Every finding on record at Lincoln Village Healthcare

Based on Record Review and Interview, the facility failed to ensure residents with significant pressure injury, poor skin integrity and wound infections were provided physician ordered pressure ulcer treatments and skin assessments for two of three residents (R1, R2) reviewed for pressure ulcers in the sample of three.Findings include:The facility's Pressure Ulcer and Wound Prevention/Management Program policy, dated 9/30/25, documents To provide a guideline for the appropriate nursing management of skin breakdown when it occurs. It is the policy of this facility to: Ensure a resident who has been admitted with pressure ulcers or develops pressure ulcers in-house receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing, when possible. This policy also documents Skin assessments will be completed weekly or as ordered for residents who are mild and moderate, high and severe risk for breakdown. Facility will determine where documentation of skin assessments will be completed, such as on the Treatment Administration Record (TAR) or shower sheets by a licensed nurse.The facility's Skin and Wound Management policy, dated 1/2025, documents To ensure appropriate assessment, treatment, monitoring and documentation of skin and skin alteration. Wound care procedures and treatments should be performed according to physician orders. Preventative measures, such as barrier creams can be employed to help maintain skin integrity as well as utilization of pressure relieving surfaces, floating heels, protective boots and use of positioning devices. Document in the clinical record when treatments are performed.1. R1's current Care Plan, dated 7/8/26, documents R1 was admitted to the facility on [DATE] with diagnoses including Heart Failure, Stage three Pressure Ulcer, and Stage two Pressure Ulcer of the left ankle. This care plan documents Problem: (R1) has a pressure ulcer on his left posterior ankle related to impaired physical mobility. Approach: Treatment as per orders. Assess and record the condition of the skin surrounding the pressure ulcer. Problem: (R1) has a pressure ulcer to his left second toe related to impaired physical mobility. Approach: Treatment as per orders. Problem: (R1) has a pressure ulcer to coccyx related to impaired physical mobility and weakness due to heart failure, and anemia. Problem: (R1) has a pressure ulcer on left medial ankle related to impaired physical mobility and weakness due to heart failure, ASHD (atherosclerotic heart disease), and Anemia. Problem: (R1) has a pressure ulcer to left heel related to impaired physical mobility and weakness due to heart failure, ASHD and Anemia. This same care plan documents R1 has pressure ulcers and impaired skin integrity to his right and left buttocks related to diagnoses and impaired mobility.R1's Physician Order Summary (POS) and Treatment Administration Record (TAR), dated 7/1/26- 7/29/26, documents R1 has a pressure ulcers treatment order for Wound Care: right posterior thigh: cleanse with normal saline solution, pat dry and apply (combination barrier paste), dime thick, once a day. This TAR documents R1 did not receive the scheduled thigh treatments on 7/6, 7/7, 7/9, 7/11, or 7/13. R1's same POS/TAR includes scheduled pressure ulcer treatment orders to the left posterior ankle, left posterior thigh, right medial ankle, left lateral second toe, right buttocks, left lower extremity, left heel, and coccyx, as well as an order for skin assessments to be completed daily. This same TAR documents three out of 19 scheduled treatments to R1's left posterior ankle were not administered, five of 21 scheduled treatments to R1's left posterior thigh were not administered, two of seven scheduled treatments to R1's right medial ankle were not administered, one of seven scheduled treatments to R1's left lateral second toe was not administered, seven out of 23 scheduled treatments to R1's right buttocks were not administered, six out of 30 scheduled treatments to R1's left lower extremity were not administered, six of 35 scheduled treatments to R1's left heel were not administered, two out of 21 scheduled treatments to R1's coccyx were not administered and R1's daily skin assessments were not completed on 7/6, 7/11 and 7/12. Of the 32 unadministered pressure ulcer treatments, four document a reason for not administering of did not have time, two document a reason for not administering of not my shift and one documents not administered, previous shift. The remainder of unadministered treatments do not document a reason.R1's Nursing Progress notes, dated 7/29/26 at 1:43 PM, documents (R1) seen by wound provider today. Wound to coccyx remains stable. Wounds to left lower leg, left buttock, left 2nd toe & left medial ankle are all healing. Wound to left heel has declined. New order from wound provider to send resident to be evaluated related to positive osteomyelitis x-ray.R1's Nursing progress notes, dated 7/29/26 at 6:26 PM, documents R1 was sent to the local emergency room by ambulance for an osteomyelitis evaluation. On 8/4/26 at 10:40 AM, V4 (Licensed Practical Nurse/ Wound Nurse) stated she has been the facility's wound nurse for several months and confirmed that R1 has multiple pressure wounds. V4 stated The TAR for (R1) shows that he was not provided treatments. Those treatment administrations were not in the record and I did not realize it until this morning. Treatment charting should be completed in the computer. I have no proof that treatments were completed on the dates in question. Normally if I do the treatment, I make a record in the computer and chart on the electronic TAR. V4 verified that R1's electronic record does not document any nursing notes or further explanation of why R1's pressure treatments were not administered on several occasions prior to him going to the hospital.2. R2's Care Plan, dated 5/21/26, documents R2 is [AGE] years old and admitted to the facility on [DATE] with diagnoses including Multiple Sclerosis, Osteomyelitis of vertebra, sacral and sacrococcygeal region, Paraplegia and Adult Failure to Thrive. This plan of care documents (R2) has a pressure ulcer on her left anterior ankle related to multiple sclerosis, paraplegia and adult failure to thrive.R2's POS and TAR, dated 6/1/26-6/18/26, documents R2 had a pressure ulcer treatment orders for left anterior ankle: paint with (tinted antiseptic solution) one time daily and left ankle superior: cleanse with normal saline, apply honey and cover with dry dressing one time daily. This same TAR documents R2 did not receive six out of 32 scheduled left ankle treatments. This record documents two reasons for not administering the treatment were not enough time, two reasons were not administered, previous shift and the remaining two did not document a reason for not providing the treatment.On 8/4/26 at 2:00 PM, V2 (Director of Nursing) verified that R2's wound treatment shows missing treatments. V2 verified that if nursing staff enter not enough time and check the treatment as not administered in the computer, it causes the order to appear complete. V2 stated That is likely how treatments would be missed. If the nurse can't do the treatments, they should not be checking the orders off. Wound treatments should be completed and documented as ordered by the doctor or wound specialist.

