Every finding on record at Legrand Healthcare and Rehabilitation Center

Based on observation, interview and record review, the facility failed to ensure that a resident received appropriate treatment and services to prevent urinary tract infections to the extent possible by failing to document urine output for 1 (#59) of 1 residents reviewed with a urinary catheter.Findings:On 05/11/2026 at 9:20 a.m., observation of resident #59 revealed he had a urinary catheter.Review of the medical record revealed Resident #59 had an admission date of 09/04/2024 with diagnoses which included epilepsy and retention of urine. Review of the May 2026 physician orders revealed an order to monitor urine output. Review of the May 2026 urine output log revealed the following:On 05/07/2026 there was no documentation of urine output on the night shift. On 05/08/2026 there was no documentation of urine output on the night shift. On 05/09/2026 there was no documentation of urine output on the day, evening and night shifts.On 05/10/2026 there was no documentation of urine output on the day, evening and night shifts.On 05/11/2026 there was no documentation of urine output on the evening and night shifts.On 05/12/2026 at 11:10 a.m., interview with S2DON confirmed there were gaps in the urine output log of Resident #59's urine output from 05/07/2026 through 05/11/2026.

Based on observation, record review and interview, the facility failed to ensure nurse aides were able to demonstrate competency in skills and techniques necessary to care for resident needs for 1 (#59) of 1 residents reviewed for urinary catheters by failing to report lack of urine output to the nursing staff.Findings:On 05/11/2026 at 9:20 a.m., observation of resident #59 revealed he had a urinary catheter.Review of the medical record revealed Resident #59 had an admission date of 09/04/2024 with diagnoses which included epilepsy and retention of urine. Review of the March 2026 physician orders revealed an order to monitor urine output. Review of the March 2026 urine output log revealed on March 28, 29 and 30 on all three shifts the recorded output was zero.Review of the progress notes revealed there was no documentation CNAs notified nursing staff that Resident #59 had zero urine output. On 05/12/2026 at 11:10 a.m., interview with S2DON confirmed there was no documentation that the CNAs notified the nursing staff that Resident #59 had zero urine output.

Based on observation and interviews the facility failed to maintain, store, prepare, distribute and serve food under sanitary conditions. The facility failed to monitor and document the refrigerators and freezer temperature.Findings:During a brief tour of the kitchen on 05/11/2026 at 8:00 a.m. the following was observed: the reach in refrigerator had a temperature of 35 degrees Fahrenheit, the walk in refrigerator had a temperature of 35 degrees Fahrenheit, and the walk in freezer had a temperature of 5 degrees Fahrenheit.Further observation of the kitchen revealed there was no log documenting the temperature readings of the reach in refrigerator, walk in refrigerator, or walk in freezer.On 5/11/2026 at 8:12 a.m. an interview with S3Dietary Manager reported she did not keep a log documenting the temperatures of the reach in refrigerator, walk in refrigerator, or walk in freezer.On 05/11/2026 at 10:30 a.m. an interview with S1Administrator confirmed S3Dietary Manager should have be monitoring and documenting the temperatures of the refrigerators and freezer daily.

Based on observations, record review and interview, the facility failed to ensure drugs and biologicals used in the facility were stored properly in a locked compartment by having medications in resident's room for 1 (#14) of 1 residents reviewed for accident hazards. Findings:Review of the facility's undated Storage of Medication policy revealed the following in part:Policy StatementThe facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Review of the medical record for Resident #14 revealed an initial admission date of 05/03/2025 with a readmit date of 07/04/2025. Resident #14 had diagnoses that included chronic obstructive pulmonary disease, bipolar disorder, schizophrenia, and seizures.Review of the current care plan revealed Resident #14 had impaired cognitive function/dementia or impaired thought processes. Interventions included to administer medications as ordered and to assist resident with all decision making. Review of the annual MDS assessment dated [DATE] revealed Resident #14 had a BIMS score of 12 which indicated moderate cognitive impairment for daily decision making.On 05/11/2026 at 9:33 a.m. and 3:00 p.m. observations of Resident #14's room revealed a bottle of Artificial Tears on the overbed table, and an Albuterol Sulfate 90 mcg inhaler was observed in the bathroom.On 05/12/2026 at 8:30 a.m. observation of Resident #14's room with S2DON revealed a bottle of Artificial Tears on the overbed table, and an Albuterol Sulfate 90 mcg inhaler was observed in the bathroom. At this time S2DON confirmed Resident #14 should not have medications left unattended in her room.

Based on record review and interviews the facility failed to ensure the nursing staff had appropriate competencies and skill sets to provide nursing care for 1 (#1) of 3 (#1, #2, #3) sampled residents reviewed. The nurse failed to: 1) review Resident #1 discharge orders when writing his admission orders to the facility and 2) clarify with the Physician if Resident #1 need to continue his home medications.Findings:Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses included encounter for surgical aftercare following surgery on the nervous system, type 2 diabetes mellitus with diabetic neuropathy, low back pain, hyperlipidemia, post-traumatic osteoarthritis, insomnia, constipation, depression, intervertebral disc disorders with myelopathy, thoracolumbar region, edema, and hypokalemia.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated Resident #1 was cognitively intact for daily decision making.Review of the Resident #1's discharge orders from the hospital dated 07/31/2025 revealed an order to continue home medications; see attached list. Review of the attached medication list revealed Pioglitazone 45 milligrams (mg) daily. Further review revealed Riluzole 50 mg twice a day was not listed.Review of Resident #1's admission orders dated 08/01/2025 written by S3ADON revealed an order for Pioglitazone 30 mg by mouth (po) daily. Further review of the admission orders revealed there was no order for Riluzole 50 mg po twice a day.Review of the August 2025 Electronic Medication Administration Record (EMAR) revealed documentation Resident #1 received Pioglitazone 30 mg po daily. Further review revealed Resident #1 did not receive Riluzole 50 mg po twice a day.On 09/30/2025 at 8:32 a.m., an interview with Resident #1 revealed he was admitted to the facility on [DATE] to receive therapy after having back surgery on 07/29/2025. Resident #1 reported his step son and daughter-in law transported him to the facility and they brought all of his home medications. Resident #1 reported he specifically told the nurse that he needed to continue his home medication, Riluzole 50 (mg) tablet twice a day for 1 month. Resident #1 reported the nurse took all of his home medications with her. Resident #1 reported his daughter-in law was present when he told the nurse about needing to continue taking the Riluzole medication.Resident #1 reported on 08/27/2025 when he was being discharge from the facility S5Licensed Practical Nurse (LPN) went over his discharge instructions. Resident #1 revealed S5LPN went over his medication list with him. Resident #1 reported his home medication, Riluzole, was not on the discharge medication list. Resident #1 reported they also had Pioglitazone 30mg daily. Resident #1 reported normally took Pioglitazone 45 mg daily. Resident #1 reported S5LPN returned his home medications and that is when he notice that the bottle of Riluzole, was still full. Resident #1 reported he became upset when he found out he had not received the medication. Resident #1 reported S2Director of Nursing (DON) and S3Assistant Director of Nursing (ADON) informed he did not receive Riluzole because it was not on his discharge orders from the hospital. On 09/03/2025 at 1:20 p.m., an interview with S2DON revealed S3ADON wrote Resident #1 admission orders. Surveyor asked S2DON about the discrepancy between Pioglitazone 45 mg po daily that was on Resident #1's discharge orders dated 07/31/2025 and the admission orders dated 08/01/2025 which had Pioglitazone 30 mg po daily. S2DON reported she was not aware of the discrepancy. On 09/30/2025 at 3:25 p.m., a telephone interview with S4LPN revealed she admitted Resident #1 to the facility on [DATE] at 1:30 p.m. S4LPN revealed Resident #1 arrived via private auto with his step son and daughter-in law. S4LPN reported they brought his home medications with him. S4LPN reported they normally do not use the resident's home medication unless it is a medication that they are not able to obtain from the pharmacy. S4LPN revealed she was given a bag containing Resident #1's home medications and she stored them in the medication room. S4LPN revealed she did not recall Resident #1 telling her that he needed to continue taking his home medication, Riluzole. S4LPN reported Resident #1's daughter-in law told her not to reorder Riluzole from the pharmacy. On 09/30/2025 at 4:24 p.m. an interview with Resident #1's daughter-in law revealed she was present when Resident #1 told the nurse he needed to continue taking the Riluzole 50 mg tablet twice day for 1 month after his surgery. Resident #1's daughter-in law revealed Resident #1 brought all of his home medication with him in a bag and Resident #1 handed the bottle of Riluzole to the nurse and told her he need to continue it twice a day for 1 month. Resident #1's daughter-in law reported she instructed the nurse to use his home medication of Riluzole and not to reorder the medication because there was a month supply in the bottle. On 10/01/2025 at 1:55 p.m. an interview with S4LPN revealed she admitted Resident #1 on 08/01/2025 at 1:30 p.m., but she did not write his admission orders. S4LPN revealed S3ADON wrote Resident #1's admission on [DATE]. S4LPN revealed she received the admission orders shortly after he was admitted . Surveyor reviewed Resident #1's discharge orders date 07/31/2025 with S4LPN. S4LPN reported this was the first time she had seen the discharge orders.On 10/01/2025 at 2:20 p.m. an interview with S3ADON confirmed she wrote Resident #1's admission orders on 08/01/2025 from the information that was faxed over to the facility on [DATE] which had Pioglitazone 30 mg po daily. S3ADON reported she was not aware of the of hand written orders dated 07/31/2025 that came with Resident #1 when he arrived to the facility that had Pioglitazone 45mg mg daily.On 10/01/2025 at 3:55 p.m. an interview with S2DON revealed S3ADON wrote Resident #1's admission orders on 08/01/2025 based on the information that was faxed over to the facility on [DATE] which had Pioglitazone 30 mg daily. S2DON revealed S3DON should have reviewed the discharge orders dated 07/31/2025 that came with Resident #1 when he arrived to the facility on [DATE] which had Pioglitazone 45mg daily. S2DON confirmed S3ADON should have contacted Resident #1's Physician and clarified the correct dosage for Pioglitazone.S2DON further confirmed S4LPN should have contacted Resident #1's Physician to clarify if Resident #1's home medication, Riluzole 50 mg po BID, should be continued after Resident #1 informed her it needed to continue for 1 month.

