Every finding on record at Hillside Heights Rehabilitation Center

Based on interview and record review it was determined the facility failed to follow physician orders for a prosthetic limb referral for 1 of 3 sampled residents (#4) reviewed for accommodation of needs. This placed residents at risk for unmet needs. Findings include: Resident 4 was admitted to the facility in 1/2026 with diagnoses including post-operative below knee amputation (BKA). Review of a physician's order dated [DATE] indicated Resident 4 was to be referred to a provider for an evaluation for a prosthetic leg. The order had an expiration date of [DATE]. Review of a Discharge Planning & Summary dated [DATE] indicated Resident 4 had a right BKA and was admitted to the facility following this procedure. The discharge summary did not include a referral for a prosthesis. Review of a physician's note dated [DATE] indicated the family expressed concerns Resident 4 still did not have a prosthetic leg and a referral appointment was sent to a local prosthetics company. Review of Resident 4's clinical record from [DATE] through [DATE] found no documented evidence the facility had implemented the resident's [DATE] physician order to be referred for an evaluation for a prosthetic limb. In an interview on [DATE] at 9:35 AM. Staff 5 (Unit Manager) stated the referral for Resident 4's prosthetic limb was made on [DATE] after the physician order expired and no appointments were made by the facility for the resident to see a prosthetist. In an interview on [DATE] at 9:42 AM, Witness 6 (Office Assistant for Prosthetics Company) stated no referral had been made for Resident 4 to obtain a prosthesis. Witness 6 stated they did receive a referral from a Home Heath company on [DATE] but the resident was never seen for a prosthetic limb. In an interview on [DATE] at 10:05 AM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged that the facility did not follow the physician's order to refer Resident 4 for a prosthetic limb.

Based on interview, and record review, it was determined the facility failed to ensure ongoing assessments were conducted for non-pressure skin wounds for 1 of 3 sampled residents (#4) reviewed for non-pressure skin wounds. This placed residents at risk for worsening wounds. Findings include: A review of the facility's Skin and Wound Management Guidelines indicated the following skin changes required assessment, measurement, photography, and documentation in the Skin and Wound Module:-Neuropathic ulcer (nerve related sore).-Infected skin tear, regardless of size.-All vascular-related wounds (wounds due to blood vessels), venous or arterial. Resident 4 was admitted to the facility in 11/2025 with diagnoses including open wound of left great toe and diabetes with polyneuropathy (a condition where many nerves in the body are damaged, causing numbness, weakness, or pain in the hands and feet). The 11/20/25, admission MDS indicated Resident 4 was cognitively intact and had a diabetic foot ulcer. A Wound Clinic Note dated 11/20/25 indicated Resident 4 had a blister that was incised (cut into the skin with a sharp tool) on the left great toe with minimal to moderate amount of drainage. Total wound surface area was 20 cm^2 or less. A Skin and Wound Evaluation dated 11/24/25 indicated Resident 4 had an other wound on the first digit of the left foot measuring 10.06 cm, with a length of 5 cm and a width of 2.7 cm. The wound bed showed epithelial (new skin), granulation (healing tissue) and slough (dead tissue) layers, but did not indicate percentage of each. The wound had moderate amounts of serosanguineous (clear and blood-tinged) drainage. Resident 4's evaluation did not include an assessment of the resident's wound edges, swelling, temperature, pain, treatment type and the care goal.A 12/11/25 Wound Clinic Note indicated Resident 4's left great toe wound had regressed and was aggressively debrided. The tissue debrided was callus (hardened skin), fibrin (protein build-up) and slough. There was no documented evidence in Resident 4's clinical record of further Skin and Wound Evaluations being completed after 12/11/25. On 4/2/26 the State Survey agency received a public complaint alleging Resident 4 had an infected toe due to facility negligence. Approximately 24 hours after discharge, a nurse became ill after examining the wound and reported black edges. Resident 4 was sent to the hospital and placed on IV antibiotics. On 4/7/26 at 10:06 AM, Resident 4 confirmed the above complaint and stated her/his toe was still painful. On 4/8/26 at 11:22 AM and 12:21 PM, Staff 3 (LPN) confirmed she completed wound care on the left great toe the day before discharged on 12/30/25. She recalled slight amount of dried blood but no black discoloration. She noted blanchable (temporary) redness but no infection. Staff 3 stated weekly wound assessments were set to trigger automatically on admission and the wound nurse typically completed evaluations. On 4/8/26 at 12:31 PM, Staff 2 (DNS) stated he expected staff to complete weekly skin and wound assessments for residents. Staff 2 stated because of budget cuts the facility no longer had a wound nurse, and it was difficult for nurses to complete the weekly evaluations.

Based on interview and record review, it was determined the facility failed to provide adequate catheter care for 1 of 3 sampled residents (#1) reviewed for catheter care. This placed residents at risk for unmet catheter needs. Resident 1 was admitted to the facility in 12/2025 with diagnoses including obstructive and reflux uropathy (disease of the urinary system caused by blockage and backward urine flow). The 1/2026 TAR indicated for staff to change the suprapubic catheter every 30 days. On 1/12/26 the TAR indicated to hold the treatment and referred the reader to Administration Notes. A 1/12/26 Administration Note indicated the suprapubic catheter was not changed because staff were waiting for pending special instructions from the in-house provider because of a penile implant (device surgically inserted into the penis). There was no documented evidence that Resident 1 received a suprapubic catheter change in 1/2026. Resident 1's 2/2026 TAR indicated for staff to change the suprapubic catheter every 30 days. On 2/11/26 the TAR indicated the catheter was changed by Staff 10 (LPN). Review of Resident 1's progress notes found no documentation of the resident's 2/11/26 suprapubic catheter change. A 2/18/26 Nursing Note documented Resident 1 had notified Staff 3 (LPN) of bladder pain and spasms. Resident 1 requested a urinalysis as she/he believed there was an infection. Physician orders signed 2/19/26 directed staff to complete a urinalysis. On 2/19/26 the State Survey agency received two public complaints indicating Resident 1 had been at the facility since 12/2025 and the suprapubic catheter had not been changed since admission. Resident 1 believed there was a urinary tract infection. Review of Resident 1's clinical record found no documentation the resident received the ordered urinalysis. On 4/8/26 at 11:17 AM, Staff 3 stated she had not been sure whether the catheter should be changed in the facility or at the urology clinic. Staff 3 stated she did not work on 1/13/26 and did not know if Resident 1 received a catheter change in 1/2026. On 4/8/26 at 12:15 PM, Staff 10 stated she did not recall ever completing a catheter change on Resident 1. She stated usually she would normally document the treatment in the notes. Staff 10 stated she most likely documented she completed the suprapubic change but did not complete the treatment. On 4/8/26 at 12:28 PM, Staff 2 (DNS) stated documentation was lacking on the follow-through related to communication in 1/2026 regarding the penile implant and changing of the suprapubic catheter orders. Staff 2 stated he did not believe Resident 1 had a penile implant and staff had mistaken the suprapubic catheter for an implant. Staff 2 stated Resident 1 had developed chest pain and pneumonia, and staff focused on the pneumonia instead of the physician-order urinalysis, resulting in failure to perform the urinalysis. Staff 2 confirmed physician ordered treatment was not completed.

Based on observation, interview, and record review it was determined the facility failed to ensure proper labeling of biologicals for 2 of 3 treatment carts reviewed for medication storage and failed to ensure treatment carts were properly secured during a random observation. This placed residents at risk for reduced efficacy of medication and unauthorized access to medications. Findings include:1. On 1/28/26 observations were made from 11:21 AM to 11:31 AM of the treatment cart on the west hall near the nurses' station, it was left unlocked and unattended.On 1/28/26 at 11:31 AM Staff 8 (LPN) acknowledged the treatment cart was left unlocked and unattended and contained insulin and other treatments.2. On 1/28/26 at 11:34 AM on open insulin glargine pen was observed in the west hall treatment cart with no open date.On 1/28/26 at 11:34 AM Staff 8 (LPN) acknowledged the insulin pen was open and not labeled with an open date.3. On 1/28/26 at 12:54 PM one open Tresiba insulin pen was observed in the east hall treatment cart with no open date.On 1/28/26 at 12:54 PM Staff 7 (RN) acknowledged the insulin pen was open and not labeled with an open date.

Based on interview and record review it was determined the facility failed to follow the facility bowel protocol and administer medication as ordered for 2 of 5 sampled residents (#s 5 and 8) reviewed for medication. This placed residents at risk for constipation. Findings include:The undated bowel protocol indicated residents without a bowel movement in excess of three days would be assessed by the nurse, including a physical assessment of the gastro-intestinal (GI) system, signs and symptoms of constipation, impaction, or obstruction, and complete a resident and/or staff interview. When needed, a bowel protocol would be implemented as established by physician orders including administration of stool softeners, administration of laxatives or bowel stimulants, and administration of an enema. If after completion of the bowel protocol orders, the resident did not have a bowel movement, the physician would be notified. 1. Resident 5 admitted to the facility in 12/2025 with diagnoses including diabetes. A review of the bowel records from 12/31/25 through 1/28/26 indicated the resident did not have a bowel movement on 1/3/26, 1/4/26, 1/5/26, 1/6/26 and 1/7/26.A review of the 1/3/26 through 1/7/26 progress notes and MARs indicated no bowel assessments were completed, and additional bowel medications were not offered to the resident. On 1/29/26 at 2:13 PM Staff 2 (DNS) acknowledged a bowel assessment was not completed for Resident 5 and she/he did not receive bowel care interventions as ordered on the identified dates.2. Resident 8 admitted to the facility in 12/2025 with diagnoses including heart failure.A review of the bowel records from 1/1/26 through 1/29/26 indicated the resident did not have a bowel movement on 1/19/26, 1/20/26, 1/21/26 and 1/22/26.A review of the 1/19/26 through 1/22/26 progress notes and MARs indicated no bowel assessments were completed, and additional bowel medications were not offered to the resident.On 1/30/26 at 10:57 AM Staff 2 (DNS) acknowledged a bowel assessment was not completed for Resident 8 and she/he did not receive bowel care interventions as ordered on the identified dates.

Based on observation, interview and record review it was determined the facility failed to ensure residents' narcotic drug records were in order and an account of all controlled drugs was maintained for 2 of 3 medication carts reviewed for medication storage. This placed residents at risk for inaccurate clinical records related to narcotics and drug diversion. Findings include:1. On 1/28/26 at 8:38 AM the west hall Controlled Substance Book was reviewed with Staff 8 (LPN). There was only one signature observed for the 1/28/26 day shift controlled medication count. Staff 8 immediately signed the book and stated he completed the count earlier that morning with another staff, but did not sign the book.On 1/30/26 at 11:39 AM Staff 2 (DNS) stated the expectation was for two staff to count controlled medications between shifts, compare them to the Controlled Substance Book and each sign the signature page after the count was completed.2. On 1/28/26 at 9:23 AM Staff 7 (RN) was observed to administer oxycodone (controlled medication) to Resident 19. Staff 7 signed out the oxycodone from the Controlled Substance Book. There were only four pills remaining after the administration, but the book indicated there were five remaining. Staff 7 stated she completed the controlled medication count with the night shift nurse but they missed the discrepancy between the oxycodone medication card and the book.On 1/30/26 at 11:39 AM Staff 2 (DNS) stated the expectation was for each responsible staff to count controlled medications between shifts and compare them to the Controlled Substance Book to ensure accuracy.

