Every finding on record at La Bella of Alton

Based on interview and record review, the facility failed to notify the physician of a change in condition and holding diabetic medication for 1 of 4 residents (R2) reviewed for notifications in the sample of 4.Findings include:R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including dementia and diabetes mellitus type 2 with hyperglycemia.R2's Physician Order dated 9/10/25 documents Humalog (insulin) Injection Solution per sliding scale at meals and at bedtime for diabetes mellitus type 2 with hyperglycemia. R2's Care Plan initiated 9/15/25 documents R2 has the potential for high and low blood sugar related to diabetes mellitus. R2's Care Plan interventions include diabetes medication and blood sugar checks as ordered by physician.R2's Minimum Data Set (MDS) dated [DATE] documents R2 was cognitively impaired, ambulates with supervision, and R2 received insulin medication.R2's Physician Order dated 9/18/25 documents monitor for signs and symptoms of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar).R2's Medication Administration Record (MAR) does not document R2's blood sugar was checked or Humalog was given on 10/25/25 at 11:30 AM, 10/25/25 at 4:30 PM, 10/25/25 at 9:00 PM, 10/26/25 at 6:30 AM, 10/26/25 at 11:30 AM, or 10/26/25 at 4:30 PM.R2's Progress Notes do not document R2's Physician was notified regarding blood sugars not being checked or insulin not being given.On 10/30/25 at 12:45 PM, V10, Licensed Practical Nurse (LPN), stated on 10/25/25 R2 she was having behaviors and combativeness. She finally went to sleep, and on 10/26/25 she was still sleeping. She did not check R2's blood sugars or give her insulin because she felt sleeping was best for her at that time and did not notify the physician of this.The Facility's Employee Counseling Form dated 10/28/25 documents V10 failed to notify physician of change of condition and failure to provide notification to physician and family.On 10/31/25 at 10:41 AM, V1, Administrator, stated she would expect nurses to notify physician of any changes or missed medications.The Facility's Notification of Changes Policy reviewed 10/28/25 documents, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification.The Facility's Medication Errors Policy reviewed 8/21/25 documents the Facility shall ensure medications will be administered according to physician orders. If a medication error occurs, the nurse assessed the resident's condition and notifies the physician or health care practitioner as soon as possible.

Based on interview and record review, the Facility failed to ensure a resident with known diabetes received timely blood glucose monitoring per physician orders for 1 of 4 residents (R2) reviewed for quality of care in the sample of 4. This past non-compliance occurred from 10/25/25 to 10/28/25.Findings include:R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including dementia and diabetes mellitus type 2 with hyperglycemia.R2's Minimum Data Set (MDS) dated [DATE] documents R2 was cognitively impaired, ambulated with supervision and took insulin.R2's Care Plan initiated 9/15/25 documents R2 has the potential for high and low blood sugar related to diabetes mellitus. Care Plan interventions include diabetes medication and blood sugar checks as ordered by physician.R2's Progress Note dated 10/26/25 at 4:03 AM documents R2 had been sleeping since the start of shift at 10:00 PM the night before.R2's Physician Order dated 9/10/25 document Insulin Glargine Solution (100 units/milliliter), inject 40 units twice daily related to diabetes mellitus type 2 with hyperglycemia.R2's Physician Order dated 9/10/25 documents Humalog Injection Solution per sliding scale at meals and at bedtime for diabetes mellitus type 2 with hyperglycemia.R2's Physician Order dated 9/18/25 documents monitor for signs and symptoms of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar).R2's Medication Administration Record (MAR) does not document R2's blood sugar was checked or Humalog was given on 10/25/25 at 11:30 AM, 10/25/25 at 4:30 PM, 10/25/25 at 9:00 PM, 10/26/25 at 6:30 AM, 10/26/25 at 11:30 AM, or 10/26/25 at 4:30 PM.On 10/30/25 at 12:45 PM, V10, Licensed Practical Nurse (LPN), stated on 10/25/25, R2 was having behaviors and combativeness. She finally went to sleep, and on 10/26/25 she was still sleeping a lot. She did not check R2's blood sugars or give her insulin because she felt sleeping was best for her at that time.On 10/31/25 at 10:41 AM, V1, Administrator, stated she would expect nurses to monitor blood glucose levels as prescribed by physician.The Facility's Blood Glucose Monitoring Policy revised 9/15/25 documents, It is the policy of this facility to perform blood glucose monitoring to diabetic residents as per physician's orders. The facility will perform blood glucose monitoring as per physician's orders.Prior to the survey date 1/7/2026, the facility took the following actions on 10/28/2025 to correct the noncompliance:1-All residents with diabetic management orders were reviewed to ensure active monitoring schedules were followed. 2-Staff involved were removed from duty pending investigation and retraining.3-Staff failed to recognize the critical importance of adherence to prescribed blood glucose monitoring times.4-On 10/28/25, all diabetic residents requiring blood glucose monitoring had special alert added within the electronic health record (EHR) to generate notification for blood glucose checks. 5-On 10/28/25, facility policy was reviewed and updated to include: All physician-ordered clinical monitoring (including blood sugar checks) must be completed at the ordered time regardless of sleep status unless contraindicated by physician order. by V15, V2, V3, and V1.Ongoing Actions:1-On 10/28/25, V2, V3, V22, V23, and V1 performed mandatory re-education completed for all licensed staff on diabetic management, physician order compliance, and change-of-condition protocols to be ongoing for new hires and agency.2-V2, V3, V22 and V23 audits 100% of diabetic monitoring logs daily for 2 weeks, then weekly for 1 month, then monthly ongoing. 3-Audit results reported during monthly QAPI meetings.

Based on interview and record review, the facility failed to administer subcutaneous insulin medication as ordered by a physician for 1 of 4 residents (R2) who had a diagnosis of Diabetes Mellitus Type 2 with Hyperglycemia, reviewed for medication in the sample of 4. Findings Include:R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including Dementia and Diabetes Mellitus Type 2 with Hyperglycemia.R2's Minimum Data Set (MDS) dated [DATE] documents R2 was cognitively impaired and took insulin.R2's Care Plan initiated 9/15/25 documents R2 has the potential for high and low blood sugar related to diabetes mellitus. Care Plan interventions include diabetes medication and blood sugar checks as ordered by physician.R2's MAR (Medication Administration Record), dated 10/1/25 - 10/31/25, documents an order dated 9/10/25, for Insulin Glargine Solution 100units/ml (milliliters). Inject 40 units twice daily. The MAR documents that this was not given on 10/25/25 at 8:00 AM, 10/25/25 at 8:00 PM, or 10/26/25 at 8:00 AM.R2's MAR, dated 10/1/25 - 10/31/25, documents an order dated 9/10/25, for Humalog Insulin, inject as per sliding scale before meals and at bedtime. The MAR documents that this was not given on 10/25/25 at 6:30 AM, 10/25/25 at 11:30 AM, 10/25/25 at 4:30 PM, 10/25/25 at 9:00PM, 10/26/25 at 6:30 AM, 10/26/25 at 11:30 AM, and 10/26/25 at 4:30 PM.R2's MAR, dated 10/1/25 - 10/31/25, documents an order dated 9/18/25 to perform (blood glucose monitoring) before meals and at bedtime. The MAR documents this was not completed on 10/25/25 at 11:30 AM, 10/25/25 at 4:30 PM, 10/25/25 at 9:00 PM, 10/26/25 at 6:30 AM, 10/26/25 at 11:30 AM, and 10/26/25 at 4:30 PM. R2's Progress Note, dated 10/26/25 at 6:00 PM, documents the following: Called to room by CNA (Certified Nursing Assistant) to assess resident per resident's daughter at bedside, stated Mom is clammy. VS (vital signs) taken 97.0; 74; 14; 90/70. First (blood glucose check) performed read 230. Unable to arouse resident. Shallow breathing noted, when this writer voiced concern of breathing patter, daughter stated That is the way mom breaths when she's sleeping. Nurse manager notified. R2's Progress Note, dated 10/26/25 at 6:05 PM, documents the following: Second (blood glucose check) obtained at this time with results reading HI.On 10/31/25 at 10:41 AM, V1, Administrator, stated she would expect insulin to be given as ordered. The Medication Error Policy, with a revision date of 8/21/25, documents the facility shall ensure medications will be administered according to physician's orders.

Based on interview, observation, and record review the facility failed to implement a resident's bed mobility care plan and failed to have the proper number of staff were present to change the resident's position in bed as directed by the resident's facility-created care plan for 1 of 5 residents (R2) reviewed for falls in the sample of 7. This failure resulted in R2 falling from R2's bed and sustaining a raised hematoma above the left eye, bruising below the left eye, bruising behind the left ear, bruising covering the left side of R2's neck and multiple bruises covering the left side of R2's face. Findings Include:R2's face sheet, dated 7/24/25, documented R2 has diagnoses including Alzheimer's disease, chronic embolism, and thrombosis of left femoral vein, type 2 diabetes, vascular dementia, hyperlipidemia, and hypertension. R2's MDS (Minimum Data Set), dated 4/16/25, does not have a cognition score documented. On 7/24/25 at 1:52 PM surveyor asked V1, Administrator, since R2's cognitive impairment test score is blank does that indicate R2 is severely cognitively impaired and V1 replied yes.R2's MDS, dated [DATE], documented R2 is dependent on staff for bed mobility and requires a mechanical lift for transfers. R2's care plan, undated, documented bed mobility: the resident needs extensive help to move and reposition in the bed. Will need two-person assistance to change position or scoot up in bed with an initiation date of 10/10/23. R2's care plan also documented R2 is at risk for falls related to confusion, gait/balance problems, incontinence, limited mobility, medication use, and unaware of safety needs. This care plan documented R2 is diagnosed with terminal condition and has chosen Hospice services. R2's progress note, dated 7/16/25 at 1:47 PM, documented CNA (Certified Nurse Assistant) was performing AM care in the resident's bed. The resident sustained a ground level fall from bed. Laceration noted left side of lateral forehead and bruising noted to left frontal forehead. Scraped area noted to left knee. Bruising noted to left eye. R2's fall report, dated 7/16/25 at 7:45 AM, documented CNA was performing am care in the resident's bed. The resident sustained a ground level fall from bed. Laceration noted left side of lateral forehead and bruising noted to the left frontal forehead. Bruising noted to left eye. Resident unable to give description. CNA educated on resident requiring (2) staff to perform ADL (activities of daily living) care r/t (related to) resident being dependent on staff. Injuries observed at time of incident: hematoma to face, laceration to top of scalp and left knee. IDT (Interdisciplinary Team) discussing fall on 7/16/25. RCA (root cause analysis) resident sustained a ground level fall from bed during am care. Attempted to interview resident following the incident, resident was unable to provide statement of events due to cognition secondary to dementia. Per interview with resident's roommate, the CNA was performing care and providing incontinent care, the resident was positioned side lying, the CNA reached for a cleaning wipe, the resident moved slightly and rolled off of the side of the bed landing on the ground. The CNA yelled for assistance from the room. The nurse and ADON (Assistant Director of Nursing) arrived. The resident was laying on the left side of the bed. A small laceration was noted to the left side of the resident's head, in addition to a developing hematoma to the left forehead. The resident was triaged with first aid at bedside and hospice provider call for notification and instruction. Neuro assessment noted to be at baseline with no deviation noted. Hospice nurse arrived at facility and instructed the resident did not require higher level of care at this time and instructed facility to continue to monitor. (Cognition score) is 99. Resident has diagnosis of Alzheimer's. It continues, Resident requires max assist with ADLS, and requires mechanical lift for transfers. Intervention: Education to nursing staff related to requiring 2 staff assist for bed mobility. R2's progress note, dated 7/17/25 at 5:16 AM documented peri orbital area of left eye light purple in color. Head remains bandaged in circular fashion with gauze, which is clean, dry, and intact. Resident does not complain of pain. On 7/24/25 at 9:35 AM surveyor observed R2 laying on a low bed, resident was non-verbal during this observation. R2 had 2 wound closure strips applied to her left forehead near her hairline, a purple raised hematoma above her left eye, purple bruises below her left eye, yellow bruises covering the left side of her face, purple and yellow bruises behind her left ear, and yellow bruising covering the left side of her neck. On 7/24/25 at 12:20 PM surveyor observed V11, Restorative CNA, and V8, CNA, perform incontinent care on R2. R2's bed has grab bars on each side. Surveyor asked V11 if R2 has the ability to reach for and hold on to the grab bars. V11 stated sometimes we do hand over hand with her. V11 then asked R2 to reach for the grab bar during turning and repositioning, and R2 was unable to follow commands. V11 then placed her hand over R2's hand and guided it onto the grab bar as she was turned onto her left side. R2 was only able to hold on to the grab bar for approximately 10 seconds without assistance. V8 stated she should definitely be a 2 person assist. V11 stated generally when a resident requires a (mechanical) lift, then they are supposed to have 2 staff for turning and repositioning. On 7/24/25 at 12:46 PM V9 CNA stated she was by herself when she was cleaning and turning R2 on 7/16/25. V9 stated she was never told there had to be 2 CNAS to turn R2. V9 stated she raised R2's bed to her waist level, turned R2 towards the window, turned back to grab the wipes that were on the other side of the bed, felt R2 jerk, and put her leg against the bed to soften R2's fall. On 7/29/25 at 8:48 AM V2, DON, stated she expects the staff to follow the care plan for each resident's bed mobility needs.The facility's Repositioning policy, dated 5/2013, documented the purpose of this procedure is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning to promote comfort for all bed or chair bound resident and to prevent skin breakdown, promote circulation and provide pressure relief for residents. Preparation: 1. Review the resident's care plan to evaluate for any special needs of the resident. 2. Assemble the equipment and supplies as needed. It continues, repositioning the resident in bed: 1. Check the care plan, assignment sheet or the communication system to determine the resident's specific positioning needs including special equipment, resident level of participation and the number of staff required to complete the procedure.

Based on observations, interviews and record reviews the facility failed to provide complete incontinent care to prevent urinary tract infections (UTI) for 1 of 3 residents (R68) reviewed for incontinent care in a sample of 66. Findings include: R68's Face Sheet documented she was admitted to the facility on [DATE] with diagnoses of, in part, hemiplegia, dementia, and schizophrenia. R68's Physician's Order, with start date of 6/1/25 and end date of 6/6/25, documented Amoxicillin-Pot Clavulanate Tablet 875-125 mg (milligrams), give 1 tablet by mouth every 12 hours for UTI for 5 days. R68's Minimum Data Set (MDS) dated [DATE] documented she was severely cognitively impaired. R68's Care Plan dated 4/24/25 documented she has an ADL (activities of daily living) self-care performance deficit, needs and participation may vary r/t (related to) Dementia. R68's Care Plan also documented on 12/20/2023 R68 has urinary incontinence and included an intervention of providing incontinent/peri-care PRN (as needed). On 6/11/25 at 12:45 PM, V23, Certified Nursing Assistant, CNA, wheeled R68 to her room and assisted her to the toilet. R68's incontinent brief was soiled, and she continued to have a bowel movement on the toilet. When R68 was done using the toilet, V23 wiped R68's rectum region but did not wipe her front peri region before putting a new brief on and pulling her pants up. 6/11/25 at 1:50 PM V29, CNA, stated during peri care for a resident that is incontinent and uses the toilet, she always wipes their front region and back never just the back if they have a bowel movement. 6/12/25 at 9:19 AM, V31, CNA stated whenever a female resident has soiled their brief and needs a new one or uses the toilet, she would wipe entire perineal vaginal region and the rectum completely, not just the rectum. 6/12/25 at 9:20 AM, V36, CNA, stated she would completely clean and wipe a female resident's front vaginal region and rectum after being incontinent, at the toilet or in the bed. On 6/12/25 at 11:43 AM, V1, Administrator, stated she expects peri-care to be performed completely. The facility's Incontinent Care Policy dated 2/2018 documented for a female resident wash perineal area, wiping from front to back; wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks .

Based on interview and record review the facility failed to change an indwelling urinary catheter per Physician order and failed to perform urinary catheter care per Physician order for 2 of 3 (R1, R3) residents reviewed for quality of care. Findings include: 1.R1's EMR (Electronic Medical Record) undated documents that the resident was admitted to the facility on [DATE]. R1's EMR dated 12/31/24 documents a diagnosis of unspecified injury at unspecified level of cervical spinal cord, subsequent encounter and pressure ulcer of sacral region, stage 4. R1's Care Plan dated 2/05/25 documents The resident has Indwelling Catheter r/t (related to) Urinary Retention related to neurogenic bladder secondary to Cervical spine injury and Pressure Injury. R1's MDS (Minimum Data Set) dated 3/4/25 documents a BIMS (Brief Interview for Mental Status) score of 15 out of 15. The MDS documents that the resident requires partial/moderate assistance for roll left and right. The MDS documents that the resident requires substantial/maximal assistance for sit to lying and lying to sitting on side of bed. The MDS documents that the resident is dependent for sit to stand, chair/bed to chair transfer, and tub/shower transfer. The MDS documents that the resident has an indwelling catheter. R1's Physician Order dated 2/22/25 documents (Urinary) Catheter care and securement device q (every) shift and PRN (as needed) Please change (urinary) catheter monthly starting 2/22/25; every 1 month(s) starting on the 22nd for 28 day(s) for Prophylaxis. On 4/30/25 at 11:09 AM, R1 stated that he has not had his catheter changed since he was admitted . He stated that it should be changed every month. On 4/30/25 at 1:14 PM, V3, Wound Nurse/Licensed Practical Nurse (LPN) stated that she missed the order to change (R1's) catheter because it was combined with another order. She stated that she would change his catheter now and separate the order, so it does not happen again. 2.R3's EMR undated documents that the resident was admitted to the facility on [DATE]. R3's EMR dated 8/3/24 documents a diagnosis of acute kidney failure, unspecified. R3's EMR dated 3/18/24 documents a diagnosis of neuromuscular dysfunction of bladder, unspecified. R3's EMR dated 4/11/25 documents a diagnosis of retention of urine, unspecified. R3's Care Plan dated 4/11/25 documents The resident has an Indwelling (urinary) Catheter r/t diagnosis of Neurogenic bladder and urinary retention. R3's MDS dated [DATE] documents a BIMS score of 15 out of 15. The MDS documents that the resident has an indwelling catheter. The MDS documents that the resident requires supervision or touching assistance for roll left and right. The MDS documents that the resident requires partial/moderate assistance for sit to lying. The MDS documents that the resident requires substantial/maximal assistance for lying to sitting on side of bed and sit to stand. The MDS documents that the resident is dependent for chair/bed to chair transfer and toilet transfer. R3's Physician Order dated 3/9/25 documents (Urinary) Catheter Care; every shift AND as needed for soiling or leakage. On 4/30/25 at 11:20 AM, R3 stated . the (facility) staff do not clean it every shift. On 4/30/25 at 1:35 PM, V8, CNA (Certified Nursing Assistant) stated that urinary catheter care should be done every shift. She stated that she has not completed catheter care for (R3) yet today. On 4/30/25 at 1:41 PM, V9, CNA stated that she does catheter care every time she changes a resident. She stated that she has not done catheter care on (R3). On 4/30/25 at 2:09 PM, V8 was questioned about urinary catheter care for (R3). She stated that the midnight shift switched (R3's) leg bag to the regular bag. She stated that she did not complete catheter care for (R3). Facility's Policy Catheter Care, Urinary dated August 2022 documents The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections.

Based on interview and record review, the facility failed to ensure residents were free from verbal abuse for 2 of 2 residents (R2, R3) reviewed for abuse in the sample of 6. Findings include: R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, end stage renal disease, dependence on renal dialysis, schizoaffective disorder, and bipolar disorder. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as cognitively intact, had no behaviors, and was able to transfer self with supervision. R2's Undated Care Plan documents R2 has a behavioral problem. The goal is for R2 to have fewer episodes of vulgar language toward others. R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including history of mental and behavioral disorders and substance abuse. R3's MDS dated [DATE] documents R3 as moderately cognitively impaired, had behavioral symptoms not directed toward others, ambulated via wheelchair, and was able to transfer with supervision. R3's Undated Care Plan documents R3 has a behavioral problem with goal of having fewer episodes of being verbally abusive. On 2/7/25 at 2:15 PM, R2 stated R3 calls him bad names and has been doing so for the past two or three weeks. He said sometimes R3 curses at him, and staff are aware, but it has continued. On 2/7/25 at 9:02 AM, R3 stated R2 used to be his roommate. R3 stated, (R2) would bend over in the bathroom and let those ladies clean his butt. I would say, (R2) why don't you clean your own self? It's not that hard. On 2/7/25 at 8:58 AM, V6, Licensed Practical Nurse (LPN), stated R3 antagonizes R2 and calls him S***ty (R2). V6 stated he has spoken to R3 about it multiple times, but R3 likes to get in front of people in common areas like the dining room and call him that name. V6 stated it has really bothered R2. On 2/7/25 at 9:25 AM, V8, Dietary Aid, stated R3 and R2 are always picking on each other. R3 calls R2 S***man, S***tyman, or P***yman. They will shout out to each other from opposite sides of the dining room. On 2/7/25 at 9:30 AM, V4, LPN, stated R2 and R3 are always picking on each other. R2 calls R3 Stupid and Bonehead. R3 makes jokes about R2's incontinence. On 2/7/25 at 9:35 AM, R5 stated R2 and R3 have it out at each other and are like little kids. R3 picks on R2, but R2 also picks on R3. R3 came into the dining room about two weeks ago and started picking on R2. I think R3 needs to be placed somewhere else. On 2/7/25 at 9:40 AM, V9, Social Services Director, stated R3 is just an obnoxious little guy. On 2/7/25 at 10:42 AM, V11, Certified Nursing Assistant (CNA), stated R2 and R3 used to yell at each other when they were roommates. On 2/7/25 at 11:13 AM, R6 stated R3 is really loud and likes to call people names. R2's 2/4/25 Progress Note by V13, Social Services Director, documents V13 spoke with R3 regarding issues he is having with R2. V2 stated R3 has been calling him vulgar names, and R3 continuously tries to get a reaction out of R2. On 2/7/25 at 1:18 PM, V13 stated she used to work at the front desk and remembers overhearing R2 say R3 called him names. She recently spoke with both R2 and R3 because R3 called R2 S***typants. On 2/7/25 at 3:20 PM, V1 stated she expects the facility to follow its abuse policy. The Facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program reviewed 11/24 documents, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

Based on interview and record review, the facility failed to follow physician's hospital discharge order and apply a wound vac and coordinate care for an abdominal wound for 1 (R2) of 4 residents reviewed for quality of care/treatment in the sample of 4. Findings include: R2's Face Sheet documents he was initially admitted to the facility on [DATE] post recent abdominal surgery, multiple ostomies and lower bowel ishchemia. R2's Hospital Discharge Paperwork, dated 12/4/2024 documents R2 is to have a wound vac to abdominal wound to be restarted on 12/4/2024. R2's Health Status Note, dated 12/5/2024 at 12:11 AM, documents wound vac ordered. R2's Nurtritional Progress Note, dated 12/5/2024 at 2:21 PM, documents open surgical abdominal wound has order for wound vac. R2's Physician's Order Sheet (POS) dated 12/2024 documents a physician's order for 12/5/2024 External Debridement Ointment apply to abdomen topically two times a day for dressing change cleanse wound with wound cleanser apply santyl to base of wound gently pack with Dakins moistened kerlex cover with ABD (abdomen) pad and midipore tape change BID (twice a day) and PRN (as needed) use this order if wound vac is off. R2's Medication Administration Record (MAR) dated 12/5/2024 through 12/12/2024 staff documented the above physician's treatment order was administered to R2's abdominal wound. R2's POS, dated 12/11/2024 documents a physician's order cut white foam to fill wound bed cut black foam to fit over white foam and apply - abdomen, check wound vac for proper functioning. Setting maintain at 125 mmHg, change wound vac dressing 3 times per week and PRN (when necessary) or malfunction and change wound vac canister weekly and PRN filling. R2's Treatement Adminstration Record dated 12/12/2024 staff documented the wound vac was applied and started per physicians orders dated 12/11/2024. On 1/14/2025 at 1:45 PM, V16 Wound Nurse, LPN stated when R2 was initially admitted to the facility she read on his hospital discharge paperwork that he was to have a wound vac on his abdominal wound but she spoke with V15, Wound Care Specialist and he said to discontinue the wound vac order and to apply a specific dressing to the wound. She started the specific dressing the day after R2 was admitted to the facility and V15 assessed the wound on 12/10/2024 and the wound was smaller and was showing improvement so V15 stated to keep the wound vac order discontinued. R2 told her that he was supposed to wear a wound vac and she again discussed it with V15 but he stated since the wound was healing and getting smaller he confirmed R2 didn't need a wound vac. On 1/14/2025 at 10:45 AM, V2 Director of Nurses (DON) stated R2 was an emergency admission from the emergency room (ER) and he wasn't admitted with abdominal wound physician's orders so the facility wound specialist gave orders for a treatment and that was administered until there was clarification on the wound vac and then it was administered. V2 stated she didn't know how many days it was that R2 didn't have a wound vac on at the facility and wasn't sure why the hospital discharge paperwork that she reviewed didn't document that R2 was to have a wound vac but that she expected staff to read the hospital discharge paperwork and to communicate with nursing what the physician's discharge orders were to ensure they are followed. V2 stated she always expects staff to follow physician's orders no matter if the orders came from the hospital or a physician at the facility. V2 stated all treatment orders should be documented on the TAR but sometimes they accidentally go on the MAR. On 1/14/2025 at 3:37 PM V15 stated when R2 was admitted to the facility V16 communicated to him that there was an physician's order from the hospital discharge paperwork that he should have a wound vac on this abdominal wound. It was V15's understanding that R2 wasn't being followed by a wound care specialist for the abdominal wound so he discontinued the wound vac order because he ordered a different treatment and when he initially assessed the wound the second week of December 2024 the abdominal wound was getting smaller and showed improvement so he again stated not to start a wound vac. Then R2 went to an outside physician's appointment he returned to the facility with a wound vac order and the wound vac was placed on 12/12/2024. No harm was done and the abdominal wound was healing and getting smaller so in his professional opinion a wound vac wasn't needed for this abdominal wound. The Facility's Medication and Treatment Orders Policy, revised July 2016, documents orders for medications and treatments will be consistent with principles of safe and effective order writing.