Based on observation, interview, and record review, the facility failed to ensure that a resident with a urinary catheter received appropriate care and services to prevent urinary tract infections by having the urinary catheter tubing on the floor and not having justification for the use of an indwelling Foley catheter for 1 (#8) of 2 (#8, #63) residents reviewed for urinary catheters. Findings: Review of the record for resident # 8 revealed an admitted [DATE] with diagnoses in part of urinary tract infection, frequency of micturition, overactive bladder, type 2 diabetes mellitus with diabetic chronic kidney disease, and cystitis. Record review revealed a physician's order dated 12/12/2024 for resident # 8 to have a Foley catheter changed on the 12th of every month related to frequency of micturition. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #8 had a brief interview for mental status (BIMS) score of 4 which indicated severe cognitive impairment. Further review of the MDS data revealed the presence of an indwelling urinary catheter, and required substantial/maximal assistance with toileting hygiene. Review of the record for revealed resident #8 had urinary tract infections on 12/15/2024, 01/16/2025, and 02/02/2025 and was treated with antibiotics. Further review of the record revealed resident returned from the hospital on 02/07/2025 with continued treatment for a UTI. Observations of resident #8 on 03/24/2025 at 10:21 a.m., 03/24/2025 at 11:37 a.m., and 03/25/2025 at 12:29 p.m. revealed resident was up in her wheelchair and her indwelling urinary catheter tubing was noted laying on the floor beneath her wheelchair. An interview and observation was conducted with S2Director of Nursing (DON) on 03/25/2025 at 1:15 p.m. in resident # 8's room. Resident # 8's indwelling urinary catheter tubing was observed on the floor. S2DON confirmed that resident # 8's indwelling urinary catheter tubing should not be laying on the floor. An interview with S2DON on 03/25/2025 at 3:43 p.m. confirmed that resident #8 did not have a justification for the use of an indwelling urinary catheter placement.

Based on record review and interview, the facility failed to ensure that the licensed nurses have the specific competencies and skill sets necessary to care for a resident's needs for 1 (# 8) of 5 (#8, #14, #37, #41, #57) residents reviewed for unnecessary medications. The licensed nurses were duplicating documentation of administration of 2 different short-acting insulins. Findings: Review of the record for resident # 8 revealed an admitted [DATE] with diagnoses in part of urinary tract infection, frequency of micturition, overactive bladder, type 2 diabetes mellitus with diabetic chronic kidney disease, and cystitis. Record review revealed a physician's order dated 09/23/2024 for Humulin R (short-acting insulin) injected subcutaneously twice daily per sliding scale. Further review revealed an order dated 10/18/2024 for Novolin R (short-acting insulin) injected subcutaneously before meals and at bedtime per sliding scale. Review of the March 2025 Medication Administration Record (MAR) revealed the order for Humulin R (short-acting insulin) dated 09/23/2024 was documented 49 times from 03/01/2025 to 03/25/2025. Review of the March 2025 MAR revealed the order for Novolin R (short-acting insulin) dated 10/18/2024 was documented 99 times from 03/01/2025 to 03/25/2025. An interview conducted with S2Director of Nursing (DON) on 03/26/2025 at 1:30 p.m. confirmed the licensed nurses were duplicating documentation of administration of 2 short-acting insulins for resident #8. S2DON verified that resident #8 only received 1 short-acting insulin.

Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 3 (#2, #13, and #27) of 4 (#2, #13, #33, and #27) sampled residents reviewed for environmental issues. The facility failed to ensure: 1. Resident #2, #13, and #27's air conditioning/heating units were free from trash and debris; 2. Resident #2's air conditioning/heating unit had control knobs attached; 3. Resident #2's television frame remained in good repair; and 4. Resident #13's dresser and bed footboard remained in good repair. Findings: Resident #2 On 03/24/2025 at 10:04 a.m. observation of resident #2's room revealed the air conditioning/heating unit contained debris and the unit control knobs were missing. The television frame was also observed separated from the top left corner of the television. On 03/25/2025 at 9:06 a.m. observation of resident #2's room revealed debris remained in air conditioning/heating vent and control knobs remain missing. On 03/26/2025 at 10:35 a.m. the surveyors and S1Administrator observed the air conditioning/heating unit and he confirmed debris in air conditioning/heating unit and control knobs missing from unit. S1Administrator stated he would have control knobs replaced and debris cleaned from air conditioning/heating unit or have unit replaced. On 03/26/2025 at 2:00 p.m. the surveyors and S1Administrator observed broken television frame and he confirmed that frame on top left of television was broken and separated from the television. S1Administrator stated he would have frame repaired or replace television. Resident #27 On 03/24/2025 at 9:00 a.m., 03/25/2025 at 8:50 a.m., and 03/26/2025 at 8:50 a.m., observations of resident #27's room revealed the air conditioning/heating unit contained debris. On 03/26/2025 at 10:35 a.m. the surveyors and S1Administrator observed all above environmental concerns and he confirmed air conditioning/heating unit vents were dirty and would have them cleaned or replaced. 22575 Resident #13 Observations on 03/24/2025 at 9:09 a.m. and 03/25/2025 at 9:25 a.m. of resident #13's room revealed her air conditioner (AC) ventilation (vent) cover was dirty with a buildup of dirt and grime. Also, the AC vent area had a large amount of trash and debris noted on the bottom portion of the vent. Further observation revealed the left side of resident #13's bed footboard was not attached or secured to the bed frame which caused the left side of the footboard to be positioned lower than right side. Also, resident #13's small dresser's middle drawer was missing the facing. On 03/26/2025 at 10:35 a.m., the surveyors and S1Administrator observed all the above environmental concerns and he confirmed resident #13's AC vent cover and ventilation area were dirty and were in need of cleaning. S1Administrator also confirmed resident #13's small dresser and bed footboard were in need of repair.

Based on record reviews, observations, and interviews, the facility failed to ensure a resident with limited range of motion (ROM) received appropriate treatment and services to increase ROM or prevent further decrease in ROM for 2 (#3 and #23) of 3 (#3, #23, and #35) residents reviewed for limited range of motion. Findings: Resident #3 Review of the record for resident #3 revealed an admitted [DATE] with diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right non-dominant side, contracture right wrist, abnormal posture, dysphagia following cerebral infarction, muscle wasting and atrophy of left thigh, right lower leg, right thigh, and aphasia following other cerebrovascular disease. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 10 indicating moderately impaired cognition. Further review of the MDS revealed resident requires maximal assistance with activities of daily living and functional limitation in range of motion on 1 side for upper and lower extremities. Review of the March 2025 Physician's Orders for resident #3 revealed an order dated 08/10/2024 for Certified Nurse Aid (CNA) to perform active/passive ROM to upper and lower extremities daily for 5 minutes due to diagnosis of hemiparesis. Review of the February 2025 and March 2025 Medication Administration Record (MAR) revealed no documentation of ROM daily to upper and lower extremities provided to resident #3. Review of resident #3's current care plan revealed the care plan included hemiparesis/hemiplegia with the following intervention: ROM active or passive with morning/evening care daily. Observations of resident #3 on 03/24/2025 at 9:55 a.m., 03/25/2025 at 1:10 p.m. and 03/26/2025 at 10:05 a.m. revealed resident was up in his wheelchair and had a contracture to his right hand, right wrist, and right elbow. An interview on 03/26/2025 at 10:38 a.m. with S9CNA revealed she provides care to resident #3 and confirmed resident does have a contracture to his right hand, right wrist, and right elbow. S9CNA confirmed she has not documented ROM for resident #3. An interview on 03/26/2025 at 10:45 a.m. with S8Licensed Practical Nurse (LPN) revealed resident #3 has a contracture to his right hand, right wrist, and right elbow. An interview on 03/26/2025 at 11:00 a.m. with S2Director of Nursing (DON) confirmed resident #3 has a contracture to his right hand, right wrist, and right elbow, and confirmed resident #3 should be provided active and passive ROM daily. S2DON further confirmed there was no documentation of ROM provided for resident #3 for February and March 2025. Resident #23 Review of the record for resident #23 revealed an admitted [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, monoplegia of lower limb following cerebral infarction affecting right dominant side, vascular dementia unspecified severity without behavioral/psychotic/mood disturbance, and anxiety, vascular dementia unspecified severity with behavioral disturbance, epilepsy unspecified no intractable without status epilepticus. Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 6 indicating severe cognitive impairment. Further review of the MDS revealed resident required moderate to maximal assistance with activities of daily living, and functional limitation in ROM with impairment on 1 side to upper and lower extremities. Review of March 2025 Physician's Orders for resident #23 revealed an order dated 08/13/2024 for a CNA to perform active/passive ROM to upper and lower extremities during daily personal care daily for 5 minutes due to a diagnosis of hemiparesis. Review of the February 2025 and March 2025 MAR revealed no documentation of ROM daily to upper and lower extremities provided to resident #23. Review of resident #23's care plan dated 11/18/2020 revealed the care plan included potential for impaired activities of daily living independence related to hemiplegia and right sided weakness. Further review of the care plan revealed an intervention to provide ROM as tolerated. Observations of resident #23 on 03/24/2025 at 9:00 a.m., 03/25/2025 at 1:05 p.m., and 03/26/2025 at 10:05 a.m. revealed resident had a contracture to his right hand. An interview on 03/26/2025 at 10:38 a.m. with S9CNA revealed she provides care to resident #23 and confirmed resident does have a contracture to his right hand. S9CNA confirmed she has not documented ROM for resident #23. An interview on 03/26/2025 at 10:45 a.m. with S8LPN revealed resident #23 has a contracture to his right hand. An interview on 03/26/2025 at 11:00 a.m. with S2DON confirmed resident #23 has a contracture to his right hand, and confirmed that resident should have active and passive range of motion daily. S2DON further confirmed there was no documentation of ROM provided to resident #23 for February and March 2025.

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out Activities of Daily Living received the necessary services to maintain good grooming and personal hygiene for 1 (#35) of 3 (#3, #23, #35) residents reviewed for Activities of Daily Living (ADL) care. Findings: Resident #35 was admitted to the facility on [DATE] with a diagnosis of cerebral infarction with hemiparesis affecting right dominant side. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed in section C- Cognitive Patterns that resident #35 had a brief interview of mental status (BIMS) score of 6 which indicated severe cognitive impairment. Further review of the MDS revealed in section GG-Functional Abilities that resident #35 was dependent on staff for personal hygiene care that included nail care. Review of March 2025 physician orders revealed an order dated 03/12/2025 for fingernail care every shift for resident #35. Review of the Electronic Medication Administration Record for March 2025 revealed fingernail care was documented every shift for resident #35.from 03/12/2025 - 03/24/25. Observation of resident #35 on 03/24/2025 at 11:13 a.m. revealed his right hand was contracted with long fingernails. On 03/25/2025 at 12:44 p.m., an observation of resident #35`s right hand was conducted in his room, and S5Licensed Practical Nurse (LPN) confirmed resident #35`s fingernails to his right hand were long and in need of trimming. On 03/25/2025 at 01:21 p.m., an interview with S2Director of Nurses (DON) confirmed there should not have been documentation of nail care being provided every shift if it was not provided.

