 21's Stage 2 PU on his coccyx with Calcium Alginate (absorb wound fluid resulting in gels that maintain a physiologically moist environment and minimize bacterial infections at the wound site) and medihoney (a special honey that is derived from the nectar of the Leptospermum plant used to treat wounds and ulcers). During an observation on 3/25/24 at 10:41 AM, Resident 21 was still on his back, lying on his bed. During an observation on 3/25/24 at 3 p.m., Resident 21 was on his bed, lying on his back. During an interview on 3/25/24 at 4:56 p.m., the DON stated Resident 21 was a high risk for pressure ulcer development, and the DTI on his right heel and the PU on his coccyx was facility acquired. The DON stated residents on LAL mattresses still need to be T&R every two hours. The DON stated, if residents were not T&R every two hours and incontinence care was not provided every two hours or more often, as needed, then the facility policy was not followed. The DON stated residents not being T&R every two hours and incontinence care not provided every two hours or more often, as needed, could result in development of pressure ulcers, worsening of pressure ulcers and infection. The DON stated pressure ulcers also involved pain and could result in decreased quality of life. During an observation on 3/25/24 on 5:32 p.m., Resident 21 was still in bed lying on his back. During an interview on 3/26/24 at 10:22 a.m., the Nurse Practitioner (NP) stated she was not aware Resident 21 was refusing to be T&R. The NP stated Resident 21 was a high risk for developing pressure sores. The NP stated she expected staff to notify her or the physician if Resident 21 was refusing to be T&R because that would prompt an assessment, which could lead to interventions to be put in place to decrease risk of Resident 21 in developing PU's and to prevent his existing PU from worsening. The NP stated, if a resident was wearing a medical device, such as PRAFO, the expectation would be that staff monitor the resident's skin every shift for redness or potential skin issues. During an interview on 3/26/24 at 12:50 p.m., the Medical Record (MR) confirmed there was no order to treat Resident 21's PU on his coccyx, from 12/2023 and 1/2024. During an interview on 3/26/24 at 1:55 p.m., the DSD and the IP stated one would need a valid treatment order from the physician in order to treat a PU. The DSD and the IP stated, ensuring there was a valid treatment order ensured the nurses were providing the accurate treatment and the PU would not worsen or get infected. During an interview on 3/26/24 at 2 p.m., the DON stated, acquiring an appropriate treatment from the physician or NP ensured a resident's PU was receiving an appropriate treatment. The DON stated, nurses providing treatment without a physician's order could lead to a PU getting worse or infected. During an interview on 3/26/24 2:48 p.m., the DON verified Resident 21 did not have a treatment order for the PU on his coccyx, from 12/2023 up to 1/2024. A review of hospital referral wound docs indicated Resident 21 was admitted to the hospital on 1/25/24, with a PU on his coccyx. A review of Resident 21's Physician's Order Summary, dated 12/2023 and 1/2024, indicated there was no treatment order for Resident 21's PU on his coccyx. There were no Weekly Skin Integrity Assessment for Pressure Sore/Post OP sheets for 12/2023 and 1/2024, identifying Resident 21's PU on his coccyx. There were no documentation to indicate the nurses were tracking Resident 21's PU on his coccyx, from 12/2023 and 1/2024. A review of Resident 21's Braden Scale for Prediction of Pressure Sore Risk, dated 12/7/23, indicated he scored 14, meaning he had a moderate risk for developing PU's due to his skin being occasionally moist, he was confined in bed, his mobility was very limited, and he required moderate to maximum assist when moving. A review of Resident 21's MDS Assessment, dated 9/12/23, indicated he was at risk for developing PU's but did not have any PU's at that time. 44968 Resident 33 During a review of the Face Sheet indicated Resident 33 was admitted on [DATE], with diagnoses, including but not limited, to Hemiplegia and Hemiparesis (paralysis of one side of the body); Contractures (a loss of full active and passive range of motion [ROM - the extent or limit to which a part of the body can be moved around a joint or a fixed point] in a limb, which can result from limitations imposed by the joint, muscle, or soft tissue) of left hand and left knee; and Peripheral Vascular Disease (PVD - a blood circulation disorder). During a review of the facility document titled, Joint Mobility Assessment, dated 9/16/23, indicated Resident 33 had severe limitation to his left hip and left knee; and moderate to severe limitation to his left ankle. During a review of the Pressure Ulcer (also known as bedsore - damage to an area of the skin caused by constant pressure on the area for a long time) Care Plan, initiated on 10/09/23, indicated Resident 33 was at risk for pressure ulcers related to impaired mobility. Care Plan interventions include, but were not limited to: Float heels while in bed, monitor for placement; Avoid shearing resident's skin during positioning, transferring, and turning; Keep bony prominences from direct contact with one another with pillows; Report any signs of skin breakdown (sore, tender, red, or broken areas); and turn and reposition every two hours. During a review of the MDS, dated [DATE], indicated Resident 33 had a BIMS score of 03 out of 15 points (Brief Interview for Mental Status - a 15-point cognitive (relating to the mental process involved in knowing, learning, and understanding things) screening measure that evaluates memory and orientation. A score of 13 to 15 is cognitively intact, 08 to 12 is moderately impaired, and 00 to 07 is severe impairment). The MDS indicated Resident 33 had functional limitation in range of motion to both upper and lower extremities; Resident 33 was dependent on staff to roll from lying on back to left and right side. During a review of the facility document titled, Wound Management Review, dated 3/15/24, indicated Resident 33 had a Stage 3 (full thickness skin loss, where the subcutaneous fat [a type of fat that's stored just beneath your skin] may be visible to the naked eye) on his left lateral foot (the little toe side of the foot) measuring 1.5 cm (centimeter - a unit of length) x (by) 1.6 cm x 0.6 cm. During an Observation in Resident 33's room on 3/18/24 at 11:20 a.m., Resident 33 was asleep, lying on his back. His left knee was bent away from his body. Resident 21 had a knee brace (a medical device that stabilizes your knee joint and holds it in place) and heel protector (helps with pressure ulcers and is made with pressure-relieving polyfoam) in place; however, his left foot was resting on the bed surface. During an Observation in Resident 33's room on 3/19/24 at 11:58 a.m., Resident 33 was awake, lying on his back with his left and right knee bent away from his body in a frog leg position. Resident 33's foot of bed was elevated. Both heels had heel protectors; however, both feet were resting on the bed surface. During an Observation in Resident 33's room on 3/19/24 at 3:54 p.m., Resident 33 was lying on his back with his left knee bent away from his body, his left foot had heel protector and was touching the bed surface. During an Observation in Resident 33's room on 3/20/24 at 9:39 a.m., Resident 33 was lying on his backwith his left knee bent away from his body, his left foot had heel protector and was touching the bed surface. During an interview with Unlicensed Staff C on 3/20/24 at 10:16 a.m., when Unlicensed Staff C was asked about the reason for not getting Resident 33 out of bed, Unlicensed Staff C stated, to prevent [Resident 33] from having pressure ulcer. When Unlicensed Staff C was asked how is a pressure ulcer prevented when Resident 33 was not getting out of bed, Unlicensed Staff C stated, by turning [Resident 33] every two hours. Unlicensed Staff C stated it is the facility's practice to turn the residents in bed every two hours. During an Observation and concurrent interview with Unlicensed Staff C on 3/20/24 at 10:28 a.m., in Resident 33's room, Resident 33 was awake, lying on his back. When Unlicensed Staff C was asked how much assistance Resident 33 required to turn and reposition in bed, Unlicensed Staff C stated Resident 33 was dependent on staff with turning and repositioning in bed. During an Observation in Resident 33's room and concurrent interview with Unlicensed Staff C on 3/21/24 at 10:14 a.m., Resident 33 was lying on his back with his left and right knee bent away from his body. When Unlicensed Staff C repositioned Resident 33's left leg, Unlicensed Staff C could barely stretch Resident 33's left leg. Unlicensed Staff C stated Resident 33 could not stretch both his left and right leg. During a wound treatment observation, record review and interview with Licensed Staff L on 3/25/24 at 10:48 a.m., Resident 33 was lying on his back with his left and right knee bent away from his body. Resident 33's right foot was resting on top of his left foot. Both feet had heel protectors. Two wound sites were seen on Resident 33's left lateral foot: The wound closest to his left little toe was noted with blackish matter approximately 0.5 cm in length and 0.5 cm in width; and an open wound farthest from his left little toe measuring approximately 1.5 cm. in length, 1.5 cm in width and 0.3 cm. deep. There was also an open wound to Resident 33's left outer aspect of his heel measuring approximately 2 cm. in length, 1.2 cm in width and 0.3 cm. deep. When Licensed Staff L was asked if Resident 33's left heel wound was new, Licensed Staff L stated, No, and stated she had treated the wound a few times. After review of the Treatment Administration Record with Licensed Staff L, Licensed Staff L stated the was a treatment order for Resident 21's left lateral foot. However, Licensed Staff L stated there was no treatment order written for the left heel. When Licensed Staff L was asked if there was a skin assessment for Resident 33's left heel, Licensed Staff L stated there was no skin assessment in Resident 33's medical record. When Licensed Staff L was asked what would happen if there was no record of baseline (an imaginary starting point or basis of comparison for something) wound measurement of Resident 33's left heel, Licensed Staff L stated there would be no comparison to determine whether the wound was bigger or had worsened. When Licensed Staff L was asked how she would classify Resident 33's left heel wound, she stated, Stage 2 pressure ulcer. When Licensed Staff L was asked about the facility's process for wound assessment, she stated an initial skin assessment would be completed upon identification of new skin breakdown(s) and would be assessed and measured separately every week. She stated for new wounds and worsened wounds, both treatment and charge nurses were responsible to notify the doctor and obtain wound treatment orders. She stated wound assessment and documentation should be done every shift. During an interview with the (NP - registered nurse who has advanced education and clinical train[TRUNCATED]

Based on interviews and records review, the facility failed to assess, monitor and provide necessary care and services, in accordance with professional standards of practice, for two of 23 sampled residents (Resident 21 and Resident 61), when: 1. Resident 21, who was at high risk for wounds due to Diabetes Mellitus (disease that result in too much sugar in the blood), developed a facility-acquired deep tissue injury (DTI - purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure) on his right heel on 12/20/23, and developed an open wound on his right lateral lower leg on 12/24/23, from the facility's use of a PRAFO boot (Pressure Relief Ankle Foot Orthosis - a device worn on the calf and foot, designed to, float the heel and hold the ankle in a neutral, 90 degree, position). However, nursing staff did not assess and monitor Resident 21's right foot and right leg for the development of new wounds and worsening of an existing wound after the identification of the wounds. This deficient practice resulted in the worsening of the wound, causing Resident 21 to be transferred to the hospital approximately one month after his right lateral lower leg wound was discovered. Resident 21 was found to have Osteomyelitis (inflammation or swelling that occurs in the bone) and gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection) of his toes. Resident 21 subsequently received above-the-knee amputation (AKA - removing the leg from the body by cutting through both the thigh tissue and femoral (thigh) bone); and, 2. Resident 61 was nonverbal and had a history of stroke, hemiplegia (total or nearly complete paralysis on one side of the body) and hemiparesis (weakness or paralysis on one side of the body) on the right side, and was dependent on staff for bowel management (the process which a person with a bowel disability uses to manage fecal incontinence or constipation); however, nursing staff did not monitor for signs of constipation (a condition of the bowels in which the feces [stool - waste matter discharged from the bowels after food has been digested] are dry and hardened, and evacuation is difficult and infrequent), did not administer medication to treat the constipation per physician orders and nursing standards of practice, and did not notify Resident 61's physician or family that he was experiencing constipation. These deficient practices caused Resident 61 to: 1. Experience projectile vomiting (when your body expels vomit with more force than usual) and abdominal distention (abdomen measurably swollen beyond its normal size); and, 2. Be transferred to the hospital emergently, where he was diagnosed with a small bowel obstruction (partial or complete blockage of the small intestine; a medical emergency requiring immediate care), severe constipation, acute kidney injury (AKI; also known as acute renal failure, a sudden episode of kidney failure or kidney damage that occurs within a few hours or a few days), and hypernatremia (high blood sodium levels, an electrolyte imbalance). Findings: 1. Resident 21 During a review of the Face sheet (A one-page summary of important information about a resident) indicated Resident 21 was admitted on [DATE], with diagnosis including but not limited to: Diabetes Mellitus; Morbid obesity (resident weighed 100 pounds over his recommended weight); and Hemiparesis of the left side of the body. During a review of the Minimum Data Set (MDS -health status screening and assessment tool used for all residents), dated 12/10/23, indicated Resident 21 had a BIMS score of 15 out of 15 points (Brief Interview for Mental Status - a 15-point cognitive ([relating to the mental process involved in knowing, learning, and understanding things] screening measure that evaluates memory and orientation. A score of 13 to 15 is cognitively intact, 08 to 12 is moderately impaired, and 00 to 07 is severe impairment). The MDS indicated Resident 21 required Substantial/maximal assistance (Helper lifts or holds trunk or limbs and provides more than half the effort) from staff to roll from lying on his back to left and right side. During a review of the Progress Note, dated 12/20/23 at 3:26 p.m., the Progress Note indicated Resident 21 was found with deep tissue injury to the back of his right heel. The Progress Note indicated Resident 21 had a PRAFO boot on. During a review of Resident 21's January 2024, Physician's Order indicated an order written on 12/20/23, to monitor the popped blister (a small pocket of body fluid within the upper layers of the skin) on Resident 21's right heel every shift and to report to the physician if the condition worsened. During a review of the facility document titled, Weekly Skin Integrity Assessment for Non-Pressure Sore, dated 12/24/23, indicated an old scar on Resident 21's right lateral lower leg reopened due to, medical equipment damage. During a review of the facility document titled, Weekly Skin Integrity Assessment for Non-Pressure Sore, dated 1/10/24, indicated Resident 21's right lateral lower leg wound measured 14 cm. (centimeter - a unit of length) in length and 3 cm. in width. The document indicated, wound has drainage. During a review of the facility document titled, Weekly Skin Integrity Assessment for Non-Pressure Sore, dated 1/17/24, indicated Resident 21's right lateral lower leg wound measured 16 cm. in length, 3.5 cm in width and 2.5 in depth (deepness). The document indicated the wound had irregular edges, slough (thick, stringy, yellow dead tissue) on the wound bed (the base or open area of a wound) and had wound drainage. During a review of the facility document titled, Weekly Skin Integrity Assessment for Non-Pressure Sore, dated 1/24/24, indicated Resident 21's right lateral lower leg wound measured 16 