Based on Record Review and Interview, the facility failed to ensure a resident's physician ordered Gabapentin (Multiple Sclerosis nerve treatment medication) was administered as prescribed and ensure the physician was notified of consecutive missed/refused medication doses for one of three residents (R2) reviewed for Medication Administration in the sample of three.Findings include:The facility's Medication Administration policy, dated 10/25/14, documents Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the medication management system in the facility. The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. This policy also documents Medications are administered in accordance with written orders of the prescriber. If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time, the space provided on the front of the MAR (Medication Administration Record) for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record. If an electronic MAR system is used, specific procedures required for the resident identification, identifying medications due at specific times, and documentation of administration, refusal, holding doses, and dosing parameters such as vital signs and lab values are described in the system's user manual.The facility's Preventing and Detecting Adverse Consequences and Medication Errors policy, dated 10/25/14, documents The facility employs a system to assure that medication usage is evaluated on an ongoing basis. When a resident has a change in condition, medication-related problems are considered. Significant medication-related problems are assessed, documented and reported as appropriate to the resident's attending physician, the quality assessment and assurance committee, the pharmacy, the consultant pharmacist, and the food and drug administration program or medication error reporting program. This policy also documents The attending physician is notified promptly of any significant error or adverse consequence.The Full Prescribing Information drug fact sheet for Neurontin (Gabapentin), dated 10/2017 and located at https://www.accessdata.fda.gov/drugsatfda_docs, documents Do not stop taking Neurontin without first talking to your healthcare provider. Stopping Neurontin suddenly can cause serious problems. Stopping Neurontin suddenly can cause serious problems. Stopping a seizure medicine suddenly in a patient who has epilepsy can cause seizures that will not stop (status epilepticus).R2's Clinical Query Documentation Primary Diagnosis form, dated 5/13/26 and signed by V11 (Facility's Medical Director/ R2's Physician), documents R2 has a primary diagnosis of Multiple Sclerosis and current treatment is Gabapentin 600 milligrams by mouth, three times a day along with restorative and therapy evaluations.R2's Care Plan, dated 5/21/26, documents R2 is [AGE] years old and admitted to the facility on [DATE] with diagnoses including Multiple Sclerosis, Osteomyelitis of vertebra, sacral and sacrococcygeal region, Paraplegia and Adult Failure to Thrive. R2's Physician Order Sheet and Medication Administration Record (MAR), dated 6/1/26-6/18/26, documents R2 had an order for Gabapentin 600 milligrams by mouth three times daily. This MAR documents R2's Gabapentin was not administered on 21 out of a possible 53 opportunities. Including zero doses of Gabapentin being given on 6/3/26, and only one dose being administered on 6/4, 6/12, 6/15, 6/16, 6/17 and 6/18. Of the non-administered doses, 19 document a reason of refused and two document resident unavailable.R2's electronic medical record does not document any progress notes, assessments or physician orders to address R2's not administered doses of Gabapentin.On 8/4/26 at 12:51 PM, V1 (Administrator in Training) stated Refused medications should have a medication refusal sheet faxed to the physician and then those are scanned into the electronic chart. V1 verified that R2 was discharged from the facility on 6/18/26 and her electronic chart contains a medication refusal form that was faxed to the R2's physician (V11) for R2's noon dose of Gabapentin refusal on 5/26/26 .On 8/4/26 at 12:54 PM, V2 (Director of Nursing) verified that Gabapentin withdrawal can occur and the medication should not be stopped abruptly. V2 confirmed that multiple doses of R2's Gabapentin were not administered as ordered and stated she does not have documentation to show that V11 was made aware of the non-administered doses. V2 stated Nurses should be reporting those (medication refusals) to the doctor, each time it is refused and documenting any changes or assessment in the medical record.

Based on interview and record review the facility failed to prevent a fall for one resident (R1) of three residents reviewed for falls in the sample of five. Findings include:The Fall Evaluation and Safety Guideline policy dated 1/14/26 documents Purpose- To consistently identify and evaluate residents at risk for falls and those who have fallen, to treat or refer for treatment appropriately, and to build organization-wide ownership of fall prevention in order to: Prevent or reduce injuries related to falls. Intent of This Guideline- To ensure the facility provides an environment free from controllable hazards and delivers appropriate supervision to each resident through the following process: 3. Implementation of interventions.The Activities of Daily Living policy dated 2/2023 documents Purpose: Based on a comprehensive assessment of the resident and consistent with the resident's needs and choices, our facility provides necessary care and services to ensure that resident's abilities in activities of daily living (ADL) do not diminish unless the circumstances of the individual's clinical condition demonstrates that such decline was unavoidable. Guideline: In accordance with the comprehensive assessment, together with respect for individual resident needs and choices, our facility provides care and services for the following activities: Elimination: Toileting.R1's computerized Medical Record documents that R1 is a [AGE] year-old that was admitted to the facility on [DATE] with diagnoses which included Unspecified sequelae of cerebral infarction, Chronic Respiratory Failure with Hypoxia, Type 2 Diabetes Mellitus, Dysphagia, following Cerebral Infarction, Tracheostomy Status, Contracture of Right and Left hand, and Aphasia Following Cerebral Infarction.R1's MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) of 9, indicating (moderate cognitive impairment). R1 has lower extremity impairment, is dependent on two staff for all activities of daily living, bed mobility, and transfers.R1's Care Plan documents that R1 is at risk of falling related to impaired physical mobility related to Sequelae of Cerebrovascular Accident. The Care Plan also documents that R1's bed mobility has deteriorated and R1 requires two assists for bed mobility. (R1) will roll side to side and maintain a side lying position with 2 (two) staff assistance while cares are provided.R1's Fall Report documents on 4/14/26 at around 9:45 PM. R1 fell from bed and was lying face down with his head against the nightstand. There was no injury noted but R1 was sent to the emergency room for evaluation since R1 hit his head. The fall was witnessed by V3/Certified Nursing Assistant. On 6/8/26 at 2:25 PM, V3/Certified Nursing Assistant/CNA stated that R1 was in bed and V3 and V12/CNA Manager were doing incontinent care on R1. R1 was on his side with V3 on one side of the bed and V12 on the other side. V12 left the bedside to get the washcloths wet. While V12 was in the bathroom R1 rolled out of bed and fell to the floor. On 6/8/26 at 2:32 PM, V12/CNA Manager stated she was helping V3 with incontinent care for R1. R1 was lying on his side and when V12 went to the bathroom to wet the washcloths R1 rolled out of bed landing on the floor. V3 also stated that R1 is care planned for two staff when providing care for R1.On 6/10/26 at 12:00 PM, V1/Administrator stated that per the care plan R1 should have had two people at the bedside during incontinent care.

Based on observation, interview and record review the Facility failed to provide adequate staffing requirements for Registered Nurse coverage and a full-time Director of Nursing meeting the requirements of a Facility with a Resident census over the amount of 60 Residents. This failure has the potential to affect all 83 Residents residing in the Facility.Findings include: The Facility Resident Census Report documents 83 Residents residing in the facility.The Facility Assessment, 7/10/25, documents: the Facility must have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure Resident safety and highest practicable well-being of each Resident; serves as a record for staff and management to understand the reasoning for decisions made regarding staffing and other resources; licensed to provide for 126 Residents; identifies Nursing Services staff members required to provide needed the support and care of Residents (Director of Nursing, Registered Nursing, Licensed Practical Nurse, Infection Preventionist, Restorative Nurse and Minimum Data Set/MDS); the title of Director of Nursing as V2 (Director of Nursing); personnel with administrative duties as two Registered Nurses and four Licensed Practical Nurses.The Director of Nursing Job Description, undated, documents: monitoring of all major nursing programs, overall compliance with the Facility's State and Federal regulatory nursing program compliance; observations regarding nursing issues; assure proper staffing of the nursing departments via the hiring process in accordance with established staffing budgets; create and maintain work schedules and determine and delegate work assignments to assure the Facility nursing services maintain all State, Federal and local regulations.The Facility Nurse Schedules (2/2/26, 2/3/26, 2/6/26, 2/10/26, 2/16/26, 2/17/26, 2/19/26, 2/20/26, 2/22/26, 2/25/26, 2/26/26, 2/27/26, 2/28/26, 3/1/26, 3/3/26, 3/4/26, 3/5/26, 3/6/26, 3/7/26, 3/8/26, 3/17/26, 3/19/26, 3/25/26, 4/1/26 and 4/2/26) document V2 (Director of Nursing) as the primary assigned nurse. On 2/2/26, 2/3/26, 2/6/26, 2/16/26, 2/17/26, 2/18/26, 2/19/26, 2/20/26, 2/26/26, 2/28/26, 3/1/26, 3/3/26, 3/5/26, 3/6/26, 4/1/26 and 4/2/26, the Schedule documents V2's assignment ([NAME]/Cadence Hallway) on the 6:00 am to 2:00 pm shift. The Schedule documents V2's assignment ([NAME]/Cadence Hallway) on 2/17/26 (8:00 pm to10:00 pm), 2/22/26 (2:00 pm to 6:00 pm shift), 2/25/26 (4:00 pm to 10:00 pm), 2/27/26 (6:00 pm to 10:00 pm), 3/7/26 (6:00 am to 11:00 am), 3/17/26 (6:00 pm to 10:00 pm, 3/19/26 (6:00 pm to 10:00 pm). The Schedule documents V2's assignment (Harmony Two Hall) on 2/10/26 at 6:00 am to 8:00 am). The Schedule documents V2's assignment (Respiratory Hall) on 3/4/26 (6:00 to 10:00 pm), 3/8/26 (6:00 am to 9:00 am) and 3/25/26 (6:00 pm to 10:00 pm). On 4/1/26 and 4/3/26 (during the hours of 8:30 am and 2:00 pm), V2 (Director of Nursing) was the primary nurse assigned to the [NAME]/Cadence Hallway. On 4/1/26 and 4/3/26 at 8:30 am to 9:30 am, V2 performed a medication pass to Residents.The Facility Nurse Schedules (2/8/26 and 2/22/26) do not document a Registered Nurse assignment.On 4/3/26 at 10:11 am, V10 (Licensed Practical Nurse/Wound Nurse) stated, (V2) has to help on the floor quite a bit.On 4/1/26 at 9:30 am, V2 (Director of Nursing) stated, I work the floor a lot because we need coverage.On 4/3/26 at 1:15 pm, V5 (Clinical Nurse Consultant) stated, We have a very difficult time staffing this building and (V2) does have to help on the floor a lot. We just cannot seem to be able to hire nurses in this building.