Based on observation, interview and record review the facility failed to ensure residents received a shower. The facility also failed to document residents who received a shower for 4 of 4 residents (R2, R4, R1, R3) reviewed for Activities of Daily Living care for dependent residents in a sample of 4. Finding include: 1. R2's Undated Face Sheet documents R2 was admitted to the facility on [DATE] and has a diagnosis of need for assistance with personal care. R2's Minimum Data Set (MDS) dated [DATE] documents R2 has no cognitive deficits and needs substantial/maximal assistance with showering/bathing. R2's Undated Care Plan documents R2 has an activities of daily living (ADL) self-care performance deficit related to limited mobility, with interventions documenting to use a mechanical lift for transfers. R2 currently requires assistance with ADL's such as personal hygiene and bathing with extensive help from one staff member. R2 is on a restorative grooming program as R2 is unable to bathe/groom self independently related to weakness with interventions to encourage R2 to participate in dressing and grooming with substantial/max assistance as tolerated. R2's care plan undated documents R2 has expressed personal and lifestyle preferences, including R2's bathing routine preference is day shift and preferred bathing type is a shower. R2's Bath and Skin Report Sheet, dated November 2024 documents R2 is to receive a shower on Tuesdays and Fridays evenings. Shower sheet documents shower were to be given on 11/1/2024, 11/5/2024, 11/08/2024, 11/12/2024, 11/15/2024, 11/19/2024, 11/22/2024 with no documentation of a shower given or refused. R2's Documentation Survey Report v2, dated November 2024 documents R2 was showered on 11/6/2024, 11/16/2024 and 11/20/2024. No other showers documented for the month of November 2024. R2's progress notes dated November 2024 showed no documentation R2 was showered or that R2 refused a shower. On 11/26/2024 at 8:51 AM R2 sitting up in bed with dryness noted to her face and hair is matted and oily. R2 stated she has not had a shower in about 4 weeks or had her hair washed. R2 stated she has an appointment to go to today and feels like she is not ready to go due to smelling from not having a shower. R2 stated about a week ago her shower schedule was changed from days to evenings, and she does not want to take showers in the evenings due to having to use a mechanical lift. R2 stated the medications she takes in the evening make her tired and she does not feel safe using the mechanical lift after taking them. 2. R4's Undated Face Sheet, documents he was admitted to the facility on [DATE] with no diagnosis regarding need for assistance with personal care. R4's Quarterly MDS, dated [DATE], documents Brief Interview of Mental Status (BIMS) 10/15: moderately cognitively impaired. Shower and personal hygiene: substantial/maximal assistance. Lower extremities impairment on both sides. R4's Undated Care Plan, documents resident is an ADL self-care performance deficit r/t (related to) limited mobility, left BKA (below the knee amputation.) and right BKA. Goal: none documented. Interventions/tasks: bathing: extensive - total x1. Review of R4's Bath and Skin Report Sheet, dated November 2024 documents he is to be showered on Mondays and Thursdays in the PM. According to the shower sheet, the dates R4 should have been showered are 11/4/2024, 11/7/2024, 11/11/2024, 11/14/2024, 11/18/2024, 11/21/2024 and 11/25/2024. The form showed no documentation R4 was showered on these days. R4's Documentation Survey Report v2, dated November 2024 showed on 11/15/2024 staff documented codes 98 which means resident refused and 97 not applicable. R4's Progress Notes, dated November 2024 showed no documentation R4 was showered or that he refused a showered. On 11/26/2024 at 11:55 AM R4 stated they don't shower me here and I don't know why. R4 stated they also don't shave him and he prefers to be shaved but he can't shave himself because he has a scab on his upper right cheek and he doesn't want to accidentally rip it off, he would allow staff to shave him but no one has offered that service. During the interview observation made of resident, he had long facial hair and oily/greasy hair and there was white flakes on his t shirt from dry skin on his arms. Observation during the interview showed R4 is a bilateral amputee and uses a wheelchair for mobility device. 3. R1's Undated Face Sheet, documents admitted [DATE] with diagnosis of need for assistance with personal care. R1's quarterly MDS, dated [DATE] documents BIMS 11/15 moderately cognitively impaired. Shower: substantial/maximal assistance and personal hygiene: dependent. R1's Care Plan initiated on 7/31/2023 documents resident has an ADL self-care performance deficit need and participation may vary r/t (related to) needing assistance with personal care. Goals: resident will maintain current level of ADL function, resident free from complications related to ADL deficit and resident will be kept clean and comfortable. Interventions: ADL care: resident may need assistance x1 or x2 for ADL care. Bathing specifically was not addressed on the care plan. Review of R1's Bath and Skin Report Sheet, dated November 2024 documents he is to be showered on Wednesdays and Saturdays in the PM. According to the shower sheet, the dates R1 should have been showered are 11/2/2024, 11/6/2024, 11/9/2024, 11/13/2024, 11/16/2024, 11/20/2024 and 11/23/2024. The form showed no documentation R1 was showered on these days. Review of R1's Documentation Survey Report v2, dated November 2024, documents he was showered on 11/14/2024 and 11/17/2024. R1's Progress Notes, dated November 2024 showed no documentation R1 was showered or that he refused a shower. On 11/26/2024 at 11:15 AM V11, CNA observed giving R1 a bed bath and stated she will shave him as well. Observation of R1 at that time showed his fingernails had dark substance under them. On 11/26/2024 at 11:45 AM R1 stated, I don't get showered or cleaned up very often, this is the most clean I have been since I was admitted to the facility this year. No staff offer to give me a shower or shave me, it has to have been weeks since I've received a shower or been shaved. I can't shower and shave myself anymore. 4. R3's Undated Face Sheet documents R3 was admitted to the facility on [DATE] and has a diagnosis of Heart failure, Chronic Kidney Disease, Dementia, Aphasia, Hypertension, and Hypothyroidism. R3's MDS dated [DATE], documents R3 is cognitively impaired and needs substantial/maximal assistance with showering/bathing. R3's Undated Care Plan documents R3 has an ADL self-care performance deficit and needs and participation may vary. Interventions include R3 may need assistance with one or two staff members for ADL care. R3 participates in restorative nursing programs including dressing and grooming. R3 has expressed personal and lifestyle preferences including bathing type preference as showering. R3's Bath and Skin Report Sheet, documents R3 is to receive a shower on Monday and Thursday evenings. Shower sheet documents shower were to be given on 11/04/2024, 11/07/2024, 11/11/2024, 11/14/2024, 11/18/2024, 11/21/2024, and 11/25/2024, with no documentation of a shower given or refused. R3's Documentation Survey Report v2, dated November 2024 documents a shower was given on 11/14/2024. No other showers were documented as given or refused. R3's Progress Notes, dated November 2024 showed no documentation R3 was showered or that R2 refused a shower. On 11/26/2024 at 9:28 AM V5, CNA stated no residents are complaining of not being showered. V5 stated when she showers a resident, she documents it in the shower book located at the nurse's station. On 11/26/2024 at 9:45 AM V6, CNA stated when she showers a resident, she documents it in the shower book located at the nurse's station. On 11/26/2024 at 9:52 AM V7, CNA stated residents are showered every day, most residents are showered twice a week and resident specific shower days are documented in the hall shower book that is located at the nurse's station. V7 stated she documents when she gives a resident a shower on the resident's shower sheet in the hall shower book. On 11/26/2024 at 9:53 AM V9, Licensed Practical Nurse (LPN) stated certain residents refuse showers and when they do, she expects the CNA to report the refusal so she can go talk to the resident about the shower as well. CNAs are expected to document when they give a resident a shower in the hall shower books that are located at the nurse's station. Hospice CNAs document in the hospice book when they shower a resident. V9 stated (R2) refuses showers unless staff offer them to her as the exact time she wants to take them. (R2) is a night shower due staffing. (R1), (R3) and (R4) do not refuse showers to her knowledge. The Facility's Activities of Daily Living (ADLs), Supporting, revised March 2018, documents residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support with assistance with hygiene (bathing, dressing, grooming and oral care.)

Based on observation, interview and record review the facility failed to uphold resident rights for 1 of 3 residents (R2) reviewed for resident rights in a sample of 3. Findings include: R2's Undated Face Sheet, documents she was admitted on [DATE] with diagnosis includes need for assistance with personal care. R2's Care Plan undated documents R2 has an activities of daily living (ADL) self-care performance deficit related to limited mobility with interventions documenting to use a mechanical lift for transfers. R2 currently requires assistance with ADL's such as personal hygiene and bathing with extensive help from one staff member. R2 is on a restorative grooming program as R2 is unable to bathe/groom self independently related to weakness with interventions to encourage R2 to participate in dressing and grooming with substantial/max assistance as tolerated. R2's care plan undated documents R2 has expressed personal and lifestyle preferences, including R2's bathing routine preference is day shift and preferred bathing type is a shower. R2's Minimum Data Set (MDS) dated [DATE] documents R2 has no cognitive deficits and needs substantial/maximal assistance with showering/bathing. R2's Bath and Skin Report Sheet, dated November 2024 documents R2 is to receive a shower Tuesday and Friday evening. On 11/26/2024 at 8:51 AM R2 stated about a week ago her shower schedule was changed from days to evenings, and she does not want to take showers in the evenings due to having to use a mechanical lift. R2 stated the medications she takes in the evening make her tired and she does not feel safe using the mechanical lift after taking them, so she doesn't want to shower in the evening for this reason. On 11/26/2024 at 2:21 PM V2, Director of Nurses (DON) stated she was informed by V6, Certified Nursing Assistant (CNA) that (R2) told her she is an evening shift shower, and she wants to be a day shift shower. V2 stated residents have the right to chose if they are a day or evening shower and she has updated staff to report these issues to her or the Administrator when resident report issues regarding resident rights. On 11/26/2024 at 3:35 PM V13, Regional Clinical of Operations stated (R2's) shower went from day shift to evening shift on 3/5/2024 and she wasn't aware (R2) didn't want to be an evening shower. The Resident Rights Policy revised 2/2021 documents employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to be supported by the facility in exercising his or her rights, be informed of, and participate in his or her care planning or treatment and participate in decision-making regarding his or her care. Staff will have appropriate in-service training on resident rights prior to having direct-care responsibilities for residents.

Based on interview and record review, the Facility failed to respond to call lights in a timely manner for 3 (R1, R3, and R7) of 7 residents reviewed for adequate and timely care in the sample of 8. Findings include: 1-R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus, congestive heart failure, and aphasia, hemiplegia, and hemiparesis following cerebral infarction. R1's Minimum Data Set (MDS) dated [DATE] documented R1 was moderately cognitively impaired, required partial/moderate assistance with toileting and transfer, required substantial/maximal assistance with rolling from side to side, had colostomy, and was occasionally incontinent of urine. R1's Care Plan initiated 1/26/23 documents R1 has a self-performance deficit with activities of daily living and is frequently incontinent of urine. On 10/3/24 at 8:50 AM, R1 was lying in bed in her room. She was unable to articulately express responses, but was able to nod her head yes and no with continued attempts at verbalization. R1 nodded yes and no when asked about specific time frames for call lights and indicated staff usually take around 20 minutes to answer the call light which she feels is too long. She pointed at her incontinent brief which was saturated and indicated she needed to be changed. 2-R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure, severe protein calorie malnutrition, and need for assistance with personal care. R3's MDS dated [DATE] documented R3 was cognitively intact and always incontinent of bowel and bladder. R3's mobility was not assessed. R3's Care Plan initiated 4/28/23 documents R3 has a self-performance deficit with activities of daily living and requires extensive assistance with activities of daily living and transfer. On 10/3/24 at 8:52 AM, R3 was lying in bed in her room. She stated call lights take a long time to get answered, especially on the midnight shift. On 10/3/24 at 1:25 PM, R3 stated, It makes me feel like I want to get out of here. It is hard, and I have a muscle disease where I'm supposed to be turned every 2 hours and I always have to push my call light and remind them. 3-R7's Face Sheet documents R7 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus, right above the knee amputation, and left below the knee amputation. R7's MDS dated [DATE] documented R7 was moderately cognitively impaired. The Facility's Grievance/Complaint Report dated 8/2/24 by R7 documents, Call light responses take too long. On 10/3/24 at 2:40 PM, R7 was sitting in his wheelchair in his room. He stated, They (call lights) have gotten worse than before. They take so long I just go ahead and clean myself up. The Facility's Grievance/Complaint Report dated 7/19/24 by Resident Council Group documents, CNA's (Certified Nursing Assistants) are doing the best they can however it is still taking them a bit longer to answer call lights in a timely manner. The Facility's Anonymous Grievance/Complaint Report dated 9/23/24 documents, Res (Resident) reports waiting 4 hrs (hours) for help getting out of bed over the weekend. 9/22 waited 40-50 minutes for call light responses. The Facility's Grievance/Complaint Report dated 9/30/24 by V7, R2's Family, documents, Concerned about call light times. On 10/3/24 at 8:40 AM, V4, CNA, stated she usually has no trouble answering call lights timely unless they are really short staffed, but today someone called off and another person went home sick. On 10/4/24 at 12:06 PM, V2, Director of Nursing (DON), stated she expects call lights to be answered timely, and if staff are busy at that time, she would expect them to pop their head in the door and tell them they will assist them as soon as possible. On 10/4/24 at 12:08 AM, V1, Administrator stated he does not have policies on call lights or resident rights.

Based on interview and record review, the facility failed to update and have appropriate documentation regarding the Code Status/Advanced Directives for 2 of 3 residents (R3, R4) reviewed for Advanced Directives in the sample of 12. Utilizing the reasonable person concept, R3 made his advanced directive choices clear when updating his directive status in [DATE] to Do No Resuscitate (DNR) status. Due to the facility failure to correctly identify his DNR, R3 experienced life saving measures including intubation and extubation prior to expiring. The Findings Include: 1. R3's Face Sheet, undated, documents R3 was originally admitted to the facility on [DATE] and was discharged to the hospital on [DATE] with diagnosis of Chronic Obstructive Pulmonary Disease (COPD), Respiratory Failure, Panlobular Emphysema, Type 2 Diabetes Mellitus (DM), Malnutrition, Schizophrenia, Hypertension (HTN), Dependence on Supplemental Oxygen, COVID-19, and Deep Vein Thrombosis (DVT). R3's Care Plan, dated [DATE] documents: ([DATE]) R3 Is a FULL CODE, CPR Order: Attempt CPR. Interventions: [DATE]: Resident is a FULL CODE, Allow opportunity to review and initiate Advanced Directives with the resident and/or appointed health care representative. R3's Minimum Data Set (MDS), dated [DATE], documents R3 had a moderate cognitive impairment and required setup or clean up assistance for most ADLs. On [DATE] at 12:19 PM, V5, Registered Nurse (RN) stated I was the emergency room (ER) Nurse who took care of (R3) when he went to theER on [DATE]. (R3) was very hypoxic upon arrival to the hospital with the Fire Department getting an oxygen saturation of 65%. The Emergency Medical Service (EMS) guys told us that the Nurse at the facility who was taking care of (R3) knew nothing about him and stated she was just a temp there working. No one at the facility was able to tell EMS when (R3) was last seen well, or how long he was like that. The facility gave EMS paperwork that indicated (R3) was a Full Code, so we intubated (R3) in attempts to resuscitate him. The facility did not call (R3's) brother, who was also his POA (V6), to let him know they were sending (R3) to the ER, and when (V6) showed up at the facility to see (R3), he was told that (R3) was taken to the hospital. Then (V6) showed up at the ER and saw (R3) intubated, he told us that (R3) was a Do Not Resuscitate (DNR) and that he did not want to be intubated. He told us they signed the appropriate paperwork back in [DATE] for that, and he provided that paperwork to the facility, and they should have sent that. The ER Physician had to withdraw care and let R3 pass away. On [DATE] at 12:40 PM, V6, R3's Brother/POA, stated I went to the facility to check on (R3) on [DATE]. When I got to the facility, I went to (R3's) room, and he was not there, and his roommate stated that they took (R3) to the hospital. When I asked, it took three different staff members just to tell me which hospital he went to. When I got to the ER, I found out that the hospital had intubated (R3) and they should not have done so because (R3) was a DNR/Do Not Intubate (DNI). The ER Nurse showed me the paperwork from the facility that was sent with (R3) and it did show that (R3) was a Full Code. I signed paperwork in [DATE] with (R3) indicating that (R3) was a DNR and the facility should have had that in his record, but they sent the wrong one. I was not happy because my sister and I had to make the decision to terminate (R3's) care, so they extubated (R3) and let him pass away. On [DATE] at 9:05 AM, V1, Administrator, stated I was aware that (R3) went to the hospital due to respiratory distress and had passed away in the hospital, but I was not aware of any issues. On [DATE] at 9:25 AM, V16, Social Service Director, stated It looks like (R3's) POA paperwork that was given to us in [DATE] was scanned into his medical record by the Business Office Manager and that is weird because she shouldn't be the one doing that. I didn't even know that (R3's) family brought in new paperwork. I think this would fall on this facility's communication. (R3's) POLST should have been updated once we received the new POA paperwork and we should have sent the new POLST and the POA paperwork with (R3) when he went to the hospital. I feel bad because I heard the family had to make that tough decision to let him go like that. On [DATE] at 9:40 AM, V4, VP Clinical Operations, stated I did my own audit of the facility and found the same issues with some residents having an outdated POLST that did not match other documentation in the medical record. I also saw some resident Care Plans that had conflicting Advance Directives and I fixed those. I did see that (R3) had the two conflicting Advance Directives in his Care Plan, but I was not aware of (R4's) because that was back in May. I would expect the MDS Nurse to make appropriate changes to the Care Plan with updated information when necessary. I would also expect the staff to make sure Nursing has the most up to date information available to them. R3's POLST, dated [DATE], documents R3 was a Full Code. R3's POA Paperwork, dated [DATE], documents R3 and his POA signed indicating R3 did not want lifesaving sustaining treatment. R3's Physician Order, dated [DATE], documents Advance Directive: Full Code. R3's Hospital Record - page 2, dated [DATE], documents [AGE] year-old male with a history of COPD, acute respiratory failure with hypoxia, panlobular emphysema, moderate protein calorie malnutrition, type 2 diabetes, hyperlipidemia, hyponatremia, hypoosmolality, electrolyte imbalance, schizophrenia, dysphagia, hypertension, oxygen dependence that was brought in by EMS secondary to altered mental status and hypoxia. Upon arrival, EMS noted, patient last known well was last night approximately 9:00 PM, however has not been seen until 10:00 AM this morning, all of the nurses at the facility where traveler's and did not know this patient. They did note that he is normally up and smoking however. Upon arrival, EMS noted patient was altered, not following commands, satting in the mid 60s, unsure of how long this has been going on, improved to the 90s with a non-rebreather. No family is at the bedside. R3's Hospital Record - page 13, dated [DATE], documents Spoke with the brother (V6) at the bedside, he notes the patient was a DNR and has a very poor quality of life over the last number of days to weeks. He states the signed paperwork is at the facility however the paperwork we initially received has him as a full code. He is going to call his sisters, although he is the POA, to confer and decide the next steps at this time. Brother has opted for extubation and removal of care, comfort measures only. Time of death called, ultrasound confirmed cardiac standstill, brother at the bedside, will page his primary care. R3's Hospital Record - Page 17, documents Patient's brother to bedside. Patient's brother states what facility told EMS was not true and patient has been weaker/not normal since Sunday. Patient's brother also states patient is DNR/DNI, brother is POA. [NAME] (ER Physician) to bedside to discuss POC (plan of care) due to paperwork from facility showing full code. 2. 2. R4's Face Sheet, undated, documents R4 was originally admitted to the facility on [DATE] and was discharged on [DATE] with diagnosis of Metabolic Encephalopathy, Fracture Tibia, Mitral Valve Insufficiency, Adult Failure to Thrive, Malnutrition, Pulmonary Hypertension, Anemia, Hypothyroidism, Cardiomyopathy, Gangrene, HTN, Cellulitis Left Lower Extremity (LLE), Rhabdomyolysis, Peripheral Vascular Disease, Congestive Heart Failure, and Acquired Absence of Right Above Knee Amputation (AKA). R4's Care Plan, dated [DATE], documents ([DATE]) R4 has an Advanced Directives on record. Interventions: Advise resident and/or appointed health care representative to provide copies to the facility of any updated Advanced Directives, Discuss Advanced Directives with the resident and/or appointed health care representative. ([DATE]) R4 is a Full Code. Interventions: Allow opportunity to review and initiate Advanced Directives with the resident and/or appointed health care representative. R4's MDS, dated [DATE], documents R4 had a moderate cognitive impairment and was dependent on staff for all ADLs. R4's POLST, dated [DATE], documents R4 is a Full Code. R4's POA Paperwork, dated [DATE], documents R4 does not want treatments to prolong her life or delay her death, but she does want treatment or care to make her comfortable and to relieve her of pain. The Facility's Advanced Directives Policy, dated ,d+[DATE], documents The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. 1. The facility defines the following in accordance with current OBRA definitions and guidelines: a. Advance care planning - a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions. b. Advance Directive - a written instruction, such as a living will or durable power of attorney for health care, recognized by state law (whether statutory or as recognized by the courts of the state), relating to the provisions of health care when the individual is incapacitated (per S489.100). (2) Durable Power of Attorney for Health Care (i.e., Medical Power of Attorney) - a document delegating authority to a legal representative to make health care decisions in case the individual delegating that authority subsequently becomes incapacitated. (3) Do Not Resuscitate (DNR) - indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used. 1. If the resident or the resident's representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the resident's medical record and are readily retrievable by any facility staff. 2. The director of nursing services (DNS) or designee notifies the attending physician of advance directives (or changes in advance directives) so that appropriate orders can be documented in the resident's medical record and plan of care. 3. The resident's wishes are communicated to the resident's direct care staff and physician by placing the advance directive documents in a prominent, accessible location in the medical record and discussing the resident's wishes in care planning meetings. 4. The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive. 7. The interdisciplinary team will review annually with the resident his or her advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded in the medical record. 8. Changes or revocations of a directive must be submitted in writing to the administrator. The administrator may require new documents if changes are extensive. The interdisciplinary team will be informed of changes and/or revocations so that appropriate changes can be made in the resident medical record and care plan. 9. The nurse supervisor is required to inform emergency medical personnel of a resident's advance directive regarding treatment options and provide such personnel with a copy of the advance directive or POLST when transfer from the facility via ambulance or other means is made.