Based on interview and record review it was determined the facility failed to ensure medical records were accurate for 1 of 5 sampled residents (#5) reviewed for medication. This placed residents at risk for medication errors. Findings include: Resident 5 admitted to the facility in 12/2025 with diagnoses including atrial fibrillation.The 12/19/25 physician order indicated Resident 5 was to receive digoxin 250 mcg once daily.The 12/2025 and 1/2026 MARs indicated Resident 5 was to receive digoxin 250 mg from 12/20/25 through 12/31/25 and from 1/1/26 through 1/8/26.On 1/29/26 at 1:15 PM Staff 2 (DNS) stated there was a transcription error when digoxin was entered into the MARs and acknowledged the MARs indicated the resident was to receive digoxin 250 mg when the order was for digoxin 250 mcg.

Based on interview and record review it was determined the facility failed to provide dental services for 1 of 3 sampled residents (#7) reviewed for dental services. This placed residents at risk for unmet dental needs. Findings include:Resident 7 admitted to the facility in 2023 with diagnoses including heart failure.The 11/6/25 progress note indicated Resident 7 had poor dentition.The 11/26/25 Care Conference indicated Resident 7 was interested in having a dental appointment. On 1/26/26 at 1:59 PM Resident 7 stated she/he had dental problems and requested to see the dentist at the last care conference several months ago but staff did not follow up on the request. There was no information in the clinical record to indicate a follow up was completed for Resident 7's request to see the dentist.On 1/29/26 at 2:13 PM Staff 2 (DNS) acknowledged Resident 7 indicated she/he wanted to see the dentist at the 11/26/25 care conference and a dental appointment was not set up for the resident.

Based on observation, interview and record review it was determined the facility failed to maintain a medication error rate of less than 5%. There were 2 errors in 27 opportunities resulting in a 7% error rate. This placed residents at risk for adverse medication side effects. Findings include:Resident 46 admitted to the facility in 2019 with diagnoses including atrial fibrillation.The 1/22/26 physician order indicated Resident 46 was to receive the following:-Lasix every Monday, Wednesday and Friday for lower extremity edema;-Lactulose once daily for increased ammonia levels.On 1/28/26 at 8:42 AM Staff 7 (RN) was observed to administer morning medications to Resident 46. The medications administered did not include Lasix or Lactulose.On 1/28/26 at 8:54 AM Staff 7 acknowledged Resident 46 did not receive Lasix and Lactulose as ordered because the medications were not available.

Based on interview and record review the facility failed to ensure residents were free from unnecessary medications for 1 of 5 sampled residents (#5) reviewed for medication. This placed residents at risk for adverse drug events. Findings include:Resident 5 admitted to the facility in 12/2025 with diagnoses including atrial fibrillation.The 12/19/25 physician order indicated Resident 5 was to receive digoxin (antiarrhythmic) 250 mcg once daily.The manufacturer recommendations indicated to monitor the heart rate for one full minute before administration and notify the health care provider if the heart rate was less than 60 beats per minute or any significant changes in rate, rhythm or quality of the pulse.There was no indication in the clinical record that staff monitored Resident 5's heart rate each time before administering digoxin.On 1/29/26 at 12:45 PM Staff 7 (RN) stated she held the medication if the pulse was below 60 beats per minute, but did not always check the pulse before administering digoxin. Staff 7 stated if the CNAs recently checked the pulse and it was recorded in the electronic health record, then she administered the medication using that data. On 1/29/26 at 12:53 PM Staff 9 (LPN) stated Resident 5 did not have parameters for digoxin noted in the electronic health record. Staff 9 stated she held the medication if the resident's heart rate was in the 50s. Staff 9 further stated she looked at the CNA vital signs recorded in the electronic health record and administered the medication if the CNAs checked the pulse within the last hour.On 1/29/26 at 1:15 PM Staff 2 (DNS) acknowledged Resident 5 had an order for digoxin with no parameters noted in the clinical record. Staff 2 stated staff were to check the resident's pulse before administering digoxin and hold it if the pulse was too low.

Based on interview and record review it was determined the facility failed to process physician laboratory orders timely for 1 of 1 sampled resident (#113) reviewed for abuse. This placed residents at risk for untreated medical needs. Findings include:Resident 113 was admitted to the facility in 11/2024 with diagnoses including stroke and anxiety.A 12/13/24 physician order instructed staff to obtain a sexually transmitted infection (STI) risk panel laboratory test. A 12/14/24 risk panel report indicated no test was specified on the requisition (official request form) for the specimen. The report requested the test code and corresponding test name for the specimen received. The STI increased risk panel required an Aptima swab (A device designed for the collection of samples from various specimen sites to detect infections.) The word URGENT appeared in large letters across the page.A 12/16/24 Encounter Note written by Staff 32 (Former Doctor of Nursing Practice) revealed Resident 113 had foul smelling vaginal discharge and the STI test was denied by the lab. UTI testing was positive, and the plan was to treat as a UTI and follow up as needed for ongoing concerns for the STI.A 12/18/24 STI Increased Risk Panel indicated the test was not performed as no suitable specimen was received. The report directed staff to review the test requirements on the laboratory's website.A 12/20/24 Nursing Note indicated Resident 113 experienced hallucinations. Resident 113 reported she/he had not experienced hallucinations in the past.A 12/26/24 Encounter Note written by Staff 32 indicated Resident 113 had foul smelling vaginal discharge which was off-white and chunky in nature. Unable to obtain STI testing in the facility. Resident 113 completed a round of antibiotics for a UTI with no improvement in symptoms. The best option would be to send Resident 113 out the emergency department for evaluation and access to faster laboratory results.On 11/5/25 at 8:30 AM, Staff 32 stated she was frustrated about Resident 113's STI laboratory testing. Staff 32 reported the facility informed her the lab testing was not within the financial budget. She explained the lab company used by the facility would refuse certain tests, and it was a battle to get lab testing completed.On 11/5/25 at 11:41 AM, Staff 2 (DNS) stated he was unsure what occurred with Resident 113's laboratory results.

Based on observation, interview, and record review it was determined the facility failed to provide assistance with eating as care planned for 1 of 3 resident (#112) reviewed for hydration. This placed residents at risk for unmet needs. Findings include:Resident 112 was admitted to the facility in 2/2025 with diagnoses including dysphagia and dementia. A 10/3/25 Quarterly MDS indicated Resident 112 required supervision or touch assistance with eating. A revised care plan dated 9/3/25 revealed Resident 112 had an ADL self-care performance deficit and was dependent on staff to eat. Resident 112 fed herself/himself some of the time but was not consistent and required assistance. In a continuous observation on 11/3/25 at 12:31 PM Resident 112 was observed sitting up in bed with a food tray in front of her/him. He was unable to answer questions, and no staff were observed in room. At 12:45 PM Staff 6 (CNA) was observed walking by Resident 112's room and did not check on Resident 112. At 12:47 PM Staff 6 went into Resident 112's room and asked if she/he was all done and Resident 112 stated I don't know. Staff 6 stated it looks like it and left the room with the food tray. The plate still had approximately 90 percent of the food on the plate. On 11/5/25 at 10:39 AM Staff 6 confirmed she was assigned to Resident 112 on 11/3/25. Staff 6 stated Resident 112 was care planned for eating with the assistance of one person and needed supervision. Staff 6 stated the one person was there to provide queuing to eat. Staff 6 stated on 11/3/25 she may have been sitting in the room with Resident 112, but she did not remember. On 11/5/25 at 11:38 AM Staff 2 (DNS) stated the staff working with Resident 112 on 11/3/25 did not know Resident 112 and confirmed she/he required assistance to eat.

Based on interview and record review it was determined the facility failed to maintain a safe environment free from accident hazards for 1 of 3 sampled residents (#103) reviewed for accidents. This placed residents at risk for injury. Findings include:Resident 103 was admitted to the facility in 5/2024 with diagnoses including unsteadiness on feet and traumatic brain injury.A baseline care plan initiated on 5/20/24 indicated Resident 103 experienced two falls on 5/20/24. Interventions included a PT consultation for strength and mobility, one on one activities if bed bound, and monitoring for bruising, changes in mental status, confusion, and sleepiness.An Unwitnessed Fall investigation dated 5/21/24 revealed at 3:11 AM, Resident 103 rolled out of bed onto the floor. The brakes on both beds in the resident's room were not functioning properly. The incident was considered avoidable due to the bed malfunction.On 11/3/25 at 9:05 AM, Staff 18 (Maintenance Director) stated the bed brakes were checked monthly in the facility. Staff 18 confirmed there was no documentation to verify the checks were completed and no work orders from 5/1/24 through 6/30/24 related to malfunctioning bed brakes.On 11/4/25 at 10:40 AM, Staff 14 (Former LPN Unit Manager) confirmed Resident 103's bed wheel brakes were not functioning at the time of Resident 103's fall on 5/21/24.On 11/5/25 at 11:33 AM, Staff 2 (DNS) stated staff were expected to check bed wheel brakes before leaving a resident's room to ensure they were locked.

Based on interview and record review, it was determined the facility failed to investigate a potential case of abuse and investigate a fall in a timely manner for 2 of 4 sampled residents (#103 and 113) reviewed for accidents and abuse. This placed residents at risk for abuse and neglect. Findings include:1 Resident 103 was admitted to the facility in 5/2024 with diagnoses including unsteadiness on feet, and traumatic brain injury.An Unwitnessed Fall investigation revealed on 5/28/24 at 8:27 PM, Resident 103 sustained a fall while attempting to go outside the facility. The report indicated the investigation was completed on 6/10/24.On 11/5/25 at 11:33 AM Staff 2 (DNS) stated investigations are expected to be completed by staff within five days.2. Resident 113 was admitted to the facility in 11/2024 with diagnoses including stroke and anxiety.A 11/8/24 hospital History and Physical report revealed Resident 113 was a poor historian and mostly responded with, I do not remember.A 11/14/24 SLUMS (St. Louis University Mental Status Examination - a test that checks memory, language and thinking skills) completed for Resident 113 revealed a score of six. A score between zero and 20 indicates dementia.A 11/18/24 admission MDS indicated Resident 113 was rarely understood and had both short-term and long-term memory problems.A 12/13/24 physician order directed staff to obtain a sexually transmitted infection (STI) risk panel laboratory test. A 12/26/24 Encounter Note written by Staff 32 (Former Doctor of Nursing Practice) indicated Resident 113 had foul smelling vaginal discharge which was off-white and chunky. STI testing could not be completed at the facility. Resident 113 completed a round of antibiotics for a UTI with no improvement. Staff 32 recommended sending Resident 113 to the emergency department for faster laboratory results.On 12/27/24, the State Agency received a public complaint alleging Resident 113 had been diagnosed with a sexually transmitted disease.A 12/29/24 hospital Discharge Summary revealed Resident 113 was diagnosed with trichomonal vaginitis (a sexually transmitted infection).No documentation was found in Resident 113's clinical record of an investigation into potential sexual abuse for Resident 113.On 11/5/25 at 8:30 AM, Staff 32 stated Resident 113 reported to her she had not been sexually active in the facility but had been sexually active before admission.On 11/5/25 at 11:41 AM, Staff 1 (Administrator) stated he expected staff to complete an investigation into possible sexual abuse for Resident 113.