cm. in length, 4 cm in width and 2.5 in depth. The document indicated the wound had irregular edges, slough on the wound bed and wound had drainage and odor. During a review of the Progress Note, dated 1/24/24 at 1:16 p.m., indicated the Wound Consultant saw Resident 21 on 1/24/24, and recommended to send Resident 21 to the hospital for debridement (the removal of damaged tissue or foreign objects from a wound). During a review of the hospital document titled, Wound Documents, dated 1/25/24, indicated Resident 21 had right fibula (the outer and usually smaller of the two bones between the knee and ankle in the hind or lower limbs) Osteomyelitis, bilateral (both) foot cellulitis (a common, potentially serious bacterial skin infection) and gangrene of his toes. During a review of the hospital document titled, Discharge Documents, dated 1/31/24, indicated Resident 1 had right above-the-knee amputation on 1/28/24. During an interview and concurrent record review with the Director of Nursing (DON) on 3/22/24 at 9:56 a.m., when the DON was asked about her expectation from the nurses on what to look for when a resident had a PRAFO boot, the DON stated she expected the treatment nurse and charge nurses to check the boot to make sure it was padded and applied properly, and to assess the skin underneath every shift for any skin breakdown. The DON stated, when a new wound was identified, she expected the nurses to assess and monitor the wound every shift and document the site and measurement of the wound, describe the appearance of the periwound (the area around the wound) whether redness, swelling, or maceration (a condition that occurs when a wound experiences excessive moisture, leading to the softening and breaking down of the surrounding skin) was observed, warm skin may indicate infection, document for presence of wound discharge or odor, undermining (occurs when significant erosion occurs underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface), tunneling (wound that has progressed to form an opening underneath the surface of the skin), assess for presence of pain, and document stage of the wound if a pressure sore. She stated nurses were to notify the resident's physician for new or worsening wounds and expected the physician to assess the wound within 48 hours. After review of the Licensed Nurses Progress Notes with the DON related to Resident 21's wound assessment, from 12/20/23 to 1/24/24, the DON stated there was no documentation from the nurses, every shift, of their wound assessment for Resident 21 to indicate whether the wound had improved or had worsened. During an interview with Licensed Nurse L on 3/25/24 at 10:48 a.m., when Licensed Nurse L was asked about the facility's process for wound assessment, she stated an initial skin assessment would be completed upon identification of new skin breakdown(s) and would be assessed and measured separately, every week. She stated, for new wounds and worsened wounds, both treatment and charge nurses were responsible to notify the doctor and obtain wound treatment orders. She stated wound assessment and documentation should be done every shift. Review of the Facility policy and procedure titled, Prevention of Pressure Ulcers, revised on 1/2024, indicated, The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed .Pressure can also come from splints, casts, bandages, and wrinkles in the bed linen. If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected. Review of the Facility policy and procedure titled, Change of Condition, revised on 1/2024, indicated, The licensed nurse responsible for the resident will continue assessment and documentation every shift for seventy-two (72) hours or until condition has stable. 31424 2. Resident 61 During an interview on 03/22/24 at 11:30 p.m., Confidential Family Member (CFM) stated Resident 61 had a hospital stay due to constipation. The CFM stated the facility nurses told her Resident 61 had no bowel movement for ten days and staff had to, clean him out at the hospital. When asked if facility nursing staff had informed her of Resident 61's ten-day constipation, CFM stated, No. When asked if nursing staff had informed Resident 61's physician of the constipation, the CFM stated she did not know. Review of Resident 61's facility medical record indicated a Nurse's Progress Note, dated 12/29/23 at 10:05 p.m., that indicated, . Resident had 3 episodes of projectile vomiting at around 8 p.m. Emesis (vomit) yellowish in color with moderate amount. HOB (head of bed) elevated to prevent aspiration (vomit getting into the lungs) . Assessed resident and noted with distended abdomen (swollen abdomen) . Resident is on G tube (gastrostomy tube; a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine), cont. (continuous) feeding . No s/s (signs or symptoms) of pain. (Hospital) MD and RP (family) notified . Non-emergency ambulance to transfer resident to hospital for further evaluation and treatment. While waiting for the ambulance resident vomited again x 2 (twice) with moderate amount and yellowish in color . Resident left the facility via gurney . Review of Resident 61's hospital medical record (reflecting Resident 61's seven-day hospital stay from 12/29/23 through 1/5/24), Physician Discharge Summary (dated 1/5/24), indicated Resident 61 had a, .history of stroke, (was) non-verbal, G-Tube dependent . Brought by ambulance from (the facility) for multiple episodes of vomiting and abdomen distension. In the ED (Emergency Department) . CT (Computed Tomography; a computerized x-ray imaging procedure) of abdomen and pelvis showing [sic] SBO (small bowel obstruction) . Documentation of Resident 61's hospital course indicated Resident 61 was, .found to have severe constipation. Surgery (provider) evaluated patient, recommended aggressive bowel regimen (set of medications to help people avoid or relieve constipation; may involve medications, laxatives, and lifestyle changes). Patient was started on aggressive bowel regimen, which resolved his constipation. Once constipation resolved, patient tolerated his tube feeds (liquid nutrition via G-tube) well sodium elevated to 153 (normal sodium is 135-145) . likely secondary to dehydration. Hypernatremia and acute kidney injury resolved after IV (intravenous) fluids and increased free water flushes (into his feeding tube) . Review of Resident 61's nursing care plan, (dated 1/6/24), indicated, (Resident 61) is at risk for constipation r/t (related to) decreased mobility d/t (due to) complex medical conditions . Care plan interventions indicated, . Follow facility bowel protocol for bowel management . Review of Resident 61's medical record revealed a nursing summary assessment, dated 12/25/23 (four days prior to hospital transfer), that indicted Resident 61's last bowel movement was 12/22/23 (three days earlier). Review of Resident 61's December 2023 MAR (Medication Administration Report; record where nurses document interventions and medications) indicated nurses administered Dulcolax suppository (fast-acting stimulant laxative) and Milk of Magnesia (laxative) on 12/28/23 (three days after documenting his constipation). Fleets Oil enema (lubricant laxative that lubricates and softens the stool) and Senna tablet (laxative used to relieve constipation) were ordered to be given as needed; nursing staff did not document these medications were given. Review of Resident 61's physician orders (with order range dates from 12/12/23 through 12/29/23), indicated the following active (prior to Resident 61's transfer to the hospital) medication orders: Dulcolax Suppository (ordered 12/12/23) . Insert 1 suppository rectally every 24 hours as needed for Bowel Regularity if MOM ineffective (daily/PRN) . Fleet Oil Enema (ordered 12/12/23) . Insert 1 application rectally as needed for Bowel Regularity if Dulcolax is ineffective, GIVE FLEET ENEMA ON THE NEXT SHIFT . Mild of Magnesia Suspension . (ordered 12/12/23) Give . needed for Bowel Regularity if no BM in 2 days . Senna Oral Tablet (ordered 12/13/23) . as needed for bowel Regularity Give 2 tablet(s) via G-Tube as needed at bedtime . A physician order, dated 12/12/23, indicated, Bowel Care Management. Call MD for further intervention/instruction if Fleet Enema is not effective. During an interview on 3/26/24 at 9:59 a.m., the Nurse Practitioner (NP) was asked about her expectation for nursing staff regarding bowel care for Resident 61. The NP stated all residents were started on a bowel regimen and it was standard (nursing) practice to implement bowel care (such as medication administration) if a resident did not have a bowel movement for three days. During an interview and concurrent medical record review on 3/26/24 at 10:52 a.m., the Director of Staff Development (DSD) reviewed Resident 61's bowel care, December 2023 MAR, and nursing summaries. The DSD stated Resident 61's routine bowel care (prior to his hospitalization ) did not include scheduled medication (given routinely). The DSD confirmed the nursing summary, dated 12/25/23, indicated Resident 61's last bowel movement was on 12/22/24, but nursing did not administer medication to treat the constipation for an additional three days (on 12/28/23). The DSD confirmed nursing staff did not administer medication (already ordered by the physician) to treat Resident 61 for three days after his constipation was discovered by nursing on 12/25/23; he confirmed on 12/28/23, nursing staff medicated Resident 61 with Milk of Magnesia and Dulcolax. During the same interview on 3/26/24 at 10:52 a.m., the DSD confirmed nursing staff did not document they called anyone (including Resident 61's physician and family) regarding his constipation. When asked what his thoughts were regarding Resident 61's care, the DSD stated, We didn't do good bowel care, and he ended up in the hospital. When asked what nursing staff should have done on 12/25/23, the DSD stated the nurse should have given the ordered medication (to treat constipation) and asked (the doctor) for an order to perform a digital check for constipation (also called a digital exam; technique used to assess the presence of constipated stool in the rectum). The DSD confirmed the nursing care provided to Resident 61 did not reflect his high risk for constipation. When asked if he was aware Resident 61 had been impacted (inability to evacuate large, hard stool in the lower gastrointestinal tract) with stool, the DSD stated he heard about it after Resident 61 returned from his hospital stay. Review of facility policy titled, Bowel (Lower Gastrointestinal Tract) Disorders - Clinical Protocol (revised 1/2024), indicated, . 2. Examples of lower gastrointestinal tract conditions and symptoms include: . i. Constipation . 3 . the nurse shall assess . d. Presence of fecal impaction; e. Signs of dehydration . f. Abdominal assessment; g. Digital rectal exam . i. All current medications . Under subtitle, Treatment/Management, the policy indicated, 1. The physician will identify and order pertinent cause-specific interventions, for example, modify tube feedings . institute a regimen to prevent constipation . 3. The staff and physician will address significant complications due to bowel dysfunction . 5. The physician will help identify the possible need for hospitalization to manage a gastrointestinal disorder . Under subtitle, Monitoring and Follow-Up, the policy indicated, The staff and physician will monitor the individual's response to interventions and overall progress, for example . frequency and consistency of bowel movements . 2. The physician will adjust interventions based on . resident responses to treatment .

Based on interview and record review, the facility failed to prevent an avoidable physical altercation between two residents, Resident 3 & Resident 4 who were left alone, unsupervised in the Activity Room on 11/18/22. This failure resulted in a bloody nose injury to Resident 4, which required transfer to Emergency Department by ambulance. Findings: A review of the facility record titled, Resident to Resident Altercation 5-day Summary Report, dated 11/25/22, incident date 11/18/22, at 1:45 p.m., in the Activity/Dining Room indicated, per a report by [LN N] Charge Nurse at approximately 1:45 p.m., Resident 3 was found with Resident 4 in the Dining Room. Resident 3 had a bloody nose. The report indicated LN N immediately separated both residents, and body assessments were done. First aid was provided for Resident 3. There were no noted witnesses to the incident. Resident 3 was a [AGE] year-old male who was admitted to the facility on [DATE], with the diagnosis of dementia and repeated falls, with a BIMS (Brief Interview for Mental Status) of Zero (0), indicating Resident 3 had severely impaired cognition. Resident 4 was a [AGE] year-old male who was admitted on [DATE], with diagnoses of epileptic seizures and multiple sclerosis, with BIMS score of 15, which indicated he had no cognitive impairment. Resident 4 stated Resident 3 called him inside the Dining/Activity Room. Resident 4 wheeled himself inside the room, and Resident 3 punched Resident 4, and in return, Resident 4 punched Resident 3 in the nose in self-defense. During a telephone interview on 8/9/23 at 1:20 p.m., the DSD (Director of Staff Development) stated he provided in-services training to all staff twice a year, or as needed, on abuse and dementia. The DSD stated residents must be supervised while in the Activity/Dining room. During an interview on 8/9/23 at 3 p.m., the Director of Nursing (DON) stated there must be a staff present to supervise residents while in the Dining/Activity Room. The DON stated, if there was no staff present, then no resident should stay inside the Dining/Activity Room. The DON stated, if residents were left alone in the Dining/Activity Room, there was potential for un-witnessed falls and resident-to-resident altercations. During an interview on 8/9/23 at 2:40 p.m., Unlicensed Staff E (Activity Assistant) stated, on 11/18/23 at 2 p.m., there was no activity in the room at that time, and no residents should be in the room without staff supervision. During an interview on 8/9/23 at 3:33 p.m., Unlicensed Staff F (Activity Assistant) stated, after Dining or Activities, all residents returned to their own rooms by the Certified Nursing Assistant (CNA) to be cleaned and have changed undergarments. Unlicensed Staff F stated there should be no residents left inside the Dining/Activity Room due to the area needing to be cleaned after use. During an interview on 8/9/23 at 3:40 p.m., License Nurse (LN) G stated, if there was no staff in the Dining/Activity Room, then there should not be any unsupervised residents. During an interview on 8/9/23 at 3:50 p.m., the Administrator (ADM) stated there should be a staff member inside the Dining/Activity Room to supervise residents. A review of the Policy & Procedures (P&P) titled, Staffing, Sufficient and Competent Nursing, revised 8/2022, indicated, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. Under Sufficient staff: 4) Licensed nurses are required to supervise nurse aides/nursing assistants and are scheduled in such a way that permits adequate time to do so. 5) Nurse aides/nursing assistants are individuals providing nursing or related services to residents in the facility, including those who provide services through an agency or under a contract with the facility. 6) Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident ' s plan of care, the resident assessments and the facility assessment. 7) Factors considered in determining appropriate staffing ratios and skills include an evaluation of the diseases, conditions, physical or cognitive limitations of the resident population, and acuity. Under Competency Staff: 1) Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupation functions successfully. 4) Licensed nurses and nursing assistants are trained and must demonstrate competency in identifying, documenting, and reporting resident changes of condition consistent with their scope of practice and responsibilities. 7) Inquiries or concerns relative to our facility ' s staffing should be directed to the Director of Nursing Services or his/her designee. A review of, Lesson Plan, for, Mandated Reported of Elder Adult Abuse, dated, 2/5/23, 3/11/23, 4/26/23 & 7/10/23, indicated, Abuse can occur anywhere, including at home and in care settings. People with dementia are especially vulnerable because the disease may prevent them from reporting the abuse or recognizing it. They also may fall prey to strangers who take advantage of their cognitive impairment. Strained or tense relationships and frequent arguments between the caregiver and person with disease may be a sign of abuse. Abuse may originate from either a caregiver or a person with dementia. A person with dementia may exhibit more aggressive behaviors as the disease progresses and cognitive function and ability to reason decline. No one should live in threat of harm or danger to themselves or others.