The Facility failed to document accurate and timely medication administration for six of six Residents (R1, R2, R3, R4, R5 and R6) reviewed for medication administration in a sample of six.Findings include: The Facility Medication Administration Policy, dated 10/25/14, documents: medications are administered in accordance with good nursing principles and; medications are administered within sixty minutes of scheduled time; the individual who administers the medication dose records the administration on the Resident's Medication Administration Record/MAR directly after the medication is given; at the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented.The Facility Registered Nurse Job Description, undated, documents: provide licensed nursing care to Residents on assigned unit in accordance with current Federal, State and Local standards, guidelines and regulations; dispense medications as ordered by the attending Physician in accordance with Facility policies; and ensure that appropriate documentation/charting is completed as required and in accordance with established policy and procedures.The Facility Licensed Practical Nurse Job Description, undated, documents: provide licensed nursing care to Residents on assigned unit in accordance with current Federal, State and Local standards, guidelines and regulations; dispense medications as ordered by the attending Physician in accordance with Facility policies; and ensure that appropriate documentation/charting is completed as required and in accordance with established policy and procedures.R1's Medication Administration Record/MAR, dated 2/1/26 through 3/31/26, documents: antibiotic medication administration (Amoxicillin-Potassium) start date of 2/28/26 and end date of 3/15/26 and the MAR documents late administration/charted late on 2/28/26 through 3/6/26, 3/8/26 through 3/15/26 and 3/26/26 through 3/31/26; pain medication (Hydrocodone-Acetaminophen 10-325 milligram/mg twice a day) start on 2/16/26 and end 3/30/26, the MAR documents late administration/charted late on 2/16/26 to 2/18/26, 2/20/26 to 3/6/26, 3/8/26 to 3/16/26, and 3/21/26 through 3/29/26; and antibiotic (Doxycycline Hyclate 100 mg every 12 hours) start on 2/28/26 and end 3/15/26, the MAR documents late administration/charted late on 2/28/26 to 3/6/26 and 3/8/26 to 3/15/2, 3/26/26 to 3/31/26.R2's Medication Administration Record/MAR, dated 2/1/26 through 3/31/26, documents: intravenous antibiotic medication (Zerbaxa three grams every eight hours) start: on 2/4/26 and end 2/13/26, the MAR documents late administration/charted late 2/4/26 to 2/10/26 and 2/12/26 to 2/13/26; intravenous antibiotic (Fetroja two grams every six hours for Severe Sepsis) start date of 3/4/26 and end date of 3/16/26, MAR documents late administration/charted late 3/4/26 through 3/16/26 with undocumented doses on 3/6/26 at 12:00 PM and 3/11/26 at 12:00 PM; and insulin (Lantus U-100 Insulin 54 units twice a day for Type II Diabetes Mellitus) start date of 2/4/26, MAR documents late administration/charted late on 2/4/26, 2/5/26, 2/7/26 to 2/16/26, 2/18/26 to 2/23/26, 3/6/26 to 3/17/26, 3/19/26 to 3/26/26, and 3/28/26 to 3/31/26.R3's Medication Administration Record, dated 2/1/26 through 3/31/26, documents: antibiotic medication (Amoxicillin-Potassium Clavulanate every 12 hours for Pneumonia) start date of 3/25/26 and end date of 3/31/26, MAR documents late administration/charted late on 3/25/26 to 3/31/26; antibiotic (Doxycycline Hyclate 100 mg/milligrams every 12 hours for pneumonia) start on 3/25/26 and end date of 4/3/26, MAR documents late administration/charted late on 3/25/26 through 3/27/26, and on 3/30/26; antibiotic (Meropenem two grams intravenous every 8 hours) start date of 2/24/26 and end date of 3/3/26, MAR documents late administration/charted late on 2/25/26 through 3/1/26, with an undocumented dose on 3/3/26 at 2:00 PM; and antibiotic (Vancomycin 500 mg/milligrams intravenous once a day for Bacteremia) start date of 2/25/26 and end date of 3/2/26, MAR documents late administration/charted late on 2/25/26, 2/27/26, 2/28/26, and 3/2/26.R4's Medication Administration Record/MAR, dated 2/1/26 through 3/31/26, documents: medications (Enoxaparin 40 milligram/mg for blood thinner, Hydrocodone-Acetaminophen 10-325 mg for pain) MAR documents late administration/charted late on 2/3/26 through 2/19/26, 2/21/26 and 2/26/26; and medication (Micafungin for Sepsis) MAR documents late administration/charted late on 3/25/26 through 3/28/26 and 3/31/26.R5's Medication Administration Record, dated 2/1/26 through 3/21/26, documents: medication (Xarelto 20 mg), MAR documents late administration/charted late on 2/3/26 through 2/9/26, 2/11/26 through 2/13/26, 2/17/26 through 2/22/26, 2/24/26, 2/26/26 through 2/28/26; medication (Xarelto blood thinner) MAR documents late administration/charted late on 2/2/26 through 2/9/26, 2/11/26 through 2/13/26, 2/17/26 through 2/22/26, 2/24/26, 2/26/26 through 2/28/26; medication (Zosyn antibiotic) MAR documents late administration/charted late on 2/13/26, 2/14/26, 2/16/26 through 2/18/26, 2/20/26 through 2/22/26; and medication (Xarelto blood thinner) MAR documents late administration/charted late on 3/2/26 through 3/13/26, 3/16/26, 3/21/26, 3/24/26 through 3/29/26.R6's Medication Administration Record, dated 2/1/26 through 3/21/26, documents: medication (Buspirone 15 mg) MAR documents late administration/charted late on 2/1/26 through 2/28/26, 3/1/26 through 3/16/26, 3/19/26 through 3/31/26; medication (Ibuprofen 600 mg) MAR documents late administration/charted late on 2/1/26, 2/4/26 through 2/6/26, 2/12/26, 2/16/26 through 2/19/26, 2/25/26 and 2/28/26; medication (Ibuprofen 600 mg) MAR documents late administration/charted late on 2/1/26 through 2/3/26, 2/5/26 through 2/28/26; medication (Vanlafaxine 75mg) MAR documents late administration/charted late on 2/1/26, 2/4/26 through 2/6/26, 2/12/26, 2/16/26 through 2/19/26, 2/25/26 and 2/28/26, and 3/30/26; medication (Haloperidol 0.5 mg) MAR documents late administration/charted late on 3/1/26 through 3/16/26, 3/19/26 through 3/31/26.On 4/3/26 at 10:11 am, V10 (Licensed Practical Nurse/Wound Nurse) stated, There are different steps to completing the medication pass in the electronic charting system. The first step the nurses take is when they dispense the medication. Then after they administer the medication, I think they are not going back and hitting the 'complete' button, so all their administration charting is late. Also, I think they get so far behind that they do not have the time to actually go back and hit that 'complete' button, and they just do it at the end of their shift. It is a bad habit they have gotten in to.On 4/1/26 at 12:50 pm, V2 (Director of Nursing) stated, The nurses are giving the medications, but it looks like they are just using the electronic medication administration record charting wrong. They are not charting that the medications are given/completed immediately after they administer the medications, they wait until after the entire medication pass or at the end of their shift.On 4/3/26 at 1:15 pm, V5 (Clinical Nurse Consultant) stated, The nurses are not completing the charting correctly. They should complete the medication administration in its entirety right after they administer the medication, and follow the charting through till the end.