Based on record review and interviews the facility failed to ensure residents with a history of falls, received appropriate interventions to prevent future falls for 1 (#22) of 4 (#22, #30, #41, #63) residents reviewed for falls. Findings: Record review revealed resident #22 was admitted to the facility on [DATE] with diagnoses including profound intellectual disabilities, generalized anxiety disorder, epilepsy, right femur fracture, and autistic disorder. Review of accident/incident reports revealed resident #22 had a fall from his bed witnessed by S3Certified Nursing Assistant (CNA) Supervisor as she was assisting him to get dressed on 02/07/2025. Review of the S3CNA Supervisor`s hand written witness statement included in the complaint investigation revealed resident #22 was on the floor tangled up in his bedding. On 03/26/2025 at 2:31 p.m., an interview with S3CNA Supervisor confirmed she was assisting resident #22 getting dressed on 02/07/2025. S3CNA Supervisor reported resident #22 was fully dressed laying on top of the bed covers. S3CNA Supervisor turned away from resident #22 to get his shoes, which were on the floor beside the bed. S3CNA Supervisor reported as she had her back turned away from resident #22 she heard a noise, and discovered resident #22 was on the floor on the opposite side of the bed. S3CNA Supervisor did not mention the resident being tangled up in his bedding on the floor. Review of resident #22's fall investigation report dated 02/07/2025 revealed the fall committee determined the new intervention would be to have CNA to place resident's pants on while in bed . Review of the active care plan related to falls revealed an intervention for staff to get resident #22 dressed and put pants on while in bed after the fall on 02/07/2025. On 03/26/2025 at 5:45 p.m., S1Administrator and S2Director of Nurses were informed the interventions were not appropriate related to resident #22`s fall on 02/07/2025.

Based on record review and interview, the pharmacist failed to identify and report irregularities to the attending physician, the facility's medical director, and director of nursing for 1 (#8) of 5 (#8, #14, #37, #41, #57) residents reviewed for unnecessary medications Findings: Review of the record for resident # 8 revealed an admitted [DATE] with diagnoses in part of urinary tract infection, frequency of micturition, overactive bladder, type 2 diabetes mellitus with diabetic chronic kidney disease, and cystitis. Review of the Medication Record Review (MRR) for February 2025 revealed no documented evidence that the pharmacist identified duplicate short-acting insulin therapy for resident #8. Record review revealed a physician's order dated 09/23/2024 for Humulin R (short-acting insulin) injected subcutaneously twice daily per sliding scale. Further review revealed an order dated 10/18/2024 for Novolin R (short-acting insulin) injected subcutaneously before meals and at bedtime per sliding scale. Review of the March 2025 Medication Administration Record (MAR) revealed the order for Humulin R (short-acting insulin) dated 09/23/2024 was documented 49 times from 03/01/2025 to 03/25/2025. Review of the March 2025 MAR revealed the order for Humulin R (short-acting insulin) dated 10/18/2024 was documented 99 times from 03/01/2025 to 03/25/2025. An interview conducted with S2Director of Nursing (DON) on 03/26/2025 at 1:30 p.m. confirmed the pharmacist failed to identify and report the irregularity for the duplication of administration of 2 short acting insulins for resident #8.

Based on record review and interviews, the facility failed to ensure a resident was free from unnecessary medications by failing to implement a gradual dose reduction for a psychotropic medication for 1 (#14) of 5 (#8, #14, #37, #41, #57) residents reviewed for unnecessary medications. A psychotropic drug is any drug that affects brain activities associated with mental processes and behaviors. These drugs include, but are not limited to, drugs in the categories of antipsychotics, antidepressants, anti-anxiety, and hypnotics. Findings: Record review revealed resident #14 was admitted to the facility on [DATE] with diagnoses that included generalized anxiety disorder, delirium due to known physiological condition, essential hypertension, lower back pain, neuralgia, and neuritis. Review of the March 2025 physician orders revealed the following orders dated 08/05/2024: Quetiapine Fumarate (Seroquel, an antipsychotic medication) 50 milligrams (mg) tablet give one tablet orally one time a day, Bupropion Hydrochloride (HCL) extended release (Wellbutrin, an antidepressant medication) 150 mg tablet give one tablet orally two times a day, Xanax (an anti-anxiety medication) 0.5 mg tablet give one tablet three times a day. Review of the March 2025 Electronic Medication Administration Record (EMAR) revealed documentation resident #14 received Seroquel 50 mg tablet orally every day, Wellbutrin 150 mg tablet orally twice daily, and Xanax 0.5 mg tablet orally three times daily. Review of the Consultant Pharmacist report dated 03/14/2025 revealed there was a recommendation to decrease Seroquel to 25 mg orally (po) qd (every day). S7Family Nurse Practitioner (FNP) had checked the box I agree, please write the order(s) on 03/20/2025. S7FNP did not want to reduce Wellbutrin or Xanax. Further review of the letter revealed documentation S6Licensed Practical Nurse (LPN) had noted and initialed the letter on 03/22/2025. On 03/26/2025 at 10:17 a.m., an interview with S7FNP revealed she reviewed the Consultant Pharmacist gradual dose reduction letter and agreed with the pharmacist's recommendation to decrease Seroquel to 25 mg qd on 03/20/2025. S7FNP further revealed she did not want to decrease the Wellbutrin dosage or Xanax dosage. On 03/26/2025 at 11:15 a.m., an interview with S6LPN revealed she reviewed resident #14's consultant pharmacist psychotropic gradual dose reduction letter on 03/22/2025, but did not notice the order to decrease Seroquel to 25 mg po qd. During an interview on 03/26/2025 at 11:20 a.m. with S2Director of Nursing (DON) revealed she had not reviewed the consultant pharmacist psychotropic gradual dose reduction letter dated 03/14/2025. Surveyor and S2DON reviewed the consultant pharmacist psychotropic gradual dose reduction letter together, and S2DON confirmed S7FNP had agreed with the pharmacist recommendation to decrease Seroquel to 25 mg po qd on 03/20/2025. S2DON confirmed resident #14's Seroquel should have been decreased to 25 mg po qd.

Based on record review and interview the facility failed to notify the resident's representative after an accident for 2 (#1, #2) of 2 (#1, #2) residents reviewed for falls. Findings: Resident #1 Review of the record for resident #1 revealed an admitted [DATE] with diagnoses in part of alcohol dependence with withdrawal, other seizures, pain, anxiety disorder, shortness of breath, malignant neoplasm of palate, pulmonary embolism without acute cor pulmonale, malignant neoplasm of overlapping sites of oropharynx, cerebral ischemia, dysphagia, and severe protein calorie malnutrition. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident #1 had a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive impairment. Review of the current plan of care for resident #1 revealed at risk for falls related to impaired balance, and unsteady gait. Review of the Incident and Accident report dated 12/10/2024 at 2:20 a.m. revealed resident #1 was found by S3Licensed Practical Nurse (LPN) sitting on the floor with no injuries noted. Further review of the medical record revealed no documented evidence that S3LPN notified resident #1's responsible party of the fall. On 01/07/2025 at 3:00 p.m., an interview with S2Director of Nurses (DON) confirmed S3LPN should have notified resident #1's responsible party after a fall on 12/10/2024. Resident #2 Review of the record for resident #2 revealed an admitted [DATE] with diagnoses in part of epilepsy, profound intellectual disabilities, congenital malformation syndromes predominately affecting facial appearance, autistic disorder, dysphagia, scoliosis, microcephaly, and Hallermann-[NAME] Syndrome. Review of the Quarterly MDS assessment dated [DATE] revealed unable to assess resident #2's BIMS score and was dependent on staff for all activities of daily living. Review of the current plan of care for resident #2 revealed at risk for falls, history of falls, multiple risk factors related to impaired balance, poor coordination and unsteady gait. Review of the Incident and Accident report dated 12/10/2024 at 5:30 p.m. completed by S3LPN revealed resident #2 was kicked in the side by another resident resulting in a fall with an injury to his face. Further review of the medical record revealed no documented evidence that S3LPN notified resident #2's responsible party of the fall. On 01/07/2025 at 3:00 p.m., an interview with S2DON confirmed S3LPN should have notified resident #2's responsible party after a fall on 12/10/2024.

Based on record review and interview the facility failed to ensure that each resident was free from unnecessary medication use for 3 (#15, #60 and #122) of 6 (#15, #24, #34, #55, #60 and #122) residents reviewed for unnecessary medications. The facility failed to monitor for side effects and behaviors for residents #15 and #122 when administerd a psychotropic medication, and the physician failed to give a rationale for continuing a PRN psychotropic medication greater than 14 days for resident #60. Findings: Review of the facility's current policy on Pharmacy Services: Medication Regimen Reviews revealed in part: 5. The Medication Regimen Review (MRR) involves a thorough review of the resident's medical record to prevent , identify, report, and resolve medication related problems, medication errors and other irregularities, for example: d. inadequate monitoring for adverse consequences; 9. An irregularity refers to the use of medication that is inconsistent with accepted pharmaceutical services, standards of practice; is not supported by medical evidence; and/or impedes or interferes with achieving the intended outcomes of pharmaceutical services. It may also include the use of medication without indication, without adequate monitoring, in excessive doses, and or in the presence of adverse consequences. Resident #15 Review of the medical record for resident #15 revealed an admitted [DATE] with diagnoses including depression, atrial fibrillation, protein calorie malnutrition, and diabetes mellitus. Review of the care plan revealed resident #15 is at risk for side effects from antipsychotic drug use related to medication interactions. Further review of the care plan revealed the interventions were to monitor for side effects of psychotropic drugs such as blurred vision, mental confusion, worsening depression, and dizziness. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making and required assistance with activities of daily living. Review of the physician's orders dated 01/08/2024 revealed an order for Zoloft (antidepressant) 25 milligrams (mg) per tube every day. Review of the Monthly Medication Review dated 01/26/2024 revealed the pharmacist recommended that the nurses need to document adverse effects and behaviors when administering Zoloft to resident #15. Review of the January 2024 and February 2024 Medication Administration Record (MAR) revealed no documented evidence that the facility was monitoring the resident's behaviors or medication side effects while receiving Zoloft. On 02/28/2024 at 11:30 a.m., an interview with S2Director of Nursing (DON) revealed the nurses failed to monitor for side effects and behaviors when resident #15 received Zoloft. Resident #122 Review of the medical record for resident #122 revealed diagnoses of hemiplegia, open angle glaucoma, depression, hypertension, cerebral infarction, anxiety, schizoaffective disorder, and dementia. Review of the care plan revealed resident #122 had psychosocial well-being including sad and crying, and to administer medications as ordered. Review of the admission MDS assessment dated [DATE] revealed the resident had moderately impaired cognitive skills for daily decision making. Review of the physician's orders dated 02/07/2024 revealed an order for Zoloft 25 mg at bedtime. Review of the February 2024 MAR revealed no documented evidence that the facility was monitoring the resident's behaviors or medication side effects while receiving Zoloft. On 02/28/2024 at 11:45 a.m., an interview with S2DON revealed resident #122 was not being monitored for side effects and behaviors when administered Zoloft. 43405 Resident #60 Review of resident #60's record revealed an admitted [DATE] with diagnoses including Alzheimer's disease, major depressive disorder, type 2 diabetes mellitus, hypertension, hyperlipidemia, gout, anemia, psychotic disorder with hallucinations, anxiety disorder, and mood disorder. Review of the February 2024 Physicians Orders revealed an order dated 11/14/2023 for Clonazepam (Klonopin) 0.5 mg 1 tablet by mouth (po) twice daily as needed. Review of the Consultant Pharmacist Communication to Physician dated 01/26/2024 indicated resident #60 has an order for Klonopin 0.5 mg 1 tablet po twice daily (bid) as needed (prn) agitation/crying. The pharmacist included that Center for Medicare and Medicaid Services (CMS) now requires that all prn psychotropic medication orders be limited to 14 days unless the prescriber believes the duration should be extended. If the above prn order is to be continued past 14 days, please document the rationale and include an intended duration. The physician continued Klonopin 0.5 mg bid prn for the next 6 months on 01/31/2024, but the physician did not include a rationale to continue psychotropic medication prn. An interview on 02/28/2024 at 10:25 a.m. with S2DON confirmed the pharmacy consultant letter dated 01/26/2024 requested physician address resident #60's prn order for Klonopin 0.5 mg bid prn agitation/crying due to a prn psychotropic medication be limited to 14 days. S2DON confirmed the physician did continue prn psychotropic medication for 6 months beginning 01/31/2024 but did not include a rationale for the continuation of the medication.