Based on interviews and records review, the facility failed to assess and monitor for signs of constipation (a condition of the bowels in which the feces [stool - waste matter discharged from the bowels after food has been digested] are dry and hardened and evacuation is difficult and infrequent) and did not administer medication to relieve constipation according to the doctor ' s order for one of three sampled residents (Resident 1). This failure resulted in Resident 1 ' s emergent transfer to the hospital due to large bowel (large intestine - the place where feces are formed) obstruction (a blockage that keeps gas or stool from passing through the body). Findings: During an interview with Family Member A on 7/24/23 at 10:54 a.m., Family Member A stated Resident 1 was transferred to the hospital sometime in November of 2022. Family Member A stated Resident 1 was constipated, and the facility did not do anything. Family Member A stated, [Resident 1] had two feet of constipation in her bowels. He stated the hospital had to place a tube in Resident 1 ' s throat and in her rectum (the final section of the large intestine, terminating at the anus) to relieve Resident 1 from constipation. During a record review for Resident 1, the Face sheet (A one-page summary of important information about a resident) indicated Resident 1 was admitted on [DATE], with diagnoses including but not limited to: Malignant Neoplasm (means that a tumor [a swelling of a part of the body, generally without inflammation, caused by an abnormal growth of tissue] is cancerous [affected by or showing abnormalities characteristic of cancer]) of the Right Kidney; Congestive Heart Failure (CHF - blood often backs up and fluid can build up in the lungs, causing shortness of breath); Diabetes Mellitus (disease that result in too much sugar in the blood); Morbid obesity (resident weighs 100 pounds over her recommended weight); and Ileus (Inability of the intestine (bowel) to contract normally and move waste out of the body). During a record review for Resident 1, the Minimum Data Set (MDS -health status screening and assessment tool used for all residents), dated 11/05/22, indicated, Resident 1 ' s cognitive (relating to the mental process involved in knowing, learning, and understanding things) skills for daily decision making was severely impaired (have a very hard time remembering things, making decisions, concentrating, or learning). The MDS indicated Resident 1 was non-ambulatory (unable to walk) and was occasionally incontinent (having no or insufficient voluntary control) of bowel and bladder function. During a record review for Resident 1, the document titled, Order Review Report, for November 2022, indicated a doctor ' s order, written on 5/26/22, for Bisacodyl Suppository (a cylindrical shaped laxative, designed to be inserted into the rectum to treat constipation by softening hard stools or stimulating bowels to get moving) and Docusate Sodium capsule (a laxative), as needed for constipation; however, the order did not specifically indicate a parameter when nurses should administer the medication. During a review of the Care Plan, initiated on 6/03/22, indicated Resident 1 was at risk for constipation due to decrease in mobility and use of narcotics (a drug [such as opium or morphine] that in moderate doses dulls the senses and relieves pain). The Care Plan interventions indicated: Assessment of resident; monitor bowel movement; provide diet high in fiber if possible; increase activity; medications as ordered; and notify doctor for any signs and symptoms of constipation or if no BM in 3 days. During a record review for Resident 1, the Progress Note titled, Nurses Notes, dated 11/05/22 at 5:16 p.m., indicated, [Family Member A] called 911 (fire service personnel provide initial response to 911 calls in fire trucks) without telling the staff anything. He claimed [Resident 1] was having trouble breathing, but never once made any of the staff aware. Paramedic (a healthcare professional who responds to emergency calls for medical help outside of a hospital) arrived and took [Resident 1] to the ER. (emergency room ). During a review of the hospital record titled, History and Physical (H & P - a formal and complete assessment of the patient and the problem), dated 11/05/22, indicated Resident 1 presented to the hospital with, two days history of progressive worsening abdominal pain with distention. [Resident 1] has not had bowel movement for more than 5 days, also has been having intermittent nausea with occasional vomiting. The document listed problems for Resident 1, including but not limited to, large bowel obstruction and fecal impaction (stool builds up in the rectum, eventually becoming hard and impacted that makes it more difficult to pass, loose, runny stool behind the impaction begins to leak out around the impaction). During a review of the hospital record titled, Computerized Tomography (a procedure that uses a computer linked to an x-ray machine to make a series of detailed pictures of areas inside the body), dated 11/05/22, indicated Resident 1 had a Large bowel obstruction with severe fecal loading (the volume of fecal material in the colon) in the rectosigmoid colon (the terminal portion of the large intestine before reaching the rectum). During an interview with Licensed Staff B on 9/11/22 at 11:42 a.m., when asked how did the nurses ensure residents were free from constipation, Licensed Staff B stated NOC (night) shift nurses were responsible for pulling the bowel report and would provide medication to treat constipation, to residents who did not have bowel movement, according to the doctor ' s order. Licensed Staff B stated, if the initial medication administered was ineffective, AM shift nurses would administer another medication that was listed from the doctor ' s order, for constipation. During an interview with Licensed Staff B on 9/11/22 at 12:14 p.m., when asked how would she know if a resident was constipated or had fecal impaction, Licensed Staff B stated the resident could have a distended abdomen, decreased to no bowel sounds, nausea, little and hard or loose stool. Licensed Staff B stated loose stool did not mean a resident had diarrhea. During an interview with Licensed Staff C on 9/11/22 at 12:21 p.m., when asked how would she know if a resident was constipated or had fecal impaction, Licensed Staff C stated the resident could have no bowel movements for days, could have hard stool in his/her rectal vault (this is where the stool collects just before it's ready to come out), the resident could have decreased oral intake, and absent bowel sounds (abdominal sounds - made by the movement of the intestines as they push food through), and the resident could also show signs of discomfort. Licensed Staff C stated Resident 1 was always irritable and often refused to eat prior to her hospitalization . During a review of Resident 1 ' s Face sheet and concurrent interview with the DON (Director of Nursing) on 9/11/23 at 12:49 p.m., the DON verified Resident 1 ' s Face sheet indicated Resident 1 had a diagnosis of Ileus. When asked about her expectations from the nurses on what to monitor when a resident had ileus, the DON stated the nurses were to monitor the resident ' s bowel movement. After review of the document titled, Documentation Survey Report, for October 2022, for Resident 1 with the DON, the DON verified Resident 1 had no bowel movement on 10/27/22 and 10/28/22; large soft stool on 10/29; small, loose stool on 10/30/22 and 10/31/22. The DON stated, small loose stool could also be a sign of constipation and not diarrhea. The DON stated this could also mean that hard stool was just sitting in the rectum and loose stool escaped. During a review of the Medication Administration Record (MAR) for Resident 1 and concurrent interview with the DON on 9/11/23 at 1:05 p.m., the DON verified Resident 1 had a doctor ' s order written on 5/26/22, for Bisacodyl Suppository and Docusate capsule, as needed for constipation. The DON stated Resident 1 received Docusate capsule on 10/05/22, and Bisacodyl Suppository on 10/14/22; however, Resident 1 did not receive either Docusate capsule or Bisacodyl Suppository from 10/27/22 to 10/31/22. The DON stated nurses should have provided the medication to Resident 1 on the second day of no bowel movement. The DON also stated Resident 1 did not have an order for a routine bowel regimen (bowel regimen is a set of medications to help people avoid or relieve constipation) which Resident 1 should have, considering Resident 1 had ileus and was on routine narcotic for pain management, putting Resident 1 at high risk of constipation. During a review of the document titled, Documentation Survey Report, for November 2022, the document indicated Resident 1 did not have bowel movement on 11/01/22; had small, soft stool on 11/2/22; large soft stool on 11/3/22; small soft stool on 11/4/22 and small loose stool on 11/5/22. During a review of the November 2022, MAR for Resident 1; the MAR from 11/01/22 to 11/05/22, did not indicate Resident 1 received either Bisacodyl Suppository and Docusate capsule. Review of the Facility policy and procedure titled, Bowel (Lower Gastrointestinal Tract) Disorders - Clinical Protocol, revised in September 2017, indicated, As part of the initial assessment, the staff and physician will help identify individuals with previously identified lower gastrointestinal tract conditions and symptoms. Policy ' s Treatment/management indicated, The physician will identify and order pertinent cause-specific and symptomatic interventions; for example, stop medications causing ileus, and institute a regimen (a prescribed cours

Based on observation, interview and record review, the facility failed to ensure residents received care to prevent pressure ulcers from developing and worsening, for one out of three sampled residents (Resident 3), when the facility did not create and implement a care plan (a document that specifies your health care and support needs and outlines how your provider will meet your requirements) to address Resident 3's risk for developing pressure sore (an injury that breaks down the skin and underlying tissue, caused when an area of skin is placed under pressure), did not implement the physician order or recommendation to place Resident 3 on a low air loss mattress (LAL, a mattress designed to prevent and treat pressure wounds) and was unable to provide proof Resident 3 was being turned and repositioned, consistently, every two hours to prevent formation or worsening of pressure sores. These failures resulted in Resident 3 developing an infected wound and acquiring a Stage 4 pressure sore (the most severe type of pressure ulcer, where the skin is severely damaged, and the surrounding tissue begins to die (tissue necrosis) on his buttocks and sacrum (a large, triangle-shaped bone in the lower spine). Findings: During a review of Resident 3's face sheet, it indicated Resident 3 was [AGE] years-old and was initially admitted to the facility on [DATE]. His diagnoses included Depression (a mental disorder characterized by persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities), Diabetes Mellitus (DM, a condition that happens when the body can't use glucose (a type of sugar) normally), Anemia (a condition where the body does not get enough oxygen-rich blood. The lack of oxygen can make you feel tired or weak) and Dysphagia (difficulty swallowing). His initial Minimum Data Set (MDS, a standardized assessment tool that measures health status in nursing home residents, Brief Interview for Mental Status -- BIMS, a mandatory tool used to screen and identify the cognitive condition of residents), dated 11/1/22, indicated a score of 10, suggesting a moderately-impaired cognition. The MDS assessment also indicated Resident 3 needed a limited assistance of one staff in performing his Activities of Daily Living (ADL's, activities related to personal care such as bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). The MDS assessment, section M for Skin Conditions, dated 11/1/22 and 1/23/23, indicated Resident 3 had no pressure sores during that assessment period. The MDS assessment, dated 3/17/23, section M, indicated Resident 3 now had a Stage 4 pressure sore. A review of the Nurse Note, dated 3/17/23, 10:09 p.m., indicated Resident 3 had a Stage 4 pressure sore on his sacrum (a large, triangle-shaped bone in the lower spine) when he was sent to the hospital. During an interview on 3/28/23 at 10:59 a.m., Unlicensed Staff A stated residents should be checked and changed for incontinence episode every two hours because if this was not done, it could result in pressure sore development and skin infection. Unlicensed Staff A stated residents with pressure sores should be on a LAL mattress to prevent development or worsening of pressure sores. Unlicensed Staff A stated staff should turn and reposition residents' frequently every two hours as well, to prevent the development or worsening of the pressure sores. Unlicensed Staff A could not recall whether Resident 3 had a two-hour turning and repositioning schedule or log staff filled out to indicate Resident 3 was being turned and repositioned every two hours. Unlicensed Staff A stated, if a resident was not on a LAL mattress and staff were not turning and repositioning residents' frequently, it could lead to pressure sore development. Unlicensed Staff A stated this could also lead to residents experiencing pain. During an interview on 3/28/23 at 11:07 a.m., Unlicensed Staff B stated it was the facility's policy to check and change incontinent residents every two hours. Unlicensed Staff B stated, if residents were left soaked in their urine or feces, this could result in skin issues, wounds and infection. Unlicensed Staff B stated the facility policy was to ensure residents were on a LAL mattress to prevent development or worsening of pressure sores. Unlicensed Staff B stated staff should turn and reposition residents every two hours at least, per facility policy. Unlicensed Staff B stated, if a resident did not have a LAL mattress and staff were not turning and repositioning residents every two hours, it could lead to pressure sore development and further skin issues. Unlicensed Staff B stated these could lead to residents feeling depressed and in pain. During an interview on 3/28/23 at 11:30 a.m., Licensed Staff C stated the facility policy was to ensure residents had a LAL mattress, especially for residents with sores or who were at risk for skin breakdown. Licensed Staff C did not recall whether Resident 3 was on a LAL mattress. Licensed Staff C stated staff should also turn and reposition residents frequently at least every two hours. Licensed Staff C stated, if a resident was not on a LAL mattress and was left soiled with urine or feces for a long period of time, this could lead to development and worsening of pressure sore. During an interview on 3/28/23 at 11:42 a.m., Licensed Staff D stated, per the facility policy, staff should check and change residents for incontinence episodes every two hours. Licensed Staff D stated, if this was not done, then the facility policy was not followed. Licensed Staff D stated, if residents were left sitting in urine and feces for a long period of time, it could result in skin issues. Licensed Staff D stated residents would feel they were ignored, like nobody wanted to help. Licensed Staff D stated the facility policy was to ensure residents who were at a high risk for skin breakdown, be on a LAL mattress. Licensed Staff D did not recall if Resident 3 was on a LAL mattress. Licensed Staff D stated staff should be turning and repositioning residents every two hours to prevent skin issues and increase circulation. Licensed Staff D did not recall whether Resident 3 had a two-hour turning and repositioning schedule or log staff filled out to indicate if he was being turned and repositioned every two hours. Licensed Staff D stated, if residents who were at high risk for skin breakdown or residents who already had a pressure sore did not have a LAL mattress and staff were not turning and repositioning them every two hours, this could result in further skin issues, and development or worsening of pressure sores. During an interview on 3/28/23 at 11:54 a.m., the MDS coordinator stated he was not sure of what the facility's policy was with regards to incontinence care. The MDS coordinator stated, if a resident was left sitting in urine or feces for a long period of time, it could lead to skin impairments, and worsening or development of wounds or pressure sores. The MDS coordinator stated residents with pressure sores should be on a LAL mattress, so the sore did not worsen. The MDS coordinator could not recall whether Resident 3 was on a LAL mattress. The MDS coordinator stated, if a resident was not on a LAL mattress and was not being turned and repositioned frequently, it could lead to skin breakdown, and development or worsening of wounds or sores. During an interview on 3/28/23 at 12:54 p.m., the DON stated incontinence care should be rendered to residents every two hours and as needed, per the facility policy. The DON stated, if this was not done, it could result in skin breakdown and skin infection. The DON stated residents with pressure sores should be placed on a LAL mattress to prevent development or worsening of wounds or sores. The DON stated staff should be turning and repositioning residents every two hours. The DON stated, if staff were not turning or repositioning residents every two hours, it could lead could to skin impairments, and development or worsening of wounds or sores. During a concurrent interview, nursing note, care plan and weekly skin assessment record review on 4/3/23 at 9:31 a.m., the MDS coordinator verified Resident 3's nursing admission skin assessment indicated Resident 3 had no pressure sores when he was initially admitted to the facility. The MDS coordinator, upon reading the weekly skin assessments, verified Resident 3 was noted with a Stage 2 pressure sore (occurs when skin breaks open or wears away, which was usually tender and painful. The sore expands into deeper layers of the skin. It can look like a scrape [abrasion], blister, or a shallow crater in the skin) on his left buttocks on 2/2/23, measuring 4 centimeters (cm, a unit of measurement) in length by 4 cm in width but with no depth. The MDS coordinator also verified Resident 3's right buttocks and sacrum were noted with a Suspected Deep Tissue Injury on 2/2/23 (SDTI, a pressure ulcer defined as purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure or shear), measuring 6 cm by 5 cm with no depth. The MDS coordinator verified there was a weekly skin assessment documentation, dated 2/9/23, indicating Resident 3's pressure sores on his left and right buttocks, including the sacrum, had all fused into one SDTI, measuring 9 cm by 11 cm with no depth. The MDS coordinator verified the weekly skin assessment, dated 2/23/23, indicated Resident 3 had a Stage 4 pressure sore on his sacrococcyx area (the area between the apex of the sacrum and the base of the tailbone), measuring 10 cm by 11.5 cm by 3 cm in depth. The MDS coordinator verified Resident 3's weekly skin assessment, dated 3/1/23, indicated Resident 3's Stage 4 pressure sore was measured at 10 cm by 12 cm by 2.5 cm in depth. Resident 3's weekly skin assessment, dated 3/8/23, indicated Resident 3's stage 4 pressure sore was measured at 10 cm by 11 cm with 2.5 cm in depth. The MDS coordinator verified the Stage 4 wound measurement on 3/15/23, remained at 10 cm by 11 cm with 2.5 cm in depth. The MDS coordinator stated, based on these weekly skin assessment documentation, Resident 3 was admitted with no pressure sore but developed a worsening pressure sore while at the facility. The MDS coordinator stated residents with pressure sores were placed on a LAL mattress as a preventative measure, to help heal existing pressure sores or to decrease the chance of the pressure sore from worsening. The MDS coordinator stated it was also important to turn and reposition residents frequently and clean them up immediately when they were soiled. He stated not having a LAL mattress, not consistently turning and repositioning residents or leaving a resident soiled for a long period of time, could result in development or worsening of pressure sores. The MDS coordinator verified Resident 3 had no care plan that specifically addressed his risks for pressure sore development. During an interview on 4/3/23 at 10:30 a.m., Licensed Staff D stated Resident 3 should have a care plan that addressed risk factors for pressure sore development. Licensed Staff D stated the interventions to prevent development and worsening of pressure sores included a LAL mattress, especially when a resident had a pressure sore already, turning and repositioning every two hours, and not leaving a resident wet or soiled for a long period of time. Licensed Staff D stated LAL mattress was important because it offloaded pressure on wounds and bony prominence's. Licensed Staff D stated, if a resident did not have a LAL mattress, and staff were not turning and repositioning the resident every two hours , or if staff were leaving a resident soiled for a long period of time, this could put the resident at risk for developing or worsening of pressure sores. During a review of the Advantage Medical wound notes on 4/4/23 at 4 p.m., the wound physician note, dated 2/9/23, indicated the sacrum pressure sore was worsening. The Advantage Medical wound notes by the wound physician, dated 2/23/23, indicated Resident 3 was sent to the hospital on 2/13/23, for sepsis (severe infection), infected sacral pressure sore. The note indicated Resident 3 had stool present on his periwound, and he was not on a LAL mattress. The wound note also indicated the wound physician recommended to offload pressure and to turn and reposition Resident 3 every two hours. The Advantage Medical wound notes by the wound physician, dated 3/1/23, indicated Resident 3's pressure sore had foul odor and the sore was deteriorating. The note indicated, patient continued having loose BM and unformed stool (feces) was present on the peri-wound (the area around the wound) and within the wound. The note also indicated Resident 3 still was not on an offloading mattress, while the physician continued to recommend pressure relieving measures and offloading (relieving pressure on a part of the body) as tolerated. The Advantage Medical wound notes by the wound physician, dated 3/8/23, under a 2/9/23 entry, indicated Resident 3 was on an isolation unit without being frequently assessed and repositioned, and Resident 3 was not on a LAL mattress. The Wound note also indicated there was a large amount of stool present covering Resident 3's sacral areas, buttocks and thighs. The wound physician continued to recommend the facility implement pressure relieving measures and offloading as tolerated. The Advantage Medical wound notes by the wound physician, dated 3/15/25, indicated the physician ordered a LAL mattress while continuing to recommend pressure relieving measures and offloading. During a review of Resident 3's Braden Scale (a standardized, evidence-based assessment tool commonly used in health care to assess and document a patient's risk for developing pressure injuries) for Prediction of Pressure Sore Risk score on 4/5/23 at 2:30 p.m., the Braden Score for 10/25/22, was 11, indicating Resident 3 was a high risk for developing pressure sore. Resident 3's Braden Score for 1/17/23, was 11, indicating Resident 3 was a high risk for developing pressure sore. During a phone interview on 4/5/23 at 4:35 p.m., the wound doctor verified that during her weekly wound rounds with Resident 3, she had not seen Resident 3 on a LAL mattress. The wound doctor stated she had actually spoke to both the DON and the Administrator this day, about ensuring Resident 3 was placed on a LAL mattress, was turned and repositioned every two hours and not left soiled for a long period of time, so he did not develop a new pressure sore and his current pressure sore did not worsen. The wound doctor stated Resident 3 not being placed on a LAL mattress and not being turned and repositioned every two hours consistently, contributed to Resident 3's developing and worsening pressure sore on his sacrum. During a review of the facility's policy and procedure (P&P), titled, Pressure Ulcers/Skin Breakdown- Clinical Protocol, revised 4/2018, the P&P indicated the nursing staff and practitioner would assess and document an individual's significant risk factors for developing pressure ulcers .the physician would order pertinent wound treatments including pressure reduction surfaces .