Based on observation and interview it was determined the facility failed to ensure the kitchen was cleaned, failed to ensure food was stored appropriately and discarded in a timely manner, and failed to monitor refrigerator temperatures for 1 of 1 kitchen and 1 of 2 refrigerators reviewed for sanitary conditions. This placed residents at risk for foodborne illness. Findings include: 1. On 8/26/24 at 9:29 AM during the initial tour of the kitchen the following was observed: a. Walk-in refrigerator: -A plastic container with pickle spears, opened and undated. -A cardboard box containing bananas that were dark brown in color. -A stick of margarine, open to air and undated. -Food crumbs, brown splatters, and various small debris on the floor throughout the walk-in refrigerator. b. Walk-in freezer: -A bag of frozen tapioca hot dog buns with a manufacture expiration of 12/22/22. -A bag of frozen chicken strips, opened to air and undated. -A bag of frozen hamburger patties, opened to air and undated. -A bag of frozen veggie vegan patties, opened to air and undated. -A zip lock gallon bag labeled pizza sausage, freezer burnt and date illegible. -Food crumbs and brown splatters of debris on the floor throughout walk-in freezer. c. Main Kitchen area: -A wire rack with shelves located next to a garbage can contained metal containers with splatters of debris. -Drips of white and brown debris located on the bottom self of the steam table where clean pots and pans were stored. -A wire shelf containing clean bowls had a sticky brown film on the surface. -Food crumbs, brown splatters, and various small debris on the floor throughout the main kitchen area. On 8/26/24 at 10:04 AM Staff 17 (Dietary Manager) acknowledged the identified findings. 2. On 8/26/24 at 9:54 AM a small refrigerator containing juice, milk, and yogurt located in the kitchen was observed with a thermometer inside. On 8/26/24 at 9:56 AM the temperature log binder located in the kitchen was reviewed and there was no temperature log for the small refrigerator. On 8/26/24 at 9:57 AM Staff 19 (Dietary) and Staff 21 (Dietary) did not know of a temperature log for the small refrigerator and acknowledged the temperature for the small refrigerator was not monitored. On 8/26/24 at 10:04 AM Staff 17 (Dietary Manager) acknowledged there was no temperature log for the small refrigerator that contained juice, milk, and yogurt for residents and acknowledged the temperature for the small refrigerator was not monitored.

Based on observation, interview and record review it was determined the facility failed to ensure a system was in place to honor resident food preferences for 4 of 4 sampled residents (#s 17, 19, 21, and 37) reviewed for dietary needs. This placed residents at risk for unmet nutritional needs and lessened quality of life. 1. Resident 17 was admitted to the facility in 2016 with diagnoses including diabetes. On 8/27/24 at 10:36 AM Resident 17 stated she/he was not given a menu to select her/his preferred meals. On 8/29/24 at 10:38 AM Staff 22 (CNA) stated about one month ago the facility stopped providing residents with a menu to choose between the main or alternate meal. Staff 22 stated several residents, including Resident 17, were upset about this as their opportunity to make a choice was taken away. On 8/29/24 at 2:00 PM Staff 18 (Dietitian) stated the facility recently changed the menu system from providing menus to residents each day to providing menus once per week on Fridays. On 8/30/24 at 9:54 AM Resident 17 stated she/he did not receive a weekly menu on Fridays. On 8/30/24 at 12:02 PM Staff 1 (Administrator) stated the facility recently changed the menu distribution to once per week on Fridays. Staff 1 stated the change was discussed in Resident Council and at a food committee which some residents attended. 2. Resident 19 was admitted to the facility in 12/2023 with diagnoses including diabetes. On 8/26/24 at 10:33 AM Resident 19 stated she/he was not given a menu to select her/his preferred meals. Resident 19 stated the facility did not inform her/him of any changes related to menus. On 8/29/24 at 10:38 A Staff 22 (CNA) stated about one month ago the facility stopped providing residents with a menu to choose between the main or alternate meal. Staff 22 stated several residents, including Resident 19, were upset about this as their opportunity to make a choice was taken away. On 8/29/24 at 2:00 PM Staff 18 (Dietitian) stated the facility recently changed the menu system from providing menus to residents each day to providing menus once per week on Fridays. On 8/29/24 at 2:10 PM Resident 19 stated she/he did not receive a weekly menu on Fridays. On 8/30/24 at 12:02 PM Staff 1 (Administrator) stated the facility recently changed the menu distribution to once per week on Fridays. Staff 1 stated the change was discussed in Resident Council and at a food committee which some residents attended. 34703 3. Resident 21 was admitted to the facility in 1/2020 with diagnoses including heart disease. On 8/26/24 at 11:32 AM Resident 21 stated the kitchen removed the menus and she/he was not able to make choices for a meal. Resident 21 stated she/he used to look forward to meals but now there was nothing to look forward too because the kitchen delivered whatever they cooked. Resident 21 stated she/he wanted the menus back to be able to choose her/his meal. Resident 21 stated she/he does not receive a weekly menu on Fridays. On 8/28/24 at 12:41 PM Staff 10 (CNA) stated about one month ago the facility stopped providing residents with a menu to choose between the main or alternate meal. Staff 10 stated several residents were upset about this as their choices were taken away. On 8/29/24 at 12:35 PM Staff 23 (CNA) stated the facility stopped providing residents with a menu for at least a month and were upset they were not given the right to make choices about their meals. On 8/29/24 at 2:00 PM Staff 18 (Dietitian) stated the facility recently changed the menu system from selection based to preference based and residents received a weekly menu every Friday. 4. Resident 28 was admitted to the facility in 11/2023 with diagnoses including diabetes. On 8/30/24 at 8:53 AM Resident 28 stated about a month ago the facility stopped providing menus to residents to choose their meals. Resident 28 stated she/he received a meal of whatever the kitchen cooked. Resident 28 stated she/he was not given a menu on Fridays and wanted the menus back. On 8/28/24 at 12:41 PM Staff 10 (CNA) stated about one month ago the facility stopped providing residents with a menu to choose between the main or alternate meal. Staff 10 stated several residents were upset about this as their choice was taken away. On 8/29/24 at 12:35 PM Staff 23 (CNA) stated the facility stopped providing residents with a menu for at least a month and were upset they were not given the right to make choices about their meals. On 8/29/24 at 2:00 PM Staff 18 (Dietitian) stated the facility recently changed the menu system from selection based to preference based and residents received a weekly menu every Friday. 5. Resident 37 was admitted to the facility in 7/2022 with diagnoses including stroke. On 8/27/24 at 12:45 PM Resident 37 stated the facility stopped providing residents with menus for at least a month. Resident 37 stated she/he wanted her/his choices of meals back. Resident 37 stated she/he was not given a menu on Fridays. On 8/28/24 at 12:41 PM Staff 10 (CNA) stated about one month ago the facility stopped providing residents with a menu to choose between the main or alternate meal. Staff 10 stated several residents were upset about this as their choice was taken away. On 8/29/24 at 12:35 PM Staff 23 (CNA) stated the facility stopped providing residents with a menu for at least a month and were upset they were not given the right to make choices about their meals. On 8/29/24 at 2:00 PM Staff 18 (Dietitian) stated the facility recently changed the menu system from selection based to preference based and residents received a weekly menu every Friday.

Based on interview and record review it was determined the facility failed to ensure an RN was available for at least eight consecutive hours per day for 3 of 31 days reviewed for RN coverage. This placed residents at risk for delayed nursing assessments. Findings include: A review of the Direct Care Staff Daily Reports from 7/26/24 through 8/25/24 revealed the following dates with no RN coverage: -8/20/24 -8/21/24 -8/22/24 On 8/29/24 at 10:38 AM Staff 1 (Administrator) acknowledged the lack of RN coverage on the identified dates.

Based on observation, interview and record review it was determined the facility failed to ensure Staff 13 (LPN) had the appropriate competencies and skills for infection control during CBG checks and administration of insulin. This placed residents at risk for bloodborne illness and reduced efficacy of medications. Findings include: a. On 8/29/24 at 12:17 PM Staff 13 (LPN) was observed to obtain a CBG for Resident 24. Staff 13 exited the room and placed the glucometer in the east hall treatment cart without cleaning it. On 8/29/24 from 12:17 PM to 12:40 PM continuous observations were made. Staff 13 passed medication and administered insulin to multiple residents. Staff 13 did not clean the glucometer during the observations. On 8/29/24 at 12:40 PM Staff 13 stated Resident 24 was the last CBG check she had to complete prior to lunch. Staff 13 stated she cleaned the glucometers at the beginning and end of shift with purple wipes. Staff 13 further stated she worked at the facility for one month and this was her first nursing job. Staff 13 stated she was trained for about three weeks and did not think the facility checked her for nursing competencies. On 8/29/24 at 12:57 PM Staff 2 (DNS) Staff 2 stated nursing competencies were not completed for Staff 13. b. The Novolog manufacturer instructions indicated to prime the insulin pen with two units prior to drawing up the insulin for administration. On 8/29/24 at 12:37 PM Staff 13 (LPN) was observed to administer Novolog insulin via insulin pen to Resident 24. Staff 13 did not prime the insulin pen with two units prior to drawing up the insulin for administration. On 8/29/24 at 12:40 PM Staff 13 acknowledged she did not prime the insulin pen prior to administration and stated she was not aware the Novolog insulin pen needed to be primed. Staff 13 stated she was trained for about three weeks and did not think the facility checked her for nursing competencies. On 8/29/24 at 12:57 PM Staff 2 (DNS) Staff 2 stated nursing competencies were not completed for Staff 13.

Based on observation, interview, and record review it was determined the facility failed to ensure proper storage temperatures were maintained for 1 of 2 medication storage refrigerators, and proper labeling of biologicals and securing of treatment carts for 1 of 3 treatment carts reviewed for medication storage. This placed residents at risk for reduced efficacy of medication and unauthorized access to medications. Findings include: 1. The 8/2024 east hall medication refrigerator temperature logs indicated the temperatures exceeded 46 degrees F on multiple occasions and the temperatures were as high as 73 degrees on 8/21/24. On 8/30/24 at 12:00 PM the medication refrigerator on the East Hall was observed with Staff 2 (DNS) and contained flu vaccines and insulin. On 8/30/24 at 12:00 PM Staff 2 (DNS) stated the medication refrigerator on the east hall contained flu vaccines and insulin and the temperatures were to be kept between 36 degrees F and 46 degrees F. Staff 2 acknowledged the 8/2024 temperature logs indicated the east hall medication refrigerator exceeded 46 degrees F on several occasions and the temperatures were as high as 73 degrees F on 8/21/24. 2. On 8/29/24 at 12:13 PM two open Tresiba insulin pens were observed in the East Hall treatment cart with no open dates. On 8/29/24 at 12:13 PM Staff 13 (LPN) acknowledged the two Tresiba pens were open and were not labeled with open dates. 34703 3. On 8/26/24 at 12:38 PM an East Hall treatment cart was observed to be unlocked. The cart was in the middle of the hall with residents and staff walking by. Nursing staff walked by the cart multiple times but did not lock the cart. On 8/26/24 at 12:43 PM Staff 14 (LPN) acknowledged she left the treatment cart unlocked and the cart was to be secured at all times. 4. On 8/27/24 at 9:22 AM an East Hall treatment cart was observed to be unlocked. The cart was in the middle of the hall with residents sitting around it and staff walking by. Nursing staff walked by the cart multiple times but did not lock the cart. On 8/27/24 at 9:30 AM Staff 14 (LPN) acknowledged she left the treatment cart unlocked both times and the cart was to be secured at all times.