Based on interview and record review, the facility failed to notify the resident's responsible party prior to a transfer to an acute care facility for evaluation and treatment of a change in condition for 2 of 3 residents (R3, R4)) reviewed for hospitalization in the sample of 12. The Findings Include: 1. R3's Face Sheet, undated, documents R3 was originally admitted to the facility on [DATE] and was discharged to the hospital on 8/16/24 with diagnosis of Chronic Obstructive Pulmonary Disease (COPD), Respiratory Failure, Panlobular Emphysema, Type 2 Diabetes Mellitus (DM), Malnutrition, Schizophrenia, Hypertension (HTN), Dependence on Supplemental Oxygen, COVID-19, and Deep Vein Thrombosis (DVT). R3's Care Plan, dated 7/25/24, documents R3 has a behavior problem related to threatening and cursing staff. R3 refuses labs, and wearing oxygen, R3 is a smoker/tobacco user and refuses to give cigarettes to staff for safe keeping. It continues 8/16/24: R3 is at Risk for rehospitalization and or unsuccessful discharge related to health determinant needs, resident refuses care such as keeping oxygen on and lab draws. It continues 8/16/24: R3 has actual/potential altered respiratory status related to: COPD, Emphysema, Respiratory Failure, history of COVID. R3 refuses oxygen at times. Interventions: Administer medications / inhalers / nebulizers as ordered, monitor for effectiveness, elevate head of bed as needed to facilitate ease of breathing, maintain a clear airway by encouraging resident to clear own secretions with effective coughing. If secretions cannot be cleared, suction as ordered/required to clear secretions, monitor for changes in/development of signs and symptoms of breathing difficulty and report to nurse if noted: Shortness of breath, cough (productive or non-productive), fever, chills, difficulty speaking, bluish skin color, changes in cognition, monitor lab/diagnostics as ordered and report results to physician, monitor skin integrity of ears, nasal area, or facial areas for pressure or friction issues related to nasal cannula or Oxygen (O2) mask, report any noted skin irritation or breakdown, notify nurse for any observed or reported breathing difficulty, excess secretions, or persistent coughing, report changes in respiratory status to physician, administer continuous oxygen as ordered via: O2 at 3 liters per mask (LPM) or nasal cannula, administer as needed (PRN) oxygen as ordered via O2 concentrator and or etank: via: nasal cannula, provide resident/responsible party education PRN to include: coughing/deep breathing, fluid needs, pursed-lip breathing, need for rest, compensatory strategies, and encourage compliance with O2 therapy. It continues R3 has an Activities of Daily Living (ADL) self-care performance deficit. Interventions: The resident is independent/set up and able to move and reposition in the bed but check with the resident every few hours to remind and assist if needed, Bed Mobility: Supervision-Independent, Transfer: Supervision-Independent, Walking: Supervision-Independent, Eating: Independent, Bathing: Supervision. R3's Minimum Data Set (MDS), dated [DATE], documents R3 had a moderate cognitive impairment and required setup or clean up assistance for most ADLs. On 8/19/24 at 12:19 PM, V5, Registered Nurse (RN) stated I was the emergency room (ER) Nurse who took care of (R3) when he went to theER on [DATE]. (R3) was very hypoxic upon arrival to the hospital with the Fire Department getting an oxygen saturation of 65%. The Emergency Medical Service (EMS) guys told us that the Nurse at the facility who was taking care of (R3) knew nothing about him and stated she was just a temp there working. No one at the facility was able to tell EMS when (R3) was last seen well, or how long he was like that. The facility gave EMS paperwork that indicated (R3) was a Full Code, so we intubated (R3) in attempts to resuscitate him. The facility did not call (R3's) brother, who was also his Power of Attorney (POA/V6), to let him know they were sending (R3) to the ER, and when (V6) showed up at the facility to see (R3), he was told that (R3) was taken to the hospital. Then (V6) showed up at the ER and saw (R3) intubated, he told us that (R3) was a Do Not Resuscitate (DNR) and that he did not want to be intubated. He told us they signed the appropriate paperwork back in June 2024 for that, and he provided that paperwork to the facility, and they should have sent that. The ER Physician had to withdraw care and let R3 pass away. On 8/19/24 at 12:40 PM, V6, R3's Brother/POA, stated I went to the facility to check on (R3) on 8/16/24. When I got to the facility, I went to (R3's) room, and he was not there and his roommate stated that they took (R3) to the hospital. When I asked, it took three different staff members just to tell me which hospital he went to. When I got to the ER, I found out that the hospital had intubated (R3) and they should not have done so because (R3) was a DNR/Do Not Intubate (DNI). The ER Nurse showed me the paperwork from the facility that was sent with (R3) and it did show that (R3) was a Full Code. I signed paperwork in June 2024 with (R3) indicating that (R3) was a DNR and the facility should have had that in his record, but they sent the wrong one. I was not happy because my sister and I had to make the decision to terminate (R3's) care, so they extubated (R3) and let him pass away. R3's Nursing Note, dated 8/16/24 at 9:53 AM, documents Upon walking past room Therapy stopped me and informed me that the resident didnt look good. Upon assessment resident noted to be in respiratory distress and slow to respond. PA (Physician Assistant) notified and Nurse informed to call 911 and have resident sent to ED (Emergency Department) for eval and treatment. This was documented by the Assistant Director of Nursing (ADON) at that time and is no longer at the facility. There was nothing documented about notifying R3's POA. R3's Hospital Record - page 2, dated 8/16/24, documents [AGE] year-old male with a history of COPD, acute respiratory failure with hypoxia, panlobular emphysema, moderate protein calorie malnutrition, type 2 diabetes, hyperlipidemia, hyponatremia, hypoosmolality, electrolyte imbalance, schizophrenia, dysphagia, hypertension, oxygen dependence that was brought in by EMS secondary to altered mental status and hypoxia. Upon arrival, EMS noted, patient last known well was last night approximately 9:00 PM, however has not been seen until 10:00 AM this morning, all of the nurses at the facility where traveler's and did not know this patient. They did note that he is normally up and smoking however. Upon arrival, EMS noted patient was altered, not following commands, satting in the mid 60s, unsure of how long this has been going on, improved to the 90s with a non-rebreather. No family is at the bedside. R3's Hospital Record - page 13, dated 8/16/24, documents Spoke with the brother (V6) at the bedside, he notes the patient was a DNR and has a very poor quality of life over the last number of days to weeks. He states the signed paperwork is at the facility however the paperwork we initially received has him as a full code. He is going to call his sisters, although he is the POA, to confer and decide the next steps at this time. Brother has opted for extubation and removal of care, comfort measures only. Time of death called, ultrasound confirmed cardiac standstill, brother at the bedside, will page his primary care. R3's Hospital Record - Page 17, documents Patient's brother to bedside. Patient's brother states what facility told EMS was not true and patient has been weaker/not normal since Sunday. Patient's brother also states patient is DNR/DNI, brother is POA. [NAME] (ER Physician) to bedside to discuss POC (plan of care) due to paperwork from facility showing full code. 2. R4's Face Sheet, undated, documents R4 was originally admitted to the facility on [DATE] and was discharged on [DATE] with diagnosis of Metabolic Encephalopathy, Fracture Tibia, Mitral Valve Insufficiency, Adult Failure to Thrive, Malnutrition, Pulmonary Hypertension, Anemia, Hypothyroidism, Cardiomyopathy, Gangrene, HTN, Cellulitis Left Lower Extremity (LLE), Rhabdomyolysis, Peripheral Vascular Disease, Congestive Heart Failure, and Acquired Absence of Right Above Knee Amputation (AKA). R4's Care Plan, dated 5/6/24, documents R4 has need/wants for an enabling device. Interventions: Bed in lowest position, call light in reach, Increased frequency of monitoring, mat next to bed, visual and or verbal reminders to use call light. R4 is also noted to be non-compliant at times with transfers. Interventions: Transfers: Mechanical Lift x 2 assist, non-weight bearing to left lower extremity (Fracture) - in knee brace. Right lower extremity has gangrene to foot. Encourage the resident to use bell to call for assistance. It continues R4 is at risk for falls related to her generalized weakness and impaired cognition. Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, check the environment for clutter or trip hazards and area is well lit, fall risk evaluation, monitor/encourage appropriate footwear PRN, keep bed in lowest position acceptable by the resident when the resident is in bed, remind to request assistance when getting up if needed. R4's MDS, dated [DATE], documents R4 had a moderate cognitive impairment and was dependent on staff for all ADLs. On 8/19/24 at 1:45 PM, V7, R4's family member/friend, stated that R4 was her grandfather's significant other for a long time and R4 became like her own grandmother. V7 stated that her grandfather is POA over R4. V7 stated that in December 2023, or January 2024, R4 was treated for cellulitis in that same leg and finally had a physician figure out that she was having a vascular issue. V7 stated they did an Ultrasound and a CT scan and found that R4 had a femoral artery clot. V7 stated that the physician decided they needed to amputate her right leg and did an AKA. V7 stated that a month or so later, her grandfather got a phone call from the hospital asking for consent for R4 to have surgery. V7 stated that her grandfather visited R4 on a Thursday evening, and no one said anything about R4 having a surgery. V7 stated that next day is when the hospital called wanting consent for surgery to do another AKA of her left leg. V7 stated the facility did not notify her grandfather that R4 was even going to the hospital. R4's Nursing Note, dated 5/1/24 at 10:47 AM, documents (Nurse) at (Local Hospital) notifed nurse that resident surgery for amputation on Friday May 3, 2024 at 10 AM and to be at hospital at 7:30 AM, resident ready for transport at 6:30 AM. R4's Nursing Note, dated 5/3/24 at 9:52 AM, documents Resident LOA (leave of absence) from facility for surgery at (Local Hospital). There is no documentation of the facility notifying R4's POA prior to transport to the hospital. On 8/20/24 at 9:05 AM, V1, Administrator, stated I was aware that (R3) went to the hospital due to respiratory distress and had passed away in the hospital, but I was not aware of any issues. On 8/20/24 at 12:00 PM, V12, Registered Nurse (RN), stated If I am sending a resident to the ER, I would first make sure I called the physician and got an order, I would print out all of the resident's orders, Physicians Orders for Life Sustaining Treatment (POLST), the transfer sheet, and the facesheet, and will give it all to the EMS. I would call the residents family/POA and let them know what is going on. After the resident leaves the facility with EMS, I will call the ER and give them a report on why the resident is being sent. On 8/21/24 at 10:30 AM, V18, Licensed Practical Nurse (LPN), If I am sending a resident to the hospital and calling 911, I would make sure I call the POA and the Physician, then I would prepare the transfer paperwork including the facesheet, POLST, order summary, and any other pertinent information. If there is a POLST and POA paperwork in the record, I would send both of them. On 8/21/24 at 10:40 AM, V19, LPN, If I was sending a resident to ER via 911, I would call the Physician, check the resident's code status, send all of the orders, and the POLST. I would send the most up-to-date paperwork we have on that resident. I would give report to the EMS, including the resident's age, name, date of birth, any physical changes, how the resident was acting, any allergies, and basically everything I would know about the resident. The Facility's Transfer or Discharge, Facility Initiated Policy, dated 10/2022, documents Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. Notice of Transfer or Discharge (Emergent or Therapeutic Leave): 4. Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable (e.g., in a monthly list of residents that includes all notice content requirements). 7. Nursing notes will include documentation of appropriate orientation and preparation of the resident prior to transfer or discharge. Orientation for Transfer or Discharge (Emergent or Therapeutic Leave): 2. For an emergency transfer or discharge to a hospital or other acute care institution, implement the following procedures: a. Call 911 if the resident meets clinical/behavioral criteria per facility policy, or assist in obtaining transportation; b. Notify the resident's attending physician; c. Orient/prepare the resident for transfer; and d. Prepare for medical record transfer. Information Conveyed to Receiving Provider: 1. Should a resident be transferred or discharged for any reason, the following information is communicated to the receiving facility or provider: a. The basis for the transfer or discharge; b. Contact information of the practitioner responsible for the care of the resident; c. Resident representative information including contact information; d. Advance directive information; e. All special instructions or precautions for ongoing care, as appropriate such as: (1) treatments and devices (oxygen, implants, IVs, tubes/catheters); (2) transmission-based precautions such as contact, droplet, or airborne; (3) special risks such as risk for falls, elopement, bleeding, or pressure injury; and/or (4) aspiration precautions; f. Comprehensive care plan goals; and g. All other information necessary to meet the resident's needs, including but not limited to: (1) resident status, including baseline and current mental, behavioral, and functional status, (2) recent vital signs; (3) diagnoses and allergies; (4)medications (including when last received); (5) most recent relevant labs, other diagnostic tests, and recent immunizations; (6) a copy of the residents discharge summary; and (7) any other documentation, as applicable, to ensure a safe and effective transition of care.

Based on interview and record review, the facility failed to administer medications as ordered for one of 5 residents (R8) reviewed for medication administration in the sample of 12. Finding include: On 8/21/24 at 8:15 AM R8 stated there is one certain agency nurse who does not come in and give her the 3 little thyroid pills she is supposed to have at 4:30 AM . She stated she did not know who the nurse was and she did not report it to anyone because she couldn't remember when it happened. R8's Minimum Data Set (MDS) dated [DATE] documents R8 is alert and oriented. R8's active Physician Order dated 11/30/23 documents she is to receive Levothyroxine 25 micrograms (mcg) Give 75 mcg by mouth one time a day for hypothyroidism. R8's Medication Administration Record (MAR) dated 8/1/24 to 8/31/24 does not document R8 received her scheduled dose of Levothryroxine on 8/12/24. On 8/22/24 at 10:25 AM V2, Director of Nursing (DON) , stated R8 was in the facility on the morning of 8/12/24 and should have received her Levothyroxine as ordered. V2 stated she would expect all residents to receive their medications as ordered by the physician. The facility's policy, Administering Medications, revised April 2019, documents, Medications are administered in a safe and timely manner, and as prescribed.

Based on interview and record review the Facility failed to ensure communication and continuity of care between the facility and dialysis center for 1 of 3 residents (R2) reviewed for dialysis in the sample of 6. Findings include: R2's Physician Order Sheet (POS) for [DATE] documents diagnoses of end stage renal disease, atherosclerotic heart disease of native coronary artery without angina pectoris, type 2 diabetes mellites with hyperglycemia, cardiomyopathy, peripheral vascular disease, chronic systolic (congestive) heart failure, unspecified essential (primary) hypertension, need for assistance with personal care, difficulty in walking, gout, primary pulmonary hypertension, paroxysmal atrial fibrillation, systemic inflammatory response syndrome of non-infectious origin without acute organ dysfunction. R2's POS also documents she is to receive dialysis one time a day every Monday, Wednesday, and Friday for kidney disease. R2's Care Plan dated [DATE] documents problems: ESRD (end stage renal disease), Short term goal remain free from complications of dialysis. Dialysis three times a week. CHF (congestive heart failure) remain free from complications of cardiac, monitor for /ss (signs and symptoms) of CHF (example SOB [shortness of breath]). R2's Minimum Data Set, dated dated dated [DATE] documents she is cognitively intact for decision making for activities of daily living. R2's Health Status Note dated [DATE] at 7:38 AM, Note Text: resident was brushing hair and talking with staff when she went unresponsive. Resident slumped towards right side in wheelchair and would not respond to verbal or physical stimuli. 911 called. Resident became alert and responsive after a few minutes. Notified 911 of current status. EMS (emergency medical services) arrived at 7:25 AM, times two attendants. Resident evaluated by EMS, resident refused transport to ER (emergency room ). VS (vital signs) ,d+[DATE] 64 20 97.5 92% on 3 lpm. BS (blood sugar) 144. NP (Nurse Practitioner) notified of episode. No new orders at this time. Will continue to monitor for change in condition. R2's Progress Notes dated [DATE] at 12:12 PM, Note Text: Message from resident's Dialysis center that resident coded while at Dialysis. Resident currently being taken to (Hospital) for treatment. On [DATE] at 1:11 PM V5, Licensed Practical Nurse (LPN) stated she remembered (R2) because she was the one that I called 911 after (R2) became unresponsive and then when the EMT (Emergency Medical Technician) got here she started doing her hair, laughing, and joking. When the EMT got here she refuses to go, and she even signed a paper refusing to go out. I am not sure of the name of the ambulance but learned later she passed away when she was out on dialysis. On [DATE] at 12:42 PM, V17, Certified Nursing Assistant (CNA) stated, I was the CNA that morning when (R2) was not acting herself. She was just off a little. I went and told the nurse and as I was getting her ready, she then went unconscious. We immediately called the ambulance but by the time they got there she was awake, and she told them she felt better and did not want to go out. Later, I found out she coded when she went out to dialysis. One can never forget that. On [DATE] at 1:11 PM, V18, Registered Nurse (RN) Clinical Manager of Dialysis stated, The fact that (R2) was unconscious earlier in the day, this should have been communicated to us 1 million percent. Dialysis is a four-hour long procedure and the resident coded while she was with us. If we would have known (R2) may have had a better outcome. I did not know she even had anything going on with her until the EMS arrived and told me they had been to the facility earlier that day because (R2) had been unconscious. While the EMT were giving CPR to (R2) I found out she had been acting unusual earlier in the day. It's essential that the facility communicate with us any changes or decline in conditions that may or may not be related to dialysis so that we can implement the appropriate interventions. We did not have any communication and the facility never told us anything about (R2) not feeling ill, acting strange and/or being unconscious. If we would have known she was unconscious earlier, we would not have had her come to dialysis and would have rescheduled the appointment. If we would have known she may have had a better outcome. On [DATE] at 9:02 AM, V2, Director of Nursing (DON) stated, I was not the DON in April. We have a form that staff are supposed to fill out it is a communication form. The form is filled out by staff and then given to the dialysis center. Our copy is in the computer and then the form goes to the dialysis center. It lists all medications and if there are any changes with the patients. I would expect this form to be completed on all dialysis residents before their appointments and given to the staff at the dialysis center. I cannot confirm or deny if there was a form given to the dialysis center indicating (R2) had a been unresponsive before the treatment. If the form was completed it should be available. Let me go back and look. On [DATE] at 10:24 AM, V19, Dialysis Medical Director, stated, I would have expected the facility to notify us especially since she was found at the facility unconscious earlier in the day. If we would have known that detail, we would have advised (R2) to be evaluated at the hospital before we even started treatment. We would ensure all was well before we started the dialysis treatment. This was (R2's) first dialysis treatment and there was no continuity of care from the facility. We should have been given this information and it absolutely would have affected our treatment for (R2). It is my understanding she expired in the emergency room . I cannot not say one way or the other whether the outcome would have been different it's impossible to know that absolute. I only know if we had been given that information, we would have sent her out. On [DATE] at 11:32 PM, V1, Administrator stated We have no documentation for (R2) that we provided on [DATE] to the dialysis center. The Facility Dialysis contract dated [DATE] documents, Long Term Care Facility shall ensure that each Resident is prepared to spend an extended length of time at Dialysis Facility, as necessary for the administration of Resident's prescribed treatment, and has received proper nourishment and any necessary medications before arriving.

Based on observation, interview and record review, the Facility failed to operationalize their policy and procedures for testing and tracking COVID-19; wear appropriate PPE (Personal Protective Equipment), clean multi-use equipment, and perform hand hygiene after resident encounter of a COVID-19 resident, and post signage indicating the Facility is in COVID-19 outbreak. This failure has the potential to affect all 126 residents living in the Facility. Findings include: 1-The Facility's Line List for COVID-19 Outbreaks in Long Term Care Facilities documents the Facility's COVID-19 Outbreak began on 7/1/24. R6's Progress Notes document R6 was sent to the hospital for cough on 7/5/24 and returned on 7/10/24. R6's COVID Monitoring Assessment documents COVID-19 testing was not completed following hospitalization until four days later on 7/14/24. R6's Medical Records fail to document R6 was tested for COVID-19 upon 7/10/24 return to the Facility. 2-The Facility's Census Lists from 7/10/24 through 7/13/24 document R6 and R15 both resided in same room. R15's Progress Note dated 7/14/24 documents R15 tested positive for COVID-19 on 7/13/24 and was moved to a new room for isolation. R6's COVID Monitoring assessment dated [DATE] documents R6 was exposed to someone with signs and symptoms of COVID-19 and tested positive for COVID-19 on 7/14/24. R6's Medical Records fail to document R6 was tested for COVID-19 immediately after roommate R15 tested positive on 7/13/24, despite having been roommates for the three preceding days. 3-The Facility's Census List from 7/8/24 documents R21 and R22 both resided in same room. R22's Progress Note dated 7/9/24 documents R22 tested positive for COVID and was moved to another room. R21's Progress Notes document R21 was tested for COVID-19 on 7/7/24 and was not retested until 7/18/24. R21's Medical Record fails to document R21 was tested for COVID-19 between 7/7/24 and 7/18/24 which was 9 days after roommate R22 tested positive for COVID-19. 4-The Facility's Census List from 7/7/24 documents R3 and R5 both resided in room. R3's Progress Note dated 7/8/24 documents R3 tested positive for COVID-19 and was moved to another room for isolation. R5's Progress Notes document R5 was tested for COVID-19 on 7/5/24 and was not tested again until 7/14/24. R5's COVID Monitoring Assessment was completed on 7/5/24 and was not completed again until 7/14/24. R5's Medical Record fails to document R5 was tested for COVID-19 between 7/8/24 and 7/14/24 which is 6 days after roommate R3 tested positive. On 7/23/24 at 10:05 AM, V3, Assistant Director of Nursing/Infection Preventionist (ADON/IP), stated COVID-19 testing is documented in the Electronic Medical Record (EMR) and is sometimes sporadic because they cannot always test everyone in a single day. She stated she does not keep specific testing logs and enters all tests and results in the resident EMR, either in the Progress Notes or in the COVID Monitoring Assessment. She stated they aim to test the residents every 3 days, but at the very least it is done every 7 days, per policy. On 7/25/24 at 8:55 AM, V1, Administrator, stated she expects the Facility to follow policies regarding infection control. The Facility's Coronavirus Disease (COVID-19) - Testing Staff Policy revised June 2023 documents, When utilizing broad-based testing, all residents and staff identified as close contacts or on the affected unit(s) are tested , regardless of vaccination status. Testing is done immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Admission testing is done at the discretion of the facility based on recommendations from the public health authorities in the facility. If admission testing is conducted, residents are tested upon admission and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. A resident who leaves the facility for 24 hours or longer is managed as an admission. For facility outbreak testing, the following is documented: a. The date the case was identified; b. The dates that all other residents were tested ; c. The dates that residents who tested negative were retested ; and d. The results of all tests. The resident record includes that testing was offered, testing was completed (as appropriate to the resident's testing status), the results of the test and specific actions taken with the resident. If the resident refused the test, the stated reason and how this was addressed is documented. 33112 5. On 4/23/24 at 5:35 AM, R7's door had signage that R7 is on droplet precautions and to see the nurse before entering. V12, Licensed Practical Nurse, prepared AM medications for R7 which included Hydralazine 50 mg. V12 obtained a multi-use blood pressure cuff and stethoscope and entered R7's room with a N95 mask on. V12 obtained R7's blood pressure in the right arm, gave R7 the medication cup, and a cup of water. R7 swallowed the pill and drank sips of water. V12 took the medication and water cup from R7 and threw it away. V12 exited the room. V12 was questioned why R7 was on droplet precautions, V12 stated, COVID. V12 placed the blood pressure cuff and stethoscope on top of her medication cart. V12 returned to the nurses station with her medication cart, V12 then took the stethoscope and the blood pressure cuff and placed it on the 400 hall cart. V12 failed to clean the equipment or the top of the medication cart. V12 was questioned why she did not perform hand hygiene, wear the required PPE (personal protective equipment), or disinfect the multi-use equipment, V12 stated, I just forgot. On 7/24/24 at 10:52 AM, V1 stated, (V12) knows better than that. I send people home immediately if I see them enter a covid room with out the PPE on. They should be using disposable equipment on isolation residents. The policy Coronavirus Disease - Using Personal Protective Equipment, dated 5/23, documents, When caring for a resident with suspected or confirmed SARS-COV-2 infection, personnel who enter the room of the resident will adhere to standard precautions and use a NIOSH - approved N95 or equivalent or higher - level respirator, gown gloves, and eye protection. The policy Coronavirus Disease - Cleaning and Disinfecting, dated 5/23, documents, 4. Dedicated medical equipment is used when caring for a resident with suspected or confirmed SARS-CoV-2 infection. 5. All non-dedicated, non - disposable medical equipment used for that resident is cleaned and disinfected according to manufacturer's instructions and facility policies before us on another resident. The policy Hand Washing / Hand Hygiene, dated 8/2029, documents, 8. hand hygiene is the final step after removing and disposing of personal protective equipment. 6. On 7/22/24 at 8:45 AM, upon entrance, there was no sign or posting indicating that the facility is in Covid outbreak status. On 7/22/24 at 8:50 AM, V2, Director of Nurses, stated that the facility does have a Covid outbreak. The policy Coronavirus Disease - Visitor and Communal Activities, dated 6/23, documents, visual alerts at the entrance and throughout the facility with instructions regarding current infection prevention and control recommendations. The Facility's Census List dated 7/19/24 documents there are 126 residents living in the Facility.