Based on interview and record review the Facility failed to ensure authorized personnel were signing for intravenous medication administration in the electronic Medication Administration Record for two of three Residents (R2 and R3) reviewed for medication administration in a sample of six.Findings include: The Facility Medication Administration Policy, dated 10/25/14, documents: medications are administered in accordance with good nursing principles and practices and only by persons legally authorized to do so; medications are administered only by licensed personnel or other personnel authorized by State laws and regulations to administer medications; medications are administered in accordance with written orders of the prescriber; persons who prepare the dose for administration is the person who administers the dose; medications are administered within sixty minutes of scheduled time; the individual who administers the medication dose records the administration on the Resident's Medication Administration Record/MAR directly after the medication is given; at the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented; and the Resident's MAR is initialed by the person administering the medication in the space provided under the date, on the line for that specific medication dose administration.The Facility Registered Nurse Job Description, undated, documents: provide licensed nursing care to Residents on assigned unit in accordance with current Federal, State and Local standards, guidelines and regulations; dispense medications as ordered by the attending Physician in accordance with Facility policies; and ensure that appropriate documentation/charting is completed as required and in accordance with established policy and procedures.R2's Medication Administration Record/MAR for February 2026 documents an order for intravenous (IV) antibiotic medication (Zerbaxa three grams every eight hours) with a start date of 2/4/26 and an end date of 2/8/26 and another order for this same medication and dose with a start date of 2/8/26 and an end date of 2/13/26. Three total doses of the IV antibiotic were signed out by Licensed Practical Nurses/LPNs: the 2/6/26 2:00 PM dose was signed out by V15/LPN, the 2/10/26 6:00 AM dose was signed out by V16/LPN, and the 3/12/26 6:00 AM dose was signed out by V17/LPN.R2's MAR for March 2026 documents an order with a start of 3/4/26 and end date of 3/16/26 for IV antibiotic (Fetroja two grams every six hours) for Severe Sepsis Without Septic Shock. Seven total doses of the IV antibiotic were signed out by Licensed Practical Nurses/LPNs: the 3/5/26 6:00 PM dose was signed out by V10/LPN, the 3/6/26 12:00 AM dose and the 3/8/26 12:00 PM and 6:00 PM doses were signed out by V13/LPN, the 3/11/26 6:00 AM dose was signed out by V8/LPN, and the 3/12/26 12:00 AM and 6:00 AM doses were signed out by V14/LPN.R3's MAR for February 2026 documents an order for IV antibiotic (Meropenem two grams every eight hours) with a start date of 2/24/26 and an end date of 3/3/26. The 2/26/26 2:00 PM dose was signed out by V10/LPN.On 4/11/26 at 1:43 pm, V8 (Licensed Practical Nurse/LPN) stated, I do not personally administer the IV medication. (V2/DON) or (V4/Assistant Director of Nursing) are the primary nurses that administer the IV's. Usually the nurse working the floor will sign out the medications on the MAR for them (V2 and V4) after they give it.On 4/1/26 at 12:50 pm, V2 (Director of Nursing) stated, (V4/Assistant Director of Nursing) and myself are usually the only nurses that administer all of our intravenous (IV) medications. I just do not trust our nurses. I have even stayed in the hotel across the street to just be close to the Facility so I can give the Residents their 'IV meds.' Usually, the floor nurses sign out the medications for me after I administer them. I do not usually sign them out myself.On 4/3/26 at 1:15 pm, V5 (Clinical Nurse Consultant) stated, The nurse that gives the medications should be the nurse that signs out the medication on the Medication Administration Record. Licensed Practical Nurses should not be signing out 'IV' medications that only a Registered Nurse is licensed to give.

Based on interview, and record review, the facility failed to ensure adequate supervision, safe transfer practices, post-fall assessment, and timely medical evaluation for one (R1) of four residents reviewed for accidents in the sample list of four. This failure resulted in R1 sustaining multiple rib fractures and a spinal compression fracture following a fall from R1's bed on 3/10/26, with no physician evaluation or diagnostic testing completed until seven days later. Findings include:The facility's undated Assisting a Client with Bed Mobility policy documents do not leave the resident lying on the edge of the bed. Stand next to the side of the bed the person is closest to, assist them to roll to their side and face you. This policy also documents under safety to make sure the person is in the middle of the bed. Lower the bed into a standard position and adjust the head of the bed to reduce injury. The facility's Falls and Fall Risk, managing policy revised 8/2008 documents staff will identify and implement relevant interventions to try and minimize serious consequences of falling.The facilities Resident Roster dated 3/23/26 documents R1 is hospitalized and was transferred to the hospital from the facility on 3/17/26. R1's electronic therapy records document R1 required extensive assistance with activities of daily living and was dependent on staff for transfers, requiring a mechanical lift. R1's Therapy documentation indicated R1 had poor trunk control, required two-person assistance for sitting, and was non-ambulatory.R1's care plan did not contain documented interventions addressing safe positioning during care, staff positioning, or to remain with the resident during care. This care plan did not include R1's Activities of Daily Living abilities or how many staff were needed to provide R1's cares.R1's Facility Incident note dated 3/10/26 documents R1 was found on the floor between the bed and the window after being left unattended during care. The note documents only minor scratches and indicated no complaints of pain at that time. R1's Nurse Progress Note dated 3/10/26 and 3/13/26 documented administration of as needed (PRN) Tylenol and Tramadol for general discomfort and back pain.R1's Facility Incident Report dated 3/17/26 documents R1 complained of rib pain and was sent to the emergency room for evaluation.R1's Hospital Skin assessment dated [DATE] included documentation that Skin is warm and dry (scattered bruises to body, worse on left side).R1's Radiology Report dated 3/17/26 revealed a Computed Tomography (CT) scan of the chest, abdomen, and pelvis were performed and compared to prior imaging dated 1/6/26 and 12/25/25. The CT scan identified new rib fractures of fifth through eighth rib an and a spinal compression fracture of the L2 Vertebral Body that were not present on prior imaging studies.R1's Hospital documentation dated 3/17/26 included the following note: dated 3/17/26 documents Called and spoke with V8 (Licensed Practical Nurse/LPN) from nursing home. Per V8, R1 fell at their facility on March 10th, V8 confirmed R1 was not sent to a hospital for evaluation or for any imaging. Per V8, a CNA was cleaning the patient up by herself and when patient was on their side, patient slid out of bed since their mattresses are so slick and fell onto the floor.R1's emergency room Physician Note dated 3/17/26 documents We were initially given history that R1 had just been acting oddly but then we did get history of a fall that occurred. I would be concerned for a chest wall injury as this is area of pain. V17 (emergency room Physician) further documented: Patient has findings