Based on observation, interview, and record review it was determined the facility failed to ensure a resident rooms were in good repair and free of odors for 5 of 5 sampled residents (#s 6, 19, 27, 32 and 33) reviewed for environment. This placed residents at risk for lack of a homelike environment. Findings include: 1. On 8/26/24 at 1:33 PM the following observation was made: Resident 19's air conditioner unit made a loud, high pitch squeak. On 8/30/24 at 10:59 AM Staff 1 (Administrator) and Staff 9 (Maintenance Director) acknowledged the identified environment issue. 2. On 8/27/24 at 9:17 AM the following observation was made: Resident 6's light in the bathroom was burned out. On 8/30/24 at 10:31 AM Staff 20 (Nursing Assistant) stated Resident 6's bathroom light had been burned out for about one week. Staff 20 stated he reported the light and it had not been fixed. On 8/30/24 at 10:59 AM Staff 1 (Administrator) and Staff 9 (Maintenance Director) acknowledged the identified environment issue. 34324 3. On 8/26/24 at 10:57 AM the following observation was made: Resident 27's head of the bed was located by the window against the wall. A large portion of the bottom window trim paint was peeled off with exposed particle board peeling off. On 8/30/24 at 11:04 AM Staff 9 (Maintenance Director) and Staff 1 (Administrator) acknowledged the identified environment issues for Resident 27. 4. On 8/26/24 at 1:22 PM the following observations were made: Resident 33's head of the bed was located by the window against the wall. Two window trim pieces were observed to be separated in the corner with exposed edges. On 8/30/24 at 11:04 AM Staff 9 (Maintenance Director) and Staff 1 (Administrator) acknowledged the identified environment issues for Resident 33. 34703 5. Resident 32 was admitted to the facility in 8/2020 with diagnoses including urge incontinence. On 8/26/24 at 12:05 PM Resident 32's room was noted with a strong odor of urine. On 8/26/24 at 12:06 PM Resident 32 stated she/he was incontinent and wore briefs Resident 32 stated she was aware of the strong urine odor but was not sure if it was from her/his room or wheelchair or from another room. Resident 32 stated she/he would like to have staff clean her/his wheelchair. On 8/28/24 at 9:46 AM Staff 5 (CNA) the resident's room and wheelchair had a strong odor of urine. Staff 5 stated night shift cleaned the wheelchairs and the resident needed her/his wheelchair cleaned. On 8/28/24 at 9:51 AM Staff 23 (CNA) Staff 22 stated the resident's room and wheelchair had a strong odor of urine all the time. Staff 22 stated night shift was supposed to clean the wheelchairs, and Resident 32's wheelchair was to be cleaned. On 8/28/24 at 2:11 PM Staff 15 (LPN) stated Resident 32 wore more than one brief at a time and had multiple incontinent pads on her/his wheelchair. Staff 15 acknowledged the resident's room and wheelchair always had a strong odor of urine and the wheelchair needed to be cleaned. On 8/28/24 at 2:30 PM Staff 24 (Housekeeping) stated she mopped the resident's room daily. Staff 24 stated there were days the resident would not allow a deep clean of her/his room but she cleaned and mopped the room everyday. Staff 24 stated Resident 32's wheelchair also had a strong odor of urine. On 8/29/24 at 10:40 AM Staff 3 (LPN-Unit Manager) stated Resident 32 was incontinent and doubled or tripled her/his briefs for more protection which caused the strong urine odor. On 8/29/24 at 11:55 AM Staff 2 (DNS) and Staff 4 (Corporate RN) stated the resident's room and wheelchair had a strong urine odor. Staff 4 stated wheelchairs were to be cleaned on night shift, and acknowledged there was no documentation wheelchairs were cleaned and no documentation Resident 32 refused to have her/his wheelchair cleaned.

Based on interview and record review, the facility failed to develop and implement an effective discharge planning process for 1 of 3 sampled residents (#4) reviewed for safe discharge. Resident 4 fell multiple instances in her/his home and was transported to the emergency roiagnom on e day after discharge from the facility. Findings include: A 11/2017 facility Policy and Guidelines for Implementation Discharge Planning revealed the discharge plan is re-evaluated and updated to reflect changes of the plan if the resident's condition changes. -The plan will include needs that must be addressed before the resident can be discharged . -Identify post-discharge needs such as medical equipment, nursing and therapy services, ADL assistance or home modifications. -If the resident wishes to discharge to the community, the facility will determine if appropriate and adequate supports are in place and are capable of meeting the resident's needs. -This determination will be made with the involvement of the resident and/or resident representative as well as other family members and/or significant others. Resident 4 was admitted to the facility in 8/2020 with [DIAGNOSES REDACTED]. A 9/2/20 care plan indicated Resident 4 wished to be discharged home or to another facility. Interventions included: -Evaluate and discuss with Resident 4, family, and caregivers the prognosis for independent or assisted living. -Identify, discuss and address limitations, risks and benefits and needs for maximum independence. -Evaluate Resident 4's motivation to return to the community. -Evaluate and record Resident 4's abilities and strengths with family and caregivers. -Determine the gaps in abilities which will affect discharge. A 9/18/20 Discharge Planning Review Note revealed Resident 4 needed assistance and was wheelchair bound. Resident 4's home environment had stairs with her/his bathroom and bedroom located upstairs. Occupational Discharge Summary dated from 8/29/20 through 9/29/20 revealed Resident 4 needed contact guard assist for most of her/his ADLs and self-care tasks due to her/his left hip giving out without warning and she/he required moderate to maximum assist to recover from a fall. Recommendation for Resident 4 was for her/him to have caregivers due to lack of awareness of her/his left side of body and decreased cognition. Discharge recommendations included home health services. A Physical Therapy Discharge Summary dates of service 9/5/20 through 9/29/20 revealed at discharge of physical therapy Resident 4 was not assessed for a four wheel walker due to her/his left lower extremity buckling. Resident 4 ambulated 234 feet with wheelchair follow due to left side buckling. Recommendation was for Resident 4 to complete a home exercise program and to sit down as soon as her/his left side felt weak. A 9/28/20 signed physician order [REDACTED]. The order had a handwritten note which indicated it was received on 9/29/20. A 9/30/20 nurse practitioner Encounter Note indicated Resident 4 was a one person standby assist for functional mobility and ADLs. Resident 4 had a supportive neighbor to transport her/him home. The facility would conduct routine welfare checks to support the neighbor. Resident 4 needed homebound status, due to her/his inability to leave the home without the help of others. Staff 3 (Nurse Practitioner) observed Resident 4 briefly on 10/1/20 prior to her/his discharge visit. Resident 4 discharged before Staff 3 could return and complete a formal visit. Resident 4 had left-side upper and lower extremity weakness. A 9/30/20 at 12:22 PM Discharge Transfer (with a completion date of 10/6/20) revealed Resident 4 was to discharge on 10/1/20 home with primary [DIAGNOSES REDACTED]. Resident 4 had risk alerts, and her/his skin was not intact. Resident 4 had an open area to her/his right eyebrow with steri-strips in place and her/his mental status was alert and oriented. Resident 4 completed both physical and occupational therapy on 9/29/20 and needed assistance with walking, bathing, and dressing. Transfer ability of Resident 4 was not documented. Resident 4 needed a front wheel walker with a bedside commode. The form indicated the following were sent with Resident 4: face sheet, medications list, discharge medication record, treatment record, history and physical, consult records, therapy information, lab information and her/his advance directive. A follow up appointment was scheduled 10/2/20 with follow up instructions to have home health assigned with therapies and nursing in place. A front wheel walker and bedside commode were ordered to be delivered to Resident 4's home. A Care Transfer Form dated 9/30/20 revealed Resident 4 may not administer her/his own medications. A handwritten on the form indicated a neighbor and home health would administer Resident 4's medication. The form instructed to apply [MEDICATION NAME] (an antiseptic) to the left great and fifth toe. Leave the toes open to air or wrap with loose with Kerlix. The form indicated services needed were home health services with physical, occupational therapy, social services and bath aide. The form was signed 10/1/20 by Staff 3. A 9/30/20 investigation revealed on 9/30/20 at 11:15 PM Resident 4 was found sitting on the floor with a cut over her/his left eye and a bruise and small bump over her/his left eye. Resident 4 had a skin tear to the outer left arm and a small abrasion to her/his left knee. Resident 4 was unsteady on her/his feet and stated she/he was attempting to transfer to the bed side commode and lost her/his balance and fell . Resident 4 stated she/he did not think she/he hit her/his head or got hurt. Resident 4 was placed on neurological checks and alert charting for a non-witnessed fall with head injury. The nurse practitioner was notified of the fall. Resident 4 was discharged from the facility on 10/1/20. A 10/1/20 Discharge MDS revealed Resident 4 required limited assistance with bed mobility, transfer, walk in room, locomotion on and off unit, dressing and personal hygiene. Resident 4 required extensive assistance with toilet use. A 10/1/20 Nursing Note revealed Resident 4 was referred to home health services. A 10/1/20 Nurse Practitioner Progress Note revealed Resident 4 was a one person, standby assist for functional mobility and activities of daily living. Resident 4 had a supportive neighbor who would transport her/him home. There would be home health rehabilitation, social services, nursing, and bath aide. A front wheel walker was ordered and she/he would go home with a loaner until it arrived. Resident 4 needed homebound status, because her/his inability to leave home without the help of others. Staff 3 briefly observed Resident 4 on 10/1/20 before the formal discharge visit due to Resident 4 discharged . Resident 4 had questionable judgement and insight. A 10/1/20 signed physicians order indicated a front wheel walker and bedside commode for home use. A hand written note revealed the order was faxed to medical supply on 10/1/20. An undated and unsigned Nursing Transfer Summary revealed Resident 4 walked with assistance, washed hands, bathed her/himself, dressed self and home health aide was ordered to assist. Resident 4 was a fall precaution with continued teaching needed for safety awareness, which would be completed by home health. Resident 4's skin wound condition was documented as N/A with a diagram marked as left great toe. An undated and unsigned Nursing Transfer Summary provided by Witness 5 (friend) on 10/14/20 (which was provided to Resident 4 at discharge on 10/1/20) revealed no information provided for Activity Status for mobility, hygiene, eating, and dental, and that Resident 4 needed a walker for equipment. Under General Mobility no information was provided. Skin and wound condition was documented as N/A and no markings were indicated on the diagram for skin conditions. A 9/29/20 signed physician orders [REDACTED].([MEDICAL CONDITION]) one capsule one time a day, Tylenol one tablet three times a day. No documentation was found in clinical records Resident 4 or her/his representative received physician orders [REDACTED]. A 10/2/20 Emergency Department Encounter indicated Resident 4 was found by a neighbor slumped over in her/his chair. Emergency medical services found Resident 4 with a blood pressure of 75 systolic (the blood pressure when the heart is contracting) and was transported to the emergency department. A 10/13/20 Nursing note for a late entry from 10/2/20 revealed Witness 5 called Staff 2 (DNS) with concerns regarding Resident 4. Witness 5 indicated Resident 4's home health did not go to the home and Witness 5 was concerned Resident 4 was not doing well. Staff 2 advised Witness 5 to transport Resident 4 to the hospital. On 10/14/20 at 9:20 AM Witness 3 (Complainant) stated the first time she received information from the facility was on 10/1/20 regarding a request for in home services. Witness 3 stated it was her understanding Resident 4 would complete an assessment to determine what she/he would require at home before discharge. Witness 3 stated no services were in place including meals on wheels when Resident 4 discharged home. On 10/14/20 at 9:28 AM Witness 7 (Home Health) stated the referral paperwork for home health was received the end of 9/2020 from the facility for Resident 4 which was incomplete. Witness 7 stated she faxed to the physician to complete and did not obtain a response. Home health services was never started due to imcomplete paperwork and no response from the physician. On 10/14/20 at 11:39 AM Witness 5 stated he transported Resident 4 from the facility to her/his home. When Witness 5 picked Resident 4 up at the facility a nurse assistant brought her/him out to the car in a wheelchair. No medical equipment was provided to Resident 4 to take home except for a device to measure urine output. The facility did not provide a front wheel walker to loan to Resident 4. A bag with medication and some paperwork was given to her/him to take home. Witness 5 stated nothing was explained to him in regard to Resident 4's care or needs. Witness 5 stated Resident 4 was disoriented and Witness 5 borrowed a front wheel walker from Resident 4's neighbor to assist the transfer from the car into her/his home. On 10/15/20 at 9:08 AM Staff 7 (CNA) stated she was assigned to Resident 4 on 10/1/20. Staff 7 stated Resident 4 was always confused and had anxiety. Resident 4 told her she/he fell the night before and was sleep walking. Staff 7 stated she did not spend much time with Resident 4 on 10/1/20 due to her being late to work, and Resident 4 had a medical appointment (urologist) before she/he discharged . Staff 7 stated she did not transport Resident 4 out to the car when she/he discharged . On 10/15/20 at 10:25 AM Witness 6 (Friend) stated Resident 4 fell at least five times after she/he arrived home which was in the presence of herself or another neighbor. Witness 6 stated she was elderly and did not have the strength to assist Resident 4 to get up from a fall and her other neighbor had medical conditions which hindered his ability to assist Resident 4. Witness 6 believed Resident 4 may have fallen more times while no one was in her/his home. Witness 6 stated Resident 4 could not administer her/his own medications and she/he was not taking them according to the instructions. Resident 4 could not obtain her/his own meals. Resident 4's leg gave out on her/him and she/he fell . Resident's 4 apartment was a mess as she/he would drop items due to no control over her/his left side. Resident 4 could not problem solve and could not figure out how to use her/his remote control for the TV or how to work her/his phone. On 10/1/20 in the evening Resident 4 was observed outside in her/his robe which exposed her/his brief and Resident 4 did not know where he/she was going. A neighbor assisted her/him back into her/his apartment. Witness 6 stated Resident 4 requested Witness 6 to buy some Aspercreme (pain relief cream) because her/his big toe on the left foot was hurting. Witness 6 stated the toe appeared to be infected and looked nasty. On 10/20/20 at 10:28 AM Staff 5 (RN) stated Resident 4 was always confused and she/he was educated multiple instances not to get up by herself/himself. Staff 5 stated on 9/30/20 in the evening Resident 4 attempted to toilet by herself/himself and she/he was not strong enough to go that far. Staff 5 stated Resident 4 could stand on her/his own but was not steady. Staff 5 stated if Resident 4 did not have something to stabilize herself/himself it would not be safe. Staff 5 stated he felt it would not be safe for Resident 4 to be home by herself/himself. Resident 4 needed 24 hour caregiver as she/he was unpredictable. On 10/21/20 at 10:16 AM Staff 22 (Occupational Therapy) stated he did not personally evaluate Resident 4 but rather he reviewed the documentation and signed. Normally he discussed with social services what was required for a resident for equipment and services. Staff 22 stated Resident 4 needed a caregiver to assist at her/his home. Staff 22 stated if a resident fell the night before a discharge he did not believe it would be safe to discharge the resident home the next day. On 10/22/20 at 12:15 PM Staff 1 (Administrator) stated the facility did not track or log when medical equipment was loaned to a resident upon discharge. Staff 1 stated it was usually documented in the resident's discharge note. On 10/23/20 at 11:50 AM Staff 6 (Unit Manager) stated she was usually the staff member to provide education with the resident and the family through telephone or upon discharge in regard to medications, treatments and needs of the resident. Staff 6 did not know who transported Resident 4 out to the car on the day of discharge. She stated the bedside commode and front wheel walker were to be delivered to the home and it could sometimes be the next day or up to five days. Staff 6 stated she went over Resident 4's medications, skin care to and upcoming appointments with Resident 4 and asked if she/he had any questions. Staff 6 stated she did not know who would transport Resident 4 to her/his medical appointment on 10/2/20 and Resident 4 could not take her/his own prescribed medications and could not transfer to the toilet by herself/himself. Staff 6 stated Resident 4 had difficulty with problem solving. Staff 6 felt Resident 4's discharge home would be safe and felt after her/his fall on 9/30/20 there would be enough supervision to go home. Staff 6 stated she spoke to Witness 5 and he was going to provide assistance but was not specific on medications. She stated she would normally document completed education to caregivers but did not complete this for Resident 4. Staff 6 stated Witness 5 could assist during certain times of the day to support Resident 4. On 10/23/20 at 12:54 PM Staff 4 (Social Services) stated she obtained the order from the nurse practitioner on 10/1/20 for the bedside commode and front wheel walker so she faxed it over to medical supply on 10/1/20. On 10/27/20 at 5:37 PM Staff 2 stated Resident 4 was provided a copy of a 9/28/20 discharge orders and the facility completed additional changes to the final discharge orders which included wound care and updated equipment needs and the final orders were updated and signed on 10/1/20.