Based on interview and record review, the Facility failed to employ a qualified Infection Preventionist (IP) with specialized training needed to track Facility infections and prevent the spread of infectious diseases, including COVID-19. This has the potential to affect all 126 residents living in the Facility. Findings include: The Facility's Line List for COVID-19 Outbreaks in Long Term Care Facilities documents the Facility has been in COVID-19 Outbreak Status since 7/1/24. On 7/23/24 at 12:15 PM, V3, Assistant Director of Nursing/Infection Preventionist (ADON/IP), stated she does not have the IP certification, but is currently working on the training. On 7/25/24 at 8:30 AM, V1, Administrator, stated V2, Director of Nursing (DON) and V7, Minimum Data Set (MDS) Coordinator, oversee infection control since V3, ADON/IP is not yet certified. She stated V2 and V7 both have full time roles, in addition to overseeing infection control. On 7/25/24 at 8:55 AM, V1, Administrator, stated she expects the Facility to follow policies regarding infection control. The Facility's Infection Preventionist Policy revised 8/2022 documents, The infection preventionist is responsible for coordinating the implementation and updating of the infection prevention and control program. The infection preventionist is qualified by education, training, experience and/or certification and has sufficient knowledge to perform the role. The Policy documents, The infection preventionist has obtained specialized IPC training beyond initial professional training or education prior to assuming the role and Evidence of training is provided through a certificate(s) of completion or equivalent documentation. The Facility's Census Report dated 7/19/24 documents there are 126 residents living in the Facility.

Based on interview, observation, and record review, the facility failed to provide the physician prescribed medication. There were 25 opportunities with 2 errors resulting in a 8% medication error rate. The errors involved R13 in the sample of 22. Findings include: On 7/23/24 at 5:21 AM V12, Licensed Practical Nurse (LPN), went to her medication cart to prepare R13's 5:00 AM medications. V12 was unable to locate the Levoxyl or the Omeprozole that was prescribed for R13. V12 stated that these medications have been ordered but have not came in yet. R13's July 2024 Physician Orders, documents, Levoxyl Tablet 88 MCG (micrograms) (Levothyroxine Sodium) Give 1 tablet by mouth one time a day for low thyroid hormone. This medication is scheduled for 5:00 AM. R13's July 2024 Physician Orders documents Omeprazole Oral Tablet Delayed Release 20 MG (milligrams) (Omeprazole). Give 1 tablet by mouth one time a day for GI (gastrointestinal). This medication is scheduled for 5:00 AM. R13's July 2024 Medication Administration Record documents that the Levoxyl and the Omeprozole were not available to give. On 7/23/24 at 2:30 PM, V13, LPN, stated, (R13's) Levoxyl was found in the medication room and the Omeprazole is over the counter. V13 was questioned if she gave the 2 medications on her shift, V13 stated, No. The policy Administering Medication, dated 4/2019, documents, Medications are administered in accordance with prescriber orders, including required time frame. This policy fails to document what the procedure is if the medication is not available.

Based on Interview and Record Review the facility failed to accommodate and inform 1 of 5 residents (R5) of change in shower schedule. Findings include: R5's Face sheet documents an admitted [DATE]. Diagnosis include Congestive Heart Failure, Atherosclerotic Heart Disease, Protein Calorie Malnutrition, Gastrointestinal Hemorrhage. R5's Minimum Data Set, MDS, dated [DATE] documents R5 has no cognitive deficits and requires partial/moderate assist with showering. R5's Care Plan with a revision date of 10/24/2022 documents R5 has an activity of daily living, ADL's, self-care performance deficit related to ADL needs and participation vary, Fatigue, Impaired balance, Limited Mobility, Weakness. Resident is currently receiving skilled therapy services with goal of returning home upon completion of rehab. Interventions include Bathing: Physical Limited - assist/1 staff. R5's progress notes dated 7/6/2024 at 11:04AM documents R5 very upset about many things going on. R5 is upset about the shower change schedule and states she wasn't given an option. R5 filed a grievance with the Social Services Director, SSD, last week, and is wanting to talk to the Director of Nursing, DON, to get things cleared up. SSD will email the DON about talking to the R5. Grievance dated 7/1/2024 documents R5 stating Director of Nursing, DON, changed shower schedule causing resident to miss therapy this morning. R5 states lots of schedules have been changed without telling residents. Findings of Investigation: R5 stated that evening showers are better for her. R5 would like showers on Wednesday evening and Saturday evening. R5's shower sheets dated 7/4/2024 documents R5 refused shower and stated She's not changing shower days. R5's shower sheet dated 7/8/2024 documents Refused very upset. On 7/9/2024 at 9:45AM, V5, Certified Nursing Assistant, CNA, stated the shower schedule has been changed and is still being worked out. The residents have set shower days. We have had some residents complain about not liking their shower days and as far as I know the shower days have not been changed to what they want. R5 was really upset about it. On 7/9/2024 at 10:55AM stated V6, R2's Power of Attorney, POA, stated R2 was scheduled showers in the evening, and she struggles with evenings. She has Sundowners. I try not to even visit her of an evening, because she gets so upset and cries. I don't know if the shower situation has been fixed. They didn't even ask her family if evening showers would work for her. I haven't been able to talk to anyone in management about it yet. I talked to the staff, and they said they were told schedules were not to be changed back. On 7/9/2024 at 2:00PM R5 stated - They changed the shower schedule, and no one knew it was going to change. They didn't tell anybody even the Certified Nursing Assistants, CNA's. I was so mad I refused showers for a while. I did my own protest. On 7/9/2024 at 2:30PM V2, Director of Nursing, DON, stated she was not aware of grievance filed by R5. V2 stated the schedule can be tweaked to accommodate residents preferences. Facility's undated ADL policy states Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care).

Based on observations, interview, and record review, the facility failed to provide showers for 4 of 4 residents (R2, R5, R6 and R17) in the sample of 21 reviewed for showers. Findings include: 1.R2's face sheet, dated 6/27/24, documented that R2 was admitted to the facility on [DATE]. R2's medical diagnosis sheet, dated 6/27/24, documented that R2 has the following diagnoses: cerebral ischemia, hypertension, history of cerebral infarction, depression, anxiety, muscle weakness, schizoaffective disorder, and need for assistance with personal care. R2's MDS (Minimum Data Set), dated 3/15/24, documented R2 is cognitively intact, R2 requires partial moderate assistance with hygiene and is dependent on staff for all mobility. On 6/25/24 R2's bath and skin report sheet, dated June 2024, documented that R2 had 2 showers in June on 6/8/24 and 6/15/24. On 6/25/24 at 9:20 am R2 was lying in bed with dried food stuck to her left arm and chest. R2's hair appeared greasy, and she appeared unkempt. R2 stated that she had not had a shower in about two weeks. R2 stated that she asked for one last Saturday but that no one gave her a shower. 2.R5's face sheet, dated 6/27/24, documented that R5 was admitted to the facility on [DATE]. R5's medical diagnosis sheet, dated 6/27/24, documented that R5 has the following medical diagnoses: cerebral infarction, Alzheimer's disease, chronic kidney disease, congestive heart failure, type 2 diabetes mellitus, hypertension, intervertebral disc degeneration, and need for assistance with personal care. R5's MDS, dated [DATE], documented that R5 is moderately cognitively impaired, requires partial/moderate assistance with showers and partial/moderate assistance with transfers into the shower. On 6/25/24 R5's bath and skin report sheet, dated June 2024, documented that R5 had a shower on 6/3/24, 6/17/24, and 6/24/24. On 6/25/24 at 9:40 am R5 was observed lying in bed and appeared disheveled, unshaven and hair greasy. R5 stated that he received a shower last night but that he usually only gets a shower every 2-3 weeks. R5 stated he would like to receive at least two showers per week. 3.R6's face sheet, dated 6/27/24, documented that R6 was admitted to the facility on [DATE]. R6's medical diagnosis sheet, dated 6/27/24, documented that R6 has the following medical diagnoses: Parkinson's disease with dyskinesia, spinal stenosis, vascular dementia, congestive heart failure, cognitive communication deficit, depressions, and need for assistance with personal care. R6's MDS, dated [DATE], documented that R6 is moderately cognitively impaired and is dependent on staff for showers/bathing. On 6/25/24 R6's bath and skin report sheet, dated June 2024, documented that R6 only received one shower in June on 6/20/24. On 6/25/24 at 9:48 am R6 stated that he hasn't had a shower in about a month and he usually gets one every other week. R6 appeared disheveled with food stuck to his shirt and dried food on his beard. 4.R17's face sheet, dated 6/27/24, documented that R17 was admitted to the facility on [DATE]. R17's medical diagnosis sheet, dated 6/27/24, documented that R17 has the following diagnoses: chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, chronic kidney disease (end stage and on dialysis), hypertensive heart failure, hypertension, and need for assistance with personal care. R17's MDS, dated [DATE], documented that R17 is cognitively intact and requires substantial/maximum assistance with showers/bathing and mobility. On 6/25/24 R17's bath and skin report sheet, dated June 2024, did not document that R17 received any showers for the month of June. On 6/25/24 at 10:55 am R17 stated that she has not had a shower since she moved to her new room about 3 weeks ago. R17 stated that her name was not on the shower list, and she still has not had a shower even though she lets the Certified Nurse Assistants (CNA) know several days ago. On 6/25/24 at 12:45 pm V10 LPN (Licensed Practical Nurse) stated that the showers are supposed to be documented in the shower book after they are completed by the CNAS. On 6/25/24 at 12:50 pm V11 CNA stated that many of the shower sheets are blank so either the CNAS are not getting the showers completed or they are forgetting to document the showers. On 6/26/24 at 11:50 am V15 CNA stated that they document the residents' ability to complete a shower or bath in the EMR (Electronic Medical Record) every day and that they chart when the actual showers are given on the monthly bath and skin report sheet. On 6/26/24 at 11:58 am V16 CNA Supervisor stated that the CNAS are supposed to be using the paper bath and skin report sheets to document when the showers are given. The facility's Activities of Daily Living (ADLs) Policy dated March 2018, documented residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. It continues, appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care).

Based on interview and record review the facility failed to a protect a resident from misappropriation of property by a staff member for 1 of 2 residents (R8) reviewed for theft, in the sample of 11. This failure resulted in $1100 being diverted from R8's bank account by staff causing R8 to be upset and deprived of money for her room and board. Findings include: R8's Care Plan, undated, documents that R8 is at risk for abuse-vulnerability due to her deficits in cognitive/mental status. R8's Care Plan also documented on 1/12/2024 that resident made allegations of missing money from the business offices. R8's Care Plan documented the following interventions, To address resident concerns as they arise, encourage participation in programs of choice, encourage resident to voice concerns to administration, observe changes in customary routines, 1:1(one to one) with social services as needed. R8's Bank statement, dated 12/1/2023-1/5/2024, documented a withdrawal from R8's account on 12/18/2023 for $400.00 from an ATM (Automatic Teller Machine). Again on 12/19/2023 for $400.00 from the same ATM. R8's banking statement, also documents a withdrawal from her account on 1/4/2024 for $300.00 from an ATM. R8's Facility Transaction Report, dated 12/1/2023 to 1/31/2024, documented, Total December 2023: 551.00. It continues, Total January 2024 551.00. Total due from Patient Liability 1,102.00. Total For Resident: 1,102.00. The Local Police Department's, Incident Report, dated 1/12/24, documented, Upon investigating further, (R8) contacted her bank, (local bank), who advised she had a total of three (3) withdrawals, one (1) for $400.00, one (1) for $400.00 and one (1) for $300.00, totaling an amount of $1,100.00. (R8) advised she does not have transportation and did not go to any (local bank) location or Automatic Teller Machines (ATM) to withdraw these funds. (R8) advised she provided her (Local Bank) debit card number (XXXX-XXXX-XXXX-.8) along with her PIN to (V3, Former Business Office Manager) on several occasions, with the understanding that (V3) was making her monthly payments for her. The new Office Manager, (V9), advised that she contacted (V3) via telephone on 1/11/2024 and asked her where (R8's) money was. (V9) advised that (V3) admitted to making withdrawals, using (R8's) debit card, but stated the money would be in the safe in the office. (V1, Administrator) advised she attempted to contact (V3) via telephone on 1/12/24 to gather additional information; however, that attempt yielded negative results. (V1) provided me with a copy of the receipt (V3) had given (R8), along with a copy of (R8's local bank) Debit Card that was used in this incident. (Police Officer) later uploaded these copies to this report. (Police Officer) advised (R8) and (V1) to call (the local bank) immediately and put a hold on the Debit Card to avoid any further transactions being attempted. (V1) advised that an employee of (the facility) would be responding to (local bank) with (R8) on 1/17/2024 to gather photocopies of (R8's) bank withdrawals. It continues, (Police officer) observed three (3) withdrawals totaling an amount of $1,100.00. (Police officer) observed two (2) withdrawals on 12/19/2023 for $400.00 each. (Police officer) observed the third withdrawal on 1/4/2024 for a total of $300.00. (Police officer) contacted the alleged suspect, (V3), via telephone to ask her some questions regarding this incident. (V3) advised that she did go to the automatic teller machine (ATM) for (R8) on approximately three (3) occasions. (V3) advised this was not uncommon for the employees in the office to do this for residents if they were of sound mind and understood the process. (V3) advised that (R8) pays approximately $550.00 per month to stay at (Facility). It should be noted, (V3) advised (R8) was behind on her monthly payments, so she was assisting her in getting caught up. On 01/17/2024 at 9:07 AM, R8 could explain her banking account and bill at the facility without any issues during this investigation. R8 stated that she gave her debit card and pin number to an employee but could not remember her name and that she was able to describe the employee to the facility and she worked in the business office. R8 stated that the employee no longer worked at the facility and that this came up because she was told that the facility did not receive payment for her rent. R8 stated that the amount taken from her account was $1100, $400.00 in two separate transactions and the bank has confirmed another transaction for $300 this month. R8 stated, Like a ninny, I gave her my card and pin number twice. R9 stated that she has spoken to the police as they have been at the facility and that she banks at a regional bank, but she is going to the local bank branch today to get her statements and get a new debit card and pin number. R8 continued to state that her debit card has been frozen. R8 stated that she (V3, Former Business Officer Manger) asked for my card to pay rent. R8 stated, I don't understand all of this, and it is upsetting that someone would steal my money. I just want to get my money back. On 1/17/2024 at 9:22AM, V1, Administrator, stated that she reported the allegation of theft to the (local police department and State Agency). V1 stated that this past Friday (1/12/2024), R8 was asking the new business office manager (V9) about her rent. V1 stated that R8 reported that she had given her debit card and pin number to V3 who had withdrew $400 x2 and this was supposed to be for her room and board. V1 continued to state that the bank had verified those withdrawals, one on 18th of December and one on the 19th from ATM. R8 reported that (V3) had previously gotten a money order for $400.00 also. V1 stated that V3 has been terminated earlier in the week prior to this for attendance issues. V1 stated that she did call V3 and V3 reported to her there was a money order in the back of her drawer for $400.V1 stated the money order was dated, but the money order was dated 12/7/2023. V1 continued to state that (V9) the new business office manager is going to the bank with R8 and when get the statements going to try to determine the amounts withdrawn. On 1/17/2024 at 1:25 PM, V9, Business Office Manager, stated that her first day as business office manager was 1/9/2024. V9 stated that R8 came to her office over a discrepancy in her monthly billing statement. V9 stated the R8 reported to her the statement said she still owed money. R8 told V9 that it could not be right as she had given the business office person prior to (V9) her debit card and pin number. R8 told V9 that there had been (2) $400 withdrawals and one $300 withdrawal from her banking account. V9 stated that she contacted the previous ownership regional office to see if there had been any payments made because you can go on the website and make payments. V9 stated that regional staff did not find where any payments had been made. V9 stated she then had R8 come to her office, and they called R8's bank together. V9 stated that she found out that the withdrawals were made using R8's debit card from an ATM. The facility's Abuse and Neglect- Clinical Protocol, undated, documented, The facility management and staff will institute measures to address the needs of resident and minimize the possibility of abuse and neglect. The facility contract between Resident and Facility, Attachment E statement of resident rights, documented, The facility shall exercise reasonable care for the protection of the resident's property from loss of theft.

Based on interview and record review, the facility failed to provide appropriate assist and supervision while turning a resident in bed for 1 of 4 residents (R2) reviewed for falls with injury in the sample of 14. This failure resulted in R2 rolling out of her bed during care and falling to the floor, sustaining a right hip fracture. Findings include: R2's Face Sheet documents, she was admitted to the facility on [DATE] with the diagnoses to include Chronic Kidney Disease, Stage 3, Basal Cell Carcinoma of Skin of Right Upper Limb, including Shoulder, Other Specified Peripheral Vascular Diseases, Chronic Pain, Anxiety Disorder, Essential Hypertension, (HTN), Gastrointestinal Hemorrhage, Gastro-Esophageal Reflux Disease Without Esophagitis, Need for Assistance with Personal Care, Unsteadiness on Feet, Anemia and Unspecified Kidney Failure. R2's Minimum Data Set. (MDS). dated 6/11/23 documents. R2 was severely cognitively impaired and required extensive assist of two staff for bed mobility, transfers and toileting. R2's Care Plan, initiated 6/11/23 documents, The resident has an ADL. (Activities of Daily Living). self-care performance deficit. The interventions for this care plan include: Resident currently requires assistance with ADLs: Bed Mobility: Extensive/1-2. The facility's document, Facility Reported Incident dated, 7/21/23 for R2's fall that occurred on 7/18/23 documents, under Final Report Findings: [AGE] year-old, currently on Hospice Care for severe protein malnutrition. History of DJD, (Degenerative Joint Disease), HTN, Chronic Anemia, Osteoarthritis, and Osseus Demineralization. ER, (emergency room ), evaluation revealed displaced angulated fracture of the distal tip of the femoral component of the right hip arthroplasty. Subtle Lucency extends cephalad into the lesser trochanter region may represent extension of the fracture. Fall from bed witnessed, patient rolled over in bed and fell to the floor. Low air loss mattress in use with bolsters in place. Corrective Action/Actions taken: ER physician discussed results and treatment options with son, patient is [AGE] years old and on hospice services, son did not want orthopedic surgery consulted. Patient returned to facility with continued hospice services and pain control. Hospice notified; equipment changed. Bed, static distribution mattress and 2 1/2 rails in place on bed. The facility's fall investigation included the following statement dated, 7/18/23, by V8, Certified Nursing Assistant, (CNA), who was providing care to R2 at the time of her fall, I was giving her a bath and rolled her on her side, and she slid out off of bolsters and between each bolster open spot. The investigation included, under Incident Description, This writer called to resident room, resident on floor on buttocks resting against w/c, (wheelchair), with right leg with rotation outward. C/O, (Complained of), pain to right hip and leg. Faint pp, (pedal pulse), to right foot and 2+ to left leg. Skin intact, resident was observed by CNA and did not hit head. CNA was giving a bed bath and rolled her over and air bolsters gave way and resident slid out of bed onto buttocks and was resting against a w/c sitting up. In pain to bilateral arms and was unable to get B/P, (blood pressure). 97.1-87-20-133/80. Resident description: I fell out of bed. On 9/21/23 at 9:05 AM V2, Director of Nursing, (DON), stated, R2 had a fall from her bed when V8, former CNA was rolling her during her bed bath and rolled her out of bed. She stated, R2's bed had bolsters at the head and foot of the mattress and R2 rolled out between them. V2 stated, if there were two people turning R2, the other person may have been able to prevent R2 from rolling out of bed, but she could not say for sure where that other person would have been standing. V2 stated, she does not know why R2 triggered on her MDS to need 2 people to turn and reposition her. V2 stated, I am not disputing the fall, because it occurred, but I don't want to say we are not following our assessment. The Care Plan documents, that R2 requires 1-2 staff for bed mobility and that is what the CNAs look at, not the MDS. On 9/22/23 at 1:33 PM V19, CNA stated, she took care of R2 frequently while she was a resident in the facility and was able to turn and reposition, R2 by herself while she was in bed. V19 stated, the CNA who was taking care of R2 when she rolled out of bed (V8) said, after R2 had already fallen, that there should be 2 staff to assist with turning and repositioning R2, but V19 stated, she told V8 that R2 only required one assist. V19 stated, the only time two staff were required was for transfers because they used a full body mechanical lift. V19 stated, V8 was an older CNA and thinks the CNA work was just getting too hard for her. On 9/29/23 at 1:15 PM V20, Physician Assistant stated, R2's fall with a fracture definitely would have hastened her death somewhat, but she was already on Hospice for diagnosis of severe protein-calorie malnutrition, and when a resident stop eating and is put on Hospice, there is a loss of momentum leading to death. V20 stated, the fracture definitely would not have helped, but R2 would most likely not have lived much longer even if fracture had not occurred, due to her overall condition. The facility's policy, Falls revised 9/1/23 documents, Standard: It will be the standard of this facility to complete an initial assessment, on-going monitoring and routine and periodic evaluation of resident condition, and subsequent intervention development in an attempt to prevent falls and injuries related to falls. 4. Based on the evaluation of risk factors and history of falls, a plan of care will be developed with pertinent interventions to be implemented by staff. The facility's policy, SG ADL Care and Assistance revised 3/27/21 documents, Standard: It will be the standard of this facility to provide the resident with Activities of Daily Living, (ADL), care and assistance while attempting to maintain the highest practicable level of function for the resident. Bed Mobility: How the resident moves to and from lying position, turns side to side and positions body while in bed or alternate sleep furniture. Extensive assistance- resident involved in activity; staff provide weight-bearing support.