Based on record reviews and interviews the facility failed to ensure each resident's drug regimen must be free from unnecessary drugs for 4 (#15, #34, #60, and #122) of 6 (#15, #24, #34, #55, #60, and #122) residents reviewed for unnecessary medications. The facility failed to: 1) Monitor residents #15 and #122 for bleeding when administered an anticoagulant, 2) Monitor resident #15's blood pressure when administered an antiarrhythmic medication, 3) Document insulin injection sites for resident #34, 4) Check resident #60 for edema when administered a diuretic, failed to monitor resident #60's blood glucose level, and, failed to 5.) Monitor resident #60 for pain while administered pain medication as needed. Findings: Review of the facility's current policy on Pharmacy Services: Medication Regimen Reviews revealed in part: 5. The Medication Regimen Review (MRR) involves a thorough review of the resident's medical record to prevent , identify, report, and resolve medication related problems, medication errors and other irregularities, for example: d. inadequate monitoring for adverse consequences; 9. An irregularity refers to the use of medication that is inconsistent with accepted pharmaceutical services, standards of practice; is not supported by medical evidence; and/or impedes or interferes with achieving the intended outcomes of pharmaceutical services. It may also include the use of medication without indication, without adequate monitoring, in excessive doses, and or in the presence of adverse consequences. Review of the facility's current policy and procedure on Pain-Clinical Protocol revealed in part: 1. The staff will reassess the individual's pain and related consequences at regular intervals; at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. Resident #15 Review of the medical record for resident #15 revealed an admitted [DATE] with diagnoses including depression, atrial fibrillation, protein calorie malnutrition, and diabetes mellitus. Review of the current care plan revealed resident #15 had the potential for injury and excessive bleeding related to the use of Eliquis (anticoagulant). Further review of the care plan revealed to monitor for signs and symptoms of bleeding every shift. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making and required assistance with activities of daily living. Review of the physician's orders dated 01/08/2024 revealed an order for Eliquis 5 milligrams (mg) per tube two times a day (bid), and Amiodarone HCL (antiarrhythmic) 200 mg to be given two times a day. Review of the Medication Regimen Review (MRR) dated 01/26/2024 revealed the pharmacist recommended that the nurses needs to monitor for bleeding when administering Eliquis, and to monitor blood pressures when administering Amiodarone. Review of the January 2024 and February 2024 Medication Administration Record (MAR) revealed no documented evidence that the staff monitored for bleeding when administering Eliquis, and blood pressure readings were not monitored for resident #15 when administering Amiodarone. On 02/28/2024 at 11:30 a.m., an interview with S2Director of Nursing (DON) revealed Resident #15 was not being monitored for bleeding while receiving Eliquis and there was no monitoring of resident #15's blood pressure when administering Amirodarone. Resident #122 Review of the medical record for resident #122 revealed diagnoses of hemiplegia, open angle glaucoma, depression, hypertension, cerebral infarction, anxiety, schizoaffective disorder, and dementia. Review of the current care plan for resident #122 revealed an approach to administer medications as ordered. Review of the admission MDS assessment dated [DATE] revealed the resident had moderately impaired cognitive skills for daily decision making. Review of the physician's orders dated 02/07/2024 revealed an order for Eliquis 2.5 mg two times a day for 4 weeks. Review of the February 2024 MAR revealed no documented evidence that the staff monitored for bleeding when administering Eliquis. On 02/28/2024 at 11:45 a.m., an interview with S2DON revealed resident #122 was not being monitored for bleeding while receiving an anticoagulant. 19121 Resident #34 Review of the medical record revealed sample resident #34 was admitted to the facility on [DATE] with diagnosis of hypothyroidism, diabetes mellitus, hypertension, abnormal posture, vascular dementia, history of falls, anxiety disorder, muscle wasting, lack of coordination, Alzheimer's disease, and osteoarthritis. Review of the yearly Minimum Data Set, dated dated dated [DATE] revealed the residents' BIMS (Brief Interview for Mental Status) score was 6, which indicates the resident is cognitively impaired and needs assistance with all activities of daily living. Review of the physician's orders revealed the following: Lantus 100 units/ml give 20 units every day at 8:00 p.m Lantus 100 units/ml give 20 units every day at 6:00 a.m Accu checks before meals and at bedtime with a sliding scale for Lispo insulin 0 units-blood sugar results of 0-200 2 units- blood sugar results of 201-250 4 units- blood sugar results of 251-300 6 units- blood sugar results of 301-350 8 units-blood sugar results of 351-400 10 units- blood sugar results over 400 and notify the Doctor. Review of the Medication Administration Record dated January and February 2024 revealed no documentation of the site insulin was given for the Lantus 20 units at 6:00 a.m and 8:00 p.m and for the sliding scale insulin given. Interview on 02/28/2024 at 10:15 a.m with S4Licensed Practical Nurse (LPN) confirmed she was sample resident #34's nurse and had not documented the site where the insulin was given. Interview on 02/28/2024 at 11:45 a.m with S2DON confirmed there was no documentation of the site the Lantus insulin was given on the medication administration record for January and February or in the medical record. 43405 Resident #60 Review of resident #60's record revealed an admitted [DATE] with diagnoses including Alzheimer's disease, major depressive disorder, type 2 diabetes mellitus, hypertension, hyperlipidemia, gout, anemia, psychotic disorder with hallucinations, anxiety disorder, and mood disorder. Review of the February 2024 Physicians Orders for resident #60 revealed the following orders: 11/14/2023- Norco 5/325 mg tab 1 by mouth (po) as needed (prn) every (q) 8 hours (hrs); 08/18/2023- Hydrochlorothiazide (diuretic) 25 mg tablet 1 po daily; and 08/18/2023- Januvia 50 mg tablet 1 po daily. Review of the January 2024 and February 2024 Medication Administration Record (MAR) for resident #60 revealed the following: -No monitoring for edema while taking Hydrochlorothiazide(diuretic); -No monitoring for pain every shift; and -No FSBS prn signs of abnormal glucose. Review of the Consultant Pharmacist Communication to Physician dated 10/20/2023 the pharmacist recommended that while resident #60 was on Januvia (antidiabetic medication)the following was to be done: Fingerstick Blood Sugars (FSBS) accucheck as needed (prn), signs of abnormal glucose and notify doctor if <50 and provide dietary intervention, if >400 notify physician. Physician agreed and signed on 10/30/2023. Review of the Consultant Pharmacist Communication to Nursing dated 10/20/2023 for resident #60 revealed recommendation for edema to be monitored and documented on MAR while resident was on Hydroclorodiazide (diuretic), and was signed and dated by S2DON on 10/23/2023. An interview on 02/28/2024 at 8:55 a.m. with S4LPN revealed she provides care to resident #60. S4LPN revealed she has not documented monitoring for edema or pain every shift, and has not performed FSBS (accuchecks) as needed on resident #60. An interview on 02/28/2024 at 10:25 a.m. with S2DON confirmed the following regarding #60's medication regimen: -no monitoring for edema every shift while taking a diuretic; -facility did not follow the pharmacist recommendation to monitor edema while taking diuretic; -no monitoring for pain every shift while taking pain medication; and -no FSBS accuchecks prn as recommended by pharmacist and ordered by the physician.

Based on record review and interview, the facility failed to ensure the pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing for 1 (#60) of 6 (#15, #24, #34, #55, #60, and #122) residents reviewed for unnecessary medications. The pharmacist failed to address no monitoring for pain every shift for resident #60 while receiving pain medication. Findings: Review of the facility's current policy and procedure on Pain-Clinical Protocol revealed, in part: 1. The staff will reassess the individual's pain and related consequences at regular intervals; at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. Review of the facility's current policy and procedure on Pharmacy Services: Medication Regimen Reviews revealed in part: 5. The Medication Regimen Review (MRR) involves a thorough review of the resident's medical record to prevent , identify, report, and resolve medication related problems, medication errors and other irregularities, for example: d. inadequate monitoring for adverse consequences; 9. An irregularity refers to the use of medication that is inconsistent with accepted pharmaceutical services, standards of practice; is not supported by medical evidence; and/or impedes or interferes with achieving the intended outcomes of pharmaceutical services. It may also include the use of medication without indication, without adequate monitoring, in excessive doses, and or in the presence of adverse consequences. Resident #60 Review of resident #60's record revealed an admitted [DATE] with diagnoses including Alzheimer's disease, major depressive disorder, type 2 diabetes mellitus, hypertension, hyperlipidemia, gout, anemia, psychotic disorder with hallucinations, anxiety disorder, and mood disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status of 3 indicating severe cognitive impairment. Review of the February 2024 Physician's Orders revealed an order dated 11/14/2023 for Norco 5/325 milligrams tablet 1 by mouth as needed every 8 hours. Review of the January 2024 and February 2024 Medication Administration Record (MAR) revealed no documentation of monitoring for pain every shift. Review of the monthly Medication Regimen Review (MRR) from August 2023 through January 2024 revealed the pharmacist did not identify that resident #60 did not have documentation for monitoring pain every shift while resident was taking pain medication. An interview on 02/28/2024 at 8:55 with S4Licensed Practical Nurse (LPN) revealed resident #60 does complain of pain at times and has administered Norco as needed. S4LPN reported she has not documented monitoring for pain every shift. Interview on 02/28/2024 at 10:25 a.m. with S2Director of Nursing (DON) confirmed that resident #60 did not have documentation of monitoring for pain every shift while taking pain medication. S2DON further confirmed that pharmacist did not identify that the facility was not monitoring for pain for resident #60.