Based on observation, interview and record review, the facility failed to provide scheduled showers and incontinence care for 10 of 16 sampled residents (Residents 1, 5, 20, 21, 31, 35, 42, 44, 49 and 151) who were dependent on staff for Activities of Daily Living (ADLs: Hygiene, mobility, toileting, dining and communication). These failures placed Residents 1, 5, 20, 21, 31, 35, 42, 44, 49 and 151 at risk of having poor hygiene and resulted in three residents (Residents 1, 20 and 151) developing Moisture-Associated Skin Damage (MASD) on their buttocks and one resident (Resident 1) developing scabs over his shins and feet. Findings: RESIDENT 1 A review of Resident 1's Facesheet indicated he was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS - an assessment tool), dated 9/7/22, indicated a Brief Interview for Mental Status (BIMs) score of 5 (scores of 0-7 indicate severe cognitive impairment). Resident 1's MDS also indicated Resident 1 was incontinent of bowel and bladder and needed, extensive assistance, with personal hygiene. A review of Resident 1's care plans indicated no care plans for hygiene or incontinence. RESIDENT 5 A review of Resident 5's Facesheet indicated he was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 5's Minimum Data Set (MDS - an assessment tool), dated 6/17/22, indicated a Brief Interview for Mental Status (BIMs) score of 3 (scores of 0-7 indicate severe cognitive impairment). Resident 5's MDS also indicated Resident 5 was incontinent of bladder, had a [CONDITION(S)] bag (a pouch artificially connected to the large intestine that collects feces), and was totally dependent on staff for personal hygiene. A review of Resident 5's care plans indicated a care plan, dated 10/8/21, titled, Noted with incontinent bladder . needs total assistance with toileting, with the following intervention, Provide peri care after each incontinence episode. RESIDENT 20 A review of Resident 20's Facesheet indicated he was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 20's Minimum Data Set (MDS - an assessment tool), dated 8/2/22, indicated a Brief Interview for Mental Status (BIMs) score of 5 (scores of 0-7 indicate severe cognitive impairment). Resident 20's MDS also indicated Resident 20 was incontinent of bowel and bladder and was totally dependent on staff for personal hygiene. A review of Resident 20's care plans indicated a care plan, dated 2/14/20, titled, Incontinent of B&B [Bowel and Bladder] . requires total assistance with . toileting, with the following intervention, Provide skin care after each incontinence. RESIDENT 35 A review of Resident 35's Facesheet indicated she was originally admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 35's Minimum Data Set (MDS - an assessment tool), dated 8/12/22, indicated a Brief Interview for Mental Status (BIMs) score of 3 (scores of 0-7 indicate severe cognitive impairment). The MDS also indicated Resident 35 was dependent on staff for toilet use and bathing. A review of Resident 35's care plans indicated a care plan, dated 12/15/15, titled, Self-care deficit with ADL functioning . needs assist in ADL's form (sic) the staff . and needs . assistance for toileting RESIDENT 151 A review of Resident 151's Facesheet indicated she was originally admitted on [DATE], with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 151's Minimum Data Set (MDS - an assessment tool), dated 7/22/22, indicated a Brief Interview for Mental Status (BIMs) score of 6 (scores of 0-7 indicate severe cognitive impairment). Resident 151's MDS also indicated Resident 151 was incontinent of bowel and bladder and was dependent on staff for toilet use and bathing. A review of Resident 151's care plans indicated no care plans for incontinence or bathing. During an interview on 9/14/22, at 3:10 p.m., the Director of Nursing (DON) stated Certified Nursing Assistants (CNAs) provided resident showers, and all residents were given showers twice a week according to the shower schedule. The DON stated residents also received showers whenever requested. The DON provided the shower schedule indicating shower days for each resident in the facility. The DON stated CNAs documented showers on shower sheets which were kept in shower binders in the nursing station. The DON stated each shower should be documented on a shower sheet, and if residents refused showers, the refusal should be documented as well. The DON provided the shower binder for residents in Wing D of the facility and stated it contained shower sheets for September 2022. A review of the shower binder indicated it contained shower sheets for July, August and September 2022. A review of the shower sheets from July to September 2022, indicated Residents 1, 5, 20, 35 and 151 received showers on the following days: Resident 1 received showers on 7/8/22, 7/15/22, 7/19/22, 8/15/22 and 8/19/22. No shower refusals documented. Resident 5 received showers on 7/25/22, 9/1/22, 9/5/22 and 9/8/22. No shower refusals documented. Resident 20 received showers on 7/4/22, 7/11/22, 7/15/22, 7/18/22, 7/22/22, 7/25/22, 7/29/22, 8/8/22, 8/19/22, 9/5/22 and 9/12/22. No shower refusals documented. Resident 35 received showers on 7/12/22, 7/26/22, 7/29/22, 8/23/22. No shower refusals documented. Resident 151 received showers on 7/4/22, 7/7/22, 7/11/22, 7/14/22, 7/18/22, 7/21/22, 7/25/22 and 7/28/22. No shower refusals documented. During an interview on 9/15/22, at 9:08 a.m., CNA F stated CNAs documented all resident care on the facility's electronic charting system. During an observation on 09/15/22 9:30 a.m., CNAs B and F were providing care to Resident 20, who was incontinent and dependent for care. CNAs B and F stated Resident 20 was soiled. During a concurrent interview, CNAs B and F stated they would clean and provide a bed bath to Resident 20. The bed bath consisted of wiping Resident 20 with a moistened washcloth. During an interview and record review on 9/16/22, at 10:24 a.m., the DON stated CNAs also documented showers on the facility's electronic charting system (CNA Flowsheets). The DON was asked to review the CNA Flowsheets for Residents 1, 5, 20, 35 and 151, for July, August and September 2022, and to indicate when those residents had showers. The DON reviewed printed copies of the CNA Flowsheets, but stated he could not interpret them. A review of the CNA Flowsheets for Residents 1, 5, 20, 35 and 151, for July, August and September 2022, indicated a field called, BATHING, with the option to document the date of the bath and the type, with the following options: Complete Bed Bath, Partial Bed Bath, Shower, Tub Bath or Other. A review of these flowsheets indicated Residents 1, 5, 20, 35 and 151, had showers on the following days in July, August and September 2022: Resident 1 received showers on 7/1/22, 7/5/22, 7/8/22, 7/19/22, 7/29/22, 8/16/22, 8/19/22, 8/23/22 and 8/30/22. No showers noted in September and no documented shower refusals. Resident 5 received showers on 7/25/22, no documented showers in August, 9/1/22, 9/5/22, 9/8/22 and 9/12/22. Resident 20 received showers on 7/8/22, 7/15/22, 7/18/22, 7/25/22, 7/29/22, 8/15/22, 8/19/22, 8/21/22, 8/26/22, 8/29/22, 9/5/22 and 9/12/22. Resident 35 received showers on 7/26/22, 8/19/22 and 9/19/22. Resident 151 received showers on 7/4/22, 7/7/22, 7/9/22, 7/14/22, 7/18/22 and 7/25/22. During an interview on 9/16/22, at 12:45 p.m., Licensed Nurse M stated she was the facility's Treatment Nurse responsible for monitoring residents with pressure ulcers or other skin wounds. She stated she consulted shower sheets to monitor skin wounds, but those sheets were not consistently and accurately complete by CNAs. She stated CNAs were supposed to provide showers to residents and check their skin during showers and document any skin problems in the shower sheets, but CNAs did not have time to shower residents and complete the shower sheets. She stated CNAs also did not have time to clean dependent, incontinent residents, and keep them clean and dry. She stated, when she checked dependent, incontinent residents, every resident was soiled, or their briefs were wet, which could damage their skin. She stated Resident 1 had developed scabs on his bilateral shins and feet because of lack of showers. She also stated CNAs only did bed baths, which were insufficient to properly clean residents' skins. During an observation on 9/16/22, at 1:24 p.m., Licensed Nurse M assessed Resident 1 who was lying in bed, on his back, looking at the ceiling. Licensed Nurse M undressed and turned Resident 1 to the side. Resident 1 was soiled with urine and feces, and his buttocks appeared inflamed. During a concurrent interview, Licensed Nurse M stated Resident 1 had Moisture Associated Skin Damage (MASD) on his buttocks from not being kept clean and dry. Resident 1's bilateral shins, from the ankles to the knees, and both his feet, were covered with scabs. Licensed Nurse M stated these scabs had developed because of lack of showers. During an observation on 9/16/22, at 1:30 p.m., Licensed Nurse M checked on Resident 151, who was lying in bed, on her back, looking at the ceiling. Licensed Nurse M undressed and turned Resident 151 to the side. Resident 151 was soiled with urine and feces. Licensed Nurse M stated, She is so wet. Resident's 151's buttocks appeared inflamed. During a concurrent interview, Licensed Nurse M stated Resident 151 had Moisture Associated Skin Damage (MASD) on her buttocks from not being kept clean and dry. During an observation on 9/16/22, at 1:38 p.m., Licensed Nurse M checked on Resident 20, who was lying in bed, on his back, looking at the ceiling. Licensed Nurse M undressed and turned Resident 20 to the side. Resident 20 was soiled with urine and feces. Resident's 20's buttocks appeared inflamed. During a concurrent interview, Licensed Nurse M stated Resident 20 had Moisture Associated Skin Damage (MASD) on her buttocks from not being kept clean and dry. A review of the specialized literature indicated: Moisture-Associated Skin Damage (MASD) is caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, [MEDICATION(S)], saliva, and their contents. MASD is characterized by inflammation of the skin, occurring with or without erosion or secondary cutaneous infection. Journal of Wound, Ostomy and Continence Nursing: May/June 2011 - Volume 38 - Issue 3 - p 233-241. Resident 21 A review of Resident 21's Face sheet indicated he was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 21's Minimum Data Set (MDS - an assessment tool), dated 4/29/22, indicated a Brief Interview for Mental Status (BIMs) score of 3 (scores of 0-7 indicate severe cognitive impairment). Resident 21's MDS also indicated he was incontinent of bowel and bladder and needed, total dependence, with personal hygiene. Review of Resident 21's care plan indicated no care plans for incontinence or bathing. During a clinical record review for Resident 21, the document titled, POC (Point of Care) Response History, for Resident 21's shower history, indicated, from 8/17/22 to 9/20/22, Resident 21 received two showers, zero complete bed baths and twenty-two partial baths. The document did not indicate Resident 21 had refused showers or partial baths. During an interview on 9/14/22 at 3 p.m., Resident 21's family member stated the facility did not take good care of Resident 21. Resident 21's family member stated the facility staff did not take Resident 21 out of bed regularly, and he was supposed to have therapy. Resident 21 was fed through a G-tube, and he did not talk well; Resident 21 spoke mainly Spanish. Resident 21's family member stated his mother came to the facility three times a week, she complained the facility did not bathe, shave or brush Resident 21's teeth. Resident 21's family member stated, when his mother came to the facility, the staff waited for her, and she would bathe, shave, and brush Resident 21's teeth. Resident 21's family member stated Resident 21 had sensitive skin, and his mother brought skin cream and applied the cream to Resident 21's skin, because the staff would not. Resident 21's family member stated his mother would bring Resident 21 clothes, and the next time she came to the facility the resident was wearing someone else's clothes. Resident 21's family member stated his mother told the nurses, but nothing ever got done. When asking Resident 21's family member if he had attended a care meeting for Resident 21. Resident 21's family member stated the facility had never called to arrange a care meeting. When asked if he asked the facility to arrange a meeting, he stated, I will do that. Resident 21's family member stated his mother had spoken to a doctor a few times, he stated she did not know who the doctor was now. Resident 21's family member stated they used to put Resident 21 in his chair and place him in the hallway, but the facility had not done that lately. During an interview on 9/16/22 at 9:51 a.m., Licensed Nurse G was asked how often Resident 21 was out of bed. Licensed Nurse G stated sometimes Resident 21 refused to get up, but when he did not, he was up in his wheelchair. When asked if Resident 21 had a shower, she stated, Yes, but sometimes refused a shower. Licensed Nurse G stated his wife came to the facility three times a week and she would give him a bed bath. Review of the paper document titled, Shower Day Skin Inspection, showed Resident 21 had a shower on 9/9/22, and refused a shower on 9/19/22. During an interview on 9/20/22 at 9:57 p.m., the DSD verified no other shower sheets were documented for September 2022. Resident 42 A review of Resident 42's Face sheet indicated he was initially admitted on [DATE], and readmitted on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 42's Minimum Data Set (MDS - an assessment tool), dated 2/26/22, indicated a Brief Interview for Mental Status (BIMs) score of 0 (scores of 0-7 suggest severe impairment). Resident 42's MDS also indicated Resident 42 was incontinent of bowel and bladder. Review of Resident 42's care plan indicated he needed total assistance with ADLs. During a clinical record review for Resident 42, the document titled, POC (Point of Care) Response History, for Resident 42's shower history indicated, from 8/17/22 to 9/15/22, Resident 42 received five showers, zero complete bed baths and fourteen partial baths. From 8/25/22 to 8/30/22, no bathing of any type was documented on the POC response history. The document did not indicate Resident 42 had refused showers or partial baths. During an interview on 9/20/22 at 9:57 a.m., the DSD stated there were no comments on the POC in, Point Click-Care (PCC), only check boxes, the comments were documented on the shower sheets by the CNAs. Review of the paper document titled, Shower Day Skin Inspection, showed Resident 42 had a shower on 9/3/22, 9/7/22 and 9/17/22, no other shower sheets were documented for September 2022. The shower sheets for August were requested during an interview with the DSD on 9/20/22 at 9:57 a.m., but the DSD could not locate them. During an interview on 9/13/22 at 10 a.m., Resident 42's family member came to the facility for an interview. Resident 42's family member was concerned that Resident 42 was not bathed on a regular basis. Resident 42's family member stated he took Resident 42 home on the weekends or when he visited, he noticed Resident 42 was not showered. Resident 42's family member stated he must wash Resident 42's hair and brush his teeth. There was one CNA who regularly showered Resident 42, and she was not here for two weeks in August, and for two weeks Resident 42 did not have a shower. The facility was supposed to dress him, change him, and get him up out of bed. When Resident 42's family member took him home, he noticed Resident 42's neck and ears were dirty. Resident 42's family member was asked if he reported this to the DON or nurses, he stated, Yes; he told the nurses several times when he came for a visit. When asked if he had attended an IDT meeting to discuss Resident 42's care, he stated in August 2022, a meeting was scheduled. The facility did not call him on the day of the meeting and called the day after to state the meeting had been canceled and gave him an update of Resident 42's condition. Resident 42's family member tried to schedule another meeting, but nothing happened. Resident 42's family member stated, The facility should train the newer staff to take better care of Resident 42. During an observation and concurrent interview on 9/16/22 at 9:51 a.m., Resident 42 was in his Geri chair fully dressed (this was the first observation of Resident 42 out of bed). Licensed Nurse G was asked how often Resident 42 was out of bed; she stated, We try to get him out of bed every other day or so if there is enough staff to help move him; [Resident 42's] family member comes to take him home on the weekends. RESIDENT 49 During clinical record review for Resident 49, the Face sheet indicated Resident 49 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a clinical record review for Resident 49, the MDS, dated [DATE], indicated Resident 49 had a BIMS score of 2 out of 15 points (Brief Interview for Mental Status - a 15-point cognitive screening measure that evaluates memory and orientation. A score of 13 - 15 is cognitively intact, 08 - 12 is moderately impaired, and 00 - 07 is severe impairment). The MDS indicated Resident 49 required total assistance from staff, with bathing. The MDS indicated it was very important for Resident 49 to choose between a tub bath, shower, bed bath or sponge bath. The MDS indicated Resident 49 did not refuse evaluation or care necessary to achieve her goals for health and well-being. During a clinical record review for Resident 49, the document titled, POC (Point of Care) Response History, for Resident 49's shower history, indicated from 8/22/22 to 9/20/22, Resident 49 did not receive any showers; however, she received four complete bed baths. The document also indicated Resident 49 received 18 partial baths on different days. RESIDENT 44 During clinical record review for Resident 44, the Face sheet indicated Resident 44 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with Resident 44 on 9/12/22 at 11:24 a.m., when asked about shower schedules, Resident 44 stated he was supposed to a have shower twice a week; however, he only got showered once a week and wanted to have more showers if possible. During a clinical record review for Resident 44, the Minimum Data Set (MDS -health status screening and assessment tool), dated 11/19/21, indicated it was very important for Resident 44 to choose between a tub bath, shower, bed bath or sponge bath. During a clinical record review for Resident 44, the MDS, dated [DATE], indicated Resident 44 had a BIMS score of 15 out of 15 points (Brief Interview for Mental Status - a 15-point cognitive screening measure that evaluates memory and orientation. A score of 13 - 15 is cognitively intact, 08 - 12 is moderately impaired, and 00 - 07 is severe impairment). The MDS indicated Resident 44 did not refuse evaluation or care necessary to achieve his goals for health and well-being. During a clinical record review for Resident 44, the document titled, POC (Point of Care) Response History, for Resident 44's shower history, indicated from 8/22/22 to 9/20/22, Resident 44 received five showers, zero complete bed baths and seven partial baths on different days. The document did not indicate Resident 44 had refused showers or partial baths. During a clinical record review for Resident 44, the document titled, Shower Day Skin inspection, indicated Resident 44 received showers on 8/31/22 & 9/15/22. RESIDENT 31 During clinical record review for Resident 31, the Face sheet (a one-page summary of important information about a resident) indicated Resident 31 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 9/13/22 at 11:34 a.m., Resident 31 was on her bed, watching TV. Resident 31 had difficulty expressing herself. Resident 31 smiled when spoken to. Resident 31's upper teeth had plaque build up. During a clinical record review for Resident 31, the MDS, dated [DATE], indicated Resident 31 had a a BIMS score of 3 out of 15 points (Brief Interview for Mental Status - a 15-point cognitive screening measure that evaluates memory and orientation. A score of 13 - 15 is cognitively intact, 08 - 12 is moderately impaired, and 00 - 07 is severe impairment). The MDS indicated Resident 31 required total assistance from staff, with bathing. The MDS indicated it was very important for Resident 31 to choose between a tub bath, shower, bed bath or sponge bath. During a clinical record review for Resident 31, the document titled, POC (Point of Care) Response History, for Resident 31's shower history, indicated from 8/22/22 to 9/20/22, Resident 31 received four showers, four complete bed baths and 22 partial baths. The document indicated Resident 31 was totally dependent with showers and partial baths. The document did not indicate Resident 31 had refused shower. During a clinical record review for Resident 31, the document titled, Shower Day Skin inspection, indicated Resident 31 received showers on 8/26/22 & 9/09/22. During an interview with Certified Nursing Assistant (CNA) W on 9/20/22 at 9:08 a.m., when asked about residents refusing showers, CNA W stated she would give the resident the option to choose between a bed bath or shower. She stated she would at least ask the resident twice if he or she wanted to have a shower, and if the resident continued to refuse, she would report it to the nurse. When CNA W was asked the difference between a bed bath and a partial bath, CNA W stated the only difference was that a bed bath involved washing of hair while a partial bath did not involve washing of hair. During an interview with CNA V on 9/20/22 at 9:15 a.m., when asked about residents refusing showers, CNA V stated she would encourage the resident to have a shower. She stated if the resident refused a shower, she would provide a complete bed bath. CNA V stated complete bed baths included washing of hair, and a partial bath did not include washing of hair. When CNA V was asked about the risk for residents if hair was not washed, CNA V stated residents could have dandruff, itchy scalp, and smelly hair. During an interview and concurrent record review with the Director of Staff Development (DSD) on 9/20/22 at 9:57 a.m., when asked where residents' showers were documented, the DSD stated the facility would document on both PCC (Point Click Care - an electronic health care record for residents) and a paper document called, Shower Day Skin Inspection. After review of the document titled, POC (Point of Care) Response History and the Shower Day Skin Inspection, with the DSD, the DSD verified, from 8/22/22 to 9/20/22, Resident 44 received seven showers; Resident 31 received six showers, and Resident 49 did not receive any showers; however, Resident 49 received four complete bed baths. When the DSD was asked about the difference between complete bed baths and partial baths, the DSD stated bed baths meant washing of the whole body including washing of hair, and partial bath meant washing the upper body, incontinence care and no washing of hair. When the DSD was asked about the risk of not washing residents' hair, she stated residents could have itchy scalp, and oily, dirty hair. A review of facility policy titled, ACTIVITIES OF DAILY LIVING (ADLs), SUPPORTING, undated, indicated: Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with . hygiene (bathing, dressing, grooming, and oral care) . elimination (toileting). Review of the Facility document titled, BED BATH, revised in 7/2015, indicated, It is the policy of this facility to cleanse, refresh and soothe the resident and to stimulate circulation.