Based on observation, interview, and record review the facility failed to utilize proper equipment, appropriate assist during resident care, and utilize care plan interventions to prevent accidents for 1 of 4 residents (R14) reviewed for supervision to prevent accidents in the sample of 14. This failure resulted in R14 falling out of bed during care and sustaining a subdural hematoma, requiring a 7-day hospitalization for treatment. Findings include: On 5/30/23 at 1:40 PM R14 was lying in bed with head of bed elevated and oxygen on per nasal cannula. R14's bed height was raised and there was a mat on the right side of her bed on the floor. There were no landing strips on the floor and R14 was lying in a standard sized bed, not an expanded bed. V14, Registered Nurse (RN) entered the room to assist R14's roommate, and she also lowered R14's bed to the lowest position at that time. R14 was yelling out but did not appear to be in any distress but yelling out in response to voices she heard in the room when V14 was talking to her. The facility's document, Federal Initial/Final Report dated 3/6/23 documents, [AGE] year old female with history of Alzheimer's dementia, A fib, Chronic CHF (Congestive Heart Failure), HTN (Hypertension), COPD (Chronic Obstructive Pulmonary Disease) and GERD (Gastro-esophageal Reflux Disease) had a fall from bed. Patient noted to have lip laceration and complains of all over pain during assessment. ER (emergency room ) assessment via CT scan (Computed Tomography Scan) reveal 4 mm left parietal subdural hematoma with 0 mass effect or midline shift. There are also multiple intracranial calcifications. CT of the cervical spine demonstrates diffuse degenerative disease, but without acute fracture or malalignment. Final Report Findings: Investigation revealed when patient was turned towards right side for care to be provided, mattress was over the frame of the bed. Patient weight on mattress caused mattress to fold and patient to slide off bed. R14's Progress Note dated 3/5/2023 at 8:00 PM documents, Resident rolled out of bed during care. Landed on L (left) side. Bit lip and complained of pain all over. ROM (Range of Motion) performed. VS (Vital Signs): BP (blood pressure)118/69, P (pulse)59, R (respirations) 20, T (temperature) 98F (Fahrenheit), O2 (oxygen saturation) 98 on RA (room air). MD (Medical Doctor) notified and NO (new order) to send to ED (Emergency Department) for further eval. POA (Power of Attorney) notified. R14's Progress Note dated 3/6/2023 at 1:09 AM documents, Called (local hospital) for update on resident and was informed resident had subdural hematoma and was being transferred to (outlying trauma hospital). R14's Progress Note dated 3/14/2023 at 9:07 AM documents, Son here, discussed patient edema in left hand. Son noted patient was not alert as she was in the hospital. Discussed hospice services. Son will think about hospice as he sees how patient condition evolves the next couple of days. R14's Physician Order dated 3/17/23 documents, Admit to (Hospice) as of 3/16/23. Dx (Diagnosis): Alzheimer's Disease. R14's Minimum Data Set (MDS) dated [DATE] documents R14 is severely cognitively impaired, and she requires extensive assist of 2 staff for bed mobility and transfers. This MDS was completed prior to R14's fall from bed. R14's Care Plan dated 1/20/23 (prior to fall) documents, The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) Dementia, weakness, terminal Illness. Interventions for this care plan include: Mechanical Lift for transfers (Full Body Mechanical Lift). This intervention was dated 1/30/2023 and documents Resident currently requires assistance with ADLs: Bed Mobility: extensive/2 Transfer: Extensive-Total/2-3 Uses (full body mechanical lift) but can be too aggressive causing lift to be unsafe. R14's current MDS dated [DATE] documents R14 is severely cognitively impaired and is dependent on 2 staff to assist with bed mobility, transfers, and toileting. R14's Care Plan dated 1/20/23 documents, Resident is at risk for falls. The resident has impaired cognition and impaired safety awareness, the resident experiences weakness, the resident has vision impairments., The resident has urinary incontinence which may create a wet floor and increase fall risk. Interventions for this care plan were updated on 3/14/23 (after her fall) with, Bed expanded out in width. Place floor mats/landing strips on the floor beside the bed while resident is in bed. The intervention, Keep bed in lowest position acceptable by the resident when the resident is in bed was dated 1/20/23. R14's Physician Progress, written by V15, Physician Assistant, dated 3/2/23 documents, I am seeing patient for routine monthly nursing home visit. She is severely demented. She is sitting comfortably in her wheelchair (w/c). Says she feels okie dokie. She is currently pleasant and cooperative. She denies any pain, says she has a good appetite, denies any GI (gastrointestinal) symptoms. Disposition: Patient is from (Assisted Living) but hopes to return there after completion of her therapy. R14's Physician Progress Note written by V15, dated 3/14/23 documents, Seeing patient acutely today for hospitalization follow-up. The patient was hospitalized at (outlying trauma hospital) from 3/6 through 3/13/23 for a subdural hematoma that she sustained after falling out of bed in the nursing facility while being cleaned by a CNA (Certified Nursing Assistant). She arrived to the facility yesterday with supplemental oxygen on. Since she arrived, she has been lethargic. Minimally interactive. On my exam she is awake, however she is not answering any questions meaningfully. She is mumbling incomprehensible speech when asked a question. She is not following most commands. The nurse tells me this is actually an improvement as this morning she was very difficult to arouse. She has not eaten anything today and spat out liquids when the nurse tried to give her water. I had a long discussion with son and daughter-in-law that if patient's mental status does not improve and she continues to not eat then will need to strongly consider changing code status and also hospice needs to be considered. Under Assessment/Plan, this Physician Progress Note documents, The obvious possible causes for altered mental status are the SDH (Subdural Hematoma) and RSV (Respiratory Syncytial Virus) pneumonia causing a delirium on top of her already advanced dementia. R14's Hospital Record, Post-Acute Care Transfer Report, dated 3/13/23, documents her Principle Problem during hospitalization as Subdural Hematoma. On 5/30/23 at 1:50 PM V2, Director of Nursing (DON), stated the staff involved with R14's care at the time of her fall was V13, Certified Nurse's Aide, CNA. V2 stated V13 reported to her that he was providing incontinent care for R14 and turned her onto her side facing the wall. V2 stated the bed was against the wall, but the mattress was bigger than the bed frame and the edge of the mattress folded down and R14 slid straight to the floor. V2 stated R14's mattress was an oversized mattress on a regular size bed frame, so part of the mattress was over hanging the side of the bed. V2 stated they put a regular sized mattress on the standard sized bed frame, and it was fine then. V2 stated she doesn't know why R14's care plan documents she is on an expanded mattress; they put a regular sized mattress on a standard sized bed frame. V2 stated R14 does not need a larger mattress. On 5/30/23 at 2:01 PM V12, CNA, who was taking care of R14, stated he does R14's incontinent care by himself when he is working. V12 stated R14 is heavier than she looks and can stiffen up, so some of the other CNAs will use two assists with R14's care, but he stated he is able to turn her by himself and provide incontinent care without help. He stated, I can do her on my own. On 5/30/23 at 2:11 PM V13, CNA, was interviewed by phone. He stated he was the CNA providing care for R14 on 3/6/23 when she fell out of bed. He stated he was getting ready to change her and had rolled her onto her side, facing the wall. He stated the mattress was too big for the bed and the mattress flipped up on his side because of her weight on the other edge, and she fell face first off, the bed. V13 stated R14 had a cut on her lip that was bleeding. He stated he ran and got the nurse and another CNA, and they used a sheet and papoosed lifted R14 back into bed and then she was sent to the emergency room . V13 stated he always changed R14 on his own. He stated R14 had just recently moved from another room, so this was the first he had an issue with her mattress. He stated he reported the problem with the mattress to the DON the next day and she took care of it. He stated the mattress would not have worked for any resident because it was too big for the frame that it was on. On 5/31/23 at 1:36 PM V3, Assistant Director of Nursing (ADON) stated he would expect staff to follow a resident's care plan, including having the appropriate number of staff needed to assist a resident with cares. If the plan of care stated a resident requires the assist of two staff for turning and positioning, there should be two staff providing the care for that resident. V3 stated the correct mattress should be utilized with the bed frame. The facility' policy, Standards and Guidelines: Falls revised 3/27/21 documents, Standard: It will be the standard of this facility to complete an initial assessment, on-going monitoring/evaluation of resident condition and subsequent intervention development in an attempt to prevent falls and injuries related to falls. 5. If a resident sustains a fall while a resident, staff should attempt to identify possible causes of the fall. After a fall, the interdisciplinary team (IDT) should review the circumstances surrounding the fall and develop an appropriate intervention(s) and plan of care. Based on evaluation of an existing fall (s) pertinent interventions will be implemented by staff such as, but not limited to: staff re-education regarding transfer techniques and safety during ADL care. The facility's policy, Standards and Guidelines: ADL Care and Assistance revised 3/27/21 documents, It will be the standard of this facility to provide the resident with Activities of Daily Living (ADL) care and assistance while attempting to maintain the highest practicable level of function for the resident. Guidelines: 1. Each resident will be assessed/evaluated upon admission or shortly after for their level of resident ability/function and staff assistance required to safely perform ADLs. 2. Each ADL should be provided at the level of assistance that promotes the highest practicable level of function for the resident, while ensuring the needs and desired goals of the resident are met safely. Extensive assistance-resident is involved in activity; staff provide weight-bearing support. The facility's policy, Standards and Guideline: Environmental Equipment Care revised 11/2017 documents, Standard: It will be the standard of this facility that staff shall properly use and care for the property, equipment and supplies that are assigned and/or necessary for use in their work. Guidelines: 1. Employees are expected and required to exercise due care and safety in the use of all facility property, equipment, and supplies. 2. Property, equipment and supplies should be used only for the purposes for which they are intended. 8. Mechanical, electrical, and patient care equipment shall be maintained in safe operating condition.

Based on observation, interview and record review, the facility failed to prevent, assess and monitor 1 of 3 residents (R3) reviewed for pressure ulcers in a sample of 19. This failure resulted in R3 developing an unstageable coccyx pressure ulcer that required debridement and developed into a Stage IV pressure ulcer. R3's Baseline Care Plan, dated 4/27/2022 documents resident is at risk for altered skin integrity. Interventions documented: apply barrier cream to buttocks/coccyx as needed, apply skin prep to heel(s) as needed, avoid prolonged periods of skin to skin contact, complete Braden Risk Assessment upon admission, quarterly and as needed, complete skin evaluation upon admission, weekly, and as needed, consult dietician as needed, discuss non-compliance issues with resident/responsible party and educate about primary risk factors and prevention PRN, (when needed), and notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing or daily care. R3's Quarterly Minimum Data Set, (MDS), dated [DATE] documents moderately cognitively impaired, limited assist of one person for bed mobility, transfers, personal hygiene, toilet use and dressing. Walked with one-person physical assist. At risk of pressure ulcers. No pressure ulcers. R3's Nursing Readmission Assessment, dated 10/25/2022 documents no pressure ulcers. The Facility's Assessment Outcomes documents R3's Braden Scale, (risk for pressure ulcers), dated 10/25/2022 documents moderate risk. R3's Admission Summary Progress Note, dated 10/25/2022 at 6:45 PM documents no pressure ulcers. R3's Progress Notes dated 10/25/2022 through 11/01/2022 documents no assessment of R3's skin. R3's NRS, (Nursing), Wound Progress Note, dated 11/01/2022 documents a facility acquired left buttock unstageable pressure ulcer (The NPUAP, (National Pressure Ulcer Advisory Panel) at https://cdn.ymaws.com/npuap.site-ym.com/resource/resmgr/npuap_pressure_injury_stages.pdf documents the definition,) Unstageable Pressure Injury: Obscured full- thickness skin and tissue loss, Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because, it is obscured by slough or eschar. If eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Measured 4 centimeters, (cm), by 4 cm. Wound bed tissue: firmly adherent eschar with no undermining/tunneling. Wound edges were attached and defined. No odors or drainage. Surrounding tissue intact. R3's Initial Wound Evaluation & Management Summary, dated 11/01/2022 documents R3 has an unstageable DTI, (deep tissue injury), of the left buttock for at least 10 days duration. The pressure ulcer measured 4 cm by 4 cm with no exudate, (drainage). Recommendations: limit sitting to 60 minutes and reposition per facility per protocol. R3's Wound Evaluation & Management Summary, dated 11/08/2022 documents unstageable DTI to left buttock was resolved. New Unstageable pressure ulcer, (due to necrosis), on coccyx measured 2 cm x 2 cm x 0.2 cm with moderate serous exudate. 100% thick adherent necrotic tissue. A new Stage III pressure ulcer of the left medial buttock measured 1 cm x 2 cm x 0.1 cm with moderate serous exudate.100% granulation tissue. No recommendations documented. R3's Significant Change MDS, dated [DATE] documents moderately cognitively impaired, total dependence with 2 physical assist for bed mobility, toilet use and transfers. Walking did not occur. Extensive assist of one person for dressing and personal hygiene. At risk for pressure ulcers and has a Stage III and an unstageable pressure ulcer. R3's NRS Wound Progress Note, dated 11/09/2022 documents Left buttock Stage IV pressure ulcer resolved. A new facility acquired coccyx unstageable pressure ulcer measured 2 cm x 2 cm x 0.2 cm. Wound bed had firmly adherent eschar with no undermining/tunneling. Moderate serous drainage. No odor. Surrounding tissue intact. A new facility acquired left medial buttock Stage III pressure ulcer on measured 1 cm x 2 cm x 0.1 cm. Wound bed firmly adherent granulation tissue. No undermining/tunneling. Moderate serous drainage. No odor. Surrounding tissue intact. R3's Wound Evaluation & Management Summary, dated 11/15/2022 documents Stage IV pressure ulcer on coccyx full thickness measured 4 cm x 2 cm x 0.2 cm with moderate serous exudate with 100% thick adherent necrotic tissue wound progress: deteriorated. Stage III pressure ulcer left, medial buttock measured 1 cm x 2.2 cm x 0.1 cm with moderate serous exudate, 10% slough and 90% granulation tissue. Wound progress: no change. No recommendations documented. R3's Care Plan documents it was not updated after she was readmitted to the facility on [DATE]. It did not address R3 was refusing ADLs, pressure ulcer treatments, to get out of bed or to turn/reposition or to eat. R3's Physician's Order Sheet, (POS), dated 11/01/2022 through 12/11/2022 documents pressure ulcer treatments were ordered. R3's Treatment Administration Record, (TAR), dated 11/01/2022 through 12/11/2022 documents staff documented pressure ulcer treatments was administered per physician's orders. On 3/08/23 at 11:10 AM, V39, R3's family representative stated, In my opinion, if they were turning (R3) every 2 hours like they were supposed to (R3) wouldn't have developed pressure ulcers in the first place. I usually visited two or three times a week for at least an hour. I had to bring pillows from home so they could help prop her up and reposition. (R3) probably did refuse to be turned at times, but I always helped encourage her when I was at the facility up until the very end. On 3/08/23 at 10:28 AM, V38, LPN/Treatment Nurse, stated, I don't recall (R3) ever having any open areas. I know for a while the CNAs were putting barrier cream on her bottom because, there was a mild redness there. It was blanchable, and they were proactive with putting that on her right away. We tried to turn her from side to side and put a pillow behind her, but she would always pull the pillow out and scoot over on the bed. I talked to (R3) about why it was important to turn and reposition and what could happen if she didn't. I might have documented that; it would be in the nurse's notes. I don't ever remember the family refusing (R3) to be turned and repositioned, but they usually tried to encourage her and help us out that way. I don't think I ever reported it because, it was just a little red and blanchable. R3's Electronic Medical Record, dated 10/25/2022 through 12 documents no skin breakdown or redness and no documentation R3 refused to turn/reposition or that she refused pillows for positioning. On 3/08/23 at 10:40 AM, V40, LPN/Treatment Nurse, stated, Every resident here can get barrier cream. It's a standing order on admission. I never put barrier cream on (R3) and I don't know if she was getting it. On 3/09/2023 at 8:15 AM V40, LPN/Treatment Nurse stated, she does wound treatments at the facility when the wound specialist sees residents. V40 didn't assess R3's skin upon readmission on 10/25/2022, that would have been the floor nurse. She couldn't recall if she did wound rounds with the wound specialist on 11/01/2022 or not but, that she would have done the wound treatment after 11/01/2022. V40 recalled the left buttock pressure ulcer spread out to the coccyx and that became one pressure ulcer. V40 couldn't recall when the left buttock pressure ulcer began to spread to the coccyx or if she notified anyone of this occurring. V40 drew a picture of R3's pressure ulcer progression on a piece of paper, a small circle was drawn representing the left buttock pressure ulcer and a small circle was drawn representing the coccyx pressure ulcer; V40 connected the 2 separate circles/pressure ulcers to show the one coccyx pressure ulcer and colored the circle in to show that it was it black/necrotic. V40 stated, the coccyx pressure was black but, it did open at one point and there was tunneling. On 3/08/2022 at 9:17 AM V2, Director of Nursing, (DON), stated, (R3) was readmitted to the facility after she had a fall and a right hip fracture in 10/2022. After (R3) was readmitted to the facility she was in a lot of pain and often refused to turn and reposition and her psychiatric behaviors got worse. (R3) had a standard pressure relieving mattress. (R3) was resisting care including pressure ulcer treatment. (R3's) family was here visiting often and they would tell staff not to touch (R3) because, she was in pain. V2 started talking to (R3's) family regarding hospice the day she was readmitted , but they weren't ready for that. V2 stated, from the get go she knew when (R3) developed the facility acquired pressure ulcer on her buttocks/coccyx area she knew it would be bad. On 3/08/2023 at 1:30 PM V27, Physician's Assistant stated, when (R3) was readmitted to the facility after she broke her hip she refused therapy, refused to eat, refused to get out of bed and refused to turn/reposition. He expected staff to frequently turn and reposition (R3) to prevent skin breakdown. If (R3's) buttocks/coccyx was red staff should have applied barrier cream or a comfort pad to prevent direct pressure to the area and should have documented the reddened area in (R3's) electronic medical record. He expected staff to document when (R3) refused activities of daily living, (ADLs). Staff should have done their best to ensure (R3) was on her side to prevent skin breakdown on her buttocks/coccyx. He expected staff to follow the skin/pressure ulcer policies and procedures. On 3/09/2023 at 9:00AM V27, Physician's Assistant stated, he took care of (R3) medically and the wound specialist took care of her wounds. It is abnormal for normal skin to become necrotic but, it could be that the previous pressure ulcer was tunneling and created a fistula connecting to the other pressure ulcer, it had to be pretty advanced at that point. The facility treatment nurse should have notes regarding R3's pressure ulcer. When you think of skin/pressure ulcers think of an iceberg you only see the top of the iceberg 10%, you can't see the other 90% of the iceberg and by the time you do its pretty advanced. On 3/08/2023 at 10:15AM V37, Wound Specialist stated, he didn't recall R3 as a resident, he has over 1,000 residents he sees a month and couldn't recall R3 specifically. The facility should document a head-to-toe skin assessment upon admission and readmission, keep the resident clean and dry and follow the facility's positioning and skin policies/procedures. If the resident was refusing to reposition/wound treatments he expected staff to document that in the resident's medical record. The Facility's Wound Care policy, revised 3/27/2021, documents it will be the standard of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and the treatment of skin impairment. Guidelines: preventive measures, such as barrier creams can be employed to help maintain skin integrity as well as utilization of pressure relieving surfaces, floating heels, protective boots and use of positioning devices. Use of barrier creams may vary according to product and may be used following incontinent care for additional prevention, provided there is no clinical contraindication.