of new rib fractures and post obstructive pneumonia as well as typical pneumonia. V17 documented concern that the injuries and resulting condition required advanced care, including potential transfer for specialized treatment. Additional hospital documentation noted scattered bruising, worse on the left side, and confirmed that no prior imaging or physician evaluation had been completed by the facility following the fall on 3/10/26.On 3/23/26 at 12:00 PM, V9 (Certified Nursing Assistant/CNA) stated she was providing care to R1 on 3/10/26 when R1 rolled off the bed. V9 stated that R1 was turned on his side and V9 stepped away to retrieve supplies, and upon return observed R1 coughing and rolling off the bed. V9 stated she attempted to stop the fall by grabbing R1's upper body, but R1 was too heavy for V9 to hold onto. V9 confirmed R1 fell completely to the floor laying on his stomach. V9 further stated R1 was lifted from the floor by staff without use of a mechanical lift because they were unable to get the lift in the area R1 was lying.On 3/23/26 at 1:19 PM, V11 (Physical Therapy Assistant) stated R1 required a mechanical lift for transfers and would not be safe to stand or transfer without it.On 3/23/26 at 1:31 PM, V12 (Occupational Therapy Assistant) confirmed R1 had poor trunk control, required assistance from two staff, and was not safe for transfers without a mechanical lift.On 3/23/26 at 1:40 PM, V2 (Director of Nursing (DON) and V3 (Assistant Director of Nursing (ADON) stated they did not oversee CNA care plan communication and were unaware of CNA access to care plans. They stated changes in care were communicated through shift report rather than direct care plan review. V2 and V3 both stated they were not aware of what an Activity of Daily Living (ADL) Care plan was or that there was no documentation as to how R1's ADL cares should be provided. V3 further stated that she believed the reason R1 fell was because he was coughing and rolled off the bed. V2 and V3 further stated that V9 should not have walked away from R1's bed to gather items while R1 was lying on the side of the bed.On 3/23/26 at 10:34 AM, V14 (Hospital Registered Nurse) stated R1 was admitted to the hospital on [DATE] after being sent from the facility in an ambulance to the local emergency room. V14 stated V8 (Licensed Practical Nurse/LPN) the facility informed V14 that R1 had fallen out of bed on 3/10/26. V14 confirmed diagnostic imaging revealed multiple rib fractures and a spinal compression fracture. The nurse further stated that facility staff reported no physician evaluation or imaging was completed following the fall.On 3/23/26 at 1:06 PM, V10 (R1's Family Member) stated the facility informed her that R1 fell out of his bed and sustained only minor scratches after the fall. V10 stated she was not given all the information as to what happened and was under the impression R1 had been evaluated by V16 (Physician) V10 expressed concern that no further medical evaluation was completed despite the severity of injuries later identified. V16 was contacted and a message was left for V16 with no return call.On 3/24/26 at 12:00 PM, V4 (Respiratory Therapist) stated R1 exhibited a change in condition on 3/17/26 when V4 went in to provide respiratory care, including confusion, elevated heart rate, and complaints of chest and rib pain. V4 stated she immediately told V3 that R1 needed evaluation at the hospital. V4 further stated that V3 evaluated R1 and sent R1 by ambulance to the hospital.On 3/23/26 at 2:04 PM, V13 (Certified Nursing Assistant Supervisor) stated when changes occur, staff place a notification in a care needs binder at the nurses' station and verbally inform other staff. V13 provided the surveyor with access to the binder and reviewed R1's care plan. Upon review, V13 stated the care plan did not include documentation regarding R1's activities of daily living (ADL) status and further stated that if staff were unfamiliar with R1, they would not know how to safely provide care. V13 stated, it looks like we dropped the ball. V13 further confirmed that V9 does not normally work on the respiratory unit and would not have been as familiar with R1.On 3/24/26 at 1:00 PM, V1 (Administrator) stated it is the responsibility of V2 and V3 to ensure care plan updates are done and that staff have the information to provide care to the residents. V1 further stated that V9 should have never walked away from R1's bed while providing cares.

Based on interview and record review, the facility failed to assess, document, and communicate the residents' Activities of Daily Living (ADL) needs, and ensure a comprehensive, person-centered care plan was timely reviewed and revised for one (R1) of four residents reviewed for care plan revision in the sample list of four.Findings include:The facility's Care Plan policy revised 1/2025 documents that care plans are revised as changes in the resident's condition dictate. The policy further states that the facility's interdisciplinary team, in coordination with the resident and family, develops and maintains a comprehensive care plan for each resident that identifies the highest level of function the resident may be expected to attain.The facility's Falls and Fall Risk Management policy (revised 8/2008) documents staff are to identify and implement relevant interventions to minimize the risk and consequences of falls.The facilities Resident Roster dated 3/23/26 documents R1 is hospitalized and was transferred to the hospital on 3/17/26.A facility incident note dated 3/10/26 documented R1 sustained a fall from bed during care and was found on the floor between the bed and the window after being left unattended during cares.R1's care plan revealed a revision dated 3/11/26 added an intervention to suction R1 prior to care due to coughing. However, the care plan did not include interventions to prevent rolling from bed during care, direction for staff to remain with the resident during care, reinforcement of two-person assistance for bed mobility and accurate documentation of R1's Activities of Daily Living (ADL) status and required level of assistance.On 3/23/26 at 12:00 PM, V9 (Certified Nursing Assistant/CNA) stated she was providing care to R1 on 3/10/26 when R1 rolled off the bed. V9 stated that R1 was turned on his side and V9 stepped away to retrieve supplies, and upon return observed R1 coughing and rolling off the bed. V9 stated she attempted to stop the fall by grabbing R1's upper body, but R1 was too heavy for V9 to hold onto. V9 confirmed R1 fell completely to the floor laying on his stomach. V9 further stated R1 was lifted from the floor by staff without use of a mechanical lift because they were unable to get the lift in the area R1 was lying.On 3/23/26 at 2:04 PM, V13 (Certified Nursing Assistant Supervisor) stated staff rely on a binder and verbal communication for care updates. Upon reviewing R1's care plan, V13 stated it did not include documentation regarding R1's ADL status and that staff unfamiliar with the residents would not know how to safely provide care. V13 stated, it looks like we dropped the ball. V13 further confirmed that CNA (V9), who was involved in the incident, did not routinely work on the unit and would not have been familiar with R1's care needs.On 3/23/26 at 1:40 PM, the Director of Nursing (V2) and Assistant Director of Nursing (V3) stated they did not directly communicate care plan updates to Certified Nursing Assistants (CNAs) and relied on shift report and supervisory staff for communication. Both stated they were unaware that R1's care plan lacked ADL care instructions.On 3/24/26 at 1:00 PM, V1 (Administrator) stated it was the responsibility of nursing leadership to ensure care plans were updated and that staff had the information necessary to provide care.