Based on observation, interview and record review, the facility failed to ensure one of 16 sampled residents (Resident 35) received care and services to prevent falls. The facility: 1) failed to supervise and assist Resident 35 during transfers to and from bed, wheelchair and bathroom; 2) failed to provide Resident 35, who had dementia and did not know how to use the room's call light system, with an alternative communication system to relay calls directly to a staff member or to a centralized staff work area, relying instead on Resident 35 yelling for help from her room as a means of alerting staff she needed help; 3) failed to ensure fall prevention interventions were appropriate to Resident 35's severely impaired cognitive level when the facility's primary fall intervention was educating and reminding Resident 35 to use the call light system to ask staff for assistance before attempting to transfer; 4) failed to revise and update Resident 35's fall care plans and implement new or different interventions post falls, after the existing interventions, such as educating Resident 35 to use the call light system, proved ineffective in preventing falls; and 5) failed to implement the fall care plan intervention of placing Resident 35 in a supervised area when she was out of bed. These failures resulted in Resident 35 falling eight times over an 11-week period from 6/22/22 to 9/7/22. Two of these falls, on 7/8/22 and 9/7/22, resulted in Resident 35 sustaining head and knee injuries requiring hospital transfer and evaluations. These failures also placed Resident 35 at risk for further falls. Findings: A review of Resident 35's Facesheet indicated she was [AGE] years-old, was originally admitted to the facility on [DATE], and had diagnoses including dementia, depression, [CONDITION(S)] (a disease that causes delusions and hallucinations), [CONDITION(S)] (muscle weakness or paralysis in one side of the body), seizures, and bilateral cataract and [CONDITION(S)] (eyes diseases that impair vision). During an interview on 9/13/22, at 2:08 p.m., Resident 35's Responsible Party (RP) stated Resident 35 falls often at the facility, and the falls result in injuries. The RP stated Resident 35 falls when she tries to transfer to and from the bed or wheelchair, to use the bathroom. The RP stated Resident 35 calls for staff to help her transfer, but staff do not assist her. Resident 35 then tries to transfer herself without staff assistance and falls as a result. A review of facility document titled, LIST OF FALL INCIDENTS (PAST 90 DAY), provided by the facility on 9/12/22, indicated Resident 35 had eight falls over a period of 11 weeks, from 6/22/22 to 9/7/22, as follows: FIRST FALL: 6/22/22 SECOND FALL: 6/26/22 THIRD FALL: 7/5/22 FOURTH FALL: 7/8/22 FIFTH FALL: 7/27/22 SIXTH FALL: 8/9/22 SEVENTH FALL: 8/12/22 EIGHTH FALL: 9/7/22 A review of Resident 35's hospital records indicated at least two of the falls, the FOURTH and the EIGHTH falls, dated 7/8/22 and 9/7/22, resulted in Resident 35's hospitalization due to injuries, as follows: Emergency Department note, dated 7/9/22, at 2:10 a.m., indicating Resident 35 was brought to the hospital for evaluation after a fall in the facility: patient fell out of her wheelchair. The note indicated Resident 35 complained of pain in her arms, back and left knee, and she had a head contusion. The note indicated a brain scan revealed Resident 35 had a moderate-severe head trauma. The note indicated final diagnoses of head contusion and left knee contusion. Emergency Department note, dated 9/7/22, at 9/14 p.m., indicating Resident 35 was brought to the hospital for evaluation after a fall in the facility: staff found patient on floor. The note indicated Resident 35 reported pain in her neck and head. The note indicated Resident 35 had a forehead contusion/hematoma and a left knee contusion. The note indicated the cause of the injuries was accidental fall. A review of Resident 35's, FALL ASSESSMENT RISK evaluations, for the months June to September 2022, indicated the following eight assessments and scores: 6/26/22: Fall Score of 12 = HIGH RISK FOR FALLS 7/5/22: Fall Score of 13 = HIGH RISK FOR FALLS 7/8/22: Fall Score of 13 = HIGH RISK FOR FALLS 7/27/22: Fall Score of 15 = HIGH RISK FOR FALLS 8/9/22: Fall Score of 10 = HIGH RISK FOR FALLS 8/12/22: Fall Score of 15 = HIGH RISK FOR FALLS 8/12/22: Fall Score of 12 = HIGH RISK FOR FALLS 9/7/22: Fall Score of 12 = HIGH RISK FOR FALLS A review of Resident 35's Order Summary Report - Active Orders as of 9/14/22 indicated Resident 35 was receiving the following four scheduled medications, all of which have side effects of lethargy, sedation and drowsiness: (1) [MEDICATION(S)] (an anti-[CONDITION(S)] medication) 100 milligrams twice a day, order dated 6/25/22. (2) [MEDICATION(S)] (an anti-psychotic medication) 25 milligrams twice a day, order dated 6/25/22. (3) [MEDICATION(S)] (an anti-depressant medication) 25 milligrams twice a day, order dated 3/30/22. (4) [MEDICATION(S)] (an anti-depressant medication) 50 milligrams at bedtime, order dated 5/23/22. A review of Resident 35's Order Summary Report - Active Orders as of 9/14/22 also indicated a PRN (as needed) order for [MEDICATION(S)] 10-325 milligram for pain, since 6/22/22. [MEDICATION(S)] also has side effects of lethargy, sedation and drowsiness. A review Resident 35's, Minimum Data Set assessments (MDS - a formal assessment tool) for the previous 90 days, dated 5/15/22 and 8/12/22, indicated Resident 35 had a BIMs (Brief Interview for Mental Status - a test of cognition) score of 3 (scores of 0-7 indicate severe cognitive impairment), was dependent on staff for transfers, dressing and toilet use, had unsteady balance during surface-to-surface transfers, moving from seated-to-standing position and moving on and off the toilet, had impairment on upper and lower extremities, used a wheelchair, and had two or more falls since admission. A review of Resident 35's, FALL INVESTIGATION REPORTS and IDT POST FALL FOLLOW-UP REPORTS, for the period of 6/22/22 to 9/7/22, indicated the following: FIRST FALL: 6/22/22 Fall Investigation Report, dated 6/22/22 at 5 a.m.: @ 500 [5 a.m.] [Resident] tried to go back on bed [from bathroom] with no help when slid down on the floor next to bed with head up did not seek for help . IDT Post-Fall Follow-Up Report, dated 6/23/22: Resident was observed sitting on the floor next to her bed . Resident spontaneously got out of wheelchair unassisted did not ask for help/assistance did not use call light . New Intervention Recommended: Will provide transfer pole . will re-adjust grab bars in the bathroom. SECOND FALL: 6/26/22 Fall Investigation Report, dated 6/26/22 at 10:30 p.m.: Resident had unwitnessed fall at 10:15 p.m., resident found sitting down on floor next to her bed, according to the resident, she was trying to get into wheelchair and slid down to the floor . encourage resident to use call light to call for help when in need for assistance . IDT Post-Fall Follow-Up Report, dated 6/26/22: Resident had unwitnessed fall at 10:15 p.m., resident found sitting down on floor next to her bed, according to the resident, she was trying to get into wheelchair and slid down to the floor . encourage resident to use call light to call for help when in need for assistance . New Intervention Recommended: Re-educate resident re; safety importance of calling/asking for help/assistance as needed. THIRD FALL: 7/5/22 Fall Investigation Report: No fall investigation report. IDT Post-Fall Follow-Up Report, dated 7/5/22: Facility licensed staff responded to resident calling out from her room. Resident was observed laying on the floor .Resident spontaneously got out of wheelchair. Did not call for assistance did not use call light . Resident continuously doing physical activities and performing ADL's unassisted beyond her physical ability. New Intervention Recommended: Non-skid strips applied to the floor and resident became verbally hostile . Non-skid floor strips was removed and resident calmed down . explained risks and benefits to resident . FOURTH FALL: 7/8/22 Fall Investigation Report, dated 7/8/22 at 11:23 p.m.: Resident was found in the bathroom, laying down on the floor, she was trying to get into the toilet and she slid down and hit her head . side of the head little swollen . has pain 8/10 . sent to hospital for further evaluation . IDT Post-Fall Follow-Up Report, dated 7/8/22, but signed 7/22/22: Resident spontaneously got out of wheelchair unassisted did not ask for help/assistance did not use call light . New Intervention Recommended: Re-educate resident re; safety importance of calling/asking for help/assistance as needed. FIFTH FALL: 7/27/22 Progress Note, dated 7/27/22 at 10:30 a.m. Heard resident's loud voice, found her on the floor, sitting position, next to her bed . Fall Investigation Report, dated 7/27/22 at 10:30 a.m.: Resident was found on the floor, next to her bed . IDT Post-Fall Follow-Up Report, dated 7/27/22: New Intervention Recommended: Keep an eye the resident and put her in front of nurse station, then if the resident wants to take a nap or wants to go back to bed and use the bathroom, CNA [Certified Nursing Assistant] will call or page to assist the resident. SIXTH FALL: 8/9/22 Fall Investigation Report, dated 8/9/22: 10:42 a.m.- I was [at] nurse station . when I heard a loud sound, I immediately went to check [Resident 35], and found her lying on floor next to her bed, wheelchair near at bedside . [Resident] non-compliant to use call light, safety instructions. IDT Post-Fall Follow-Up Report dated 8/9/22: Resident was observed laying on the floor at bedside . Resident apparently got out of wheelchair spontaneously without asking for help or assistance . New Intervention Recommended: no new interventions recommended. SEVENTH FALL: 8/12/22 Fall Investigation Report, dated 8/12/22 AT 10:30 a.m.: I was called by staff to see resident in her room. Went to her room found accompanied by CNA . according to CNAs report, she is helping Resident 35 transfer from chair to bed but resident slid on floor . IDT Post-Fall Follow-Up Report, dated 8/15/22, but signed on 9/7/22: CNA was assisting resident to transfer from wheelchair to the bed and resident unable to withstand standing up, CNA assisted resident to sit on the floor at bedside . New Intervention Recommended: Re educated RE; Safety including but not limited to calling for assistance as needed. EIGHTH FALL: 9/7/22 Fall Investigation Report, dated 9/7/22 at 8:56 p.m.: Resident found laying out on the floor in D wing hallway at 7:40 p.m. According to the resident she was bumped to the other wheelchair that cause her fell out from her wheelchair . complains of pain in the head and left knee 8/10 . sent out to hospital for further evaluation . IDT Post-Fall Follow-Up Report, dated 9/7/22: Resident found laying out on the floor in D wing hallway at 7:40 p.m. According to the resident she was bumped to the other wheelchair that cause her fell out from her wheelchair . complains of pain in the head and left knee 8/10 . sent out to hospital for further evaluation . A review of Resident 35's care plans indicated six fall care plans, as follows: FIRST CARE PLAN, titled: Resident at risk for falling related to impaired balance, unsteady gait, history of falls. Has a diagnosis of dementia, [CONDITION(S)] [[CONDITION(S)] - stroke] with right sided [CONDITION(S)]/[CONDITION(S)], [CONDITION(S)] . has poor safety awareness and non-compliance with needed assistance on transfers . resident spontaneously got out of bed unassisted, did not use call light, did not ask for help or assistance. DATE INITIATED: 11/28/19, 3/18/22 & 5/03/22. Interventions: (1) Assess resident, frequent check on resident, notify MD and RP of any change in condition; (2) continue frequent visual checks; (3) health education provided to the staff to initiate assistance based on resident's routine . (4) observe resident's routine and initiate staff assistance to the resident on the times she is usually going back to bed, getting up to wheelchair and going to the restroom; (5) remind resident on safety measures: to always lock wheelchair before getting up (6) Assessment of resident (7) assess resident's mobility (8) assure floor is free of glare, liquids, foreign objects (9) bed kept in low position; (10) establish as baseline, the resident's physical, mental, psychological, and functional level; (11) give resident verbal reminders not to ambulate/transfer without assistance; (12) keep call light in reach; (13) keep environment free of clutter; (14) keep personal items and frequently used items within reach; (15) observe frequently and place in supervised area when out of bed; (16) orient resident to environment; (17) orient resident when there has been new furniture placement or other changes in environment; (18) place resident in fall prevention program; (19) provide frequent staff monitoring; (20) provide proper, well-maintained footwear; (21) provide toileting assistance @ least 2x per shift; (21) teach safety measures: locking your wheelchair before getting up; (22) notify MD and resident representative for any change in condition. SECOND CARE PLAN, titled: Resident non-compliant in using bed alarm and chair pad alarm. DATE INITIATED: 6/9/22. Interventions: (1) call light within reach; (2) encourage resident to ask for assistance when in need; (3) explained the risks and benefits of using the bed pad and chair pad alarm. THIRD CARE PLAN, titled: Resident prefers to be independent as much as possible and continues to do things for herself beyond her capacity .has multiple episodes of falls . DATE INITIATED: 6/10/22. Interventions: (1) Resident assessment; (2) Encourage resident to continue to participate with care; (3) respect resident's wishes, desires and rights; (4) Explain risks and benefits; (5) inform MD of resident's wishes; (6) Encourage resident's family to continue to come and visit; (7) Refer to psych as ordered; (8) Inform MD and RP for COC. FOURTH CARE PLAN, titled: [Resident] was observed laying on the floor at bedside . did not call for assistance/or ask for help. DATE INITIATED: 8/9/22. Interventions: (1) Resident assessment; (2) Encourage resident to ask for help or assistance as needed .; (3) Explains risks and benefits; (4) Inform MD/RP ., (5) Re-educate resident re; safety measures. FIFTH CARE PLAN, titled: Resident has assisted fall during transfer. DATE INITIATED: 8/12/22. Interventions: (1) Assessment of resident; (2) Facility staff to ask for assistance as needed; (3) Monitor resident every shift for any COC [change in condition]. SIXTH CARE PLAN, titled: Unwitnessed fall. DATE INITIATED: 9/8/22. Interventions: (1) Assessment of the resident; (2) Encourage resident to ask help for assistance; (3) hallway must be free from any clutter. During an interview on 9/15/22, at 9:08 a.m., CNA F stated Resident 35 did not know to how use the room's call light system. CNA F stated Resident 35 just shouted when she needed help, and this was how staff knew she needed assistance. During an observation on 9/15/22, at 12:18 p.m., Resident 35 was in her room and transferred herself from toilet to wheelchair, unsupervised and unassisted. During an observation on 9/15/22, at 2:52 p.m., Resident 35 was in her room sitting in her bed shouting for help and pointing to the bathroom. Resident 35 was asked to press the room's call light button, which was next to her in bed. Resident 35 continued shouting for help and pointing to the bathroom. During an interview on 9/16/22, at 9:16 a.m., CNA B stated Resident 35 did not use the call light to ask for help. CNA B stated Resident 35 yelled, help when she needed something, and this was how staff knew she needed help. During an interview and record review on 9/16/22, at 10:08 a.m., the Director of Nursing (DON) reviewed Resident 35's chart. The DON stated Resident 35 was a high fall risk, falls a lot, and has hit and injured her head and hip several times because of the falls. The DON confirmed Resident 35 had eight falls in the past 90 days on 6/22/22, 6/26/22, 7/5/22, 7/8/22, 7/27/22, 8/9/22, 8/12/22 and 9/7/22. The DON stated Resident 35 had muscle weakness and the falls happened when Resident 35 attempted to transfer herself to and from her bed, wheelchair and toilet, unassisted by staff. The DON stated Resident 35, won't use the call light, before attempting to transfer. The DON stated Resident 35 must be constantly re-educated on the use of the call light. The DON stated, for communication, staff relied on Resident 35 yelling for help when she needed staff assistance for transfers. The DON stated for each fall, the facility investigated the fall, attempted to determine the cause of the fall and addressed the causative falls, and updated the resident's care plans. The DON confirmed the six fall care plans for Resident 35, initiated on 11/28/19, 6/9/22, 6/10/22, 8/9/22, 8/12/22 and 9/8/22. The DON confirmed the fall care plans were not updated after each fall. A review of facility policy titled, Fall Risk Intervention & Monitoring, revised 12/14, indicated: It is the policy of the company based on completed fall evaluation and current data to identify interventions related to the resident's specific risks and causes to try and prevent the resident from falling and to try to minimize complications from falling. The multi-disciplinary team, including the physician, will identify appropriate interventions to reduce the risk of falls . If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. A review of facility policy titled, Falls Management, revised 12/14, indicated: The multi-disciplinary team, in collaboration with the physician, will identify pertinent interventions to try and reduce the risks associated with subsequent falls and to address risks of serious consequences of falling, following completion of the resident's fall evaluation. In the event, underlying causes cannot be readily identified, reduced or corrected, staff will attempt various relevant interventions, based on assessment of the nature or falling episodes, until falling reduces or stops; or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance or continues to choose to exercise his/her right to walk, despite contraindications).