Based on interview, observation and record review the facility failed to assess and timely identify pressure ulcers/pressure injuries and provide treatment to prevent and/or prevent the worsening of pressure ulcers for 2 of 3 residents (R2, R3) reviewed for pressure ulcers in the sample of 16. This failure resulted in R2 developing an unstageable pressure ulcer requiring bedside debridement, and subsequently being sent to hospital for antibiotic treatment related to pressure ulcer infection. Findings include: R2's Face Sheet, undated, documents R2 was admitted on [DATE] and had diagnoses of Cerebral Infarction, Hemiplegia to the Left Side, Dehydration, Metabolic Encephalopathy, Hypertension and Need for Assistance with Personal Care. On 2/9/23 at 9:40AM, R2's pressure ulcer/pressure injury to the left buttock was observed. The pressure ulcer was approximately 7 centimeters (cm) by (x) 4cm with 2 areas of yellow slough in the center measuring approximately 2cm x 2cm each and the surrounding tissue was red and moist. R2's Care Plan, dated, 1/23/23, documents R2 is at risk for altered skin integrity. The Care Plan documents the following Care Plan Interventions, dated 1/23/23: Apply barrier cream to buttocks/coccyx as needed; complete skin evaluation upon admission, weekly and as needed, notify nurse immediate of any new areas of skin breakdown, redness, blister, bruises, discoloration noted during bathing or daily care. R2's Progress Note, dated 1/23/23 at 1:54 PM, documents R2 had no skin abnormalities identified upon admission. R2's Progress Note, dated 1/23/23 at 2:34 PM documents Skin warm dry and intact. R2's Minimum Data Set (MDS), dated [DATE], documents R2 has moderate cognitive impairment, is at risk of developing pressure ulcers and does not have any pressure ulcers. There was no documentation in R2's record that R2's skin condition had been assessed from after the admission assessment on 1/23/23 until the area was identified on 2/4/23. R2's Progress Note, dated 2/4/23 at 6:00 PM, documents Resident family visiting, curious about treatment order to resident's buttock. Treatment order reviewed with resident and reassured turning and repositioning frequently would continue, pillows used to offload left side to avoid further damage. Personal care provided frequently to avoid moisture associated dermatitis (MASD). Provider aware, family agrees with plan of care as well as resident. R2's Physician's Orders, Treatment Administration Orders and Progress Notes were reviewed and there is no documentation that a treatment order was obtained for R2's pressure injury which was identified in the Progress Note on 2/4/23. R2's Newly Identified Skin Condition, dated 2/4/23 at 8:50 PM, documents R2 has MASD with a skin tear noted to the left buttock measuring 5 cm x 4 cm x 0.1cm. Treatment order in place. The Skin Condition form documented Reported to nurse that treatment was already obtained from earlier shift. Family aware and education reinforced with family on this shift. R2's Progress Note, dated 2/5/23 at 8:23 AM, documents Resident's dressing changed to left buttock due to soiling. Measurements to area obtained 5cm (centimeters) x (by) 4cm skin tear with MASD noted. Treatment applied per order. Daughter at bedside. Resident states she doesn't feel any pain to the area. The left side is compromised from previous CVA (Cerebral Vascular Accident). Frequent position changes continue. Staff communicated and educated to assist. Linens also changed this shift. R2's Wound Evaluation and Management Summary, dated 2/7/23 by V19, Wound Care Physician, documents R2 presents with a wound on her left buttock. The Summary documented R2 has an unstageable (due to necrosis) of the left buttock for at least 9 days duration with moderate serous exudate. The Summary documents the pressure ulcer measures 7cm x 4cm x 0.3cm with 80% thick adherent necrotic tissue. The Summary documents R2's wound was cleansed and 5.6cm(2) of devitalized tissue and necrotic subcutaneous level tissues were removed at a depth of 0.4cm. As a result of this procedure, the nonviable tissue in the wound bed decreased from 80% to 60%. The Summary documented The best medical estimate of the time required for this wound to heal with continued physician evaluation and intervention is 62 days. This estimate is made with an 80% degree of certainty. Dressing treatment plan for calcium alginate and Santyl daily with a secondary dressing of gauze island border for 30 days. On 2/8/23 at 10:50 AM, V4, R2's family, states R2 did not have any wounds/pressure ulcers when she came to the facility on [DATE] after a massive stroke. V4 stated a few days after R2 arrived she developed a shear to her back. V4 stated she saw the wound this past Saturday 2/4/23 and the dressing was off, the nurse replaced it but didn't clean it and didn't perform any hand hygiene. V4 stated the wound is more than a shear. V4 stated R2 saw the wound doctor yesterday and he debrided it and changed the wound care orders to Santyl. V4 stated the nurses don't follow the wound care orders and frequently when she comes in the mornings, the bandage is either soiled or not on and R2 is soiled with urine. V4 stated they have family coming in around the clock because R2 isn't being taken care of and they can't do this anymore, so they are transferring R2 to another facility. On 2/9/23 at 7:35 AM, V5, Registered Nurse, RN, states she admitted R2 and R2's bottom was red when she was admitted and then it opened up, like a sheared area, only the top layer of skin was gone, then over this past weekend, she noticed there was a dark area in the center of the wound, she notified the MD and got orders for a Medi honey dressing. V5 stated prior to that they were applying a protective foam dressing daily. V5 stated R2 is turned and positioned every 2 hours, she didn't like being off of her back, but she has gotten better with going onto her sides. V5 stated on a rare occasion, she has had residents that didn't get their wound dressing changed as ordered but this happens very rarely. On 2/9/23 at 9:40 AM, V15, LPN/Wound Care Nurse, states she saw R2's wound on Monday 2/6/23 for the first time and it was red with a dark area in the center, resembling a DTI (Deep Tissue Injury). V15 stated V19 came in on Tuesday 2/7/23, debrided it and changed the treatment order. V15 stated it looks much better today than it did on Monday, states the dark area is gone and now there is the yellow slough area, but it does look better. V15 stated residents with a pressure ulcer are turned and repositioned at a minimum every 2 hours, more frequently if needed. V15 stated all residents are to have a skin check weekly. V15 stated the treatments are documented on the TAR when complete. R2's Fall Report, dated 2/10/23 at 6:20 AM, documented that R2 fell out of bed. On 2/14/23, at 12:06 PM, V4 stated that she requested that R2 be sent to the hospital after the fall and that R2 was admitted to the local hospital because her facility acquired pressure ulcer was infected and she is currently in the hospital on IV antibiotics. R2's Hospital Record, dated 2/10/2023 documents R2 was admitted to the hospital on 2/10/2023. The Record documented R2's pressure ulcer was cultured and was determined to be positive for Methicillin-resistant Staphylococcus aureus (MRSA). R2 was prescribed IV (intravenous) antibiotics Unasyn and Vancomycin. 2. R3's Face Sheet, undated, documents R3 had diagnoses of Paraplegia, Cardiomegaly and Hypothyroidism. R3's MDS, dated [DATE], documents R3 is cognitively intact, is at risk of developing pressure ulcers and has 2 stage 3 unhealed pressure ulcers. R3's Care Plan, dated 12/28/22, documents R2 has a pressure injury with an intervention for wound care as ordered by the physician. R3's Wound Progress Note, dated 2/8/23, documents R3 has stage 3 pressure ulcer to the right ischium measuring 2cm x 2cm x 0.1cm. R3's Weekly Skin Integrity Review, dated 1/10/23, documents R3's stage 3 pressure ulcer to the right ischium measures 1cm x 2cm x 0.2cm. R3's Weekly Skin Integrity Review, dated 1/17/23, documents R3's stage 3 pressure ulcer to the right ischium measures 1cm x 2cm x 0.1cm. R3's Weekly Skin Integrity Review, dated 1/24/23, documents R3's stage 3 pressure ulcer to the right ischium measures 0.7cm x 2cm x 0.1cm. R3's Weekly Skin Integrity Review, dated 1/31/23, documents R3's stage 3 pressure ulcer to the right ischium measures 2cm x 2cm x 0.1cm. R3's Wound Culture, dated 12/31/23, documents R3's pressure ulcer, has a heavy growth of pseudomonas aeruginosa and streptococcus agalactiae. R3's Physician Progress Note, dated 1/4/23, documents R3 wound care continues to follow for wound on buttock. Was recently started on an antibiotic due to concern for infection in wound. R3's Treatment Administration Record (TAR), documents the following physician orders: 12/28/22 - 1/31/23 and 2/2/23 - 2/8/23 - Gentamicin Sulfate Ointment 0.1%, apply to right ischium every evening for wound; 12/28/23 - 1/31/23 and 2/1/23 - 2/8/23 - Santyl Ointment 250 units/gram, apply to right ischium every evening shift for wound. The TAR fails to document that the gentamicin or Santyl treatments were completed to R3's wound on 1/5/23.,1/9/23, 1/31/23 and 2/8/23. On 2/8/23 at 1:10 PM, R3 states he has wounds to his bottom, and they change the dressings every other day. The Wound Care policy, dated 3/1/08, documents: 2. Skin will be assessed/evaluated for the presence of developing pressure injuries or other changes in skin condition on a weekly basis at least once each week or as needed by a licensed nurse. 6. Wound care procedures and treatments should be performed according to physician orders.

Based on observation, interview, and record review, the facility failed to place the call light within reach of residents for 2 of 5 residents (R76, R285) residents reviewed for reasonable accommodation of needs in this sample of 57. This failure resulted in R285 feeling sad, horrible and unwanted. R285's Care Plan, dated 10/24/22, documents Resident is at risk for falls. The resident has balance or walking impairments., The resident has a history of falls., The resident experiences weakness., The resident has urinary incontinence which may create a wet floor and increase fall risk. It continues Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. R285's Minimum Data Set (MDS), dated [DATE], documents that R285 is cognitively intact. On 1/9/2023 from 11:00 AM to 1:00 PM with 15-minute intervals R285 was observed in her room with call light attached to bedrail on opposite side of the bed against the wall, out of R285's reach. On 1/9/2023 at 11:30 AM R285 stated that she was wet and needed to be changed. R285 stated that she was waiting for the girls to come to her room. R285 stated that they would be there eventually. When asked where was her call light? R285 stated that it was over there and pointed to bedrail on opposite side of the room. When asked if she can reach the call light? R285 stated that she could not reach her call light and would have to tell her roommate to push the button or just wait for them to come to her room eventually. R285 stated that she got up around six am and got her shower and have been up in her wheelchair since then. R285 stated that she has a pressure sore on her butt near her coccyx and it hurts her to sit for so long. R285 stated that it makes her feel bad. R285 stated it makes her feel as if they don't want to take care of her. R285 stated but what do you do when nobody wants you or to help you. It makes you feel sad and horrible. On 1/9/2023 at 11:33 AM R285 then told R284 that she (R285) needed the girls and to push the call button. R284 then grabbed hold of the call light and threw it back on the bed and did not call for help. On 1/9/2022 at 1:04 PM V17, Certified Nurse Assistant (CNA), and V18, CNA, assisted R285 into the bed and performed incontinent care. On 1/10/2023 at 11:26 AM V17 stated that call lights are to be in reach at all times. V17 stated that when the staff goes in the room, they are to check to make sure the call lights are in reach. V17 stated that if they are not then the staff put them in reach. On 1/10/2023 at 12:15 V2, Director of Nursing, stated that she expects the call lights to be in reach and that she expects the staff to make sure the residents call lights are in reach. The Resident Rights for People in Long-Term Care Facilities, dated 11/18, documents As an individual living in a long-term care facility, you retain the same rights as every citizen of Illinois and of the United States. It continues Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. 43847 2.) R76 diagnosis include muscle weakness, difficulty walking, need for assistance with personal care, GERD and scoliosis. R76's Minimum Data Set, dated dated dated [DATE] documents a brief interview of mental status of a 4, which indicates R76 is severely cognitive impaired. MDS documents R76 needing extensive assist for bed mobility, locomotion, dressing and personal hygiene, and dependent for transfers. MDS also documents R76 as always incontinent of bowel and bladder. On 1/10/2023 R76's care plan documents ensure call light is in reach. On 1/3/2023 at 10:00 am observed R76 in chair in her room without call light. R76 was yelling for help and stated she needed to go to the bathroom. R76 was noted to be pulling her incontinent brief apart and throwing the cotton stuffing on the floor. On 1/5/23 at 10:00am R76 was observed up in chair in room without call light. On 1/9/23 at 10:00am R76 was observed up in chair in room without call light. On 1//9/2023 at 10:50am V7 stated R76 will use her call light at times. On 1/10/2023 at 12:15pm V2 stated she expected her staff to provide residents with call lights within reach. The facility policy, dated 9/15/2022, titled call lights states when the resident is in bed, confined to a chair or using the toilet and bathing facilities the call light should be within easy reach of the resident.

Based on interview and record review the facility failed to monitor a bruise for 1 of 3 residents (R3) reviewed for change in condition in the sample of 11. This failure resulted in R3 having decline in condition and increased pain due to an unidentified and untreated rib fracture. Findings include: R3's Care Plan, revision date 11/21/22, documents Resident is at risk for falls. The resident has IMPAIRED COGNITION and IMPAIRED SAFETY AWARENESS, The resident has BALANCE OR WALKING IMPAIRMENTS, The resident has a HISTORY OF FALLS, The resident has URINARY INCONTINENCE which may create a wet floor and increase fall risk. It also documents Interventions: Increase staff monitoring. R3's Health Status Note, dated 7/10/2022 at 10:00 PM, documents Note Text: This writer was made aware by CNA (Certified Nurse Aide) staff of resident on the floor at this time. resident observed on floor bleeding noted from laceration to forehead in his room by the door in right side lying position. Resident was lying on his rt (right) arm with pants down below knees. rt leg shortening noted. walker in front of bed. noted soda spilled in middle of bedroom floor. Resident was last observed laying in bed at 9:30pm. Resident alert and verbal stating get me up . This writer stayed by resident side and talking with resident entire time until paramedics arrived. resident denies pain at this time. paramedics arrived at (10:15 PM) turned resident over to supine position and then to sitting position. resident moves both arms WNL (within normal limits) at this time. noted swelling to nose and laceration. paramedics wrap kling around laceration to forehead. resident denied pain and stood up with assist of 2 paramedic and walked to stretcher was transferred to (local hospital) for further eval and treat. MD (physician) made aware, POA (power of attorney) (V4, R3's son) made aware no concerns voiced. R3's Chest Xray from local hospital, dated 7/11/2022 at 12:40 AM, documents Bones: No acute findings. Other: No significant findings. R3's Health Status Note, dated 7/11/2022 at 06:02 AM, documents, Note Text: resident returned from ER (emergency room ) @450 am to facility via ambulance. resident transferred into bed via ambulance from stretcher. resident is noted to have stitches to laceration above left eyebrow. resident has fx (fracture) of nose. nose has bruising and swelling. skin tear to hand. resident is to f/u (follow up) with pcp (primary care physician). resident has no c/o (complained of) pain or discomfort at current time. resident is resting in bed in room covered up with blankets. resident able to move all extremities wnl. 97.8 t (temperature), 132/77 b/p (blood pressure), 63 p (pulse), 18 r (respirations). family notified of return. poa stated son will be up in the am to see resident. physician notified medprocity (secure messaging) of return to facility. on call nurse notified of return to facility. R3's Health Status Note, dated 7/11/2022 at 1:14 PM, documents Note Text: Resident remains on po (oral) antibiotics for [CONDITION(S)] (urinary tract infection) and no sign of any adverse reaction noted. sutures to left eye brow to forehead intact and bruising or discoloration on the nose and the area to forehead and dressing to skin tears on right hand intact, resident's son was here aware of resident's status and he spoke with D.O.N (Director of Nursing) and administrator. resident encouraged po fluids and drank house supplements and water and peri care given per CNA. R3's Health Status Note, dated 7/12/2022 at 9:54 PM, documents Note Text: Sutures to face CDI (clean, dry, intact) healing Tylenol given Refused to eat or drink at supper but did take meds (medications) and drink a shake at HS (bedtime) VS (vital signs) 97.9 72 20 142/76 SAT (oxygen saturation) 97% on R/A (room air) bruising noted to nose and eye and dressing to hand w/ (with) some bruising on index finger. Denies pain but moans when moved. R3's Health Status Note, dated 7/13/2022 at 2:24 AM, documents Note Text: Resident remains on PO antibiotics for [CONDITION(S)]; no S/S (signs/symptoms) of any ASE (adverse side effects) noted. sutures to left eye brow to forehead intact and bruising or discoloration on the nose and the area to forehead and dressing to skin tears on right hand intact, fluids encouraged; peri care given per CNA R3's Weekly Skin Check, dated 7/13/2022 at 9:11 AM, documents bruising to chest, 2 open areas to right hand, stitches to the left side of forehead, bruising to left side of eye and left side of nose. R3's Health Status Note, dated 7/13/2022 at 1:36 PM, documents Note Text: Resident INC f/u for fall; no new or apparent injuries noted; sutures intact bruising noted above L (left) eyebrow and L hip; all treatments completed per scheduled tx (treatment) nurse, (V29). Res also on ABT (antibiotic) for [CONDITION(S)]; no ase noted; fluids offered and accepted; appetite poor; res refused shower and bed bath; son made aware per (V24, Licensed Practical Nurse- LPN); will monitor R3's Health Status Note, dated 7/13/2022 2:15 PM Late Entry date 8/5/2022 at 2:15 PM , documents Late Entry: Note Text: Bruising also present on left rib area from fall on 7/10/22 R3's Health Status Note, dated 7/13/2022 at 2:18 PM, documents Note Text: Resident refused shower 4x's, This writer called his son (V4) and informed him of the refusal, (V4) said that is ok that he misses his shower today and for staff to wash him up when assisting him with toileting, and he will be up Saturday to make sure that he gets his shower, He also asked me to talk with the MD about getting a stronger pain medication, This writer spoke with the PA (V12, Physician's Assistant) and he said that he will assess the resident and write an order, R3's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . There is significant amount of ecchymosis. It also documents I am seeing the patient acutely today for emergency room visit follow up and also because nursing is concerned that pain is uncontrolled. Patient suffered a fall on 07/10 resulting in a laceration to his forehead and bilateral epistaxis. Was sent to the emergency room where laceration was closed with nylon sutures. Work up in the emergency room showed displaced bilateral nasal bone fractures. Nursing staff reported that patient pain is uncontrolled. R3's Health Status Note, dated 7/14/2022 at 6:02 AM, documents Note Text: Resident continues fall follow up. Resident is able to make needs known and voice no concerns at this time. Resident stitches remain intact. Resident continues ABT. Resident does not display any sign and symptoms of distress adverse reaction or fever. Resident noted to be laying in bed with eyes closed at this time. R3's Health Status Note, dated 7/14/2022 at 9:57 PM, documents Note Text: Sutures to face CDI color pink skin W/D (warm/dry) ate poorly but drank shakes X 2 denies pain and continues ABT T-97.8 No ill effects. R3's Health Status Note, dated 7/15/2022 at 1:49 AM, documents Note Note Text: Resident remains on PO antibiotics for [CONDITION(S)]; no S/S of any ASE noted. sutures to left eyebrow to forehead intact and bruising or discoloration on the nose and the area to forehead and dressing to skin tears on right hand intact, fluids encouraged; peri care given per CNA R3's Health Status Note, dated 7/18/2022 at 1:37 PM, Documents Note Text: resident tilt backwards in wheel chair. appeared at that resident was trying to position self in wheelchair. no new injuries or bruising related to this incident at this time. voiced c/o pain PRN (as needed) medication given. in bed resting at this time. resident refused lunch and returned to bed room. MD, DON and responsible party aware of incident. VS: 123/64 74 18 98.0 R3's Discharge Summary, dated 7/18/2022 at 9:00 PM, documents Note Text: Resident had previous fall last Monday. i.e. sutures, scattered bruising and discoloration of nose. Resident suffered another fall on day shift today, falling backwards out of wheelchair and hitting head. Nurse in room attempting to position resident at side of the bed to feed dinner as it has been reported resident has not eaten much since previous fall. Upon repositioning, feet flat on floor. Resident still unable to sit up straight, kept leaning back and wincing in pain. Resident's son arrived with food and assisted resident in eating, resident still refused but later had a few bites. Resident noted to be having a hard time chewing. Nurse started to assess resident's body and get vitals for Neurochecks. Huge bruise noted to left ribcage, notified doctor. (V20) gave orders for chest Xray. Son had questions about resident possibly needing CT's (computed tomography) and more labs ran r/t (related to) fall earlier in the day. Nurse agreed due to resident's continued decline, poor appetite and overall drastic change from baseline since first fall. Notified family that resident could be sent out at their request. Doctor notified of family's request to be evaluated in the ER. Doctor said Ok. Resident transferred out to (local hospital). R3's Thoracic and Lumbar spine CT, dated 8/19/2022 at 12:37 AM, Impressions: 1. Left posterior 12th rib fracture, moderately displaced. 2. Oblique fracture extending posteriorsuperior corner of L2 (2nd lumbar spine) to the mid anterior end plate with widening of up to 8mm (millimeters). On 8/4/2022 at 11:05 AM, V24, LPN, stated that she was familiar with R3 and his care. V24 stated that prior to the fall R3 was independent with occasional incontinence and family provided disposables. V24 stated that after the fall R3 had increase confusion and was weak. V24 stated that R3 was diagnosed with a [CONDITION(S)] at the emergency room . V24 stated that R3 was weak. V24 stated that she was not aware of R3 complaining of pain but do know that he would moan. V24 stated that R3 would still try to transfer himself in a weaken state. V24 stated that she was only aware of bruising to R3's face. V24 stated that it was not reported to her of R3 having additional bruising to R3's body. V24 stated if this would have been reported to her it would have been monitored for further injury and pain. V24 stated the physician, and the Director of Nursing would have been notified as well. On 8/4/2022 at 11:40 AM, V23, Registered Nurse (RN), stated that she was not notified of a bruise or discoloration on R3's side and was not monitoring a bruise to R3 rib area. V23 stated that she was only aware of the bruising and injury to R3's face. V23 stated that if notified of a bruise or would have been reported she would have assessed it, notified the doctor, V2 DON, and would have monitored it to make sure it didn't get bigger or worse. On 8/8/2022 at 9:00 AM, V12, Physician Assistant, stated that he was made aware from the mediprocity on 7/18/22. V12 stated that he was not the physician that responded as he was off. V12 stated that the nurse sent a picture of bruise. V12 stated that the bruise did not just show up and the bruise had to be there prior to the fall on 7/18/2022. V12 stated that due to the color and size of the bruise it was an older bruise. V12 stated that the bruise and the fractures to R3's ribs would have occurred on the first fall. V12 stated that he was notified of R3's pain being uncontrolled but was not notified until he reviewed the mediprosity from 7/18/2022 on the following morning. On 8/8/2022 at 3:20 PM, V15, CNA, stated that she was working when R3 returned from the hospital and R3 did not have any bruising to his left side and rib area. V15 stated that prior to R3's fall he was independent and after R3 fell he was dependent on staff for care. V15 stated that R3 was attempting to transfer himself out of bed when first returning but was unable to. V15 stated that she is not aware of him falling again but knows that initially he was trying to get out the bed. On 8/8/2022 at 3:30 PM, V16, CNA, stated that she took care of R3 after his fall. V16 stated that when caring for R3 he would yell out in pain when turning him during care. V16 stated that R3 was more confused and weaker. V16 stated that she does not remember any bruising to R3 body but does remember bruising to his face. V16 stated that prior to fall R3 was independent and after fall R3 was totally dependent. V16 stated that after the fall R3 was total care. V16 stated that she did not get R3 out of bed. V16 stated that there was no interventions put in place and that it was care as usual. On 8/8/2022 at 4:00 PM, V27, CNA, stated that when returning from the hospital R3 was different. V27 stated that R3 was independent before going to the hospital and not wanting the staff to help. V27 stated that when R3 returned from the hospital he was total care. V27 stated that she was not aware of a bruise to R3's left rib area or R3's left side. V27 stated that if she would have seen the bruise she would have told the nurse and watch it to make sure he didn't get hurt more. V27 stated that R3 was more confused and at times didn't know who she was which was different for him. V27 stated that he was in a lot of pain, moaning and yelling when touched. On 8/8/2022 at 4:20 PM, V25, LPN, stated that she was not monitoring a bruise to R3's left side. V25 stated that she did not see, nor did anyone report any bruising. V25 stated that if she would have been notified this is something that she would have monitored for additional injury. On 8/9/2022 at 1:15 PM, When asked how did V2, DON, know about the bruise, V2 stated that she was notified by V21, CNA, that R3 had the bruise. On 8/9/2022 at 1:23 PM, V21, CNA, stated that she was aware of the dark bruise to R3's rib area. V21 stated that she doesn't know what day or what shift it was that she saw it. V21 stated that it was after the first fall but before the second fall. V21 stated that she has been a CNA for [AGE] years and knows that she reported it. V21 stated that she does not know what nurse she reported it to or when she reported it due to multiple days and shifts she has worked. V21 stated that she did not notify V2. On 8/9/2022 at 1:40 PM, V2 stated that V22, CNA, was the person that notified her of R3 having bruising on 8/5/2022. V2 stated the V22 did not report it because she assumed it was because of the fall. V2 stated that when R3 went to the hospital she discussed the bruise with V12, Physician Assistant. V2 stated that V12 told her that the bruising was old and had to be there prior to the fall on 8/18. V12 stated that the nursing staff were aware of the bruising and did not monitor it. On 8/9/2022 at 1:47 PM, V22, CNA, stated that she was working the hall on a different set. V22 stated that she was asked to change R3. V22 stated that when checking R3, because he was dry she noticed a red area to R3's hip area. V22 stated that she did not see any purple or black discoloration or bruises to R3's rib areas. V22 stated that she did not lift R3's shirt up when she checked him because he was dry. V22 stated that she did see the bruises on R3's face and they were black and purple. V22 stated that she was notified of by V23, RN, of R3 having a fall. V22 stated that she did not report this to the nurse. V22 stated that she was unsure as to what day after the fall it was that this occurred. V22 stated that she was not assigned to R3's care after this. On 8/9/2022 at 2:00 PM, V23 stated that she was not aware of a red area to R3's body and this was not reported to her. V23 stated that the only bruising or discoloration she was aware of was the bruising to R3's face. On 8/9/2022 at 3:32 PM, V28 (LPN) stated that when R3 returned from the hospital she did not see any bruising or discoloration to R3's side. V28 stated that R3 had covers pulled up over self. V28 stated that she was not notified of any bruising this is something she would have documented. On 8/10/2022 at 1:53 PM, V20, Medical Director, stated that he was notified of R3's falls and injuries and bruising on 7/18/2022 at the time of the second fall. V20 stated that due to the information from the nurse that resident had a fall previously on the 10th and has been declining since lst fall. V20 stated that he was notified of R3 not eating and bruising with picture sent per mediprosity. V20 stated that he originally requested an xray but was later notified of the family wish to send to the hospital. V20 stated that he has a physician assistant that is in the building and the facility may have notified him of the bruising. V20 stated that he would expect the facility to monitor the resident and report any changes to the him or (V12). V20 stated that with a rib fracture there is a hematoma that forms and this may show up later. V20 stated that if notified he would have ordered an x-ray. V20 stated that he is not sure how the treatment would have been but there would have logically been a change in care for the resident. V20 stated that the xray on 7/11/2022, from local hospital, documents no fracture. V20 stated that he wonders if there was another fall between 7/10 and 7/18. V20 stated that he can't say that his falls hastened R3's death as he does not know what the cause of death is at this time. V20 stated that the bruise should have been reported to the physician and monitored. The facility's Change in Condition Standards and Guidelines, dated 3/27/2021, documents It will be the standard of this facility to notify the physician, family, resident, and/or responsible party/resident representative of significant changes of condition and providing treatment (s) according to the resident's wishes and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's Falls Standards and Guidelines, dated 3/27/2021, documents Guidelines 4. Following a fall. Post event monitoring should occur to monitor vitals signs, change in function, change in condition, increased pain or changes in skin condition, increased pain or changes in skin condition, etc.