Based on observation, record review, and interviews, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice by failing to assess the dialysis access site every shift, according to the facility's policy for hemodialysis access care, for 1 (#53) of 1 (#53) residents reviewed for dialysis. Findings: Review of the facility's policy and procedure on Hemodialysis Access Care revealed the following, in part: 3. Post-care of access site: b.) Nurse will inspect access port for bleeding, redness, or inflammation documenting any changes in the medical chart. Nurse is to notify medical doctor (MD) of any pertinent findings; c.) Nurse is to assess access site to ensure intactness and patency every shift (listening for bruit and feeling for a thrill); d.) Nurse is to document all findings such as condition of dressing (interventions if needed); report from dialysis facility, and observations post-dialysis. Review of the record for resident #53 revealed an admitted [DATE] with diagnoses including chronic kidney disease stage 5, unspecified atrial fibrillation, heart failure, polycystic kidney, and hypertension. Review of the record for resident #53 revealed the resident has dialysis 2 times per week on Mondays and Fridays. Review of the January 2024 and February 2024 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no documentation of monitoring the resident's dialysis access site. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 13, indicating cognitively intact. Further review of the MDS indicated resident #53 was on dialysis. Review of resident #53's dialysis care plan dated 12/08/2022 included interventions, in part, for staff to assess the access site after returning from dialysis for bleeding and signs and symptoms of infection. Review of January 2024 and February 2024 nurse's notes revealed no documentation of dialysis access site monitoring upon return from dialysis. An interview/observation on 02/27/2024 at 4:00 p.m. with resident #53 revealed that she goes to dialysis on Mondays and Fridays, and occasionally on Wednesdays, if needed. Resident #53 reported she has an access site to the right chest wall. Resident #53 reported that staff from the facility do not check her dialysis access site every shift and upon return from dialysis. Observation revealed a Tessio (central line catheter) to resident's right chest wall with 2 ports, with a Band-Aid over the insertion site. An interview on 02/28/2024 at 9:00 a.m. with S4Licensed Practical Nurse (LPN) revealed resident #53 goes to dialysis on Mondays and Fridays. S4LPN reported she monitors thrill and bruit for resident #53's dialysis access site every shift including when she returns from dialysis. An interview on 02/28/2024 at 9:00 a.m. with S2Director of Nursing (DON) confirmed that resident #53 has a Tessio central catheter to right chest wall for dialysis access. S2DON confirmed dialysis access site should be monitored every shift. S2DON confirmed there was no documentation of monitoring resident #53's dialysis access site every shift including post dialysis in her medical record.

Based on observations, interviews, and record review, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion or prevent further decrease in range of motion by failing to apply a splint daily for 1 (#4) of 1 (#4) residents reviewed for limited range of motion out of 31 sampled residents. Findings: Record Review revealed resident #4 was admitted to the facility on [DATE]. Resident #4's diagnoses included essential hypertension, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right non-dominant side, other sequelae of cerebral infarction, abnormal posture, lack of coordination, history of falling, contracture right wrist, contracture of muscle unspecified, aphasia following cerebrovascular disease, dysphagia following cerebral infarction, unspecified abnormalities of gait and mobility, and chronic pain. Review of yearly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. A further review of the MDS revealed resident was documented as having range of motion impairment on one side in his upper and lower extremities. Review of resident # 4's active February 2024 physician orders revealed an order for Certified Nurse Aide (CNA) to perform active/passive range of motion upper and lower extremities daily x 5 minutes due to hemiparesis which was ordered on 10/27/2022. Further review of the physician orders revealed there was no order for resident to wear splints. Review of the January and February 2024 nurse's notes revealed no documentation of resident #4 refusing to wear his right wrist/hand splint. On 02/26/2024 at 11:00 a.m. an observation of resident #4 revealed he was sitting in a wheel chair in his room, watching television. Resident #4 was noted to have a contracture of his right hand, right wrist, and right elbow. Further observation revealed there were no anti-contracture devices in place. On 02/27/2024 at 10:15 a.m. an observation of resident #4 revealed he was sitting in a wheel chair in his room, watching television. Resident #4 was noted to have a contracture of his right hand, right wrist, and right elbow with no anti-contracture device in place. Observation of resident #4's room revealed a blue wrist/hand splint and elbow splint sitting on the shelf of his television stand. Resident #4 reported they have not put the splints on in a long time. On 02/27/24 at 9:30 a.m. an interview with S5Rehabilitation Director, COTA (Certified Occupational Therapy Assistant) reported resident #4 last received part B services, Physical Therapy (PT) and Occupational Therapy (OT), on 12/06/2023 through 01/26/2024 due to a fall. S5Rehabilitation Director, COTA reported they put resident #4's right wrist/hand splint on 4 to 6 hours daily while he was receiving therapy. S5Rehabilitation Director, COTA reported resident #4 has not worn his right elbow splint in several years because it no longer fit properly. S5Rehabilitation Director, COTA reported the CNA or nurse should have continued applying resident #4's right wrist/hand splint 4 to 6 hours daily after he was discharged from part B services on 01/26/2024. S5Rehabilitation Director, COTA further reported the CNA should also assist resident #4 with range of motion to upper and lower extremities daily. On 02/27/2024 at 10:35 a.m. an interview with S6LPN (Licensed Practical Nurse) revealed resident #4 has not worn his splints in a long time. On 02/27/2024 at 1:20 p.m. an interview with S7CNA reveled she provided resident #4 with active and passive range of motion to his upper and lower extremities daily. S 7CNA reported resident #4 has not worn his splint on his right wrist/hand in a long time. On 02/27/2024 at 4:00 p.m. an interview with S2DON (Director of Nursing) confirmed resident #4 should wear his right wrist/hand splint 4 to 6 hours daily to help with his contracture.

Based on record review and interviews the facility failed to ensure that the plan of care had been revised for 1 (#4) of 1 (#4) residents' care plans reviewed for limited range of motion. Findings: Record review revealed resident #4 was admitted to the facility on [DATE]. Resident #4's diagnoses include essential hypertension, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right non-dominant side, other sequelae of cerebral infarction, abnormal posture, lack of coordination, history of falling, contracture right wrist, contracture of muscle unspecified, aphasia following cerebrovascular disease, dysphagia following cerebral infarction, unspecified abnormalities of gait and mobility, and chronic pain. Review of the yearly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. A further review of the MDS revealed resident was documented as having range of motion impairment on one side, in his upper and lower extremities. Review of resident #4's care plans revealed the only care plan related to contractures was a restorative nursing care plan with an onset date 08/21/2019 and ending date of 10/23/2019 that was prepared by S3ADON (Assistant Director of Nursing). Goal: Safely perform transfers, wheel chair to bed and bed to chair. Participate in exercise daily x 15 minutes. Program: Active range of motion to increase strength to extremities- participate in arch exercises for 15 minutes every day. Program: Splint/Brace Assistance - right hand/elbow splint- On in a.m. and Off in p.m. Program: Transfers- sit to stand and stand to sit, and bed to wheelchair cues for safety. Further review of the care plan related to resident #4's contractures of his right wrist and right elbow had not been updated since 10/23/2019 and there was not an active care plan to address his contractures. On 02/27/2024 at 4:00 p.m. an interview with S2DON (Director of Nursing) revealed resident #4's last documented care plan related to contractures of his right hand and elbow was the restorative nursing care plan with a beginning date 08/21/2029 and end date 10/23/2019. S2DON confirm the care plan related to his contractures had not been revised. S2DON further confirmed there was not an active care plan related to resident #4's contractures.