Based on observation, interview and record review, the facility failed to ensure: 1) Two out of two sampled residents' (Residents 351 and 44) surgical wounds were documented, assessed, and treated, to prevent complications. These failures resulted in Resident 351's re-hospitalization for wound dehiscence (partial or total separation of previously-approximated (edges of a wound fit neatly together, such as a surgical incision, and can close easily) wound edges, due to a failure of proper wound healing) and wound infection, and had the potential for Resident 44's wound to worsen or develop an infection; 2) The facility failed to properly and accurately document skin assessments for one un-sampled resident (Resident 100). This failure prevented Resident 100 from having a complete and accurate medical record; and, 3) The facility failed to ensure it used commercial-grade blood pressure monitors; instead, it used wrist blood pressure monitors intended for home use. This failure placed eight out of eight sampled residents (Residents 7, 8, 39, 3, 351,35, 151 and 46) at risk for inaccurate blood pressure readings and for potentially receiving unnecessary blood pressure medications. Findings: 1a) Review of Resident 351's Facesheet (demographics) indicated she was [AGE] years-old, and admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . It's also called Negative Pressure wound therapy) on her sacrum (a triangular bone in the lower back formed from fused vertebrae and situated between the two hipbones of the pelvis). During a concurrent observation and interview on [DATE] at 9:44 a.m., Resident 351 was lying in bed. She stated she had a surgical wound on her back. She stated she used to have a wound VAC. She stated the wound VAC had been discontinued, but she could not recall receiving surgical wound care from the nurses. She stated, I don't know if the nurses knew I have a wound on my back. During a concurrent interview and medical chart review, physician orders and Admission Assessment record review on [DATE] at 4:40 p.m., Licensed Nurse M (LN M) initially stated Resident 351 had clear skin and no wound. LN M stated she would know because, if there was a skin issue, the nurses would leave her a note to see the resident. LN M verified Resident 351 was not on the list of residents to be seen by the wound doctor this day. LN M verified the facility wound doctor had not seen Resident 351 since admission. LN M verified Resident 351 had no treatment order for the surgical wound. LN M verified there was a note on the Admission Assessment indicating Resident 351 had a wound vac on her sacrum. LN M also verified there was no Braden Scale skin assessment (a standardized tool to assess pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) risk for a resident. completed at the time of her admission. LN M verified there were no monitoring of Resident 351's surgical wound for signs and symptoms of infection. LN M stated the facility policy was not followed when Resident 351 did not have a Braden Scale assessment completed upon admission; there was no treatment order for the surgical wound care, and there was no monitoring of the surgical site, every shift, for signs and symptoms of infection. During an observation in Resident 351's room on [DATE] at 4:50 p.m., LN M turned Resident 351 on her right side to be able to visualize the surgical wound on her back. LN M verified the surgical wound was not covered with dry dressing, and there was a packing strip (a long, slender,continuous pieces of a fine-mesh, gauzy material intended to fill wounds that extend into the middle layer of the skin) on the lower end of her lumbar (lower back) incision. LN M measured the surgical incision then and provided this surgical wound measurement, 13.5 cm x 0.5 cm x 0 cm. During a concurrent interview and medical chart record review on [DATE] at 8:15 a.m., the Minimum Data Set (MDS, a federally mandated process for clinical assessment of all residents in Medicare or Medicaid facility) Coordinator stated he did not verify whether Resident 351 had a wound VAC upon admission. The MDS Coordinator verified Resident 351 had no weekly skin assessments completed. He stated Resident 351 should have had at least two weekly skin assessments completed since Resident 351's admission on [DATE]. He stated the facility policy was not followed if the nurses were not conducting weekly skin assessments. The MDS Coordinator verified the eMAR (electronic Medication Administration Record) did not show nurses were monitoring Resident 351's lower back incision for signs and symptoms of infection or wound dehiscence since the wound VAC was discontinued on [DATE]. He verified there was no treatment order for the surgical wound since the wound VAC was discontinued. The MDS Coordinator verified the facility policy was not followed when there was no baseline surgical skin assessment completed once the wound VAC was discontinued. He stated the facility policy was not followed when nurses failed to monitor the surgical incision site every shift. He stated these failures put Resident 351 at risk for further wound dehiscence, non-healing wounds, infection, [CONDITION(S)] (the body's extreme response to an infection and is a life-threatening medical emergency) and readmission to the acute hospital. During an interview on [DATE] at 8:25 a.m., Licensed Nurse G (LN G) stated the admission nurse completed the skin assessment and Braden Scale skin assessment upon admission. She stated, if these assessments were not done, the facility policy was not followed. LN G also stated the facility's policy was not followed if the nurses were not monitoring the surgical site for signs and symptoms of infection, every shift and if the nurses were not completing the weekly skin assessment. LN G stated, not monitoring the surgical site for complications every shift could put Resident 351 at risk for infection and a non-healing wound. LN G stated, not completing weekly wound assessments could result in inadequate monitoring of the wound which could result in missed opportunities to assess whether the wound was improving or getting worse or if current treatment was effective or ineffective. During an interview on [DATE] at 4:50 p.m., Licensed Nurse O (LN O) verified she admitted Resident 351 on [DATE] at 5 p.m. LN O stated the facility policy for admission included completing the nursing assessment (time of arrival, skin assessment, nutrition assessment, fall assessment, elopement assessment, pain assessment and smoking assessment). LN O verified the facility policy was not followed when Resident 351 did not have a Braden Scale skin assessment upon admission. LN O verified she did not complete Resident 351's Braden Scale skin assessment because it was the responsibility of the treatment nurse to complete it. LN O stated it was important to ensure the Braden Scale skin assessment was completed so staff were aware of any current skin issues and potential risk of further skin issues. LN O stated the findings on the Braden Scale skin assessment could then be used for care planning with the goal of addressing both the current and potential skin issues. LN O verified there was no care plan initiated for the wound VAC, upon admission. She also verified there was no care plan or treatment order initiated for Resident 351's surgical incision once the wound VAC was discontinued. LN O stated the facility's policy was not followed when there was no treatment or monitoring of the surgical incision, every shift. She stated these placed Resident 351 at risk for not receiving appropriate care, which could result in wound infection, [CONDITION(S)], non or delayed wound healing and wound dehiscence. During an interview on [DATE] at 9:28 a.m., Licensed Nurse A (LN A) verified Resident 351 was sent straight to the acute hospital after her neurosurgery (a surgical specialization that treats diseases and disorders of the brain and spinal cord) appointment on [DATE]. During an interview on [DATE] at 9:33 a.m., the Director of Nursing (DON) verified Resident 351 was at [Acute Care Hospital's Name] for further evaluation of her surgical wound. During a concurrent interview and nursing note record review on [DATE] at 10:32 a.m., the Minimum Data Set Coordinator (MDS Coordinators assess and monitor proper treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Coordinator verified the eMAR indicated nurses were checking the wound VAC, from [DATE] to [DATE], when it was already discontinued on [DATE]. The MDS Coordinator stated nurses were probably not reading what they were signing. He stated wound VAC monitoring should have ended once it was discontinued. During an interview on [DATE] at 12:46 p.m., LN M stated the Wound Doctor saw residents with skin issues, pressure ulcers, and surgical wounds,weekly, either in person or via telehealth (video or phone appointments between a patient and their health care practitioner). LN M verified the Wound Doctor had not assessed Resident 351 since admission on [DATE], [DATE] and [DATE]. When asked why the Wound Doctor did not assess Resident 351 when he was doing telehealth to other residents with skin issues on Wednesday, [DATE], LN M stated the Wound Doctor would like to assess Resident 351 in person. During a concurrent interview and electronic Treatment Administration Record (ETAR) weekly wound/skin documentation record review on [DATE] at 2:33 p.m., LN H stated the facility policy was not followed when there was no new skin assessment completed for Resident 351, once the wound VAC was discontinued. She stated the skin assessment should have been initiated because now they were able to visualize the wounds. LN H verified nurses were still monitoring the wound VAC from [DATE] to [DATE], when the wound VAC was already discontinued on [DATE]. LN H stated the wound VAC monitoring should have ceased after it was discontinued on [DATE]. She stated it was important to assess, treat and document accurately to ensure wounds were healing adequately with no complications. She stated, if treatments or documentation was not accurate, it could put Resident 351 at risk for non-healing wound, infected wound and ineffective treatment. During a concurrent interview and EMAR/ETAR record review on [DATE] at 3:11 p.m., the DON verified Resident 351's wound VAC was discontinued on [DATE]. He stated the wound VAC order for monitoring was inaccurate and should not even be documented on the eMAR after it was discontinued on [DATE]. The DON stated inaccurate documentation could lead to mistakes and could result in infected and non-healing wounds. The DON stated it was possible Resident 351's wound infection, and subsequent re-hospitalization , could have been prevented if there was adequate treatment and monitoring of symptoms was reported to the Medical Doctor. The DON stated nurses should have documented and assessed wound status after the removal of wound VAC. He stated, not doing a skin assessment and implementing treatment, was safety risk which could lead to wound infections, non-healing wounds, and [CONDITION(S)], if not treated immediately. During an interview on [DATE] at 3:32 p.m., Licensed Nurse C (LN C) verified she received a call from the doctor to discontinue the wound VAC and initiate treatment to cleanse the surgical wound with saline and cover with a dry dressing. LN C verified she did not carry out the treatment order. She stated she did not ask the frequency nor the duration of the treatment to the doctor. When asked why, LN C was silent. LN C verified, based on facility policy, she should have documented the surgical skin status after she discontinued the wound VAC. When asked why she did not document the skin status after discontinuing the wound VAC, LN C was silent. LN C stated it was important to document wound status to ensure Resident 351's surgical wound was healing adequately with no complications. LN C stated, if the wound was being monitored for complications or signs and symptoms of infection and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent interview and review of Resident 351's history and physical, dated [DATE], on [DATE] at 4:30 p.m., the MDS Coordinator verified the admitting doctor did not include wound infection on Resident 351's list of admitting diagnoses. The MDS Coordinator stated Resident 351's re-hospitalization could probably been prevented if staff were monitoring the surgical wound for signs and symptoms of infection and if there was a daily treatment implemented for Resident 351's surgical wound. During an interview on [DATE] at 5:04 p.m., LN M indicated re-hospitalization could probably been prevented if staff were assessing and monitoring Resident 351's surgical wound for signs and symptoms of infection and if staff were treating her surgical wound daily. During a review of facility's policy and procedure titled, Surgical Wound Care, revised ,d+[DATE], indicated surgical wounds should be cleansed with normal saline, pat dry and covered with dry dressing unless other special treatment /instructions were given by the surgical doctor. It further indicated documentation should be maintained in the resident's medical record, including but not limited to treatment sheets, licensed note and any appropriate area. 1b) During an interview and observation with Resident 44 outside of his room on [DATE] at 11:24 a.m., Resident 44 stated he had a sore on his tailbone bottom from a surgery. Resident 44 stated wound treatment should be done once a day; however, he was not getting it. Resident 44 stated the last wound treatment he received was two days ago. Resident 44 pointed out his bed linen was soiled with brownish-yellow stains from his wound discharge. During an interview with Resident 44 on [DATE] 10:23 a.m., Resident 44 stated nurses were not doing the treatment on his tailbone properly, Resident 44 stated one of the nurses would use band aid to cover the wound. During an interview with Licensed Nurse M on [DATE] at 12:46 p.m., Licensed Nurse M stated she was the primary treatment nurse for the whole facility. Licensed Nurse M stated licensed nurses were expected to provide wound treatment to residents on her days off; however, licensed nurses were not doing it. When Licensed Nurse M was asked about the risks for residents with wounds not receiving wound treatments according to doctor's order, Licensed Nurse M stated residents' wounds could worsen. During an interview with Licensed Nurse M on [DATE] at 1:04 p.m., when asked about Resident 44's wound care, Licensed Nurse M stated Resident 44 had a cyst (an abnormal pocket in the skin which usually contained hair and skin debris) removal on his tailbone. Licensed Nurse M stated the doctor gave instruction to cover the wound with foam dressing and change every day. When Licensed Nurse M was asked if band aid could be used to cover the wound, Licensed Nurse M stated Resident 44's wound should be covered with 6 cm x 6 cm (centimeter) foam dressing. During a clinical record review for Resident 44, the progress note, dated [DATE] at 4:25 p.m., indicated Resident 44 had a sacral (relating to the sacrum - the triangular bone just below the backbone) pilonidal cyst removed. During a clinical record review for Resident 44, the Treatment Administration Record (TAR) indicated a doctor's order written on [DATE], to keep the surgical site clean, dry and cover with foam dressing every day and as needed. During a clinical record review for Resident 44, the Care Plan for surgical wound created, on [DATE], indicated to keep the surgical site clean, dry and cover the with foam dressing every day and as needed when soiled or dislodged. 2) During a review of record, Resident 100's Face Sheet indicated she was readmitted from an acute hospital to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 100's MDS Section M (Minimum Data Set is a federally-mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes and helps nursing home staff identify health problems. Section M provides skin assessment information including the number and stage of unhealed pressure sores present on admission), dated [DATE], indicated Resident 100 was readmitted to the facility with one Stage II pressure sore or injury (open skin or an ulcer, which is usually tender and painful. The sore expands into deeper layers of the skin. It can look like a scrape, blister, or a shallow crater in the skin. Sometimes this stage looks like a blister filled with clear fluid). Review of the weekly skin integrity assessment, dated [DATE], indicated Resident 100's Stage II pressure wound was on her sacrum (the large, triangle-shaped bone in the lower spine that forms part of the pelvis). A review of a physician order, dated [DATE], indicated to cleanse the area with Normal Saline (a sterile solution of salt and water), pat dry, apply [MEDICATION(S)] (a multipurpose ointment used to treat and prevent minor skin irritations) to sacrum, with every brief change once a day and as needed, day and evening shift. The TAR (Treatment Administration Record) indicated nurses were administering the treatment as ordered, from [DATE] to [DATE]. Continued review of Resident 100's MDS, dated [DATE], [DATE], and the MDS on discharge on [DATE], indicated Resident 100 no longer had a pressure sore during those assessment months. During an interview and concurrent review of record on [DATE], at 4:20 p.m., Licensed Nurse R stated she had been working as wound nurse in the facility for about two months. Licensed Nurse R stated she worked Tuesday and Thursday while the regular wound nurse worked the other days and weekends. Licensed Nurse R found and presented the 2022, binder of the weekly skin report. During a continued interview and concurrent review of record on [DATE] at 4:20 p.m., Licensed Nurse R showed in PCC (Point Click Care - an electronic software storing medical information of residents in the facility) where the wound nurse documented weekly skin assessments. During continued review Licensed Nurse R stated it did not look like there was weekly documentation in PCC after the initial assessment on admission. During a review, the skin report binder for 2022, contained sheets of paper indicating weekly listing of residents receiving wound care, with information on the type of wound, date the wound was first discovered and assessed, whether the wound was facility-acquired or present on admission, stage of pressure sore or injury, location, characteristics and measurements of wounds, status on assessment whether worse, improved, the same, etc. During an interview on [DATE], at 1:12 p.m., Licensed Nurse M confirmed she did the documentation of the weekly skin assessment in the residents' charts after wound rounds with the wound doctors. When asked what the status of Resident 100's pressure sore was upon discharge to the acute hospital on [DATE], Licensed Nurse M stated she could not recall. When asked where the 2021, skin reports could be found, Licensed Nurse M responded the reports should be with Medical Records. During an interview on [DATE], at 4:04 p.m., the Medical Records Director stated she called the Wound Clinic providing the wound care to the facility. The Medical Records Director stated she asked for Resident 100's records, but the clinic informed her they did not have any records on Resident 100. When asked if the wound clinic was the same wound clinic providing wound care services in 2021, the Medical Records Director stated she would call and verify. A review of the of the binder of the Weekly Skin reports for 2021, provided by Licensed Nurse Z, indicated the binder contained the weekly wound assessments sheets for the months of January to June, but the weekly skin sheets for the months from July to December were missing. During a follow-up interview on [DATE], at 4:12 p.m., the Medical Records Director confirmed the same wound clinic was providing wound care services to the facility in 2021. The Medical Records Director stated she called the Wound Clinic again and confirmed there were no records of wound assessments for Resident 100. During an interview on [DATE], at 4:51 p.m., Licensed Nurse M confirmed she was the one who did the weekly assessments of Resident 100 on [DATE], but wondered why there were no progress notes after the initial wound assessments, until Resident 100 was discharged . Licensed Nurse M also stated she could not remember the wound doctor having seen Resident 100. When asked if she agreed the omission of documentation and monitoring were evidence of non-compliance, Licensed Nurse M nodded in agreement. A review of the Death Summary of Resident 100, dated [DATE], indicated Resident 100 was admitted to the acute hospital on [DATE], and expired on [DATE]. The death summary indicated Resident 100 was admitted for , altered mental status and profoundly abnormal laboratory, results, felt to be consistent with dehydration and failure to thrive like picture leading to acute kidney failure. Resident 100 was also found with ,a Stage III pressure injury on the right buttocks, present on admission, and an unstageable pressure injury of the left buttock, present on admission. The summary indicated the pressure injury were, probably due to her worsening debilitated state and primarily a fully bedbound status as she declined. It is unclear whether patient had been turned during her period of decline. A review of the facility Policy on Prevention of Pressure Ulcers, revised ,d+[DATE], page 1, indicated: The facility should have a system/procedure to assure assessments are timely and appropriate and changes in conditions are recognized, evaluated, reported to the practitioner, physician, and family, and addressed. The policy also indicated information on any change in the resident's condition should be recorded in the resident's medical record. 