Based on observation, interview and record review, the facility failed to notify a physician timely regarding frequent refusals of a (mood stabilizer) medication for one of three residents (R3) reviewed for physician notification of change in a sample of seven.Findings include:The facilities Medication Administration Policy, dated 10/25/2014, documents, B. Administration: 2) Medications are administered in accordance with written orders of the prescriber. C. Refusals of Medication: 5) Medication refusals must be reported to the prescriber after (XX) number of doses are refused and there must be documentation of prescriber notification of such. D. Documentation (including electronic): 6) If (XX consecutive doses) of a vital medication are withheld, refused, or not available the physician is notified. Nursing documents the notification and physician response.R3's Face Sheet documents R3 was admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Schizoaffective Disorder, Major Depressive Disorder, Panic Disorders, and Mild Intellectual Disabilities.R3's Care Plan documents Problem Start Date: 2/27/25- (R3) takes Depakote as a mood stabilizer for aggressive mood. Interventions: Nursing to monitor for any adverse reactions to Depakote and report to MD (Doctor of Medicine). Staff to monitor, document, and report any symptoms of schizoaffective disorder to MD. Problem Start Date: 2/27/25- (R3) exhibiting change in usual behavior as evidenced by increased restlessness, fidgety, lack of initiative/involvement, and being irritated. Interventions: Evaluate whether the behavior is attributable to organic causes or other risk factors.R3'S MDS (Minimum Data Set) Assessment, dated 10/2/25, documents R3 is moderately cognitively impaired and a behavior of rejection of cares such as refusal of medications.R3's Physician Orders, dated 11/12/26, documents Start Date: 7/9/2022- Depakote (mood stabilizer) 500mg (milligrams) take one tablet three times a day.R3's MAR (Medication Administration Record) dated September 1st, 2025, through September 30th, 2025, documents R3 refused his Depakote (mood stabilizer) 23 times out of 90 doses.R3's MAR dated October 1st, 2025, through October 31st, 2025, documents R3 refused his Depakote (mood stabilizer) 27 times out of 93 doses.R3's MAR dated November 1st, 2025, through November 12th, 2025, documents R3 refused his Depakote (mood stabilizer) 7 out of 37 does.R3's Electronic Medical Record does not include documentation of R3 refusing his Depakote on multiple occasions from September 1st, 2025, to November 12th, 2025.On 1/24/26 at 10:47 AM V18/R3's Physician stated he was not aware that R3 had missed 57 doses of Depakote from October 1st, 2025, to November 12th, 2025. V18 stated, This is the first I am hearing about (R3) refusing and not receiving his medications. I don't remember being notified of that ongoing problem. I would absolutely want to be notified of (R3's) refusals of medications and especially (R3's) Depakote. I would want to be notified if any resident was refusing medication on a regular basis.On 1/24/26 at 11:17 AM V1/Administrator verified the facility's Medication Administration Policy, dated 10/25/14, does not document the number of doses that can be missed before the doctor should be notified.On 1/24/26 at 12:02 PM V2/Director of Nursing verified R3 was refusing his noon dose of Depakote on a regular basis and stated she would expect the nurses to notify a resident's physician of any refusals of medication by a resident. V2 verified there was no documentation in R3's medical record of physician notification of R3 refusing his Depakote during the period of October 1st, 2025, to November 12th, 2025.

Based on interview and record review, the facility failed to prevent abuse for two residents of four residents (R13 and R15) reviewed for abuse in a sample of 17. Findings include:The Abuse Prevention Policy (not dated) documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This facility is committed to protecting our residents from abuse, neglect, Exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Definitions - Abuse means any physical or mental injury or sexual assault inflict upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain and/or maintain physical, mental, and psychosocial well-being. This assumes all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish. The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.1. The Final Facility Incident Report Form for 11/12/25 incident documents a resident-to-resident altercation between R1 (now identified as R14) and R2 (now identified as R15). Occurrence (R15) was ambulating into the main dining room at 6:00 AM. At that time, (R14) entered the main dining room and immediately approached (R15) without any provocation from (R15). (R14) took his [NAME] and began pushing (R15) back up against the wall. (R14) then began raising his [NAME] and pushing it against (R15). (R15) then began to push back against (R14). At this point (R14) and (R15) both were using their hands to push on each other. Staff immediately responded and separated residents. (R14) stated that (R15) was irritating him and was in his business. (R15) did not say anything or display any behavior that would have been irritating. (R15) states he does not know what happened. It all happened so fast, he only knew he had gone to the main DR (dining room) to get a cup of ice and a straw. (R14) was examined immediately with no injuries noted. (R15) was exam immediately with two scratches noted to his chin, in which he states he received while he was shaving himself.R14's computerized Medical Record documents that R14 is a [AGE] year-old that admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes Mellitus with Diabetic Neuropathy, Chronic Kidney Disease (stage 3), Mild Intellectual Disabilities, Schizoaffective Disorder, Major Depressive Disorder, and Panic Disorder. R14 discharged on 11/25/25.R14's MDS (Minimum Data Set) assessment dated [DATE] documents Section C (Cognition Patterns) a BIMS (Brief Interview for Mental Status) of 15, indicating (cognition intact). Section GG (Functional Abilities) documents R14 has no upper or lower extremity impairment and uses a Walker. R14 required set up help or supervision for all activities of daily living, bed mobility, and transfers.R14's Nursing Note dated 11/12/25 at 5:45 AM, documents that R14 was involved in peer-to-peer altercation. R14 was placed with one-to-one observation with staff. R14 continued to yell at staff and refused redirection to his room. R14 states He (R15) got in my business.R15's computerized Medical Record documents that R15 is a [AGE] year-old that admitted to the facility on [DATE] with a diagnosis of Alcohol Dependence with Alcohol Induced Persisting Dementia.R15's MDS (Minimum Data Set) assessment dated [DATE] Section C (Cognitive Patterns) documents a BIMS (Brief Interview for Mental Status) of 15, indicating (cognition intact). Section GG (Functional Abilities) documents R15 has no upper or lower extremity impairment, does not use any devices to ambulate, requires set up help or supervision for all activities of daily living, bed mobility, and transfers. R15's Nursing Note dated 11/12/15 at 11:01 AM written by V2/Director of Nursing documents that R15 spoke to R15's family about the incident. R15 had an abrasion on his forehead and denied having any pain.On 1/21/26 at 9:45 AM, R15 stated that one morning (date not given) he was walking into the dining room and another resident (identified as R14) was walking with a [NAME] towards R15. For no reason (R14) took both hands off (R14's) [NAME] and shoved R15 in the chest with both hands as R15 walked by (R14). This caused R15 to drop the cup he was carrying, and the contents spilt on the floor. R15 was trying to keep (R14) away from him by trying to push (R14) away but (R14) kept pushing the [NAME] towards R15 pushing R15 against a wall. The staff came and took (R14) away from R15. R15 stated that he was not hurt but he thought it was an act of violence by the other resident (R14). R15 also stated I didn't like (R14) pushing me but I'm glad it was me and not a resident that might have fallen. R15 then lifted his metal cup with a lid showing this surveyor how the cup was dented when it was dropped during the incident with (R14).On 1/21/26 at 1:30 PM, V2/Director of Nursing stated that on 11/12/25 at 5:45 AM, V2 had just entered the building and heard scuffling coming from the dining room. V2 went to see what was happening and R14 was pushing against R15. R15 had dropped his cup on the floor and there was liquid on the floor. R14 and R15 were separated. R15 had a scratch on his face but V2 cannot say for sure if the scratch happened during the incident between R14 and R15 or not.2. The Final Facility Incident Report Form for 12/18/25 incident documents a resident-to-resident altercation between R1 (now identified as R12) and R2 (now identified as R13) witnessed by staff. (R12) was sitting in the dining room in her normal location. (R13) was sitting in the dining room in her normal location conversating with other residents as she typically was. Both residents were waiting for dinner to be served. (R12) picked up a saltshaker and tossed it in the direction of (R13). The saltshaker made contact with (R13). R12's computerized Medical Record documents that R12 is an [AGE] year-old that admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Dementia, Anxiety, Major Depressive Disorder, Irritability and Anger,R12's MDS (Minimum Data Set) assessment dated [DATE] Section C (Cognitive Patterns) documents a BIMS (Brief Interview for Mental Status) of 2, indicating (severe cognitive impairment). Section GG (Functional Ability) documents R12 has upper and lower extremity impairment on both sides, uses a wheelchair, requires set up help for eating, is dependent on staff for all activities of daily living, bed mobility, and transfers. R12's Nursing Note dated 12/18/25 at 4:20 PM, documents that R12 became agitated with peer (R13) and threw a salt and pepper caddy at peer.On 1/21/26 at 1:15 PM, R12 was sitting in her room. R12 was unable to answer questions appropriately.R13's computerized Medical Record documents that R13 is an [AGE] year-old that admitted to the facility on [DATE] with diagnoses which included Polyarthritis, Transient Cerebral Ischemic Attack, Essential (Primary) Hypertension, and Mild Intellectual Disabilities.R13's MDS (Minimum Data Set) assessment dated [DATE] Section C (Cognitive Patterns) documents a BIMS (Brief Interview for Mental Status) of 7, indicating (severe cognitive impairment). Section GG (Functional Abilities) documents R13 has no upper or lower impairments, requires supervision for all activities of daily living, bed mobility, and transfers.R13's Nursing Note dated 12/18/25 at 7:35 PM, documents that R13 had a peer throw a salt container at R13 hitting in R13 in her lower back. R13 assessed at this time with no complaints.On 1/21/26 at 10:42 AM, R13 was sitting in the dining room with R16. R13 stated that she was hit in the back by R12 when R12 threw a plastic container at her. R13 stated that it made her back hurt, and she does not like to be around R12.On 1/21/26 at 10:42 AM, R16 was sitting in the dining room across from R13. R16 stated that he was sitting with R13 when R12 threw the plastic container that holds the sugar at R13. The container hit R13 in the back. R16 also stated that he thought R12 intentionally meant to hit R13.On 1/21/26 at 1:30 PM, V2/DON stated that she had heard yelling in the dining room (date unknown) and when V2 got to the dining room staff were intervening in an incident that had happened between R12 and R13. R12 had thrown a plastic container that holds sugar packets at R13 hitting R13 on R13's back. R13 had no sign of injury but did complain of back pain. :