Based on interview and record review, the facility failed to consult with the resident's physician and notify the resident representative when there was a significant change in the resident's physical status for 1 (#84) of 3 (#84, #102, #103) closed records reviewed. This failed practice resulted in an actual harm on [DATE] at 3:44AM for Resident #84 when she was found unresponsive with an oxygen saturation level of 74%. Twenty minutes later, Resident #84's nurse documented that the resident was still lethargic and she was unable to obtain vital signs or an oxygen saturation level. The resident's nurse stated she was unable to reach Resident #84's physician and did not want to send the resident to the emergency room without speaking to the physician first. At 8:10AM, the oncoming nurse found the resident unresponsive. Resident #84 was sent to the emergency room at 8:17AM. Findings: A review of the facility's policy for Emergent Care for an Unresponsive Resident revealed the following: Policy Interpretation and Implementation: 1. Upon finding a resident who is unresponsive, the charge nurse is to assess the resident immediately. If the resident remains unresponsive, the charge nurse must contact EMS services for transport to nearest emergency room immediately. In this instance only is the physician to be contacted after EMS services have been contacted. If the resident becomes aroused or responsive during the charge nurse assessment, the charge nurse must notify physician of resident's condition. 2. Should the resident's attending physician be unavailable, the charge nurse may attempt to contact the physician's designated referral physician or practitioner. 3. Charge nurse is to call resident's responsible party and notify them of resident's change of condition. 4. Charge nurse is to document resident's conditions, transfer, physician and responsible party notification in the resident's medical chart. A review of Resident #84's medical record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. A review of Resident #84's Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicates the resident was cognitively intact. A review of Resident #84's nurse's notes revealed the following entries: [DATE] 3:44AM Resident brought to nurses station, Resident noted to be unresponsive. Resident assisted back to room per staff and assessed per this nurse and another staff nurse. Resident assisted back to bed per staff which caused some stimulation for the resident. Oxygen applied as ordered. Resident's oxygen saturation reads 74% and heart rate is 50. Oxygen going at this time. Will continue to monitor. By S1LPN [DATE] 4:04AM Resident remains in a lethargic state unable to obtain vital signs or an oxygen saturation level at this time. Call placed to Resident's physician to give him an update of resident's condition but was unable to reach. Will continue to monitor. S1LPN [DATE] At 8:10AM was called to resident's room Noted resident in bed unresponsive to verbal stimuli. Sternal rub done. Resident began to moan. Daughter here and called family members. BP ,[DATE] digitally, Pulse 116, and ,[DATE] manually. Resident transported to hospital per ambulance at 8:17AM. Resident's physician notified of transfer and ER notified. Noted cyanosis of resident's toes. Condition unchanged upon leaving. By S2LPN A review of the physician documentation from the hospital records for Resident #84 on [DATE] revealed at 9:00AM Resident arrives from nursing home, poorly responsive with no reported trauma or fever. The patient has shortness of breath at rest. The patient's shortness of breath is aggravated by supine position. Unable to obtain review of systems due to comatose state. Positive for malaise, weakness, and shortness of breath. Negative for [MEDICAL CONDITION]. Respirations are shallow respirations that are severe, agonal, with diminished breath sounds. The patient appears lethargic, in obvious distress, severely distressed. ,[DATE], P 63, R 28, T 91.6 and 98% pulse ox. Patient is 98% on 100% oxygen by non-rebreather. EKG: 60 beats/minute rhythm is regular with normal QRS axis and interval. Clinical impression: No evidence of ischemia. admitted to ICU (Intensive Care Unit) with preliminary [DIAGNOSES REDACTED]. Started on [MEDICATION NAME] and [MEDICATION NAME]. Sent to ICU at 11AM. A review of the Physician's ICU note revealed this stated Impression: The patient is obviously in a state of shock. It is probably not infectious in origin. It looks as though she has severe renal shutdown. Will hydrate her with some fluids to see if this will help any. I have discussed the lab findings with the family and they are aware. We are going to get a PICC (peripherally inserted central catheter) line put in and repeat her labs again this afternoon at 3:00PM. [DIAGNOSES REDACTED]. A note by the emergency room doctor at 19:45 on [DATE] stated he received a call that resident was without a pulse or heart rate. Family present. Time of death-19:00. At 2:29PM on [DATE], an interview by phone was conducted with S1LPN who was caring for Resident #84 on early morning hours of [DATE]. She stated Resident #84 was brought to the nurse's station in a wheelchair by a CNA (Certified Nursing Assistant). She said the resident wouldn't talk and wasn't responding. She said she called her physician several times and also called the hospital for him but was not able to reach him. She stated she didn't send the resident out to the emergency room because Dr. _____ had told them not to send her out recently. She stated she didn't call the medical director or anyone else. She stated the resident had improved and took her morning medications at 4:30AM or 5AM. She said she told her to swallow them and she did. She said the resident stated, I swallowed them. When asked about her code status, she stated I want to say she was a DNR. She further stated resident had been sent out several times. She stated the resident's blood pressure ran low anyway but her oxygen saturation normally would be up. She confirmed she called this resident's family member at 6:54AM that morning to report a fall earlier in the shift but did not tell them about the resident being unresponsive or unable to obtain vital signs because she wasn't unresponsive anymore. She stated the resident fell earlier in the night but had no injuries. She stated she didn't know what the facility's protocol was for sending out a resident who is unresponsive. She said she was going to send her out and that my purpose to call him was to send her out. She stated Resident #84's physician had never called back when she left at 7AM. A review of Resident #84's Medication Administration Record [REDACTED]. The resident's first morning medications were scheduled for 8AM. S1LPN was asked to show documentation where she gave the early morning medications she had mentioned and she could not do so. At 02:32PM on [DATE], an interview was held with S3DON (Director of Nurses) regarding what had occurred with this resident. She stated she thought the nurse spoke with the resident's physician that night and he told her to just continue monitoring her. At 02:40PM on [DATE], an interview was held with S2LPN who came to work at 7AM on the morning of [DATE]. She said she was working two halls, the ___ hall and the ___ hall. She stated by the time she received report and counted narcotics, she had started on the ___ hall. She stated someone came and found her and told her to come check on Resident #84. She said she went to see her and found her very sluggish and not herself. She said she did a sternal rub and was able to get the resident to answer her. She said she began working with her and taking her vital signs and getting her sent out as quickly as possible. She said her blood pressure was low. She stated she and others were working together to care for her and she is unsure if they obtained an oxygen saturation level. She said she called the resident's doctor afterwards and didn't have time to call the doctor before getting the resident sent out. She said she thought she was a full code but sent someone to look in the chart who told her later she was a DNR (do not resuscitate). She said she wasn't sure of what the protocol is for sending out residents with a DNR, but she was going to send her out due to her poor condition. She stated this was not Resident #84's usual condition. In an interview on [DATE] at 9AM, S4LPN stated if she finds an unresponsive patient, she would do a sternal rub, check their vital signs, and call the doctor and the ambulance at the same time. When asked what she would do if she didn't hear back from the doctor, she said in the past she had called for an ambulance without calling the doctor. When asked what if the resident is a DNR, she stated if they have vital signs but are unresponsive, she would still call an ambulance. On [DATE] at 9:05AM, an interview was held with S5LPN. She stated if she found an unresponsive resident, she would check vital signs and oxygen level. She said she would give oxygen and would stay in the room with the resident. She further stated she would send someone to get another nurse to call an ambulance. She stated, if the resident is not breathing, I would start CPR (cardiopulmonary resuscitation) until someone checked their code status. She stated she would call an ambulance first and then call the doctor afterwards to let him know I sent the resident out. She said, When in doubt, send them out. On [DATE] at 9:50AM, an interview was conducted with S6LPN, who stated for a resident who is unresponsive, she would check to see if they are breathing, do a sternal rub, take vital signs, and call the doctor. She further stated if the resident is a DNR and is still breathing, I'm sending them out because a DNR is only if everything stops. On [DATE] at 03:35PM, a phone interview was conducted with Resident #84's primary care physician. He stated had he been called by the nurse when Resident #84 was unresponsive and her oxygen saturation was 74%, he would have told the nurse to send the resident out to the emergency room . On [DATE] at 12:10PM, an interview was conducted with S3DON. She stated S1LPN did not call her or the Administrator during the night to let her know what was going on with this resident. She confirmed that she would have sent the resident out and the doctor would have just had to be mad.