Based on interview and record review the facility failed to follow physician orders for 1 of 6 residents (R7) reviewed for pharmacy procedures in the sample of 12. This failure resulted in R7 not receiving [MEDICATION(S)] as ordered and being hospitalized with abnormal/elevated ammonia levels. Findings include: R7's Face Sheet, undated, documents R7's diagnoses as [CONDITION(S)], [CONDITION(S)] of the Liver, Type 2 Diabetes Mellitus. R7's Progress Note, dated 10/8/21, documented R7 was readmitted to the facility on this date at 10:40 PM. R7's Hospital discharge instructions dated 10/8/2021 at 2:48 PM, document a Physician's Order (PO) order for [MEDICATION(S)] (medication used as ammonia reducer to treat or prevent complication of liver disease) 0.67 gram/ml (milliliter) solution, take 30 ml (20 grams total) by mouth every 8 hours. R7's October 2021 Medication Administration Record (MAR) documents [MEDICATION(S)] Solution 10 GM/15 ML, take 30 ML by mouth one time a day. R7's MAR documents she received one dose of [MEDICATION(S)] on 10/9 and 10/10/21. R7's MAR documented she received no [MEDICATION(S)] on 10/11/21 as she was out of the facility. R7 should have received 9 doses of [MEDICATION(S)] but only received two doses in a three-day period. R7's Progress Note dated 10/12/2021 at 1:13 AM documents a late entry for 10/11/2021 at 7:30 PM. The Note documents V20, R7's friend, called facility and stated he had been talking to R7 and she told him the facility was only giving R7 [MEDICATION(S)] once per day. V20 states R7 has to have it at least twice daily if not 3 times daily to keep ammonia levels from becoming toxic. R7's Progress Note, dated 10/12/21 at 6:06 AM document This writer walked in residents' room to pass morning medication. Resident in bed unable to arouse. Nonresponsive to this writers' commands. Pulse present and labored breathing noted. The Note documented Resident sent to hospital for further Evaluation and treatment. R7's Hospital Admission Records dated 10/12/2021 at 6:16 AM, documents R7 presented to the emergency room with Ammonia level of 238 (normal range 15-45). R7's Hospital Records documents R7's final diagnoses as [CONDITION(S)], nosebleed, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)]. On 10-14-2021 11:00 AM V2 Director of Nursing (DON) stated the facility has had some errors in transcribing medications and has a Quality Assurance Performance Improvement Plan (QAPI) in place to investigate further. V2 stated she saw documentation that V20 called with concerns on 10/11/2021. The Facility's Medication Administration Policy, with a revision date of 3/27/2021 documents it will be the standard of this facility to administer medications as prescribed by the physician.

Based on interview and record review the facility failed to prevent a significant medication error in 1 of 6 residents (R7) reviewed for significant medication errors in the sample of 12. This failure resulted in R7 not receiving [MEDICATION(S)] as ordered by the physician and being hospitalized with [CONDITION(S)] and elevated/abnormal ammonia levels. Finding include: R7's face Sheet, undated, documents R7 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's Progress Noted, dated 10/8/21, documents R7 was readmitted to the facility at 10:40 PM on that day R7's Hospital discharge instructions dated 10/8/2021 at 2:48 PM, document order for [MEDICATION(S)] (medication used as ammonia reducer to treat or prevent complication of liver disease) 0.67 gram/ml (milliliter) solution. Take 30 ml (20 grams total) by mouth every 8 hours. R7's October 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R7 should have received 9 doses of [MEDICATION(S)] but only received two doses in a three-day period. R7's Progress Notes dated 10/12/2021 at 1:13 AM documents a late entry for 10/11/2021 at 7:30 PM V 20, R7's friend, called facility and stated he had been talking to R7 and she told him the facility was only giving R7 [MEDICATION(S)] once per day. The Progress Note documents V20 states R7 has to have it at least twice daily if not 3 times daily to keep ammonia levels from becoming toxic. R7's Progress Notes on 10/12/2021 at 6:06 AM document This writer walked in residents' room to pass morning medication. Resident in bed unable to arouse. Nonresponsive to this writers' commands. Pulse present and labored breathing noted. The Progress Note documents Resident sent to hospital for further Evaluation and treatment. R7's Hospital Admission Records dated 10/12/2021 at 6:16 AM, documents R7 presented to the emergency room with Ammonia level of 238 (normal range 15-45). R7's Hospital Records documents R7's final diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/14/2021 11:00 AM V2 Director of Nursing (DON) stated the facility has had some errors in transcribing medications and has a Quality Assurance Performance Improvement Plan (QAPI) in place to investigate further. V2 stated she saw documentation that V20 called with concerns on 10/11/2021. On 10/14/2021 at 2:15 PM V18, Pharmacist, stated it is possible that missed doses of [MEDICATION(S)] combined with R7's other conditions would contribute to toxic ammonia levels and the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/15/2021 at 8:50 AM, V19 (R7's Physician), stated it is possible that by not giving the [MEDICATION(S)] as ordered, contributed to V7's hospitalization . The Medication Errors Policy with a revision date of 3/27/2021 documents It is the standard of this facility that the staff and practitioner shall try to prevent medication errors and adverse medication consequences, and shall strive to identify and manage them appropriately when they occur. The Medication and Administration Policy, with a revision date of 3/27/2021 documents it is the standard of this facility to administer medications as prescribed by the physician.

Based on observation, interview and record review, the facility failed to assess, monitor, treat, utilize pressure devices and utilize turning and position for 5 of 8 residents ( R30, R49, R53, R65, R89) reviewed for pressure ulcers in a sample of 50. This failure resulted in R30's shearing to the left lower ischium progressing to a stage 4 pressure ulcer. Findings include: 1. On 3/12/2020 R30 was observed from 8:15 AM until 1:56 PM sitting in a wheelchair without any benefit of repositioning based on 15-minute intervals. On 3/12/2010 at 2:00 PM, R30 was transferred to bed. R30's buttocks were extremely red and dressing to ischium was crinkled. On 3/12/2020 at 3:00 PM V57, Certified Nurse's Aide (CNA), stated He (R30) is a midnight get up. I did not get him up. I'm on day shift. I haven't done any care with him. I'm on the other hall. On 3/12/2020 at 3:12 PM V50, CNA, stated, He is a midnight get up. He was up when I got here. I got here about 6:00 AM and he was up. I haven't done anything with him. He likes sitting up. On 3/12/2020 at 3:30 PM, R30, stated, I'm glad to be in the bed. I like sitting up, but that was long. I would rather be in the bed. My butt feels so much better. It was hurting there for a while. On 3/16/2020 at 2:55 PM, V24 Registered Nurse (RN), performed a treatment to R30's left lower ischium. V24 and V55, CNA, assisted with positioning R30 onto his side. V24 and V55 slid buttocks across the surface of the bed. V24 and V55 did not clear the surface of the bed when turning R30. R30 was heavily soiled with urine and stool. R30's incontinent brief, draw sheet were heavily soiled. R30 had no dressing in place. On 3/16/2020 at 3:20 PM, V24 stated, I am not sure how he got the area. I believe it's from shearing. He is to be repositioned at least every 2 hours. He does lay down a lot. The dressing should be in place. If the staff see the dressing is not in place, the staff is to notify the nurse so that the dressing can be applied. On 3/16/2020 at 3:48 PM, V55, CNA, stated, If the dressing comes off or there isn't one, we go get the nurse. We don't apply the incontinent brief until after the treatment is done. We wait for the nurse. R30's Care Plan, documented 10/28/2019, Unstageable left lower ischium. Monitor frequently for incontinence and change if wet or soiled. Apply barrier ointment after each incontinence care. 10/28/2019 Turn and reposition every 2 hours. R30's Narrative Nurse Progress Notes, dated 10/10/2019, documents Incontinent care was being given at 8:00 AM and noted open area to left buttock. R30's Narrative Nurse's Progress Note, dated 10/26/2019 5:00 PM Resident noted to have opens areas to bottom. Coccyx area measures 1.5 x (by) 2.5 CM (centimeter), left buttocks measures 2.2 x 2 CM and left ischium measures 3 x 1.5 CM. Resident doesn't like to lay down and moves around when in bed. R30's Initial Wound Evaluation and Management Summary, dated 10/29/2019, documents Unstageable (due to necrosis) of the left, upper ischium. Pressure 3.00 cubic centimeters with 100% thick adherent devitalized necrotic tissue measuring 1.5 x 2 x 0.2 cm. Unstageable (due to necrosis) of the left, lower ischium. Pressure 3.00 cubic centimeters with 100% thick adherent devitalized necrotic tissue measuring 2 x 1.5 x 0.1 cm. Both areas requiring surgical excisional debridement of 3.0 cubic centimeters of devitalized tissue and necrotic muscle and surrounding fascial fibers were removed at a depth of 0.3 cm. R30's Wound Evaluation and Management Summary, dated 11/5/2019, documents Stage 4 pressure wound of the left, upper ischium. Pressure 3.00 cubic centimeters with 100% thick adherent devitalized necrotic tissue measuring 1.5 x 2 x 0.1 cm. Unstageable (due to necrosis) of the left, lower ischium. Pressure 3.00 cubic centimeters with 100% thick adherent devitalized necrotic tissue measuring 2 x 1.5 x 0.1 cm. Both areas requiring surgical excisional debridement of 3.0 cubic centimeters of devitalized tissue and necrotic muscle and surrounding fascial fibers were removed at a depth of 0.3 cm. R30's Wound Evaluations and Management Summaries, dated 12/3/19, 12/10/19, 1/14/20, 2/4/20 and 3/10/20 documented V56, Wound Physician continued to see R30 for weekly surgical excisional debridement. R30's Wound Evaluation and Management Summary, dated 3/10/2020, documents stage 4 pressure wound to the left, lower ischium measuring 1.5 x 1 x 0.2 cm requiring surgical excisional debridement of 0.15 cubic centimeters of devitalized tissue and necrotic muscle and surrounding fascial fibers were removed at a depth of 0.3 cm. On 3/16/2020 at 3:51 PM, V56, Wound Physician, stated, The area started out as a shearing, sitting for extended periods of time without being position would have caused the wound to progress to a stage 4 quickly. The facility is a good home. They have lost some staff and that may be causing them some issues. He (R30) should be in the bed and repositioned in the bed. 2. R49's MDS, dated [DATE], documents R49 is totally dependent on 2 staff for bed mobility, transfers, dressing, toilet use and is always incontinent of bowel and bladder. This MDS further documents Formal and Clinical Assessment indicates R49 is at risk for pressure ulcers development. R49's Pressure Ulcer Risk Assessment, dated 1/17/2020, documents R49 is at high risk for pressure ulcer development. R49's Care Plan with goal date 4/3/2020, documents, Resident has a Stage 4 pressure ulcer to coccyx identified in-house 8/26/19. Turn and reposition every 2 hours and as needed, Float heels while in bed. R49's Wound Management Consultation Notes, dated 3/10/2020, documents, Stage 4 Pressure Wound coccyx 3 x 1.5 x 1 cm moderate serous exudate. 60% granulation, 40% necrotic. Wound Progress: No change. Plan of Care: Off load wound. Reposition per fac (facility) protocol. Dressing treatment plan: [REDACTED]. Collagen powder once daily. Mupirocin once daily. Factors complicating wound healing: Diabetes Mellitus 2. On 3/10/2020 from 10:27 AM until 1:31 PM, R49 was in bed on her right side without the benefit of repositioning based on 15-minute observation intervals. On 3/12/2020 at 10:05 AM, V27 and V22, both CNAs, provided incontinent care to R49 in bed, R49 had an incontinence of bowel episode. R49 had a dressing on her coccyx dated 3/11/20 that was loose, adhering on one side, was soiled and discolored with fecal material. On 3/12/20 at 10:20 AM, V23, LPN and V24, RN provided wound care to R49 in bed. V24 removed the loose dressing off the wound. V23 cleansed the wound which measures approximately 1.25 inches by 1 inch with 50 percent pink granulation. V23 applied dressing to the wound. 3. R53's Care Plan on Skin Integrity Changes dated related to PURA (Pressure Ulcer Risk Assessment), dated 10/12/19, at risk for pressure ulcer, Requires assistance for transfers, ambulate, turn and reposition, incontinent of bowel and bladder at times, appetite and fluid intake fair, receives routine [MEDICAL CONDITION], has [DIAGNOSES REDACTED]. Interventions: 2/14/20 Float heels while in bed. Reposition and turn every 2 hours and as needed. On 3/11/20 from 10:21 AM until 1:14 PM, R53 was in bed on her back without the benefit of repositioning based on 15 minute or less observation intervals with no offloading of her heels while in bed. The Facility Policy on Repositioning dated 12/1/2016 documents, Standards: It will be the standard of the facility to provide evaluation of the residents' needs, to aid in the development of a care plan for repositioning as needed, to promote comfort for all bed-comfort or chair-bound residents, to attempt to prevent skin breakdown, promote circulation and prevent pressure relief for residents. Guidelines: 1. Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. 2. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. 4. On 03/10/20 from 9:24 AM until 12:30 PM, R65 was lying in bed on her left side without her pressure relieving offloading boots on her bilateral feet. On 3/12/2020 at 4:00 PM, V24, RN and V34, LPN were performing wound care to R65's right hip and during care, the right leg was kept covered. When completed, V24, RN stated that they were going to do the right heel treatment at that time. When R65's blanket was removed, there were no pressure relieving offloading boots on R65's feet. V24, RN, looked at the R65's treatment administration record and stated that she doesn't know how or when the open area to the right hip started but then she and V34, LPN continued to apply a dressing to the right lateral wound. R65's physician's orders [REDACTED]. It does not document a treatment for [REDACTED]. R65's Specialty Physician Wound Evaluation and Management Summary, dated 03/10/2020, documents, Shear wound of the right buttock. It continues to document, Dressing treatment plan. Primary dressings. Alginate calcium apply once daily for 30 days; Foam silicone boarder apply once daily for 30 days; Silver [MEDICATION NAME] apply once daily for 30 days. R65's Care Plan, dated 09/30/2019, documents,(Pressure relief and off loading) boots in place at all times for prevention. It continues, See (Treatment administration record) for current treatment orders On 03/16/2020 at 2:40 PM, V31, Restorative Certified Nurse Assistant (CNA) and V40, CNA both stated that R65's boots disappear all the time and that they are usually in the laundry. Both V31 and V40 continued to state that they were not aware of the open area to R65's hip. 5. R89's Admission Nursing Assessment, dated 1/29/2020, documents R89's heels were blanchable (blanching of the skin occurs when the skin becomes white or pale in appearance). R89's Pressure Ulcer Risk Assessment, dated 1/29/2020, documents R89 is at high risk for pressure ulcers and requires assistance to turn/reposition. R89's Care Plan, dated 3/11/2020, documents, Problems: SDTI (suspected deep tissue injury) Location: right heel 2/17/2020; left heel 2/17/2020. Current ulcer/s will show improvement and no new ulcers will develop. It continues, Provide pressure redistribution as appropriate: float heels, heel protectors. R89's physician's orders [REDACTED]. The Facility's Weekly Pressure Ulcer Report dated 3/2/2020-3/8/2020, documents R89 has DTI (Deep Tissue Injury) to the right (total surface area 16) and left heel (total surface area 8), both were identified 2/17/2020. On 3/10/2020 at 1:00 PM, R89 was seen by V6, Wound Physician. R89's heel protectors were observed in R89's chair. R89 was lying in bed. V8, LPN, lifted R89's heels off the bed in order to perform R89's treatment to R89's bilateral heels. At this time, V6 stated, They attempted to float (R89's) heels with a pillow, but they did not do it properly. On 3/11/20, at 1:56 PM, V2, Director of Nursing (DON), stated, (R89's) heels (pressure ulcers) were acquired in house due to pressure. (R89) is supposed to wear the boots (heel protectors).

Based on observation, record review and interview, the facility failed to identify, assess, monitor and treat pressure sores for 2 of 3 residents (R1, R3) reviewed for pressure ulcers. This failure resulted in the development of new pressure ulcers for R3 and R1. Findings include: The Minimum Data Set (MDS), dated [DATE], documented R3 is severely impaired, but is total dependent on staff for all ADL's (Activities of daily living). The Care Plan, dated 7/27/18, documented R3 was identified as requiring assistance with dressing, grooming and personal hygiene. Weekly skin checks on shower day. Monitor heels, coccyx and all bony prominence's for redness or open areas daily during care. Assist and/or encourage resident to turn and reposition at frequent intervals as necessary. Provide tube feeding and flush as ordered. Change tubing, drain bag and catheter, and irrigate catheter per protocol or as ordered. R3 was admitted to facility on 7/10/2018 with the following diagnosis, ileus, moderate intellectual disabilities and anxiety disorder. R3's lab work dated 7/30/2018 documents in part [MEDICATION NAME] 2.4L normal range 3.5-5.5g/dl, BUN/[MEDICATION NAME] Ratio 75H normal range 6-34, Hemoglobin 8.2L normal range 14.0-18.0 g/dl, and Platelet 664H normal range 150-450 K/cmm. R3's lab work dated 8/21/2018 documents in part [MEDICATION NAME] 2.5L normal range 3.5-5.5g/dl, Sodium 154 normal range 135-145 mEq/L and BUN/Creatinine Ratio 125 normal range 6-34. R3's weekly weights were documented; 7/18/2018 100.50lbs, 7/25/2018 104.70lbs, 8/1/2018 101.90lbs, 8/8/2018 100.10lbs and 8/15/2018 86.90lbs. The Facility's 'Admit body assessment' dated 7/11/2018 documented R3's left hip-red and blanch able 7.5cm x 6cm, right hip-red and blanch able 9.5cm x 8cm, unstable area sacrum 7.5cm x 6cm, left ischium- unstageable 0.5cm x 0.5cm, red blanch able bony prominence (protruding c spine), right ear blanch able area 0.2cm x 0.5cm left lateral foot red and blanch able. On 8/23/18 from 12:30 pm until 2:45 pm R3 was sitting in chair next to bed in his room until V4 Certified Nurse's Aide (CNA) and V5 Certified Nurse's Aide (CNA) transferred to bed by mechanical lift. Deep red creases were observed on back of R3's legs just above knees. On 8/23/2018 at 2:45pm V7 stated 'I don't know how long R3's been up, would have to check with floor aides.' On 8/23/2018 at 2:55pm V4 and V5 stated, R3's mattress last night was bad, the right side was solid air and the left side was flat. We had to stuff pillows on left side to keep resident in bed. On 8/23/2018 3:30pm V6, Licensed Practical Nurse/ Wound Nurse (LPN) observed during a dressing change. Left shoulder pressure ulcer was the size of a 50 cent piece, slough filled. V6 took normal saline and gauze and patted top of slough in wound bed then applied Santyl, [MEDICATION NAME] and calcium alginate with dry dressing. Left hip dressing change, pressure ulcer was larger than a 50 cent piece, slough filled with eschar. Inflamed red tissue surrounding edge of wound. V6 patted the slough in wound bed with normal saline and applied treatment. Sacrum dressing change; pressure ulcer was greater than palm size with slough, eschar and small areas of necrotic tissue; V6 patted with normal saline and applied treatment. Right hip V6 removed a brown bandage dated 8/22/2018 with a small (new) opened area with serosanguinous drainage on the bandage. R3's left ear, no open wound areas observed. On 8/23/2018 at 3:50 pm, V6 stated that (new open area on right hip)wasn't like that on Tuesday (8/21/2018). She would be calling the doctor for new orders. V6 also stated that R3 wasn't on any antibiotics and no cultures had been done on the wounds. V6 also stated that V8, Medical Doctor (MD) usually debrides wounds on Tuesdays during weekly rounds. He debrided R3's pressure ulcers on Tuesday 8/21/2018. On 8/28/2018 at 09:15 am, V8, Medical Doctor (MD) stated, I wouldn't have expected R3 to have been sitting up for more than 2 hours. R3 entered facility with sacrum pressure ulcer only, and the others ulcers were developed in the facility. V8 also stated, I would expect staff to reposition every hour, I just write the orders. V8 also stated, Maybe I should of cultured the wounds. The Facility's Weekly Wound Documentation dated 7/25/2018 documents R3's Left shoulder stage II length 0.8cm, width 0.8cm and depth 0.1cm. The Facility's Weekly Wound Documentation dated 8/7/2018 documents R3's Left Hip pressure ulcer as length 3cm, width 2cm nothing on depth. Left Shoulder unstageable pressure ulcer as length 1.5cm, width 1cm and depth 0.2cm The Facility's Weekly Wound Documentation dated 8/14/2018 documents Left Hip pressure ulcer as length 3cm x width 2cm x not measureable cm. Left Shoulder unstageable length 1.5cm, width 1cm and depth 0.2cm The Facility's Weekly Pressure Ulcer Report dated 8/20/2018-8/26/2018 documents in part R3's Left hip Stage unstageable 3.5cm length, 3cm width and UTD (unable to determine) depth, Sacrum stage IV, 9cm length, 5cm width, 0.3cm depth, Left shoulder UTS (unstageable) 2.5cm length, 1.5cm width, 0.2cm depth, and Right hip stage 1, 1.5cm length, 3cm width. Right Hip stage I length 1.5cm and width 3cm. On 8/27/2018 R3 was sent out to local hospital, ED (emergency department). Notes document in part: the pt presents with a fever, and is highly [MEDICAL CONDITION] Lab work collected on 8/30/2018 documents [MEDICATION NAME] 2.2L normal 3.5-5.2g/dl, Hemoglobin 7.9L normal range 13.0-16.5 q/dl, and Sodium 161H normal range 136-144 mmol/L. Diagnoses; Decubitus ulcer of back stage 4, Dehydration, Elevated troponin I level, [MEDICAL CONDITIONS], and [MEDICAL CONDITION] status. Patient was given antibiotics for [MEDICAL CONDITION] sources are multiple including decubitus ulcers. 2. The Minimum Data Set (MDS), dated [DATE], documents R1 is severely impaired, is total dependent on staff for all ADL's (Activities of daily living). R1's care plan dated 6/13/2018 documents in part; asses skin weekly and document skin for color, moisture, texture and turgor. Report abnormal findings to physician and family. Turn and reposition at frequent intervals (at least every 2 hours or as tolerated). Monitor heels, coccyx and all bony prominence's for redness and open areas. Report abnormal results to the nurse. On 8/24/2018 at 10:30 am V13 exiting R1's room finishing dressing changes to R1's pressure ulcer. V13 stated that R1 has a pressure ulcer to right and left heel and coccyx. On 8/24/2018 at 11:15 am V6 stated that R1 was admitted with left heel pressure ulcer. Right heel pressure ulcer was first identified on 3/27/2018 as a stage III with necrosis. Coccyx pressure ulcer identified on 4/24/2018 stage III with 50/50 granulation, necrotic. V6 stated, That's a problem when a pressure ulcer is not identified until it's a stage III with necrosis. V6 also stated, Staff does skin checks weekly and resident is incontinent. Resident also gets a bath twice weekly. Facility's pressure ulcer report dated 8/20/2018-8/26/2018 documents R1's wounds Left heel UTS (unstageable) length 0.5 cm, 1cm width, 0.3cm depth, Right heel UTS (unstageable) 2cm length, 2cm width, 0.3cm depth, Coccyx UTS (unstageable) 4cm length, 1 cm width and 0.8cm depth. The facility's skin care prevention of pressure ulcers dated 3/03 documents in part; Perform weekly skin assessment after showers or as assigned and document results in the nurses notes.