Based on interview and record review it was determined the facility failed to accurately assess, treat and monitor skin wounds for 2 of 3 sampled residents (#s 1 and 4) reviewed for non-pressure skin conditions. As a result Resident 1 was admitted to the hospital and two toes were amputated. Findings include: A review of the 10/2019 Skin Wound Management Guidelines indicated the following: The following alterations in skin integrity will be assessed, measured, photographed and documented in skin and wound module; All vascular related wounds, venous or arterial. Alterations in skin integrity which are not followed in the Skin and Wound module, as above, will be documented by staff nurses as follows: Document a detailed description in progress notes; If the area does not resolve, was not improving or worsens within four weeks, enter it into the Skin and Wound rounds for tracking and follow on weekly skin and wound rounds. Additionally staff were to schedule a weekly skin evaluation 1. An 8/30/20 Hospital Orthopedics New Consult Note revealed Resident 1 had significant peripheral artery disease to the right foot with a chronic ischemic (reduced blood flow) ulcer. Resident 1 needed intervention soon either as inpatient or outpatient. Resident 1 was admitted to the facility in 9/2020 with [DIAGNOSES REDACTED]. A 9/2/20 Admission Readmission Evaluation revealed Resident 1 had a surgical site to the left hip and a right foot ulcer on the bottom of the foot by the fifth digit. A 9/2/20 Nurse Practitioner Encounter Note revealed Resident 1 had peripheral artery disease with an infected chronic ischemic ulceration of the right foot. Signed physician orders [REDACTED]. Staff were to apply [MEDICATION NAME] (a topical antiseptic) to all black and brown eschar (devitalized tissue) areas, allow to dry and then apply non-skid socks every day shift and every 24 hours as needed. A 9/2/20 care plan revealed Resident 1 was admitted with a chronic left (right) foot ischemic ulcer which was currently treated. Interventions included monitor, and document, report on the wound routinely in order to monitor healing. Additionally staff were to perform and document weekly skin checks and notify the physician or nurse practitioner if skin integrity became compromised and to provide treatments as ordered. A 9/3/20 Wound Evaluation revealed Resident 1 had an arterial lateral right foot ulcer which was nine months old, present on admission with an area of 1.48 (1.9) cm squared, 1.46 cm in length, and 1.3 cm in width. The evaluation was incomplete and did not address the characteristics of the wound, the wound bed, the shape or condition of the surrounding tissues. A picture of Resident 1's foot was included in the evaluation which revealed space between Resident 1's fifth digit and fourth digit with toe nails extending slightly past the toes. The foot showed no sign of swelling, and the ball of the foot and the arch were defined. A 9/6/20 Admission MDS revealed a BIMS score of 15 indicating Resident 1 was cognitively intact. A 9/6/20 Pressure Ulcer Injury CAA revealed Resident 1 was admitted with a chronic left (right) foot ischemic ulcer which was being treated. A 9/8/20 Administration Note revealed Resident 1's treatment to the right 5th toe on the underside of the foot would be completed by the wound care team. No documentation was found in clinical records the wound team completed treatment of [REDACTED]. A 9/10/20 Nurse Practitioner Encounter Note revealed Resident 1 had peripheral artery disease with an infected chronic ischemic ulceration of the right foot. An angiogram appointment with a vascular specialist needed to be rescheduled. No documentation was found in Resident 1's clinical record indicating a wound evaluation was completed on 9/10/20. A 9/11/20 Alert Note revealed Resident 1 was on alert charting for the right foot chronic ulcer due to increased pain with weight bearing activities. Staff 10 (RN) notified Staff 2 (DNS) and Staff 2 indicated she would notify the nurse practitioner of the change of condition. A 9/12/20 Alert Note revealed Resident 1 was on alert charting for increased pain with weight bearing activities of the right lateral foot ulcer with eschar and a slight hole noted. The day shift nurse stated it was not present during day shift. The wound was cleaned and [MEDICATION NAME] applied as ordered. Resident 1 stated [MEDICATION NAME] had not been applied for several days. Treatment to Resident 1's foot was charted as administered. Staff 2 was notified of the change of condition of the ulcer. Staff 2 instructed staff to monitor, medicate for pain, and to request a referral to a wound specialist. The request for the wound specialist was placed in the nurse practitioner's folder of documents for review. A 9/14/20 Nursing Note revealed Staff 2 received a call from Witness 2 (Family Member) who informed Staff 2 Resident 1 needed a follow up appointment with the doctor for her/his angiogram appointment. The vascular department was called (which was closed) and was documented a call would be made on 9/15/20 during normal business hours to scheduled Resident 1's appointment. A 9/14/20 Nursing Note revealed Resident 1 continued with the ulcer on the bottom of the right foot. Resident 1's foot appeared swollen in the evenings. A 9/14/20 physician's Encounter Note revealed the date of the encounter was on 9/15/20, and the type of visit was an admission history and physical. The note addressed Resident 1's past medical history of [REDACTED]. No rashes or skin breakdown were noted. Resident 1's skin was warm, her/his left hip incision clean and dry, left hip presented with mild [MEDICAL CONDITION] and was tender with motion. The Encounter Note did not include information in regard to Resident 1's right chronic foot ulcer and change of condition documented on 9/11/20. A 9/16/20 Administration Note revealed Resident 1 reported to Staff 10 wound care was not performed to the underside of her/his right foot on day shift. Staff 10 noticed Resident 1 had a hole below the eschar area of the wound on her/his right foot. A 9/2020 TAR instructed staff to provide skin care behind the right fifth toe on the underside of foot, cleanse and rinse the skin of the feet and legs, pat dry and dry well between the toes, apply [MEDICATION NAME] to all eschar areas and allow to dry. Apply non-skin socks every day shift with a start date of 9/3/20. It was documented treatment was completed on 9/16/20 by Staff 11 (LPN) on day shift. A 9/16/20 signed nurse practitioner order instructed staff to have the wound care nurse evaluate Resident 1's arterial ulcer as soon as possible, to continue with skilled nursing orders for the right foot arterial ulcer, to increase to two times a day in the morning and the evening, and to upload the ulcer into clinical records with measurements minimally every week. No documentation was found in Resident 1's clinical record indicating the above orders were followed. Wound care staff did not observe Resident 1's foot until 9/29/20, treatment was not increased to two times a day and measurements were not completed weekly. A 9/17/20 Skilled Nursing Note revealed Staff 10 noticed a hole below the eschar area of Resident 1's non-healing skin ulcer on the lateral portion of the right foot. Staff 10 cleaned and applied [MEDICATION NAME]. No redness, drainage, warmth swelling or pain was noted. No documentation was found in Resident 1's clinical record indicating a wound evaluation was completed on 9/17/20. In a 9/18/20 Nurses Note Staff 12 (RN) documented Resident 1 had a chronic left (right) foot ulcer with intermittent [MEDICAL CONDITION] to both lower extremities which was scant to the right foot. A 9/21/20 Nursing Note revealed an angiogram appointment was scheduled for 10/1/20, Resident 1 would discharge on 10/2/20 and would need a COVID screening. An attempt was made to call again to reschedule the appointment for after Resident 1 was discharged from the facility. 9/22/20 and 9/23/20 Nursing Notes revealed Staff 12 documented Resident 1 had a chronic left foot ulcer with [MEDICAL CONDITION] in both lower legs. A 9/24/20 Nursing Note revealed Resident 1's angiogram appointment was rescheduled for 10/7/20. A 9/24/20 Alert Note revealed Resident 1 complained of pain in the right foot. Resident 1's fifth toe was noted to be swollen with various shades of purple. The foot was draining and the top of the foot near the toe was sloughing skin. A 9/25/20 Wound Evaluation revealed Resident 1 had an Arterial lateral right foot ulcer which was 10 months old, with an area of 1.45 (2.02) cm squared, 1.67 cm in length and 1.21 cm in width. A picture with the evaluation revealed no space between Resident 1's fifth and fourth digits with toe nails extending past the toes. The foot appeared swollen with the arch of the foot and the ball not defined. The fifth digit of the foot was purple in color extending down toward the ulcer under the foot and connecting. The ulcer on the bottom of the foot had three areas of dried blood extending out from the ulcer. A 9/2020 TAR instructed staff to cleanse the left foot, below the fifth toe with wound cleanser, pat dry, apply dry dressing such as gauze and secure with tape with a start date of 9/26/20 and a discontinue date of 9/29/20. No documentation was found in clinical records Resident 1's right foot was examined by the wound center, nurse practitioner, or physician from 9/12/20 through 9/28/20. A 9/26/20 Nursing Note revealed Resident 1 had a chronic left (right) foot ulcer and the left lower extremity continued with swelling and the left (right) small toe was purple in color. A 9/29/20 Wound Care Progress Note revealed Resident 1 had a wound on the right posterior fifth toe with necrosis (dead tissue) measurements of 7.5 cm in length 7.0 cm in width .3 cm in depth and an area of 52.5 cm and a volume of 15.75 cubic cm. The area was dark purple with green drainage and with an odor. It was recommended to transport Resident 1 to the emergency room for further evaluation. A 9/30/30 hospital Vascular Surgery Consult Note revealed Resident 1 presented with [MEDICAL CONDITION] (a bacterial skin infection) of her/his right foot with a foul smell to an ischemic toe and gangrenous (decay of tissue as a result of interrupted blood flow) changes to the right foot. A 10/9/20 hospital Surgery Brief Operation Note revealed Resident 1's fourth and fifth right toes were amputated. On 10/14/20 at 9:41 AM Witness 2 (Family) stated she spoke to Staff 6 (Unit Manager) almost daily about Resident 1's wound care on her/his foot. On 9/27/20 Witness 2 finally saw Resident 1's little toe and she started calling the supervisor on 9/27/20 as the toe was black and dead. On 9/28/20 she called again and was adamant they send Resident 1 to the hospital. On 10/14/20 at 10:19 AM Resident 1 stated when she/he was first admitted to the facility the staff did not treat her/his right foot. Resident 1 stated the facility treated her/his hip wound regularly. Resident 1 stated staff only started to treat her/his right foot toward the end of her/his stay when her/his foot was infected. Resident 1 stated she/he told staff many times her/his foot was not being treated. Resident 1 stated she/he never had a wound on her/his left foot. Resident 1 stated her/his wound was on her/his right foot. On 10/16/20 at 9:47 AM Staff 11 stated he did not work for a couple of days and when he returned to work Resident 1's right foot wound ulcer worked its way from the bottom of her/his foot to the top of the foot. Staff 11 stated from the 9/21/20 through 9/24/20 he did not notice any discoloration to Resident 1's fifth toe while completing treatment to the underside of her/his foot. On 10/21/20 at 9:37 AM Staff 12 stated she never observed Resident 1's foot ulcer. Staff 12 stated Resident 1 would get swelling in both of her/his legs and they would try and keep her/his feet elevated. On 10/21/20 at 11:22 AM Staff 18 (CNA) stated around 9/12/20 Resident 1 complained to her that her/his foot was hurting and she/he complained it was not healing. Staff 18 stated she reported Resident 1's foot pain to the nurse. On 10/21/20 at 1:39 PM Witness 8 (Wound Care) stated there were two weeks when she did not enter the facility due to COVID-19. Witness 8 stated it was her expectation for the facility to contact the medical provider if there was a change in condition of a wound and wound care could not observe the wound. Witness 8 stated she observed the wound on 9/29/20 for the first time and Resident 1's foot was gangrenous and she advised she/he be transported to the emergency room . On 10/23/20 at 12:03 PM Staff 6 stated she heard Resident 4 had a concern her/his foot wound was not treated. Staff 6 stated she observed documentation and saw it was documented as completed. Staff 6 stated she may have spoken to both Staff 11 and Staff 9 and both stated they were providing treatments regularly. Staff 6 stated she observed Resident 1's foot one instance to verify treatment was completed. Resident 1 continued to complain and Staff 2 was notified. Staff 6 stated she contacted the family and Witness 2 (Family) also stated treatments were not completed. Staff 6 stated after those instances she did not hear any additional concerns from the family or the resident. Staff 6 stated she observed Resident 1's left (right) foot a couple of days into admission and toward the end of her/his stay at the facility. Staff 6 stated she was responsible for completing the weekly wound rounds as well as the other unit manager. On 10/23/20 at 2:15 PM Staff 2 stated she would review the incomplete 9/3/20 wound evaluation. No further information was provided. Staff 2 stated there was no further documentation or action in regard to Resident 1's complaints of her/his foot wound not treated. Staff 2 stated both nurses were very proactive and Staff 2 went through documentation and observed everything was completed. Staff 2 interviewed Staff 11 and Staff 9 which reported Resident 1 would go outside to smoke so Staff 11 and Staff 9 would provide treatment in the morning so she/he could go out to smoke. On 10/26/20 at 12:03 PM Staff 2 stated Resident 1's 9/16/20 order for wound care from one time a day to two times a day was not updated. 2. Resident 4 was admitted to the facility in 8/2020 with [DIAGNOSES REDACTED]. An 8/2020 TAR instructed staff to monitor Resident 4's left great toe and fifth digit [MEDICAL CONDITION]. A 9/1/20 Wound Evaluation revealed Resident 4 had an undiagnosed wound, body location was not documented, age was documented as unknown, and where the wound was acquired was not documented. Measurements of the wound were documented as area 1.41 cm (2.22) squared, 1.61 cm length and 1.38 cm width. The evaluation was incomplete and did not address the characteristics of the wound, the wound bed, and the shape and condition of the surrounding tissues. A picture indicated the wound was on the left first toe around the toenail. A 9/1/20 Contracted Wound Healing wound assessment revealed Resident 4's wound was on the left greater toe and was [MEDICAL CONDITION] which was not healed. The size of the wound was an area of 1.8 cm squared, 1.5 cm length, 1.2 cm width and 0.3 cm depth. A 9/2020 TAR instructed staff to paint left the great toe with [MEDICATION NAME] and let dry; to leave open to air every evening shift with a start date of 9/3/20. A 9/8/20 Wound Evaluation revealed Resident 4 had an open lesion on the left foot first digit. The age of the wound was documented as unknown and it was present on admission. The size of the wound was documented as an area of 0.57 cm squared, 1.0 cm length and 0.8 cm width with eschar (a dark scab or falling away of dead skin), 100% evidence of infection due to increased pain, and wound edges were attached with dry flaky fragile skin around the edges. Resident 4's pain level was a six on a one to 10 pain scale. The picture of the wound was the same area pictured as the 9/1/20 Wound Evaluation, and the evaluation did not measure all of the wound perimeter. The wound measurements were the area where Resident 4's toenail would be located. A 9/8/20 Contracted Wound Healing assessment revealed Resident 4's left great toe was at full thickness [MEDICAL CONDITION] with measurements of an area of 1.8 square cm, 1.5 cm length, 1.2 cm width, 0.3 cm depth, and a volume of 0.54 cubic cm. The wound bed was 76 to 100 percent eschar, the assessment indicated the medical complexity of the wound was putting patient at risk for limb and life. Education was provided on offloading, repositioning, wound cleansing, dressing application and nutrition to support wound healing. No documentation was found in Resident 4's clinical record indicating a wound evaluation was completed on 9/15/20, 9/22/20, or 9/29/20. A 9/30/20 nurse practitioner Encounter Note indicated Staff 3 (Nurse Practitioner) observed Resident 4 briefly on 10/1/20 prior to the discharge visit. Resident 4 discharged before Staff 3 returned to complete a formal visit. The contracted wound nurse attended to Resident 4's wounds at the facility. No documentation was found in Resident 4's clinical record indicating the contracted wound nurse observed Resident 4's left greater toe after 9/8/20. Resident 4 discharged on [DATE] to her/his home. An undated and unsigned Nursing Transfer Summary (paperwork sent home with Resident 4 upon discharge) provided by Witness 5 (Friend) on 10/14/20 revealed Resident 4's skin and wound condition was documented as N/A and no markings were entered on the diagram for her/his skin conditions. No documentation was found in clinical records Resident 4 or her/his representative received physician orders [REDACTED]. On 10/21/20 at 1:44 PM Witness 8 (Contracted Wound Care) stated she observed Resident 4 on 9/8/20 and then she/he thought she/he discharged to the hospital for surgery. Witness 8 stated she was not notified Resident 4 readmitted to the facility so she did not return to continue working with Resident 4. On 10/14/20 at 11:39 AM Witness 5 stated he transported Resident 4 from the facility to her/his home. When Witness 5 picked Resident 4 up at the facility a nurse assistant brought her/him out to the car in a wheelchair. A bag with medication and some paperwork was given to her/him to take home. Witness 5 stated nothing was explained to him in regard to Resident 4's care. Witness 5 stated Resident 4 was disoriented. On 10/15/20 at 10:25 AM Witness 6 (Friend) stated Resident 4 asked Witness 6 to buy some Aspercreme (pain relief cream) because her/his big toe on the left was hurting. Witness 6 stated the toe appeared to be infected and looked nasty. On 10/23/20 at 1:36 PM and 2:50 PM Staff 2 (DNS) and Staff 10 (RN) stated wound specialist observed Resident 4's wound on 9/1/20 and 9/8/20 and in order to proceed with continued treatment the wound specialist needed Resident 4's vascular status from a vascular specialist due to the chronic ulcer to the toe. Staff 10 stated venous and arterial doppler test results were faxed to the wound specialist on 9/16/20 and the wound specialist did not enter the facility for two weeks because COVID-19 testing was in process. Staff 2 stated the nurse practitioner could observe Resident 4's wound if wound care did not see her/his wound. Staff 10 stated there was no note in clinical records Staff 3 observed Resident 4's wound. Staff 2 stated it was the expectation of staff to provide body location, wound characteristics, the condition of the wound bed and surrounding tissue in wound evaluations. Staff 2 stated staff were expected to complete wound evaluations weekly.