Based on interview and record review the Facility failed to protect a wound from insect contamination and failed to provide appropriate physician ordered wound care leading to a decline in the Resident's physical well-being for one of three Residents (R1) reviewed in sample of five. This failure resulted in R1 requiring emergent transport to the local hospital and hospitalization. Findings include:The Facility Pressure/Skin Breakdown-Clinical Protocol Policy, reviewed 1/2025, documents: document the individual's significant risk factors; nurse must document/report a full assessment of skin condition; identify factors contributing or predisposing Residents for skin breakdown such as co-morbidities; document signs/symptoms of infection, skin condition assessment and the impact of co-morbid conditions on wound healing; and the physician will authorize pertinent orders related to wound treatments.The Facility Resident Rights for People in Long-Term Care Facilities, dated 11/2018, documents: the Facility must provide services to keep your physical and mental health, at their highest practical levels; and the Facility must be safe, clean, comfortable and homelike.The Facility Licensed Practical Nurse/LPN Job Description, undated, documents: to provide nursing care to Residents under the supervision of a Registered Nurse/RN and in accordance with federal, state and Facility standards; responsible for administering medications, performing treatments, monitoring Resident's health status and supporting the overall care plan to promote optimal health outcomes; administer treatments as prescribed in accordance with Facility policies and state regulations; monitor Resident's health status, observe for changes in condition and promptly report finding to the Registered Nurse or Physician; follow infection prevention and control procedures; maintain a safe environment for Residents; and comply with all state, federal and Facility regulations.R1's Physician Order Report, dated 8/1/25 through 8/31/25, documents diagnoses including Chronic Osteomyelitis, Anxiety, Anemia, Type Two Diabetes Mellitus with other skin complications, Atherosclerotic Heart Disease, Chronic combined Systolic and Diastolic (Congestive) Heart Failure, Alcohol dependence with withdrawal, Hypertension and Hyperlipidemia. The Physician Order Report documents Physician orders for: arterial ultrasound to bilateral feet for non-healing wounds (dated 7/24/25); Enhanced Barrier Precaution (dated 7/23/25); Left Foot and Right Foot cleanse with wound cleanser, dry well, apply skin barrier to necrotic areas, place topical medication (Calcium Alginate) to open area on Left Posterior Ankle and Right Medical Second Toe and Great Toe, and cover with dry dressing (Army Battle Dressing/ABD and Kerlix) every day (start date 7/1/25 and end date 8/4/25); and Bilateral Foot wounds topical medication (betadine) and open to air every day (start date 7/25/25 and end date 9/4/25). The Physician Order Report does not document a dry dressing order for 8/7/25 or 8/8/25.R1's Treatment Administration Record/TAR, dated 8/1/25 through 8/31/25, documents an order to R1's Right Foot and Left Foot to cleanse area with wound cleanser, dry well, apply skin barrier to necrotic areas, place topical medication (Calcium Alginate) on open area between right medial second toe and great toe and Left Posterior Ankle) and cover with dry dressing (ABD and Kerlix wrap) every shift (start date 7/1/25 and end date 8/4/25).R1's Treatment Administration Record/TAR, dated 8/1/25 through 8/31/25, documents an order to R1's bilateral food wounds for topical medication (Betadine) and open to air every day (start date 7/25/25 and end date 9/4/25). R1's Nursing Progress Note, dated 8/8/25 at 4:10 am, documents that R1 requires staff assistance with transfers, does not like to get out of bed, appetite poor and refused shower.On 8/8/25 at 6:00 am, V6's (Licensed Practical Nurse/Wound Nurse) Nursing Progress Note documents myiasis (maggots/larva) observed in the wound bed during treatment and located primarily in the base of the wound, within necrotic tissue. R1 was transported to the local emergency department ([NAME]).On 8/8/25 at 6:06 am, V6's (Wound Nurse) Nursing Progress Note documents R1 being transferred to the local hospital ([NAME]) by Emergency Services for evaluation due to complications related to bilateral foot wounds.R1's Nursing Note, dated 8/8/25 at 10:30 am, documents R1 being transferred from the local hospital ([NAME]) to a larger area hospital ([NAME]).R1's Nursing Note, dated 9/4/25 at 12:36 pm, documents hospital ([NAME]) report to the Facility for R1's return from the hospital back to the Facility. R1 was admitted to the larger area hospital ([NAME]) on 8/9/25 for a Urinary Tract Infection, Sepsis and Osteomyelitis. R1 underwent a Right above-the-knee amputation on 8/20/25, was placed on a feeding tube, insertion of an indwelling urinary catheter. On 9/2/25 R1 became unresponsive and a stroke alert was initiated, then R1 was recommended for Hospice services. R1's Paramedic Report/EMS, dated 8/8/25 at 7:21 am, documents that EMS was dispatched for complaints of foot ulcers with maggots. Staff (V6/LPN Wound Nurse) reported that V6 had started to change R1's foot dressings, approximately 30 minutes prior, and R1's diabetic ulcers were covered in maggots. R1 stated that R1 had the diabetic ulcers since approximately January or February (2025) and the Facility changed the dressings approximately one time a week, and the Facility did not notify R1 of the condition of R1's feet. R1 was transported to the local hospital ([NAME]).R1's local Hospital Triage notes ([NAME]) dated 8/8/25 at 6:37 am, documents R1 presented with Right Foot and Left Foot wounds and that when the Nursing Home staff attempted to redress the wounds, maggots were found in R1's Right Foot wound. Antibiotic was initiated for the infected wounds and an indwelling urinary catheter was placed. The Hospital Triage notes document that on 8/8/25 at 2:29 pm R1 was transported to a larger hospital ([NAME]) for treatment.R1's Hospital Notes ([NAME]), dated 9/2/25, document that when R1 presented to the Emergency Department for bilateral foot wounds, one of which was found to have maggots. The Hospital notes document that R1 had a new diagnoses including Right Above-the-Knee amputation.R1's Nursing Notes, dated 8/4/25, do not document V8 (Licensed Practical Nurse/LPN) applying a dry dressing to R1's Right Foot drainage.On 9/9/25 at 2:01 pm, V5 (Former Infection Preventionist) stated, (V6/Former Wound Nurse) told me that when (V5) was doing (R1's) Right Foot treatment, that (V6) found a ton of maggots in it. Apparently, the wrong treatment was also on it. (V8/Licensed Practical Nurse) did the dressing prior to (V6) doing it and put a dry dressing (Kerlix) on it because (V8) said that (R1's) Right Foot had drainage. (R1) was sent out immediately to the local hospital ([NAME]) for the maggots, and was then transported to a larger hospital ([NAME]) for admission.On 9/10/25 at 10:12 am, V6 (Former Wound Nurse/LPN) stated, I came in around 3:00 am on 8/8/25 to do an entire facility skin sweep and around 5:00 am, when I started to do the treatment on (R1's) right foot it had a dry dressing (Kerlix) wrapped around it. I knew this was the wrong treatment, because (V10/Wound Physician) had just changed the foot treatments a few days prior, on 8/4/25, to Betadine topical and leave open to air, so I was immediately concerned when I saw that. Then I began to remove the Right Foot dressing and immediately saw that the Right Foot was covered with over fifty maggots. Honestly, I had never seen that before and I kind of freaked out. I have no knowledge on treating maggots and I was not sure if we even had the right supplies. I tried to call (V5/Infection Preventionist) but could not get ahold of (V5), because I think(V5) was still sleeping. So I called the Physician and ended up sending (R1) out by ambulance to the hospital in [NAME]. Once (R1) got there, they sent (R1) to the big hospital in [NAME].On 9/9/25 at 1:26 pm, V10 (Wound Physician) stated, I understand that (R1) had multiple maggots in (R1's) Right Foot wound a few days after I had just seen (R1) on 8/4/25, and changed the Right Foot treatment order to Betadine and open to air because it was dry eschar at that time. I saw no signs of infection at that time. The only way the maggots would have approved is if they would have been medical maggots ordered by a physician. I did not get notified by the Facility of (R1's) Right Foot drainage and I did not order a dressing on the Right Foot for the drainage. The Facility could have called and sent me pictures or used telehealth (video calls) to notify me of the change. I cannot verify that the wound should or should not have been covered again at this point. I am not sure that (R1's) Primary Physician was notified of the change in the wound or exactly ordered the dressing.