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the resident's choices for 1 (#84) of 3 (#84, #102, #103) closed records reviewed. This failed practice resulted in an actual harm on [DATE] at 3:44AM for Resident #84 when she was found unresponsive with an oxygen saturation level of 74%. Twenty minutes later, Resident #84's nurse documented that the resident was still lethargic and she was unable to obtain vital signs or an oxygen saturation level. The resident's nurse stated she was unable to reach Resident #84's physician and did not want to send the resident to the emergency room without speaking to the physician first. At 8:10AM, the oncoming nurse found the resident unresponsive. Resident #84 was sent to the emergency room at 8:17AM. Findings: A review of the facility's policy for Emergent Care for Unresponsive Resident revealed the following: Policy Interpretation and Implementation: 1. Upon finding a resident who is unresponsive, the charge nurse is to assess the resident immediately. If the resident remains unresponsive, the charge nurse must contact EMS services for transport to nearest emergency room immediately. In this instance only is the physician to be contacted after EMS services have been contacted. If the resident becomes aroused or responsive during the charge nurse assessment, the charge nurse must notify physician of resident's condition. 2. Should the resident's attending physician be unavailable, the charge nurse may attempt to contact the physician's designated referral physician or practitioner. 3. Charge nurse is to call resident's responsible party and notify them of resident's change of condition., 4. Charge nurse is to document resident's conditions, transfer, physician and responsible party notification in the resident's medical chart. A review of Resident #84's medical record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. A review of Resident #84's Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicates the resident was cognitively intact. A review of Resident #84's medical record revealed a Louisiana Physician order [REDACTED]. No further instructions were chosen. A review of Resident #84's recent lab work revealed the following results: [DATE], creatinine level was 3.0 and glucose was 41. Results were received by the nursing facility at 17:51 on [DATE] and faxed to the physician on [DATE]. A review of Resident #84's nurse's notes revealed the following entries: [DATE] 3:13PM Resident on phone calling ER (emergency room ). Trying to call her doctor, requesting to go to hospital, stating she needs to go to hospital. This nurse went to resident's room. She is up in motorized wheelchair. Appears stable. No noted distress. Stated her head is hurting and she is in pain, stated she needs something for pain. Her daughter has arrived and she is telling her daughter to take her to the ER, attempted to reach her physician at this time, via page at the hospital, awaiting call back at this time. Addendum at 4:26PM: stated she's dying and needs to go to the hospital or go see her doctor. [DATE] 3:45PM Called to room per resident daughter who stated Mommy is vomiting. Enter room, received resident sitting on side of bed, no vomit noted, noted spit in trash can. Resident stated I just spit up phlegm and stated my head feels like it is about to burst, I want to go to the hospital, at 3:50PM out of facility to ER for evaluation per daughter, in private auto. [DATE] 5:58PM Resident returned to facility in stable condition. Resident no longer complains of headache and advised to continue to monitor nausea. ER administered [MEDICATION NAME] and 0.9% Normal saline (1000 milliliters). Daughter at bedside and resident is resting with no complaints. [DATE] at 10:24PM Resident states she has a headache and is requesting to go to the hospital. Resident's doctor has been called. Per resident's physician, resident just returned from the hospital and does not need to return. No new orders at this time. This nurse will continue to monitor resident and report to oncoming nurse. [DATE] 8:15AM Resident's son called stating Resident called him and said she has vomit all over the place. This nurse entered room to perform assessment, Resident lying supine in bed. No noted distress. No vomit noted in room. [DATE] at 1:37AM Resident out of bed on floor. Stated she was just lying there and she needed something stronger for pain. Moves upper and lower extremities without difficulty. No skin tears noted. T 97 P 70 R 18 ,[DATE]. Doctor notified and will call family in the morning. Call light in reach. Instructed resident to use call light when assistance is needed. Voiced understanding. [DATE] 3:44AM Resident brought to nurses station, Resident noted to be unresponsive. Resident assisted back to room per staff and assessed per this nurse and another staff nurse. Resident assisted back to bed per staff which caused some stimulation for the resident. Oxygen applied as ordered. Resident's oxygen saturation reads 74% and heart rate is 50. Oxygen going at this time. Will continue to monitor. By S1LPN [DATE] 4:04AM Resident remains in a lethargic state unable to obtain vital signs or an oxygen saturation level at this time. Call placed to Resident's physician to give him an update of resident's condition but was unable to reach. Will continue to monitor. S1LPN [DATE] At 8:10AM was called to resident's room Noted resident in bed unresponsive to verbal stimuli. Sternal rub done. Resident began to moan. Daughter here and called family members. BP ,[DATE] digitally, Pulse 116, and ,[DATE] manually. Resident transported to hospital per ambulance at 8:17AM. Resident's physician notified of transfer and ER notified. Noted cyanosis of resident's toes. Condition unchanged upon leaving. By S2LPN [DATE] 1:04PM Resident's family is here and stated resident expired. A review of the physician documentation from the hospital records for Resident #84 on [DATE] revealed at 9:00AM Resident arrives from nursing home, poorly responsive with no reported trauma or fever. The patient has shortness of breath at rest. The patient's shortness of breath is aggravated by supine position. Unable to obtain review of systems due to comatose state. Positive for malaise, weakness, and shortness of breath. Negative for [MEDICAL CONDITION]. Respirations are shallow respirations that are severe, agonal, with diminished breath sounds. The patient appears lethargic, in obvious distress, severely distressed. ,[DATE], P 63, R 28, T 91.6 and 98% pulse ox. Patient is 98% on 100% oxygen by non-rebreather. EKG: 60 beats/minute rhythm is regular with normal QRS axis and interval. Clinical impression: No evidence of ischemia. admitted to ICU (Intensive Care Unit) with preliminary [DIAGNOSES REDACTED]. Started on [MEDICATION NAME] and [MEDICATION NAME]. Sent to ICU at 11AM. A review of the Physician's ICU note revealed this stated Impression: The patient is obviously in a state of shock. It is probably not infectious in origin. It looks as though she has severe renal shutdown. Will hydrate her with some fluids to see if this will help any. I have discussed the lab findings with the family and they are aware. We are going to get a PICC (peripherally inserted central catheter) line put in and repeat her labs again this afternoon at 3:00PM. [DIAGNOSES REDACTED]. A note by the emergency room doctor at 19:45 on [DATE] stated he received a call that resident was without a pulse or heart rate. Family present. Time of death-19:00. A review of the blood work drawn in the emergency room revealed the following: Blood drawn on [DATE] at 9:35AM: Creatinine-4.95 and Glucose of 33. Troponin, [MEDICATION NAME], and BNP (Brain natriuretic peptide) were all a critically high level. At 2:29PM on [DATE], an interview by phone was conducted with S1LPN who was caring for Resident #84 on early morning hours of [DATE]. She stated Resident #84 was brought to the nurse's station in a wheelchair by a CNA (Certified nursing assistant). She said the resident wouldn't talk and wasn't responding. She said she called her physician several times and also called the hospital for him but was not able to reach him. She stated she didn't send the resident out to the emergency room because Dr. ___ had told them not to send her out recently. She stated she didn't call the medical director or anyone else. She stated the resident had improved and took her morning medications at 4:30AM or 5AM. She said she told her to swallow them and she did. She said the resident stated, I swallowed them. When asked about her code status, she stated I want to say she was a DNR. She further stated resident had been sent out several times. She stated the resident's blood pressure ran low anyway but her oxygen saturation normally would be up. She confirmed she called this resident's family member at 6:54AM that morning to report a fall earlier in the shift but did not tell them about the resident being unresponsive or unable to obtain vital signs because she wasn't unresponsive anymore. She stated the resident fell earlier in the night but had no injuries. She stated she didn't know what the facility's protocol was for sending out a resident who is unresponsive. She said she was going to send her out and that my purpose to call him was to send her out. She stated she works evenings but came in and split the night shift with another nurse, who had worked from 11PM-3AM and she worked from 3AM-7AM. She stated Resident #84's physician had never called back when she left at 7AM. A review of Resident #84's Medication Administration Record [REDACTED]. The resident's first morning medications were scheduled for 8AM. S1LPN was asked to show documentation where she gave the early morning medications she had mentioned and she could not do so. At 02:32PM on [DATE], an interview was held with S3DON (Director of Nurses) regarding what had occurred with this resident. She stated she thought the nurse spoke with the resident's physician that night and he told her to just continue monitoring her. At 02:40PM on [DATE], an interview was held with S2LPN who came to work at 7AM on the morning of [DATE]. She said she was working two halls, the ___ hall and the ___ hall. She stated by the time she received report and counted narcotics, she had started on the ___ hall. She stated someone came and found her and told her to come check on Resident #84. She said she went to see her and found her very sluggish and not herself. She said she did a sternal rub and was able to get the resident to answer her. She said she began working with her and taking her vital signs and getting her sent out as quickly as possible. She said her blood pressure was low. She stated she and others were working together to care for her and she is unsure if they obtained an oxygen saturation level. She said she called the resident's doctor afterwards and didn't have time to call the doctor before getting the resident sent out. She said she thought she was a full code but sent someone to look in the chart who told her later she was a DNR (do not resuscitate). She said she wasn't sure of what the protocol is for sending out residents with a DNR, but she was going to send her out due to her poor condition. She stated this was not Resident #84's usual condition. In an interview on [DATE] at 9AM, S4LPN stated if she finds an unresponsive patient, she would do a sternal rub, check their vital signs, and call the doctor and the ambulance at the same time. When asked what she would do if she didn't hear back from the doctor, she said in the past she had called for an ambulance without calling the doctor. When asked what if the resident is a DNR, she stated if they have vital signs but are unresponsive, she would still call an ambulance. On [DATE] at 9:05AM, an interview was held with S5LPN. She stated if she found an unresponsive resident, she would check vital signs and oxygen level. She said she would give oxygen and would stay in the room with the resident. She further stated she would send someone to get another nurse to call an ambulance. She stated, if the resident is not breathing, I would start CPR (cardiopulmonary resuscitation) until someone checked their code status. She stated she would call an ambulance first and then call the doctor afterwards to let him know I sent the resident out. She said, When in doubt, send them out. On [DATE] at 9:50AM, an interview was conducted with S6LPN, who stated for a resident who is unresponsive, she would check to see if they are breathing, do a sternal rub, take vital signs, and call the doctor. She further stated if the resident is a DNR and is still breathing, I'm sending them out because a DNR is only if everything stops. On [DATE] at 03:35PM, a phone interview was conducted with Resident #84's primary care physician. He stated had he been called by the nurse when Resident #84 was unresponsive and her oxygen saturation was 74%, he would have told the nurse to send the resident out to the emergency room . On [DATE] at 12:10PM, an interview was conducted with S3DON. She stated S1LPN did not call her or the Administrator during the night to let her know what was going on with this resident. She confirmed that she would have sent the resident out and the doctor would have just had to be mad. On [DATE] at 9:08AM, an interview was conducted with S2LPN who stated she could not remember if S1LPN had told her during morning report that Resident #84 had been unresponsive with a low oxygen saturation level during the night. She further stated if she had been told that, she would have checked on Resident #84 first.

Based on record review and interview the facility failed to ensure that the residents' environment remains as free of accident hazards by failing to ensure the residents identified by the facility as unsafe smokers were provided adequate supervision and monitoring during smoking for 1 (#1) of 5 (#1, #2, #3, #4 and #5) sampled residents in a total sample of 5. Review of the list of residents who smoke provided by S3DON revealed the facility had assessed 11 residents to be unsafe with smoking and 2 residents were assessed to be safe with smoking; for a total of 13 residents in the facility that smoke. This failed practice resulted in Actual Harm on 09/09/16 for resident #1 who was assessed to be an unsafe smoker when he sustained 3rd degree burns to the upper 1/3 area of the anterior torso and portions of his right upper arm and shoulder while smoking. The resident also sustained 2nd degree burns to small areas of the left upper extremity, right knee and left thigh. At approximately 4:00PM, before the incident occurred, the resident asked S11LPN to use the phone to call his wife to bring him cigarettes, but his wife did not bring any cigarettes to the facility on [DATE]. The resident obtained a cigarette from another resident who was smoking. No staff was in the smoking area monitoring residents who were smoking and resident #1 was not wearing a fire proof smoking apron. Findings: Review of the medical record for resident #1 revealed the resident had [DIAGNOSES REDACTED]. Review of the current care plan revealed the resident required extensive assistance with activities of daily living and the resident had alterations in his thought process due to cognitive skills. The resident scored an 8 (moderately impaired cognition) on the Brief Interview for Mental Status. Further review of the care plan dated 02/09/16 revealed a care plan for potential for injury related to smoking and the approaches were to instruct the resident on the designated smoking areas, and perform a smoking assessment quarterly. The resident was assessed to be a safe smoker and his family provided smoking materials for the resident and the family would leave them at the nurses station. Documentation in the care plan dated 05/04/16 revealed the resident was noted not smoking at this time due to his weak status after a recent return from the hospital, no smoking materials were left at the nurses station by the family, and at this time he was assessed as an unsafe smoker. Documentation in the care plan dated 07/25/16 revealed the resident's wife brings smoking materials to the resident and the staff was unaware. The resident will hide cigarettes in his baseball cap and he is non compliant with smoking materials, other residents and family provide the resident with cigarettes. Review of the quarterly Minimum (MDS) data set [DATE] revealed the resident scored an 8 (moderately impaired cognition) on the Brief Interview for Mental Status. The resident required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene, and required limited assistance with locomotion on the unit. Further review of the Minimum Data Set revealed the resident had range of motion impairment on the left upper and lower extremities and used a wheelchair for mobility. Review of the Safe Smoking Assessment performed by S6ADON dated 05/04/16 and 07/25/16 revealed the resident was assessed to be an unsafe smoker. Review of the Incident/Accident report dated 09/09/16 at 5:35PM revealed S11LPN was called to the smoke area by a resident. The resident was yelling for a nurse and stated that a man was on fire. S11LPN arrived outside and she noticed sampled resident #1's shirt was on fire, S8CNA put out most of the fire and S14LPN removed the resident's shirt and threw it on the ground, and S11LPN stomped out the fire on the shirt. S11LPN noted multiple burn areas to the resident's face and upper and lower extremities. The resident was taken to his room and an ambulance was called, his vital signs were taken his blood pressure was 120/70, pulse 80 and respirations 18, the physician and wife were notified. S11LPN found a lit cigarette in the resident's wheelchair and a cigarette lighter was taken from the resident's hand. Review of the investigation of the incident that occurred on 09/09/16 revealed S3DON was told that resident received a cigarette from resident #2. Resident #1 was sitting outside with 2 other residents in the smoking area when he attempted to light a cigarette with a lighter. The lighter ignited and caught his shirt on fire. The staff were notified of the incident by a resident and the staff responded immediately. The staff were unaware of the resident smoking at this time because he did not have any cigarettes at the facility. Further review of the investigation revealed resident #2 admitted to giving resident #1 a cigarette. Review of the history and physical (H&P) dated 09/09/16 from the hospital revealed the resident had 3rd degree burns to the upper 1/3 of the anterior torso and portions of his right upper arm and shoulder. Further review of the H&P revealed the resident had 2nd degree burns to small areas of the left upper extremity, right knee and left thigh. Review of the facility's Smoking Policy in place during the time of the incident revealed no lighters are be kept in resident's room, smoking will only be permitted under the direct supervision of a staff member in the facility's designated smoking area, the supervising staff member will monitor the safety of the residents during smoking, and unsafe smokers would be monitored during smoking. On 09/26/16 at 2:40PM an interview with S3DON stated the resident was not smoking after he got out of the hospital in 05/16 because he was weak and didn't go outside. S3DON stated the smoking policy prior to the incident dated 09/09/16 was to have a staff member present with the unsafe smokers while smoking. S3DON confirmed a staff member was not monitoring the residents outside when the fire incident occurred on 09/09/16; therefore the staff were not following the facility's smoking policy. On 09/26/16 at 3:30PM an interview with S11LPN stated she worked with the resident on 09/09/16 on the 3PM - 11PM shift. S11LPN stated on 09/09/16 at approximately 4:00PM the resident asked to use the phone to call his wife to bring him cigarettes, but his wife did not bring any cigarettes to the facility on [DATE]. S11LPN stated she was not aware that resident #1 went outside to the smoking area on 09/09/16 until she was informed that a resident was on fire. S11LPN stated she ran outside to the smoking area to assess the situation and found resident #1 sitting in his wheelchair and she noticed he had burns to his face, arms, side and neck. The staff members removed the resident's shirt and put out the fire. The ambulance was notified of the resident needing medical attention. The resident was taken to his room, assessed and his vital signs were taken, he was alert and responsive. The physician and the resident's wife were notified of the incident. The ambulance arrived and transported him to the hospital. S11LPN stated during the time of the incident resident #1 and #2 were the only residents smoking. S11LPN questioned where resident #1 got the cigarette and resident #2 raised his hand. S11LPN asked resident #2 if he gave resident #1 the cigarette and he nodded his head yes. S11LPN stated prior to the incident the unsafe smokers were the only ones that the staff monitored while smoking and she confirmed resident #1 was not being monitored at the time the incident occurred on 09/09/16 and was not wearing a fire proof smoking apron. On 09/26/16 at 3:55PM an interview with S14LPN stated when she heard that a resident was outside on fire she ran to assist. When she arrived to the smoking area the fire had been extinguished and the resident was sitting in his wheelchair, S11LPN was assessing the resident. Further interview with S14LPN stated the ambulance, physician and responsible party were notified of the incident and the resident was transported to the hospital for evaluation. On 09/27/16 at 11:00AM an interview with S3DON confirmed the resident was assessed as an unsafe smoker and the facility was unaware that resident #2 had given him a cigarette. S3DON further confirmed according to the care plan the resident hid cigarettes in his ball cap and was noncompliant with smoking materials. S3DON stated the staff should have monitored the resident more closely for safety issues regarding smoking.