Based on observation, interview and record review it was determined the facility failed to accurately assess pressure ulcers, notify the physician and implement care planned interventions for facility acquired pressure ulcers for 1 of 2 sampled residents (# 29) reviewed for pressure ulcers. Resident 29 experienced a worsening pressure ulcer requiring outside intervention. Findings include: Resident 29 admitted to the facility in 2014 with [DIAGNOSES REDACTED]. The CMS State Operaions Manual Appendix PP defined the following: Stage 2 Pressure Ulcer: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. This stage should not be used to describe moisture associated skin damage including incontinence associated [MEDICAL CONDITION], intertriginous [MEDICAL CONDITION] (inflammation of skin folds), medical adhesive related skin injury, or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Ulcer: Full-thickness skin loss Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the wound bed, it is an Unstageable PU/PI. Resident 29's 5/15/18 Annual MDS indicated the resident required extensive assistance with the help of two staff for bed mobility, transferring and toileting. The assessment further indicated the resident was at risk for developing pressure ulcers but did not currently have any unhealed pressure ulcers. Resident 29's 5/15/18 CAAs indicated the resident was cognitively intact. Resident 29's care plan in place as of 4/6/18 related to the resident's risk for skin integrity included the intervention to turn and reposition the resident every four hours. The 5/2018 and 6/2018 TARs directed staff to do the following: -As of 3/1/17 staff were to document PRN if the resident refused any treatment or care and to reattempt three times. If the resident refused all attempts at care, the following shift should then attempt three times. All attempts were to be documented in the resident's clinical record. There were no documented episodes of refusals on the 5/2018 and 6/2018 TARs. -As of 5/11/17 staff were to turn the resident every four hours. Staff initialed and used a check mark to denote the administration of the intervention on all except three shifts through the TARs review dates of 5/2018 and 6/2018. A 6/11/18 Wound Assessment Details Report indicated the resident had an active, facility-acquired Stage 2 pressure ulcer on her/his right buttock. Tissue type was noted as 100% bright beefy red. Wound edges were noted as distinct and attached. The current plan and comments indicated staff would continue using barrier cream and reposition as allowed by resident. Review of Resident 29's clinical record revealed no indication the resident's physician was notified of the 6/11/18 identified facility acquired pressure ulcer. A 6/18/18 Wound Assessment Details Report indicated the resident had an active, facility acquired Stage 2 pressure ulcer on her/his left buttock. Tissue type was noted as 30% bright pink or red, 65% bright beefy red, and 5% slough loosely adherent. Wound edges were noted as distinct and attached. The current plan and comments indicated staff would continue using barrier cream, repositioning and setting up with wound clinic. A 6/20/18 wound care document from the wound clinic indicated Resident 29 was seen for a Stage 3 pressure ulcer of the right buttock. Further review of the facility Wound Assessment Details Reports through 12/7/18 continued to document Resident 29's facility acquired pressure ulcer of the right buttock as a Stage 2. There were five occasions in which the resident's wound was noted to have slough. Multiple observations of Resident 29 between 12/10/18 and 12/14/18 revealed her/him to be up and seated in her/his motorized wheelchair for more than four hours at a time between day and evening shift. On 12/11/18 at 4:14 PM and 12/12/18 at 7:24 AM and 8:56 AM Staff 3 (Regional Nurse Consultant) acknowledged the 6/18/18 through 12/11/18 Wound Assessment Details Reports were inaccurate. Staff 3 acknowledged a Stage 2 pressure ulcer does not have slough present. She further stated the 6/18/18 Wound Assessment Report indicated Resident 29 had slough present on what was identified as a Stage 2 pressure ulcer. Staff 3 acknowledged the clinical record did not indicate Resident 29's physician was notified of the 6/11/18 identified facility acquired pressure ulcer. Staff 3 lastly acknowledged the resident's clinical record regarding the intervention of repositioning and turning the resident every four hours was not accurate. On 12/12/18 at 9:44 AM Staff 6 (CNA) stated the resident was usually up the entire day shift. Staff 6 further stated she worked with the resident the day prior, and noted she was unable to reposition him for two of the documented administrations of repositioning every four hours, because he was up in his motorized wheelchair. She further stated CNA staff did not chart refusals or the inability to reposition the resident, but would report this to nursing staff. On 12/12/18 at 9:44 AM Staff 7 (CNA) stated more frequently than not, the resident was up and in her/his motorized wheelchair the majority of the eight hour day shifts. On 12/12/18 at 12:04 PM Staff 5 (LPN) confirmed she signed off on the 12/2018 TAR for the administration of the 12:00 PM turning and repositioning every four hours for Resident 29, despite the resident not being in her/his bed at that time. Staff 5 confirmed the care planned intervention did not occur.