3) During an observation on [DATE] at 3:53 p.m., Licensed Nurse S used a wrist blood pressure (BP) monitor to obtain Resident 7's BP reading. During an observation on [DATE] at 8:55 a.m., Licensed Nurse C used the wrist BP monitor to obtain Resident 151's BP reading. During a review of the physician orders for Residents 7, 8, 39, 3, 351, 35, 151 and 46, it indicated these residents' blood pressure was being monitored every shift. During an interview on [DATE] at 11:31 a.m., the Director of Nursing (DON) verified that for the longest time, the facility had been using the wrist BP monitor to measure all residents' blood pressure. During a phone call with Equate Wrist BP monitor Customer Service on [DATE] at 12:55 p.m., a Customer Service representative verified the Equate Wrist BP Monitor 4500 series, currently being used by the facility, was intended for home use only and should not be used at Skilled Nursing Facility. During an interview on [DATE] at 11:25 a.m., the Director of Staff Development (DSD) stated wrist BP monitors should not be used at the facility. She stated she discussed this with the nurses about two months ago. The DSD stated wrist BP monitors gave inaccurate BP readings, which could compromise resident safety. She stated, for quality of care and standard of care, the facility should not be using the wrist BP monitor. During a concurrent interview and user's manual instruction review on [DATE] at 12:20 p.m., the Director of Nursing (DON) stated he was not aware of what the standard of practice was, with regards to the use of a wrist BP monitor. He verified the brand/model the facility was using was Equate wrist BP monitor and should only be used in a home care setting. He stated it should not have been used in the facility. The DON stated, using a wrist BP could yield inaccurate readings and could be a safety risk for the residents. The DON verified all residents had BP monitoring. He stated this could lead to residents receiving, or not receiving, BP medication based on inaccurate BP readings. During an interview on [DATE] at 2:45 p.m., Licensed Nurse H (LN H) stated the facility had been using the wrist BP monitor for a long time and now realized the facility should not be using the wrist BP monitor because it yielded inaccurate reading. She stated, using the wrist BP monitor was a safety risk because they might be administering BP medication for a resident who may not need it. LN H stated residents could be hypotensive (low blood pressure) and could be at risk for falls or dizziness. During a review of the instruction manual titled, Equate Wrist Blood Pressure Monitor 4500 series, model # BP3KC,d+[DATE]EWM, undated, the instruction manual indicated this machine was intended for self-monitoring of BP in adults and within a home environment.

Based on interview and record review, the facility failed to provided treatment, care and services to prevent pressure ulcers to two of 16 sampled residents (Residents 11 and 43). This failure resulted in Resident 11 developing a Stage III pressure ulcer and Resident 43 developing a Stage II pressure ulcer. Findings: RESIDENT 11 During a clinical record review for Resident 11, the Face sheet (A one-page summary of important information about a resident) indicated Resident 11 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with Resident 11 on 9/12/22 at 2:54 p.m., Resident 11 stated he had a pressure ulcer on his buttocks; however, wound treatment was not done daily. During an interview with Licensed Nurse M on 9/16/22 at 12:46 p.m., Licensed Nurse M stated Resident 11 had a Stage III pressure ulcer to his sacrum (the triangular bone just below the lumbar vertebrae (series of small bones forming the backbone). Licensed Nurse M stated she was the primary treatment nurse for the whole facility. Licensed Nurse M stated licensed nurses were expected to provide wound treatment to residents on her days off; however, licensed nurses were not doing it. Licensed Nurse M stated when she came back to work on 8/12/22, after 12 days of medical leave, Resident 11's right outer leg still had the same dressing from the last time she did the treatment, which was dated 7/29/22. When Licensed Nurse M was asked about the risks for residents with wounds who did not receive wound treatment, according to doctor's order, Licensed Nurse M stated residents' wounds could worsen. During an interview with the Director of Nursing (DON) on 9/19/22 at 12:53 p.m., when asked who was responsible for providing wound care when the treatment nurse was not available, the DON stated the licensed nurses were responsible to provide wound care to the residents. During a clinical record review for Resident 11, the Care Plan for his right lower leg wound, initiated on 1/26/22, indicated interventions including: Treatment as ordered. During a clinical record review for Resident 11, the Care Plan for his left buttock Stage III pressure wound, initiated on 3/10/22, indicated interventions including: Treatment as ordered. During a clinical record review for Resident 11, the Minimum Data Set (MDS -health status screening and assessment tool used for all residents), dated 7/10/22, indicated Resident 11 had one Stage III pressure ulcer not present on admission. During a clinical record review for Resident 11, the Treatment Administration Record (TAR) for September 2022, indicated a doctor's order, dated 5/11/2,2 for a daily wound treatment to Resident 11's right lower leg. The TAR indicated no licensed nurse signature on 9/4/22, and 9/10/22, indicating wound treatment was provided. During a clinical record review for Resident 11, the Treatment Administration Record (TAR) for September 2022, indicated and a doctor's order, dated 8/31/22, for a daily wound treatment to Resident 11's Stage II sacral pressure ulcer. The TAR indicated no licensed nurse signature on 9/4/22, indicating wound treatment was provided. During a clinical record review for Resident 11, the Treatment Administration Record (TAR) for September 202,2 indicated and a doctor's order, dated 9/7/22, for a daily wound treatment to Resident 11's Stage III sacral pressure ulcer. The TAR indicated no licensed nurse signature on 9/10/22, indicating wound treatment was provided. During a clinical record review for Resident 11, the document titled, Weekly Skin Integrity Assessment for Pressure Sore/Post-Op, dated 8/24/22, indicated Resident 11 had a Stage II pressure wound to his sacrum measuring 0.5 cm (centimeter) x 0.5 cm x 0.1 cm. During a clinical record review for Resident 11, the document titled, Weekly Skin Integrity Assessment for Pressure Sore/Post-Op, dated 9/07/22, indicated Resident 11 had a Stage III pressure wound to his sacrum measuring 3.0 cm x 1.0 cm x 0.3 cm. RESIDENT 43 During a clinical record review for Resident 43, the Face Sheet (A one-page summary of important information about a resident) indicated Resident 43 was admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During record review and concurrent interview with the MDS (Minimum Data Set - health status screening and assessment tool used for all residents) Coordinator on 9/16/22 at 9:36 a.m., the document titled, Weekly Skin Integrity Assessment for Pressure Ulcer/Post-Op, dated 7/6/22, indicated Resident 43 had a Stage II sacral pressure ulcer measuring 0.6 cm x 0.3 cm x 0.1 cm. During a clinical record review for Resident 43, the Treatment Administration Record for September 2022, indicated an ongoing wound treatment order for Resident 43's Stage II sacral pressure ulcer. During a clinical record review for Resident 43, the document titled, Nutritional Assessment - Registered Dietician, dated 4/27/22, indicated the Registered Dietitian (RD) wrote, [Resident 43] would benefit from additional protein supplementation for wound healing and weight stability. The RD recommended Prostat (ready-to-drink protein supplement) and [MEDICATION(S)] (an antidepressant reported to also stimulate appetite and/or increase body weight) to help increase resident 43's oral intake and weight stability. During an interview with the Director of Nursing (DON) on 9/15/22 at 10:47 a.m., when the DON was asked about the facility process for implementation of the Registered Dietitian's (RD) recommendations, he stated the RD normally would send an email to the DON if she had recommendations for a specific resident, then the resident's doctor would be notified of the RD recommendations for approval. The DON stated, if there was no email received, there would be no follow-up. During an interview and concurrent record review with the MDS Coordinator on 9/16/22 at 9:55 a.m., when asked about their process when the facility received RD recommendations for residents, the MDS Coordinator stated nursing and the Interdisciplinary Team (IDT - group of health care professionals who work together toward the goals of the resident) would discuss about the recommendation and obtain an order from the doctor for implementation. The MDS verified there was no doctor's order written for Prostat and [MEDICATION(S)], per RD recommendation for Resident 43, since 4/27/22 . When asked what would be the risk for Resident 43 when RD recommendations were not implemented, the MDS Coordinator stated Resident 43's weight would continue to decline, and her wound could get worse. Review of the Facility policy and procedure titled, Prevention of Pressure Ulcers, revised in 12/2014 indicated, It is the policy of the facility to provide guidelines regarding identification of pressure ulcer risk factors and interventions for specific risk factors. The policy indicated the following under, #7. Risk Factor- Poor Nutrition: a. Dietitian will assess nutrition and hydration and make recommendations based on the individual resident's assessment. b. Monitor nutrition and hydration status. c. Administer vitamins, mineral and protein supplements in accordance with physician orders and dietitian recommendations.

Based on observation, interview and record review, the facility failed to provide a safe environment to 28 residents, who were identified by facility staff as ambulatory and/or used wheelchairs, enabling them to independently maneuver throughout the facility, when: 1. B-wing exit door was observed left open, with no alarm for unauthorized exit or entry, and with a Wanderguard Alarm which was not functioning; 2. A-wing door alarm was off, and the door was left unlocked and able to be opened from inside and outside; and, 3. Only one of six facility exit doors had a working Wanderguard Alarm system in place (Entrance/Lobby Door). These failures could have resulted in injury, harm or even death, to all 28 residents, including one resident (Resident 1) who had a Wanderguard (monitoring device for residents who are at risk of eloping, ensuring the alarm is activated) bracelet and was able to leave the facility, undetected, and was later found in another Skilled Nursing Facility across the street. Findings: 1. A review of Resident 1's medical record indicated a diagnosis of early onset Alzheimer's Disease (progressive disease that destroys memory and other important mental functions). The medical record also indicated a placement of a Wanderguard to prevent elopement. During an observation on 11/3/21, at 8:52 a.m., B-wing exit door was cracked open and had no alarm. The B-wing door led to a laundry room, the backyard and smoking area, and also led to the back parking with two wooden gates that were also left open, with no locks and ultimately allowing access to the front of the building and the busy six-lane main road of [NAME] Boulevard. During a concurrent observation and interview on 11/3/21, at 9 a.m., Maintenance Staff A was holding the B-wing door open. Maintenance Staff A was asked why the door was left open and did not alarm. Maintenance Staff A showed the Wanderguard alarm box, and stated the alarm worked with residents who wore Wanderguard devices (such as bracelets or anklets), and if a resident without a Wanderguard exited this door, it would not be detected (the alarm would not sound). Maintenance Staff A further stated the door should be locked all the time and did not know why it was left open. During an interview on 11/3/21, at 9:30 a.m., Management Staff C was asked how often facility doors were checked to ensure safety and security. Management Staff C stated he checked all doors every day in the morning, lunch time and afternoon, to make sure they were locked, and alarms were working, but he did not document it. Management Staff C further stated, staff sometimes turned off the alarms when they exited the doors and forgot to turn them back on and left the doors unlocked and opened like what happened with A- & B-wing doors. Management Staff C stated he did not have control of staff if they wanted to go in and out of those doors. During a concurrent observation and interview, with Management Staff C, on 11/3/21, at 3:49 p.m., the B-wing door had a Wanderguard alarm but did not have an unauthorized exit and entry alarm. Management Staff C was asked to check the Wanderguard alarm, using his remote, and the alarm did not go off. When Management Staff C was asked why there was no regular alarm on this door and why the Wanderguard alarm was not working when he checked it that morning, he did not reply. 2. During an observation on 11/3/21, at 9:10 a.m., with Licensed Staff B, A-wing door was closed and had a red box alarm attached, with a key in it. When A-wing door was opened, it did not alarm. When A-wing door was closed, it was able to be opened from the outside; it did not lock when it was closed. During an interview on 11/3/21, at 10:53 a.m., Management Staff C was asked about Wanderguard alarms on the exit doors. Management Staff C stated four doors (B, C, D and Entrance/Lobby Door) had Wanderguard alarms except A-wing door. Management Staff C stated he did not know why there was no Wanderguard alarm on A-wing door. During a second observation on 11/3/21, at 10:59 a.m., with Management Staff C, A-wing door was ajar, and no alarm sounded. Management Staff C closed the door, turned on the alarm and stated somebody opened it and did not lock it and turned off the alarm. A-wing door needed a key to unlock it from the outside knob before entering, so it would lock when closed from the inside. Management Staff C stated he did not know who else had the key to A-wing door except himself and Maintenance Staff A. During an interview on 11/3/21, at 11:52 a.m., Management Staff D stated they found who had the extra key to A-wing door, it was the Housekeeping Staff F, and they instructed her to keep the door locked. During an interview on 11/3/21, at 11:56 a.m., Housekeeping Staff F stated the previous Maintenance Supervisor gave her the key to the A-wing door because she started working at 5 a.m., and she used A-wing door to enter the facility. Housekeeping Staff F stated she might have forgotten to lock the door this morning. During a third observation on 11/3/21, at 3:42 p.m., with Management Staff C, A-wing door was closed, and when opened to check for the alarm, the alarm was off. Management Staff C turned on the alarm. A review of the facility's, Wandering Resident Alarm Band Management, dated 7/2014, indicated, 7. Maintenance is required to check door alarm system minimum monthly. Alarm band company tester will be used to test individual arm bands daily or per manufacturer recommendation. A review of the facility's, Policy and Procedure on Wanderguard, dated 7/2012, indicated, Once resident with Wanderguard leaves the facility, the Wanderguard alarm will be activated. The staff at this time will be alerted that the resident is trying to go out from the facility. 3. During a concurrent observation of the D-wing door, and interview with Management Staff C, on 11/3/21, at 3:46 p.m., Management Staff C stated, A-, C- and D-wing doors did not have Wanderguard alarms, as he previously stated; they only had the regular alarm. Management Staff C did not reply when asked why he had previously indicated all doors had Wanderguard alarms. During a concurrent observation and interview, with Management Staff C, on 11/3/21, at 4:15 p.m., the Dining/Activity Room door was the exit door to the smoking area in the backyard and had two Wanderguard alarms on each side. When Management Staff C was asked to check these Wanderguard alarms using the remote, the alarms did not go off. Management Staff C stated he knew the Wanderguard alarms for the Dining/Activity Room and B-wing doors were not working when he checked them in the morning. When Management Staff C was asked how long the Wanderguard alarms were not working, he did not reply. On 11/3/21 at 3:15 p.m., the Department identified an Immediate Jeopardy situation with respect to Environmental Condition of the exit doors in the facility. On 11/3/21 at 4:38 p.m., the Facility Administrator submitted a Plan of Action (IJ Removal Plan). On 11/3/21, at 5:05 p.m., the facility's IJ Removal Plan was approved. A review of the facility's IJ Removal Plan, dated 11/3/21, at 5:05 p.m., indicated the following actions to address the Environmental Condition non-compliance listed in the IJ Template: 1. Non-compliance A, B, C and D Wing door-alarms will be left on and alarm key will be given to charge nurses and the doors will be locked at all times. Front door locked at all times and has wander guard sensor. Dining Room door will have a door alarm on. B-wing door and dining room door-new alarm will be placed. 2. Potential for serious injury, serious harm or death In-service for staff not to use the A, C and D wing doors unless for emergency purposes. In process of having wander guard system upgrade. 3. Need for immediate action for safety A-wing door-alarm will be left on and alarm key will be given to charge nurses and the door will be locked at all times. B-wing door-new alarm will be placed. Wooden gate at the back of facility-door lock will be installed on both gates and will place a self-closing hardware. Log to monitor alarms daily-Maintenance In the interim until all doors will be equipped with alarm there all resident identified as high risk for elopement will be on q30-min (every 30 minutes) monitoring. On 11/8/21, at 11:32 a.m., the Department exited with the Director of Nursing. The Department informed the facility of the deficiencies identified during the survey. The facility was informed the deficiency determinations were preliminary and subject to Supervisory review. The facility was informed the Immediate Jeopardy was not lifted as of 11/8/21. During an onsite visit on 11/17/21, at 2:55 p.m., the Immediate Jeopardy (IJ) was removed. The RN (Registered Nurse) Consultant and IP Nurse (Infection Preventionist) were present at the time the IJ was removed.