I. Based on record review, observation and interview, the facility failed to ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for 1 of 5 sampled residents with pressure sores or high risk for pressure sores (#1). The facility failed to: 1.) have documentation of turning and repositioning; 2.) have an accurate assessment of sampled resident #1's pressure sore to the coccyx; 3.) assess the effectiveness of current interventions to prevent the recurring of pressure sores on the coccyx; 4.) monitor for implementation of the resident's careplan and 5.) follow the facility's pressure sore policy for providing additional nutritional supplements. This resulted in actual harm for sampled resident #1 when she acquired a recurring pressure sore on the coccyx. Findings: 1. Review of the medical record for sampled resident #1 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Further review of the Minimum (MDS) data set [DATE] revealed the resident's cognition was severely impaired, the resident was totally dependent on staff for activities of daily living and the resident was incontinent of bowel and bladder. Review of the Braden Scale for Predicting Pressure Sore Risk dated 8/8/2011 and 2/8/2011 revealed the resident was at high risk for developing pressure sores. Review of the medical record revealed the resident was being treated at a wound clinic since 3/2011 for a diabetic/arterial ulcer on her left heel. Further review of the culture report of the left heel dated 9/27/2011 revealed [MEDICAL CONDITION] Staphylococcus Resistant Aureus. The resident was receiving Cipro. Review of the careplan revealed the following approaches: 1. weekly Registered Nurse assessment, 2. pressure relieving device (Panacea) to bed, 3. notify physician and family of any skin breakdown, 4. yellow dot to flow sheet to signify high risk, 5. weekly body audit per Licensed Practical Nurse, 6. incontinent care every 2 hours and when necessary (keep clean and dry), 7. turn every 2 hours while in bed, 8. weekly weights, 9. consult Registered Dietician as needed, 10. give multivitamin and vitamin C as ordered and 11. consult to wound clinic (3/14/2011 - left heel). Review of the physician orders [REDACTED]. Review of the Pressure Sore Program revealed residents with identified pressure sores or who are prone to chronic skin problems will receive special nutrition care. Nursing staff shall notify the dietary manager when resident develop pressure sores or skin breaks. The dietary manager or the consultant dietitian will develop a plan of care to meet the nutrition needs of the resident. Review of the lab dated 4/04/2011 revealed the [MEDICATION NAME] level was 3.6 (normal 4 - 4.9). Further review revealed there was not another [MEDICATION NAME] level done. Review of the Registered Dietician notes revealed the [MEDICATION NAME] was discontinued 5/24/2011 and not restarted. Further review revealed the Vitamin C, Multivitamin and Zinc were discontinued on 5/17/2011 and restarted on 8/09/2011. Review of the Wound Assessment sheet dated 6/1/2011 revealed the following three pressure sores acquired at the facility: 1.) coccyx #1 - stage II pressure sore measuring 2 cm x 0.7 cm, 2.) coccyx #2 - stage II pressure sore measuring 0.5 cm x 0.5 cm 3.) coccyx #3 - stage II pressure sore measuring 0.5 cm x 0.7 cm. Review of the Weekly Body Audit dated 6/1/2011 revealed the physician and responsible party were notified. Further review of the Treatment Administration Record revealed the areas were treated as ordered. Review of the Wound Assessment sheet revealed the areas were assessment weekly and healed on 6/28/2011. Review of the Wound Assessment sheet dated 8/17/2011 revealed a stage II pressure sore on the coccyx measuring 2 cm x 2 cm which was acquired at the facility. Review of the Weekly Body Audit sheet revealed the physician and responsible party were notified. Review of the Wound Assessment sheet for the coccyx revealed the following measurements: 8/22/2011 - 4.5 cm x 5 cm; 8/29/2011 - 3.5 cm x 4 cm; 9/5/2011 - 3 cm x 3.5cm; and 9/12/2011 - healed. Further review of the Treatment Administration Record revealed the areas were treated as ordered. Review of the Wound Assessment sheet dated 9/26/2011 revealed a stage II pressure sore on the coccyx measuring 5 cm x 3.5 cm with strands of eschar and small amount of bloody exudate with no odor was acquired at the facility. Further review of the Wound Assessment sheet dated 10/3/2011 revealed the coccyx wound had progressed to an unstageable pressure sore measuring 7 cm x 4.5 cm with 100% [MEDICATION NAME] necrosis. The treatment was changed from Allevyn every 3 days to Santyl everyday. Review of the Wound Assessment sheet dated 10/10/2011 revealed the stage III pressure sore on the coccyx measuring 11 cm x 6 cm x 0.1 cm with 75% slough necrosis. Review of the medical record revealed no documentation of turning and repositioning the resident every 2 hours. Observation of the resident's room revealed there was not a turn schedule on the wall. An interview with S3CNA on 10/19/2011 at 11:00AM revealed the resident was totally dependent on them for all activities of daily living. She stated that they turned the resident every two hours, but do not document turning and repositioning. An interview with S4CNA on 10/19/2011 at 11:15AM revealed the resident was totally dependent on staff for activities of daily living. She stated that they turned the resident every two hours, but do not document turning and repositioning. An interview with S1DON on 10/19/2011 at 1:30PM confirmed the facility had no documentation of turning and repositioning. S1DON confirmed the need to reassess the resident's current interventions for prevention of pressure sores. S1DON confirmed the resident's nutritional needs were not reassessed and the facility's pressure sore policy regarding providing nutritional supplements was not followed. An interview with S5Treatment Nurse on 10/19/2011 at 2:15PM revealed the nurses are to monitor for the implementation of the care, but there was no documentation of this monitoring. II. Based on record review, observation and interview, the facility failed to ensure residents having pressure sores or at high risk for pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. The facility failed to implement supplemental recommendations provided by the Registered Dietician for wound healing for 4 of 5 sampled residents with pressure sores in a total sample of 5. (sample 2, 3, 4, and 5) Findings: 1. Review of the medical record for sampled resident #2 revealed [DIAGNOSES REDACTED]. Review of the Wound assessment dated [DATE] revealed the resident has a stage II pressure sore on her right upper foot. Review of the Registered Dietician notes dated 8/21/2011 revealed the Registered Dietician recommended to add Med pass 2.0 90cc three times a day. Further review of the Registered Dietician notes dated 10/3/2011 revealed the Registered Dietician recommended to add a Multivitamin with minerals and Medpass 2.0 90 cc three times a day. Review of the physician orders [REDACTED]. On 10/19/11 at 2:00PM an interview with S1 DON confirmed the resident was not receiving the supplements as recommended. 2. Review of the medical record for sampled resident #3 revealed she was admitted [DATE] with [DIAGNOSES REDACTED]. Further review of the medical record revealed the resident was at high risk for pressure sores and was dependent on staff for ADLs. On 10/19/11 observation of the resident's skin revealed a healed area to the coccyx. Review of the Dietician notes for sampled resident #3 dated 10/3/11 revealed a recommendation to start Vitamin C with minerals (supplement) and med pass 90 cubic centimeters with medication administration for wound healing. Review of the 10/11 physician orders [REDACTED]. On 10/19/11 at 2:00PM interview with S1 DON confirmed the resident was not receiving the supplements as recommended. 3. Review of the medical record for sampled resident #4 revealed she was admitted [DATE] with [DIAGNOSES REDACTED]. Further review of the medical record revealed the resident was at high risk for pressure sores and was dependent on staff for ADLs. On 10/19/11 observation of the resident's skin revealed she had an open area behind her left ear due to a structural defect. Review of the Dietician notes for sampled resident #4 dated 3/1/11 and 6/6/11 revealed a recommendation to start Vitamin C (supplement) every day for wound healing. Review of the physician communication sheet dated 3/1/11 revealed the physician agreed to start the Vitamin C. Review of the 10/11 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 10/19/11 at 2:00PM interview with S1 DON confirmed the resident was not receiving the medication as recommended. 4. Review of the medical record for sampled resident #5 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. On 10/19/11 observation of the resident's skin revealed an open area to the coccyx. Review of the Dietician notes dated 5/2/11 for sampled resident #5 revealed a recommendation to increase med pass from 90cc to 120cc three times a day with medication administration to help with wound healing. Review of the 10/11 revealed the resident did not receive the increased supplement as recommended. On 10/19/11 at 2:00PM interview with S1 DON confirmed the resident was not receiving the increased amount of the supplement as recommended.