Based on interview and record review it was determined the facility failed to accurately assess the possible adverse side effects of administering a pain medication more frequently than prescribed and administering the medication via two different routes at the same time for 1 of 1 sampled resident (#1) who was prescribed [MEDICATION NAME] (a narcotic pain medication). As a result the resident was overmedicated. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The medication order for [MEDICATION NAME] was transcribed onto the resident's January 2013 MAR with a note to, "hold for sedation." A Physician's Telephone Order, dated 1/15/13, indicated a Physician ordered [MEDICATION NAME], 4 mg, with [MEDICATION NAME] (an anti-nausea medication), 50 mg, via IM (intramuscular) injection as needed, one injection per week, for migraines. The [MEDICATION NAME] injection order was transcribed on the resident's January 2013 Injection Medication Record (IMR) which identified it was administered to the resident on 1/15/13 and again on 1/22/13. A Nurse's Note, dated 1/24/13 at 6:00 am, identified the resident fell at 1:45 pm on 1/24/13 while attempting a self transfer and complained of severe abnormal back pain. The resident was sent out to the ER and returned to the facility at 3:45 am with no new orders. The resident's January 2013 MAR indicated the resident was administered 4 mg of [MEDICATION NAME] orally on 1/24/13 at 3:45 am and 7:30 am, which was 3 hours and 45 minutes between the doses, and at 4:00 pm and at 7:30 pm, which was 3 1/2 hours between doses. An untimed Nurse's Note, dated 1/25/13, identified the resident was crying, rocking and shaking, and calling out in extreme pain. The note indicated the resident had been unable to stay awake and morning medications had not been given. The note identified the resident was confused and forgetful and had a body temperature of 99.2 degrees Fahrenheit. The January 2013 MAR indicated the resident received an oral, 4 mg dose of [MEDICATION NAME] at 3:35 pm on 1/25/13. A Nurse's Note, dated 1/25/13 at 4:00 pm, indicated the resident continued to rock, shake, and scream in pain and the Physician was contacted regarding the situation. The note identified the facility spoke with a Triage Nurse and, at 5:00 pm, received an order to give the resident (1) 4 mg injection of [MEDICATION NAME] per day through the weekend for unresolved pain. A Telephone Note, dated 1/25/13 at 7:02 pm, from the Physician's office indicated Staff 3, LPN, reported the resident had fallen a couple of days ago with increasing back pain and was seen in the ER with no fractures found. The note identified the resident had orders which included [MEDICATION NAME] 4 mg orally every 4-6 hours and an order for [REDACTED]. The note indicated the last dose of oral [MEDICATION NAME] was administered "2 hours ago" and the Physician gave orders for a [MEDICATION NAME] injection once daily through the weekend. The order for a 4 mg [MEDICATION NAME] IM injection to be given once per day through the weekend as needed for uncontrolled pain was added to the resident's January 2013 IMR. A Nurse's Note, dated 1/25/13 at 10:00 pm, identified the resident's medications were held at bedtime due to lethargy and at 9:30 pm the resident woke up and called out in pain. The resident was given a 4 mg oral dose of [MEDICATION NAME] and an IM injection of [MEDICATION NAME]. The note indicated the resident had a body temperature of 102 degrees Fahrenheit and she was sent out to the ER for evaluation. The resident's January 2013 MAR and IMR identified the resident was administered 4 mg of [MEDICATION NAME] orally at 10:00 pm and a 4 mg IM injection of [MEDICATION NAME] at 10:00 pm. An EMT Patient Care Report identified the facility administered 4 mg tablet [MEDICATION NAME] and another 4 mg IM [MEDICATION NAME] at the same time. This brought the resident's level of consciousness down to painful stimuli and left her with shallow respirations and oxygen saturations in the 60s. The EMTs administered [MEDICATION NAME] (an antidote for narcotic overdose) which woke the resident up and raised her oxygen saturations from the 60s to 96% on 2 liters of oxygen. The Hospital Discharge Summary identified discharge [DIAGNOSES REDACTED]. Concern for excessive sedation resulting in" aspiration pneumonia. In interview on 2/25/13 at 11:00 am Staff 2, DNS, reported Resident 1 received [MEDICATION NAME] according to physician's orders [REDACTED]. In interview on 2/26/13 at 1:45 pm, Witness 2, Physician's Assistant, reported the Triage Nurse noted the resident's oral [MEDICATION NAME] dose had been given two hours prior to the call. Witness 2 stated the Physician would not have known the oral and the IM dose would be given together when the order for the 4 mg IM [MEDICATION NAME] injection order was prescribed. Witness 2 reported that giving the oral and the IM dose at the same time "was a lot" and they should not have been given together. In interview on 2/26/13 at 3:15 pm Staff 3, LPN, reported on 1/25/13 at 10:00 pm Resident 1 was calling out in pain and was lethargic but perfectly awake and alert. Staff 3 stated he gave the resident both the oral dose of [MEDICATION NAME] and the injection of [MEDICATION NAME]. He reported the resident had orders for both and "thought it was fine to give together" he stated he "thought it would help" her pain. In interview on 2/26/13 at 1:00 pm Witness 1, Complainant, identified a concern was reported to her/him that the resident was overmedicated on [MEDICATION NAME] while at the facility. In interview on 2/27/13 at 8:45 am Resident 1 reported she could not recall the events leading up to her hospitalization on [DATE] as it was "all kind of a blur." In interview on 2/27/13 at 12:35 pm Witness 2, Complainant, reported the facility administered a 4 mg tablet of [MEDICATION NAME] and a 4 mg injection of [MEDICATION NAME] which equaled an 8 mg dose of [MEDICATION NAME] which was a high dose. Witness 2 stated the resident became "more or less unresponsive" from the high dose due to respiratory depression. The resident was given 2 mg of [MEDICATION NAME] to counteract the [MEDICATION NAME], which in turn woke the resident up raised her oxygen saturations to 96%.