Based on observation, interview and record review the facility failed to evaluate, assess, and implement nutritional and hydration service to meet the resident's need for 1 resident (R3) of 2 reviewed for nutrition in a sample of 7. Findings include: 1. R3's Admission Nursing assessment dated [DATE] documents in part, Weight 117 pounds, Right ear red blanch able area 0.2 cm (centimeters) X 0.5, Red blanch able bony prominence protruding spine, Ischium unstageable are 0.5 cm X 0.5 cm, Sacrum unstageable area 7.5 cm X 6 cm, right hip red and blanch able 9.5 cm X 9 cm, left hip red and blanch able 7.5 cm X 6 cm. R3's Nurse's Note dated 7/10/2018 [DEVICE] (gastrostomy feeding tube) to left side, red around insertion site. Small abrasion to left side. Resident has red blotches all over upper chest. Approx. (approximately) 18 cm (centimeters) incision to midline that appears to be recent and is a reddish color 1 cm X 1 cm abrasion to left leg above knee. 2 cm X 2 cm red area to top of right hand above thumb. Resident right foot appears to have 3 calloused areas orange/yellow in color, bilateral heels both callused and unblanch able. R3's Physician order [REDACTED]. (hour) continuous. Flush with 175 ML (milliliters) H2O (water) 75 cc (cubic centimeters) per hr (hour). Flush [DEVICE] with 30 ml H2O before and after giving medication. R3's POS dated 7/19/2018 documents in part Dietary Consult regarding weight. R3's POS dated 8/6/2018 documents dated 8/6/2018 documents in part (MONTH) use [MEDICATION NAME] 1.2 with fiber until [MEDICATION NAME] 1.5 is here. SF (Sugar free) Prostat 30 ml (milliliters) per [DEVICE] Bid (twice daily) per dietitian recommendation for wound healing. R3's POS dated 8/8/2018 documents (MONTH) Bolus with [MEDICATION NAME] 1.5 per Q (every) 300 cc Q 4 hrs. (hours) until regular feeding arrives. R3's POS dated 8/20/2018 documents (MONTH) use [MEDICATION NAME] 1.5 until 2 cal comes in. R3's POS dated 8/21/2018 documents increase flush to 250 cc Q 3 hours D/C (discontinue) 175 cc flush. On 8/30/2018at 12:15 PM, V17, Registered Nurse (RN) stated On 8/6/2018 (R3) received [MEDICATION NAME] 1.5 bag (Closed container) entire day shift. Then switched to [MEDICATION NAME] 1.2 with fiber, I don't recall how long it ran that day but we received more [MEDICATION NAME] 1.5 on that same day. On that day I think the tube feeding was changed back to [MEDICATION NAME] 1.5, but I can't find any documentation of when. On 8/9/2018 we got new orders for bolus. It is dated for 8/8/2018 which maybe the wrongs date; no it is the right day. I gave the bolus on 8/8/2018 although the MAR (medication Administration Record) as 8/9/2018 because we didn't have the proper equipment. We didn't have the 1000 cc (Cubic Centimeter) closed system container of [MEDICATION NAME] 1.5. We only had cans so I had to use the bolus feeding. On 8/30/2018 at 12:23 PM, V2, Director of Nurses (DON) stated He went to Hi Cal 2.0 and we discontinued [MEDICATION NAME] 1.5 on 8/17/2018. On 8/30/2018 at 12:25 PM, V16, RN Case Manager stated I wrote Hi Cal 2.0 orders on 8/17/2018. I didn't know if we had any available on 8/17/2018 (Friday night). We didn't have any available in the facility but we communicated we would use it when available, but it is not documented. I think we can get a tube feeding formula the next day after we order it. The facility's (Pharmaceudical Company) invoice order dated 8/23/2018 documents Hi Cal Vanilla 8 cases. We recommend that you place orders 48 business hours prior to your regularly scheduled ship day. On 9/5/2018 at 2:30 PM V2 stated I know she ordered a 24 hour turn around for the 8/22/2018 (Pharmaceudical Company) shipment. On 8/30/2018 at 12:30 PM, V2 stated The Nurses Note documents him getting tube feeding but not on the MAR. The Nurses Notes does not say the tube feeding formula. On 8/30/2018 at 12:32 PM V16 stated We did not document his tube feeding on the MAR, but it is on the daily skilled nursing assessment, but doesn't document what the feeding is, just that a tube feeding is in place. On 8/30/2018 at 3:15 PM V2 stated The changes of (R3's) tube feeding from [MEDICATION NAME] 1.5 to [MEDICATION NAME] 1.2 and the amount of the bolus didn't go through a Dietitian. The Nurse and the Doctor just discussed it and decided according to what we had available. R3's MAR indicated [REDACTED]. May use [MEDICATION NAME] 1.2 with fiber until, [MEDICATION NAME] 1.5 is here: Documented administered 8/6/2018 hour is not documented. (MONTH) Bolus every 4 hours with [MEDICATION NAME] 1.5 300cc until regular feeding arrives administration documented 8/9/2018 6:00 AM, 10:00 AM, 2:00 PM discontinued 8/11/2018. HiCal 2.0 at (2 cal) 65 cc/hr per tube feeding continuous 8/17/2018 no documentation of administration. R3's Medication Administration Record [REDACTED]. SF (Sugar Free) Prostat 30 ml per [DEVICE] Bid for wound healing Administered 8/7/2018 no documentation of administration 8/10 through 8/13 at 6 AM, 8/13 6 PM, 8/16 6 AM, 8/21 6 AM. R3's Nurses Notes dated 8/17/2018 at 11:00 AM, documents in part Receives [DEVICE] (gastrostomy tube) tube feeding of [MEDICATION NAME] 1.5 at 75 cc/hr continuously. Resident continues to lose weight and pressure areas are not healing. Resident continues to acquire new pressure areas. Most recent labs from 7/30/2018 show total protein of 5.6, [MEDICATION NAME] 2.4, and H & H (hemoglobin and hematocrit) 8.2/26.7, Resident weight 100.5 on 7/18/18, 104.7 on 7/25/18, 101.9 on 8/1, 100.1 on 8/8, 86.9 on 8/15. Family was informed of all of the above and requested to try other options. Dietitian and this writer suggested that hospice may be needed to be an option. Requested formula change to Hi Cal 2.0 at 65 cc/hr. continuous, per [DEVICE]. Started Florastar 250 mg (milligrams) BID a [MEDICATION NAME] per brother's suggestion. R3's Nurses Note dated 8/20/2018 at 1:30 PM documents in part, TF (tube feeding) infusing at 65 ml/hr. R3's Nurses Notes dated 8/20/18 at 5:30 PM documents Made (V14, Physician) aware. Resident is to receive 2 cal per tube feeding and is unavailable at this time. Ordered received may use [MEDICATION NAME] 1.5 until 2 cal available. R3's Admission Nursing assessment dated [DATE] documents in part, Weight 117 pounds. R3's Weight record documents 7/18/2018 100.5 pounds, 7/25/2018 101.6 pounds (mechanical lift), 7/25/2018 104.7 (Chair scale), 7/29/2018 101.9 (mechanical scale), 8/1/2018 101.9 (chair scale), 8/8/2018 100.1, 8/15/2018 86.9 (chair scale), 8/17/2018 100.4 (mechanical lift), 8/22/2018 101.6 (Chair scale). R3's Laboratory blood tests dated 7/30/2018 documents in part Sodium 141 (normal range 135- 145 mEq (mill equivalent/liter), Chloride 103 (normal range 96-110 mEq), R3's Laboratory blood test dated 8/21/2018 documents in part, Sodium 154 RH (Risk High) (normal range 135-145 mEq), Chloride 112 High (normal range 96-110 mEq). R3's local hospital records document R3 was admitted on [DATE] with a [DIAGNOSES REDACTED]. R3's Intensivist Consult dated 8/27/2018 documents in part, It is unclear what (R3's) status was at the (facility) prior to being transferred to the ICU (local hospital intensive care unit) but his blood work reveals severe [MEDICAL CONDITION] with a sodium 161 with an elevated BUN (Blood Urea Nitrogen) and Chloride consistent with volume depletion. The facility's Enteral Feedings policy dated 12/2011 documents in part 6. Document the feeding in the Medication Administration Record. The facility's Weight Monitoring policy dated 11/2008 documents in part 5. Calculate significant weight changes using the weight Loss/Gain Table to determine when significant weight change has occurred. Significant Weight Change Criteria: a. 5% or more in one month, 6. Record significant weight changes in the comments section of the Weight Assessment Sheet. 8. Forward a list of significant weight changes to the Dietary Supervisor, the Care Plan Nurse, the Case Manager(s), the Director of Nursing, and the Administrator. The Dietary Manager will: 1. Forward a list of significant weight changes to the Consulting Dietitian at the time of her next facility visit or sooner if the resident's condition warrants an immediate consultation. The Care Plan Nurse will: 1. Address on the care plan: a. risks for unplanned weight changes, b. significant weight changes, 2. Address (with input from the interdisciplinary team): a. identified causes of impaired nutritional status (to the extent possible), b. resident's personal choices and goals, c. goals with time frames, d. resident specific interventions, e. parameters for monitoring. 3. Update the care plan: a. as condition changes, c. as interventions are determined to be ineffective, d. as specific causes of nutrition related problems or [DIAGNOSES REDACTED]. as appropriate approaches are considered and added. The Dietitian will: 1. Review all significant weight changes and make recommendations as appropriate. 2. On 8/24/2018 at 2:07 PM, V9, Registered Dietitian stated I started here on (MONTH) 1 (2018). We have a protocol of 14 days for initial nutrition assessment and assessment of readmits. I did a chart audit the first week I was here and there are a lot of things that have been missed like wounds, tube feedings, weights, [MEDICAL TREATMENT] and tube feedings for monthly notes. For (R3) is a multi-complex case, in my last note weight loss, wounds not healing, new wounds opening were identified. I felt he was not absorbing nutrients he is now on 2.0 cal. I just increased to 75cc/hour today. His labs were low 7/30/18 he looked like he was wasting away, at that time he was receiving [MEDICATION NAME] 1.5 55 cc/hr. When he was admitted they had followed the previous (local) hospital tube feeding orders. When I first saw him he looked not well. His skin was transparent and he was frail. I found he was not receiving enough calories. His family told me he had usually consumed about 4000 calories. His family wanted his tube feeding increased. For the previous Dietitian this facility was on the back burner for him because they were trying to get another Dietitian. (R3) is also on Prostat sugar free 30 ml BID (twice daily) at this time for wound healing. It is our company protocol to start on Prostat for wounds. On 7/19/2018 a Dietitian consult, our protocol is to try to get it done within 48 hours. The protocol is to do a nutrition assessment within 14 days. The first consult was completed 7/25/2018 out of the window of 14 days for initial consult. (R3's) initial weight was 117 pounds on 7/10/2018. On 7/12/2018 (R3's) weight was 105.2 pounds and on 7/29/2018 104.7 pounds. I would reevaluate his nutrition assessment if someone lost from 117 pound to 112 pounds. Right now (R3) has a stage 4 wound to his coccyx, one on his shoulder and left and right hips they have not been healing. He is getting more wounds on his self-turning bed. On 7/30/2018 (R3's) labs were fine, his protein and [MEDICATION NAME] were low but the others were fine. I haven't looked at the labs from 8/21/18 yet. R3's Admission Nursing assessment dated [DATE] documents in part, Weight 117 pounds, Right ear red blanch able area 0.2 cm (centimeters) X 0.5, Red blanch able bony prominence protruding spine, Ischium unstageable are 0.5 cm X 0.5 cm, Sacrum unstageable area 7.5 cm X 6 cm, right hip red and blanch able 9.5 cm X 9 cm, left hip red and blanch able 7.5 cm X 6 cm. R3's POS dated 7/19/2018 documents in part Dietary Consult regarding weight. R3's Medical Nutrition Therapy assessment dated [DATE] documents in part [MEDICATION NAME] 1.5 75 ml/hr, 175 ml Q (every) 3 hr. Nutrient content 2700 calories, 113 gram protein, 1368 + 1400 ml fluid volume. Weight Tracking Height 65 inches Admission weight 117 pounds. BMI (Body Mass Index) 19.6 IBW (ideal body weight) 62 kg (kilograms) total calories 1854-2163 kcal (kilocalories), total protein 74-93 grams, total fluids 1854-2163 ml. Patient tolerates tube feeding at good rate. Continue current rate and formula. Rate is higher than protein needs to promote wound heals and weight gain. Recommend sugar free Prostat in G tube to promote wound healing. Plan: Will monitor for tube feeding: weight, skin, lab, pertinent medication, supplement needs and plan of care. Goals: Tube feeding will be tolerated. Tube feeding will meet needs. Patient will be hydrated. Gut will function normally. Skin will show improvement. Weight will trend towards IBW. This initial Nutrition Assessment which is 15 days after admission does not consider significant weight loss since his admission, wounds, or laboratory blood test results. R3's Weight record documents 7/18/2018 100.5 pounds, 7/25/2018 101.6 pounds (mechanical lift), 7/25/2018 104.7 (Chair scale), 7/29/2018 101.9 (mechanical scale), 8/1/2018 101.9 (chair scale), 8/8/2018 100.1, 8/15/2018 86.9 (chair scale), 8/17/2018 100.4 (mechanical lift), 8/22/2018 101.6 (Chair scale). R3's RD (Registered Dietitian's) Note, dated 8/17/2018 documents in part, weight 86.9 pounds (-26.36 weight loss X 1 month), Weight history: 7/4: 117.3 pounds (hospital), 7/10: 118 pounds (local hospital), 8/01 101.9 pounds, 8/08: 100.1 pounds. Labs 7/30/18 Alb ([MEDICATION NAME]) 2.4. New labs order per family request. Labs scheduled for 8/20/2018. Estimated Needs: 1591-1818 Kcal, 54.5-63.6 gram protein, 1800 cc's fluid (1cc/kcal). Res'd (resident) at risk for severe protein calorie malnutrition as evidenced by weight loss, visual muscle wasting/atrophy, and non-healing pressure wounds. Current diet order providing 155% of calculated EEN (estimated energy needs), but res'd continues to suffer from worsening/severe muscle wasting/atrophy, weight loss, and non-healing pressure wounds. Family would like to change TF (tube feeding) formula to a higher calorie, high protein formula in hopes of promoting weight gain and wound healing. Brother states that res'd have very high metabolism and was consuming almost 4000 calories daily. Per family's request, recommend changing TF to [MEDICATION NAME] 2.0 at 65 ml/22 hours with 250 ml water flush Q 4 hours. Goal rate: 80 ml/22hours to provide 3520 kcals, 147 protein, 1232 mL free water. Will monitor res'd progress and supp. (supplement) tolerance with weekly weights, residual output, labs, and wound healing. R3's Nutrition Services Progress Note dated 8/23/2018 documents Res'd tolerating TF well. Recommend increasing TF to two cal 75 ml/22 hours to provide: 3300 kcal, 138 gram protein, 1155 ml free water. Continue with 250 ml water flush Q 4 hours. Monitor wt. (weight), residuals and tolerance. On 8/30/2018 at 1:45 PM, V2, Director of Nurses (DON) stated The assessment on 7/25/2018, and notes on 8/1/18 and 8/23/18 are the only communications I know of from a Dietitian. The facility's policy on Medical Nutrition Therapy: Assessment and Care Planning dated 9/2017 documents in part, A Registered Dietitian/Nutritionist (RDN) or other clinically qualified nutritional professional is responsible for the completion of a comprehensive nutrition assessment for all residents/patients for the purpose of identifying and planning the nutrition care based on the needs, goals, and preferences of each resident/patient. The resident/patient nutrition status will be assessed upon admission and monitored at least quarterly thereafter. 1. The RDN is responsible for the completion of the nutrition assessment for all residents within 14 days of admission. 2. The RDN will be responsible for the completion of a comprehensive assessment annually, upon referral, or as indicated by the clinical condition of the resident. 3. R3's care plan dated 7/10/2018 - 7/30-2018 documents in part, Problems: (R3) requires assessment and management of skin integrity, ADL's (activities of daily living), mobility, bowel and bladder, nutrition, psychosocial status, and discharge planning to attain/maintain their highest possible physical, mental, and psychosocial well-being. Goals: Nutritional needs will be met. R3's initial Care Plan dated 7/10/2018-7/30/2018 documents in part Feeding tube, Goal: will be free of complications from use of feeding tube, Provide tube feeding and flush as ordered. See MAR (medication administration record). Weigh weekly. Intake and output for new tube feeders for two weeks or if otherwise indicate. R3's Comprehensive Care Plan dated 7/30/2018 - Present documents in part Feeding tube- [MEDICATION NAME] 1.5 , Goal: will be free of complications from use of feeding tube, Provide tube feeding and flush as ordered. See MAR (medication administration record). Weigh weekly. Intake and output for new tube feeders for two weeks or if otherwise indicate. R3's care plan does not have individualized reference to his weight loss of 25.6 percent from admission to 8/15/2018, Laboratory blood tests out of range, or increased nutritional needs for wound healing. The facility's Medical Nutrition Therapy: Assessment and Care Planning policy dated 9/2017 documents in part 5. The RDN contributes to the comprehensive plan of care within 21 days of admission and reviews and revises the plan of care quarterly or as indicated by the clinical condition of the resident/patient. 4. On 8/30/2018 at 1:45 PM, V2, Director of Nurses (DON) stated The assessment on 7/25/2018, and notes on 8/1/18 and 8/23/18 are the only communications I know of from a Dietitian. The Medical Nutritional Therapy Recommendations Log dated 7/18/2018, 7/30/2018, 8/1/2018, 8/2/2018, 8/9/2018, and 8/14/2018 have no documentation regarding recommendations for R3. The Medical Nutritional Therapy Recommendations Log dated 7/25/2018 documents in part (R3) Recommendations: Sugar free Prostat BID, Reasons: Wounds. The facility's Medical Nutrition Therapy: Assessment and Care Planning dated 9/2017 documents in part 6. The RDN recommendation for changes in the nutrition plan of care will be communicated to the licensed nursing team and the Dining Services Director via the summary recommendation sheet. 7. The RDN will be responsible for ensuring follow up and appropriate documentation of recommended changes in the plan of care. The facility's Baseline Care Plan policy dated 10/2017 documents in part, 3. Personalize the Baseline Care Plan so it reflects as accurately as possible the resident's conditions and care needs. Delete, edit, or add problems, goals, or interventions as necessary in order provide person centered care for the resident. The Care Plan Nurse will: 1. Make changes, updates, additions or deletions to the Baseline Care Plan as needed based on changes of condition, new information regarding the resident care needs, new physician orders [REDACTED].

Based on record review and interview, the facility failed to ensure safety measures were in place for 1 of 4 residents (R2) reviewed for falls in the sample of 4. This resulted in R2's fall sustaining a subdural hematoma. Findings include: R2's undated Face Sheet documents admission to the facility on [DATE] with admitting Diagnoses: [REDACTED]. physician's orders [REDACTED]. R2's Fall Risk Assessment, dated 12/4/17, determined R2 at risk for falls. The Fall Risk Assessment documents Fall Prevention Measures were initiated on 12/3/17 which include: Keep call light within reach, Remind resident to call for assistance, Monitor frequently, Access for proper fitting w/c (wheelchair), Proper fitting leg rests. The Fall Risk Assessment documents, after a fall on 12/4/17, additional measures were initiated: Use low bed, floor mat surrounding bed. Narrative Nurse's Progress Notes, dated 12/4/17 and untimed, documents, (R2) found out of bed on floor during 2:40 P hall check. Resident laying in bed resting prior to being found on floor. He was laying on left side. Denies pain and denies hitting head. Narrative Nurse's Progress Notes, dated 12/5/17 at 3:30 AM by V5, Registered Nurse (RN), document, Vital sign monitoring as follow up for new admit et (and) found on floor. Vital signs show B/P (Blood Pressure) elevated at midnight. Resident restless et attempting to get out of bed. Placed in w/c et brought to nurse's station. Denies pain or discomfort. States 'Yes' when asked if he was having trouble sleeping. B/P improved et restless decreased after sitting up. Narrative Nurse's Progress Notes, dated 12/6/17 at 1:10 AM by V5, document, Called to residents room by CNA (Certified Nurses Assistant). Resident found lying partially on Rt (Right) side and partially on stomach with active bleeding from a Rt [MEDICAL CONDITION]. (V4, Physician) and spouse updated. (R2) to hospital for eval (evaluation). Hospital report, dated 12/6/17, documents, CT (Computerized Tomography) Head without Contrast Findings: There is an acute-on-chronic right frontal/parietal subdural hematoma with acute blood visible at both the inferior aspects of the right frontal region and at the lateral aspect of the more superior right frontal region and at the lateral aspect of the more superior right parietal region. Incident/Accident Report, dated 12/6/17 at 1:10 AM by V5, documents, This writer entered room to find resident on floor partially on stomach and partially on Rt side. Resident struck his Rt forehead and face on floor. Large Y shaped laceration with active bleeding noted. Hematoma to Rt cheek. R2's Incident investigation for 12/6/17 at 1:10 AM, V2, Director of Nurses (DON), documents, Commentary: Pt (Patient) admitted to hospital. Staff education to remain physically with patient when bed is in high/normal position-mats had been picked up from floor for transfer out of bed. Environment: bed in standard position Change in Mental Status/Confusion: Restless. Incident investigation for 12/6/17 at 1:10 AM, V7, CNA, documented, Re (Regarding): (R2) Dec (December) 6, 2017 On [DATE] early AM hours, (R2) became agitated and restless. Using his right hand pounding on rail and yelling, (R2) was able to use rail to sit on side of bed. Bed was to the floor with mats on each side. To the best of my knowledge since I was unable to understand him verbally, I decided to get him up in his wheelchair to which he was able to partially communicate he agreed by saying OK. I then asked co-worker CNA to come and help get him up after I got him ready. I changed him with a new pad, underwear, pants, and shirt while folding and removing sheets under him that were wet. After I had him dressed and ready while I raised bed to transfer position I removed mat and folded it from right side of bed and prepared wheelchair at end of bed for his transfer. He was laying more toward the bottom of the bed as he had previously in the night sat up on the side of the bed by himself. I told him 'Hold on were going to get you up in just a minute' (R2) said 'OK'. I walked to doorway to look toward desk for the coworker. Upon standing in the doorway looking toward desk, (R2) had fallen off the side of the bed as I turned around and (R2) was on the floor where he had hit his head. I yelled for help and coworkers were there in room immediately. Incident investigation for 12/6/17 at 1:10 AM, V6, CNA, documented, (V7) asked me to help her with (R2) at the time I was busy at the time she asked. (V7) was standing in the doorway of the (R2's) room as I was walking down the hall to assist I heard a loud noise and (R2) was on floor. The bed was up high enough to change the linen and the mat was up against wall. Incident investigation for 12/6/17 at 1:10 AM, V5 documented, This nurse was on hold on the Pharmerica. I observed (V7) walk into (R2's) room. (V7) stuck her head out of the door as (V6, CNA) was walking down the hall towards (R2's) room. (V6) suddenly began running and stated, 'He's fallen.' When this nurse entered room, resident found lying on stomach et partially on Rt side. Active bleed noted from [MEDICAL CONDITION]. On 12/14/17 at 10:15 AM, V5 stated, I did notice the mat was folded up and next to the wall at the head of the bed and the bed was really high up. I'm short, but the bed was really high up. On 12/14/17 at 9:40 AM, V2 stated, I would have expected, (V7) to put the bed down in the lowest position and replace the mat next to the bed before walking away from the bed. On 12/14/17 at 9:40 AM, V4, R2's Physician, stated the head injury was due to the fall and the subdural hematoma could be due to the height of the bed and the mat being not placed next to the bed. V4 stated, Yes, the bed should have been in the lowest position and the mat should have been next to the bed before walking away from the bed. On 12/13/17 at 2:03 PM, V7, stated, It all happened so fast, I thought when he said 'Ok,' he would wait for me to get him out of bed. I should have lowered the bed and put the mat back in place before I left him. The Facility's Fall Risk Assessments Policy, dated 9/2003, documents, When significant potential for falls is noted via the assessments, appropriated fall prevention measures will be implemented.