Based on interview and record review, the facility failed to provide psychosocial care needs for two of three residents (Residents 1 and 2) when: 1. The facility did not develop a plan of care for Resident 2 after an altercation, and; 2. The facility did not implement a resident-to-resident altercation care plan for Resident 1. This failure resulted in: 1. Resident 2 being unable to discuss how he felt after the physical altercation. 2. Resident 1's second physical altercation with another resident (Resident 3). Findings: 1. During a review of Resident 2's, Progress Notes, dated 11/20/20, it indicated Resident 2 was, sitting on a wheelchair when another resident came up to him and hit him in the face three times. During a concurrent observation and interview on 12/7/20 at 9:10 a.m., with Resident 2 in the dining room, Resident 2 did not have a visible wound or bruising on his face. Resident 2 stated he was sitting on his wheelchair outside the dining hall when Resident 1 hit him in the face. Resident 2 stated he did not say or do anything to Resident 1 before he was hit. Resident 2 stated he felt, stupid because he did not, fight back. Resident 2 stated he did not, feel safe staying in the facility. Resident 2 stated, nobody talked to him about how he felt after being hit in the face. During an interview on 12/7/20, at 1:06 p.m., Management Staff G stated Management Staff H met with Resident 2 for, psychosocial visits. During an interview on 12/7/20, at 1:57 p.m., Management Staff H stated she did not have documentation of whether she spoke to Resident 2 about the incident, and she did not do a one-on-one visit or follow-up with Resident 2 after he was hit in the face. During an interview on 12/7/20, at 1 p.m., Licensed Staff A stated there was no care plan for the physical altercation incident for Resident 2. Licensed Staff A stated she forgot to make a care plan. 2. During a review of Resident 1's care plan dated, 11/20/20, it indicated, Goal-Resident will not exhibit another resident-to-resident altercation in 30 days if possible, for 90 days. Interventions-SSD (Social Service Designee) will make frequent room visits x2 every shift and provide relief from any psychosocial distress. During a review of Resident 1's, Progress Notes, dated 11/20/20 thru 12/3/20, they did not show documentation the SSD provided psychosocial visits to Resident 1. During a review of Resident 1's Progress Notes, dated 11/22/20 at 4:07 p.m., they indicated, resident was in an altercation with another resident. Review of facility's, Abuse and Neglect Prevention Management, policy and procedure, with revised date, 12/2014, indicated, Incident Management- The facility system to follow up on altercations will place an emphasis on preventing future altercations. This system includes, but is not limited to: -Resident's communications and functional mobility, with consideration of proactive strategies. -A multidisciplinary approach to the development of individualized behavior care plans, including social services, recreational activities, and external consultations. -Interventions for all parties that could be involved in altercations.

Based on observation, interview and record review, the facility failed to protect three of the three residents (Residents 1, 2 and 3) from physical abuse, when it did not provide supervision to one resident (Resident 1), who was ambulatory and with a history of physical aggression. This failure resulted in Resident 2's facial cut and bruising, and feeling of not being safe in the facility, and Resident 1's cut in the forehead. Findings: During a review of Resident 1's, Minimum Data Set (MDS-assessment tool of health status for all residents in long term care facilities), dated 7/24/20, it indicated Resident 1 had highly impaired hearing, absence of spoken words and was independent of Activities of Daily Living, which included walking in room, corridor and unit. During a concurrent observation and interview on 12/7/20 at 9:10 a.m., with Resident 2 in the dining room, Resident 2 did not have a visible wound or bruising on his face. Resident 2 stated he was sitting on his wheelchair outside the dining hall when Resident 1 hit him in the face. Resident 2 stated he did not say or do anything to Resident 1 before he was hit. Resident 2 stated, he felt, stupid because he did not, fight back. Resident 2 stated he did not, feel safe staying in the facility. During a review of Resident 2's, Progress Notes, dated 11/20/20 at 12:35 p.m., it indicated Resident 2 had a linear cut to his lower left jaw measuring 3.5 cm (centimeters), bruising to the right orbital and bruising and swelling to the left orbital. During an interview on 12/7/20 at 9:43 a.m., Resident 3 stated Resident 1 took a picture of him on his phone while he was outside in the smoking area. Resident 3 stated, days before the incident, Resident 1 was taking pictures of residents and showing them to, anybody and making gestures like the, gun and motioning his hand across his neck. Resident 3 stated he went inside the dining hall and pointed to Resident 1's phone, and Resident 1 raised his arm to hit him, so he [Resident 3] grabbed Resident 1 and started fighting, and they both fell on the floor. During an interview on 12/7/20, at 12:35 p.m., Licensed Staff F stated, Resident 1 had a tiny cut on the forehead from the fight. During an interview on 12/7/20, at 10:29 a.m., Licensed Staff C stated Resident 1 did not like certain staff members and, motioning spraying, thinking that staff were, poisoning him. Licensed Staff C stated, Resident 1 was monitored for, aggressive behavior and, inappropriate behavior. During an interview on 12/7/20 at 11:27 a.m., Management Staff E stated Resident 1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Management Staff E further stated, if Resident 1 did not like the person, he would gesture his hand in front and across his neck and motion with his hand, gun. Review of Resident 1's, Care Plan for pushing another resident, dated 7/17/20, indicated Resident 1, apparently pushed another resident when victim attempted to open bedroom door. Resident 1 was, in another resident's room watching television. A care plan for unpleasant behavior, dated 3/31/20, indicated Resident 1, showing unpleasant behavior (getting in staff members' face, barely sleeping, using other residents' bathroom). A care plan for taking pictures, dated 4/9/20, indicated, .took a picture of one of the staff and pointed to the picture and gestured to cut the throat of the staff in the picture. Doing gesture to cut the throat of the Administrator and DSD (Director of Staff Development) and staff at risk for safety issues. A care plan for possible altercation, dated 7/18/20, indicated, possible altercation, Resident 1 tried to enter room [ROOM NUMBER]. Review of Resident 1's, Progress Notes, dated 11/22/20 at 9:21 a.m., indicated Resident 1 pushed Licensed Staff F, took away a bottle of medicine from Licensed Staff F and threw it on the floor. During an interview on 1/5/21, at 11:39 a.m., Management Staff G stated, a one-on-one sitter for Resident 1 was discussed as an intervention, but the staff members were, not comfortable doing it. Management Staff G stated staff members, were afraid of Resident 1's, outburst. Management Staff G stated the facility decided on every 30 minutes' monitoring of Resident 1's whereabouts instead of every 15 minutes' monitoring. Management Staff G stated it was, quite excessive for every 15 minutes' monitoring on top of what the staff members were also assigned to do. Review of facility's, Abuse and Neglect Prevention Management, policy and procedure, with revised date, 12/2014 indicated, Prevention-C. The facility staff promotes an altercation free culture through, c. Supervision.

Based on observation, interview, and record review, the facility failed to respond to residents' complaints of pain, identify changes in pain medication regimens, document pain location and type, complete the pain assessment tool, develop a pain assessment or pain management policy which addressed the use of their pain evaluation form and met standards of pain management practices, and failed to evaluate effectiveness of a pain medication care plan, for two residents (7 and 12) in a sample size of 15 residents. The failure to acknowledge symptoms of pain, and conduct comprehensive pain assessments, led to unnecessary stress for Residents 7 and 12, and led to the potential for both Residents not to achieve their highest practicable physical, mental, and social/emotional functional levels. Findings: 1. Resident 7 is alert, oriented to date, time, and place, and can speak clearly about her own needs. The Resident was admitted to the facility on [DATE], with a history of an infected sacral (near the 'tail bone') pressure wound and severe arthritis. The Resident was receiving intravenous antibiotic therapy for infection. A review of Resident 7's 1-21-12 admission pain assessment form indicated that the facility failed to identify the change in Resident 7's pain medication on admission. The Resident had been taking [MEDICATION NAME] (a narcotic pain medication) both at home and in the acute hospital. On admission to the facility, however, the physician prescribed Tylenol two tablets every 4 hours for pain if needed. Tylenol and [MEDICATION NAME] are not equal in action and strength, for pain relief. For example, [MEDICATION NAME] is a narcotic pain medication requiring a prescription from a physician and Tylenol is not a narcotic and can be bought without a prescription. Pain management guidelines, established by government agencies and the American Pain Society, and endorsed by the Board of Registered Nurses, indicate that one "nursing function of appropriate pain management includes . . . using knowledge of [MEDICATION NAME] (equal in action and strength) dosages to maintain both patient safety and pain releif as routes and types of ordered drugs change." In addition, the Resident's 1-21-12 admission pain assessment form was blank in the areas for entering a description of pain location, type, frequency and intensity, and for entering the patient's words used to describe the pain. The form, instead, indicated that on 1/21/12 the "Resident didn't complain of pain (at) this time." The facility's ongoing pain monitoring "flowsheet" indicated the Resident complained of pain on 1/24/12 and 1/25/12, and was medicated with Tylenol. However, the Resident's 1-21-12 admission pain assessment form was not subsequently completed to include a pain description. Also, a review of the facility's March 2008 pain assessment policy indicated that the policy did not address use of the admission pain assessment form, and did not address other "appropriate pain management" items endorsed by the Board of Nursing such as "ensuring informed consent for pain management," "educating patients and families . . . regarding pain management expectations," and "recognizing that prn (as needed) medications may be given around the clock." The Board of Nursing's undated "Pain Management Nursing Role/Core Competency" guide indicates that nurses work "through appropriate committees and channels" for effective pain management "policies, procedures and practices." On 1/25/12, at 8:15 a.m., two surveyors entered Resident 7's room, and noted that the Resident was moaning and rubbing her right arm/shoulder area with her left hand. The Resident asked to be repositioned off of her left side, because it "hurts really bad." The Resident also said that she had an "artificial hip," and was not supposed to be on it more than "two hours" and that she had been laying on her back all night. Resident 7 added that her right side and shoulder also "hurts," because of "arthritis." The surveyor asked the Resident if she had received any pain medication, and the Resident said "No." At 8:30 a.m., Licensed Staff N entered Resident 7's room and introduced herself to the Resident. The nurse told the resident that she was there to start the intravenous antibiotic infusion. The Resident asked the nurse several times to reposition her off of her hip, and give her pain "pills." The nurse did not reply to the residents request for pain pills, repositioning or complaints of hip pain. After the nurse started the intravenous medication infusion, she cleaned up the materials she had used and left the room without speaking with the resident about her pain. At 8:45 a.m., the Surveyors asked Licensed Staff N if she was going to go and obtain pain medication for Resident 7. Nurse stated, " I am not the medication nurse, I do IV's and other lines and dressings." Licensed Staff N turned and walked away. At 9:15 a.m., an Administrative Staff B was asked who is responsible for Resident 7's pain medication, and the staff member said, "Her med nurse knows and it is taken care of". At 9:30 a.m., the wound care nurse (Licensed Staff K) and a CNA were observed repositioning Resident 7 onto her left side, in preparation for wound care. During the repositioning, the Resident was yelling "Stop. Stop. This is really hurting me." While the CNA and nurse were moving the Resident onto her left side, the Resident said "Don't push on my right arm or side. It hurts really bad." The staff continued to move her over onto her left side and despite the Resident's request to stop. The staff told the resident they where trying to"hurry"so it wouldn't hurt so long. The surveryor asked what her pain was at the time, Resident 7 stated "It's a 100." When asked if she could use the pain scale of 1 to 10 instead, she stated "That doesn't change anything. It is still a 100. It has been hurting this bad since I got here." At 3:40 pm., Resident 7 was observed in a hoyer lift (a device that allows caregivers to lift people who are unable to stand without assistance) being positioned into a wheel chair by a CNA and Licensed Staff J for transport to the therapy room. The Resident tolerated the transfer, but did complain of pain when positioned into the wheelchair. During the hoyer transfer into the wheelchair, Licensed Staff J stated, "The first time the Resident was taken to therapy, on 1/23/212, she cried and yelled and asked for them to stop moving her because it hurt her so bad." According to Licensed Staff J, at that time Resident 7 stated her pain was, on scale of 1 to 10 , "8." Licensed Staff J added that they stopped the therapy that day, and had a medication nurse give her Tylenol 325 mg. two tablets, waited for 30 minutes for the Tylenol to take effect, and continued with minimum therapy. During a telephone interview with Resident 7's family member on 1/25/2011 at 6:39 p.m., concerning the Resident's home medications, the family member stated that the Resident "has been taking pain medications for many years over the counter and prescribed." The family member was able to supply the surveyor with a list of Resident 7's home medications, which included [MEDICATION NAME] (contains [MEDICATION NAME]) for pain. The Resident's "Pain Assessment Flowsheet" indicated that Resident 7 was given Tylenol only twice since the Resident's admission of January 21,2012. Tylenol was given once on January 24 at 4:00 p.m. and again on January 25 at 9:50 a.m. Also, according to Resident 7's family member, the facility failed to speak with the family member about the Resident's pain. 2.On document review of Resident 12 on 1/25/2012 he has been in this facility since 10/10/2008 admitted with [MEDICAL CONDITIONS], diabetes type 2, pain and anxiety. Pain management is referred to in Resident's Care plan but not followed. Has had pain since admission 3 years and has progressed with progression of disease process. However care plan has not progreessed with disease and pain progression. a. Resident 12 was observed, on 1/25/12 at 11:40 a.m., laying in his bed. The Resident was quietly moaning. On interview, the Resident was asked about his moaning and the Resident pushed his blankets back and pointed at his stomach and tried to reach his groin and said " pain". When asked on a scale from 1 - 10 what was his pain he stated "8." When asked how often he was in pain he stated "Most of the time. The pills do work when they give them to me, I have to ask for them and they forget and it is a long time before I get them. When they finally bring them it takes a long time for the pain to go away." "My scrotum is very painful. They put cream on it but it doesn't help. It has not gotten better since I have been here." A 1/15/12, 3:00 p.m. nurse's note indicated that Resident 12 complained of pain in the scrotum wound area. 1/15/12 medication records indicated that the Resident was not medicated for pain during that 24 hour period. The pain medicine was not given until 1/17/2012 at 1:00 a.m. Current physician orders [REDACTED]. [MEDICATION NAME] 5/500 mg 1 tab P.O. every 4 hours for general pain. [MEDICATION NAME] 5/500 mg. 2 tabs every 4 hours for severe pain. A review of Resident 12's pain assessment flow sheets, for the period 10/1/11 - 1/25/12, indicated that the Resident was medicated for pain, approximately once a day, on 57 of the 117 days. The Resident's pain medication orders indicated that the Resident could have been medicated for pain every four hours. In addition, a review of the facility's quarterly pain assessment document indicated that the facility documented that the Resident had no pain for the time period October 2011 through December 2011. In addition, the Resident's 10-20-11 care plan indicated that the Resident had a "risk for pain," rather than indicating the presence of actual pain. Resident 12's 10-20-11 care plan for "risk of pain" called for "quarterly" assessments to determine care plan goal achievement. However, the Resident's interdisciplinary team care planning conference form, used to document progress towards care plan goals, did not address the Resident's care plan for pain.