Based on interview and record review facility staff failed to assess and notify the physician regarding a resident change of condition in a timely manner for 1 of 3 sampled residents (#1) who had a change in their medical condition. The resident experienced a delay in medical treatment and pain due to a fractured leg. Findings include: According to the Oregon Administrative Rules (OARs), [PHONE NUMBER] Definitions: (3) "Assessment" means the process of collecting information regarding a client's health status including, but not limited to, illness, response to illness, health risks of individuals...and the environment. The skills employed during the assessment process may include, but are not limited to, obtaining client histories, conducting physical examinations, notification...and conducting a broad range of diagnostic procedures (e.g., laboratory studies, EKGs and X-Rays). Resident 1 was originally admitted to the facility in December 2004. [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] indicated the resident was cognitively impaired and was dependent on staff for all ADLs. The comprehensive care plan dated 8/24/12 indicated the resident was at risk for pain due to [MEDICAL CONDITION] and the resident was unable to verbalize pain. Included in the care plan was a problem for memory and judgement deficits with little or no communication ability. On 9/15/12 a problem was added to the care plan related to a fracture of right proximal tibia/fibula. Interventions included "the resident's hinged brace was to remain on 100 % of the time except for showers." The 7/17/12 In Room Care Plan, used by the CNAs to provide care, indicated the resident was dependent for all ADLs and to monitor for non-verbal pain indicators such as crying, grimacing or guarding. The care plan was updated on 9/17/12 to include; bed rest until further notice, brace on right leg at all times due to fracture and do not turn resident onto her/his right side. According to the facility's Summary of Events dated 9/18/12 the incident occurred on 9/14/12, a Friday. A "near miss fall" was reported to Staff 3 (LPN) at 2:00 pm. At 4:00 pm, the CNA attempted to get the resident up for dinner, the resident said "OWE" the CNA observed the resident's right knee was swollen and painful, Staff 6 (RN) was notified. Staff 6 faxed the Nurse Practitioner (NP) at 8:00 pm, regarding the resident's right knee. The CNA reported to Staff 6 (RN) "several times" within her shift the resident was painful and the resident was administered Tylenol. Staff 6 (RN) stated he was waiting for a response from the NP. The evening shift ended at 10:00 pm, without a response from the NP. Staff 6 (RN) stated he reported off to the oncoming nurse. The oncoming night nurse of 9/14/12 to am of 9/15/12 placed the resident on alert charting and documented the NP was faxed at 8:00 pm, on 9/14/12. On 9/15/12 at 9:15 am, Staff 3 (LPN) assessed the resident and called the NP. The NP ordered an X-Ray and a fracture was confirmed. At 12:00 pm, the resident was sent to the hospital for treatment of [REDACTED]. The 24 hour Nursing Report dated 9/14/12 indicated on the evening shift Resident 1 had "swollen right anterior right leg, NP faxed." The Nurse's Notes dated 9/14/12 at 10:00 pm, indicated the resident's right anterior leg was swollen, hard and painful to touch, Tylenol was administered and NP was notified by fax. The night shift (between 9/14/12 and 9/15/12) nurse charted the resident's right knee had [MEDICAL CONDITION], no warmth or redness was present, Tylenol was administered and alert charting was started. The 24 hour Nursing Report dated 9/15/12 indicated on night shift (between night shift 9/14/12 and day shift 9/15/12) "per evening LN right knee and lower leg [MEDICAL CONDITION], NP was faxed, on alert charting." The day shift documented "X-Ray shows fracture of tibia/fibula, sent to ER." According to the facility's Resident Incident Report dated 9/15/12 at 9:19 am, the resident sustained [REDACTED]. The resident was sent to the ER and returned at 6:00 pm, with a leg immobilizer. On 9/17/12 at 7:25 pm, the NP dictated notes and indicated "over the weekend this NP received a phone call reporting patient with a painful swollen leg. No redness, no heat and no fever. Nurse stated it appeared to be an injury. X-Rays were ordered and patient was found to have a fractured tibula/fibula." The resident received an order for [REDACTED]. On 9/25/12 at 2:10 pm, Staff 2 (DNS) stated there were differing stories as to how the resident was injured on 9/14/12. Staff 2 stated Staff 7 (Agency CNA) told Staff 3 (LPN) at the end of their shift "there was a near miss while doing a transfer." Staff 2 stated Staff 3 did not assess the resident since it was the end of his shift but passed the information to the on coming evening nurse. According to Staff 2 at about 4:00 pm, the evening nurse was asked by the CNA to look at the resident's knee. After looking at the resident's knee Staff 6 (RN) sent a fax to the resident's NP but not until 8:00 pm. Staff 2 stated she asked the night nurse why she did not call the NP, her reply was the resident was asleep on the night shift. On Saturday 9/15/12 the NP came in to the facility to assess the resident after receiving a telephone call. Staff 2 stated a portable X-Ray was ordered and later the fracture was confirmed. On 9/26/12 at 11:10 am, Staff 3 (LPN) confirmed he was the nurse on day shift of 9/14/12. Staff 3 stated the CNA came to him at the end of their shift and stated the resident nearly fell from the Hoyer sling during a transfer. Staff 3 stated there was no "sense of emergency" so he passed the information onto the evening nurse. Staff 3 stated he worked the next morning and went to assess the resident because it was reported that she/he was painful. Staff 3 stated he then telephoned the NP due to the resident's painful and swollen right knee. On 9/26/12 at 12:10 pm, Staff 5 (RNCM) stated the resident was evaluated in theER on [DATE] and returned with a brace. An order was received to have the resident seen by an orthopedic physician. Resident 1 was placed on bedfast status until the ortho appointment. The resident was seen by the orthopedic doctor on 9/18/12 and she/he was placed in a more stable hinged brace. Staff 5 stated the resident was currently a three person transfer. On 9/27/12 at 11:10 am, Staff 6 (RN, former employee) stated he was told by the day nurse the resident had a near fall and he had no reason to think anything was wrong with the resident. About 4:30 pm the CNA came to him, he assessed the resident's knee. Staff 6 stated "I didn't know anything was wrong, it was swollen but not badly." Staff 6 confirmed he did not call the NP and chose to send a fax but not until about 8:00 pm. Staff 6 stated he "wanted the nurse practitioner to come in over the weekend." On 9/27/12 at 2:30 pm, Staff 7 (CNA) stated she told Staff 3 (LPN) at the end of their shift the resident had a near fall. Staff 7 stated she "did not make it sound important to the nurse" more of an "FYI", the nurse thanked her and passed it on to the evening nurse. Refer to F 323

Based on interviews and record review the facility failed to provide a safe environment for 1 of 1 sampled resident's (# 1) while being transferred. Resident 1 sustained a fractured right leg. Findings include: Resident 1 originally admitted to the facility in 2004. [DIAGNOSES REDACTED]. The In Room Care Plan dated 7/17/12, used by the CNAs to provide resident care, indicated the resident was to be transferred via mechanical lift. The resident used a wheelchair for seating and had a low bed for safety. The quarterly MDS dated [DATE] indicated the resident was cognitively impaired, dependent on staff for all ADLs, was nonambulatory and incontinent. The comprehensive care plan dated 8/24/12 indicated the resident required total care for all ADLs due to progressive dementia and obesity. Interventions included to follow transfer safety instructions per in-room care plan. The care plan included a problem for being at risk for falls related to sliding out of wheelchair and poor safety awareness secondary to dementia. Interventions included to transfer per in-room care plan and use a mechanical lift for all transfers. The facility Summary of Events dated 9/18/12 indicated the incident occurred on 9/14/12. Resident 1 received a shower at 11:00 am, was dressed, assisted to the wheelchair and went to the dining room for lunch. At 1:00 pm, on 9/14/12 the resident was observed sliding down in her/his wheelchair. Staff 7 (CNA) asked Staff 4 (CNA) if she would assist her in laying the resident in bed. The resident had a Hoyer sling under her/him however, due to sliding forward in the chair the sling could not be properly placed for transfer. According to Staff 7 a two person manual pivot transfer was done using a gait belt. Halfway through the transfer the resident's legs buckled and a sudden decent towards the floor occurred, however, Staff 7 and Staff 4 were able to "catch (her/him) before (her/his) knees hit the floor." The resident was put into bed. Staff 4 stated she and Staff 7 used a Hoyer mechanical lift for transferring Resident 1. Staff 7 and Staff 4's stories differ regarding the events that took place when Resident 1 was transferred to bed. On 9/17/12 in a written statement Staff 7 (CNA) indicated on 9/14/12 at approximately 12:15 pm, she had finished assisting residents to eat in the dining room and transported Resident 1 in her/his wheelchair back into her/his room; "about 5 minutes later she saw (the resident) had scooted way down in (her/his) chair where (she/he) was close to falling out." Staff 7 stated she asked Staff 4 (CNA) for help. Staff 7 stated in her written statement she knew the resident was care planned for a mechanical lift however, "the (resident) had scooted too far forward from the Hoyer sling under her/him to safely use it." Staff 7 and Staff 4 "decided to two person transfer (her/him) before she fell out (of the wheelchair)." "I put my gait belt on (her/him) and we began the transfer...during the transfer (resident) decided not to or couldn't help anyway and (her/his) legs suddenly gave out...we were able to get (her/him) in bed safely without (her/his) legs touching the ground." Staff 7 stated after the resident was in bed she told the Charge Nurse (Staff 3) about the near fall. On 9/18/12 in a written statement by Staff 4 (CNA) the events of 9/14/12 were documented. Staff 4 stated she was assisting another resident to eat when Staff 7 (CNA) stated she was going to put Resident 1 into bed. "A few minutes later she came back and said she needed help ASAP (she/he) was falling outta (her/his) chair." "When I walked in the Hoyer was already in the room, (the resident) scooted and slouched way forward, we hooked up to the Hoyer, the straps were down by (her/his) knees. At the time (her/his) knees were bent, (Staff 7) was handling the Hoyer device, I was holding (her/his) buttocks with my hands, we got (her/him) to bed..." Staff 4 stated she left the room immediately and answered call lights. On 9/25/12 the ADL record for September 2012 was reviewed for 9/14/12. On day shift of 9/14/12 it was documented the resident had been transferred by a mechanical lift and one staff per assist. Evening shift indicated the resident remained in bed. On 9/25/12 at 2:10 pm, Staff 2 (DNS) stated the two CNAs (Staff 4 and Staff 7) were "sticking" to their stories and their statements didn't match. Staff 7 (CNA) stated a two person stand pivot transfer was used to put Resident 1 into bed. Staff 4 (CNA) stated a mechanical lift was used. On 9/26/12 at 11:10 am, Staff 3 (LPN) stated the CNA came to him at the end of their shift and stated the resident nearly fell from the Hoyer sling during a transfer. Staff 3 stated there was no "sense of emergency" and the information was passed on the the evening nurse. On 9/26/12 at 11:30 am, Staff 4 (CNA) confirmed she worked on the day shift of 9/14/12. Staff 4 stated the resident was slouched down in the wheelchair and the Hoyer sling was high in the chair. Staff 7 (CNA) stated she would put the resident to bed. "A few minutes later she came back and said I really need help now (she/he) is too far down." Staff 4 stated she went to the resident's room and they hooked up the Hoyer sling which was "off kilter" with the resident's positioning. Staff 4 stated she supported the resident's buttocks and they got the resident to bed. Staff 4 stated she immediately left Resident 1's room. Staff 4 stated she was "certain nothing (resident's legs) bumped and injury did not happen then." Staff 4 stated "no stand pivot transfer occurred when she was in the room, Hoyer only." On 9/27/12 at 2:30 pm, Staff 7 (CNA) stated she had been assisting residents to eat at lunchtime on 9/14/12. Staff 7 stated she took Resident 1 to her/his room and left. About five minutes later Staff 7 stated she noticed that Resident 1 had scooted down in her/his wheelchair. Staff 7 stated she called a co-worker for help and went to get the Hoyer lift. "There was no way to get the sling under the resident, the wheelchair was right next to the bed so we did a two person transfer to bed, legs of resident buckled." Staff 7 stated the resident's legs were not bumped, the resident was not dropped and the transfer to bed was fast. Staff 7 confirmed she knew the resident was care planned for a mechanical Hoyer lift but felt there was no way to safely use the sling at the time due to the positioning of the resident and where the sling was placed. Staff 7 stated she informed Staff 3 they had a near fall while transferring Resident 1.