Based on observation, interview, and record review the facility failed to administer prescribed opioid medications to keep residents' pain controlled, failed to perform pain assessments and implement pain relieving interventions while the residents were not receiving their prescribed pain relieving opioid medications, and failed to notify the physician of the need for a opioid medication refill order and complaints of increased pain for three of three residents (R2, R14, and R22) reviewed for pain in the sample of 30. These findings resulted in R2 experiencing restlessness and unrelieved pain after seven days of going without his prescribed opioid medication, R14 experiencing excruciating and stabbing unrelieved pain to the lower back, and R22 experiencing unrelieved severe pain to the lower back and legs.Findings include:The facility's Pain Management Policy, dated 1/2025, documents Purpose: To establish a program with a multi-level approach to pain management to assist the facility in delivering safe, individualized pain care. Policy: It is the policy of the facility to facilitate resident safety, independence, promote resident comfort, preserve and enhance resident dignity and facilitate life involvement. The purpose of this policy is to accomplish the goals through an effective pain management program. Definition: The facility will utilize a consistent pain assessment. The resident's descriptive words regarding the quality, duration, and location of pain will be used to evaluate the pain and to identify changes in pain. When the resident is unable to describe pain, physical signs such as grimacing, body posturing/protecting, vital sign changes, and changes in behavior and mood will be used to determine the presence of pain. Standards: 1. Pain assessment protocol may be initiated under any of the following situations: Any indication of pain based on the Pain Assessment performed for each resident at the time of admission, quarterly and with any condition change associated with the potential of pain, when the Minimum Data Set triggers an indication of pain (section J2, J3), Resident received routine pain medication and/or pain is not controlled, a change in a resident condition occurs to require pain control, A significant increase in the need for use of as needed use of pain medication, and a change in pain identification related to behavior, cognition or mood. 5. An interdisciplinary process and care plan will be developed and implemented based on the assessed findings, pain rating scale, and pain relieve strategies (interventions). 7. Care plans will be reviewed and updated each time the resident's pain management plan is found not to be effective and at least each quarterly care conference. 11. Documentation of assessments and the resident's response to the pain management plan will be made with each assessment. 12. The resident's physician will be notified of the resident's complaints of pain which are not relieved by comfort measures, including pain medications.The facility's Physician Orders policy dated 1/23/25 documents, Nursing staff will follow physician orders. In an event where a resident refused medication, or mediation is not available physician or nurse practitioner will be notified.1. R2's admission Care Plan dated 7/3/25 documents, (R2) is at risk of complaints of chronic pain related to infection/inflammatory reaction due to internal fixation with removal of hardware and pressure ulcers. (R2) has narcotic and non-narcotic pain medications orders prn (as needed). Approach: Administer medications as per orders. Evaluate/record/report effectiveness and any adverse side effects.R2's current Physician Order Report documents R2 was admitted on [DATE] with the diagnoses of a Pressure Ulcer of the right hip, Osteomyelitis, Pressure ulcer of the left hip, Pressure Ulcer of the right buttock, Contracture of Right Hip, Contracture of the right knee, Contracture of right lower leg muscle, Infection and inflammation reaction due to internal fixation device, and Anxiety Disorder. This same Physician Order Report documents, Start Date 6/30/25 (Admission) Hydrocodone-Acetaminophen (Norco) 10-325 mg (milligrams) one tablet every eight hours as needed.R2's Pharmacy Packing Slip dated 7/7/25 documents R2's Hydrocodone/Acetaminophen 10-325 mg 30 tablets was not delivered until 7/7/25 (seven days after R2 was admitted to the facility).R2's Medication Administration Records (MARs) dated 6/30/25 through 7/7/25 document R2 did not receive any Norco as ordered during this timeframe. R2's Electronic Health Record does not include documentation of R2's Physician (V30) being notified of the need for a prescription to fill R2's Norco, or documentation of pain relieving interventions utilized while R2 was not receiving his Norco as ordered from 6/30/25 through 7/7/25.R2's Progress Notes dated 7/5/25 at 3:45 PM and signed by V28 (Agency RN/Registered Nurse) documents, (R2) alert with confusion. Very confused on (R2's) whereabouts and day to day things. (R2) very restless at times. (R2) throws his legs and upper half of body out of the bed. Staff repositioned (R2) very frequently. (R2) is however contracted. (R2) has legs drawn up in a fetal position. (R2) frequently yells out for someone to get the people out of there while he points at his window. Will continue to monitor and follow current plan of care.On 7/15/25 at 1:35 PM R2 was lying in a low bed with the head of the bed up 90 degrees. R2 had multiple bruises to the right lower arm and a four by four bandage to the right lower arm. R2 had pressure ulcers to the right and left hip and right buttock. R2's legs were drawn up into a fetal position. R2 had facial grimacing and when asked if R2 was in pain R2 replied, Yes.On 7/16/25 at 9:50 AM V27 (CNA/Certified Nursing Assistant Manager) stated, On 7/5/25 around 2:25 PM (V28/Agency RN/Registered Nurse) was working and told me (R2) seemed to be in pain and had no medication. I called (V3/Prior Director of Nursing) and (V3) said she would take care of getting (R2's) pain medication.On 7/16/25 at 1:00 PM V28 (Agency RN) stated, I was working on 7/5/25 and it seemed throughout the shift that (R2) could not get comfortable. I looked at (R2s) MAR and noticed (R2) did not have Norco. (V27) called (V3) and (V3) was supposed to take care of getting (R2's) Norco. (R2's) Norco never did come in that day.On 7/16/25 at 1:30 PM V24 (Director of Rehabilitation) stated, I have worked with (R2) in therapy since (R2's) admission. It seems like (R2) is in a lot of pain most often when (R2) is being moved. (R2) is very contracted and has a lot of wounds. (R2) does not talk much but does say ouch whenever I roll (R2) or move (R2's) legs. I think moving (R2's) legs agitates (R2's) hip pain.On 7/18/25 at 11:10 AM V30 (R2's Physician) stated, (R2) absolutely should not go without his Norco. With all (R2's) illnesses and wounds, going without Norco would cause (R2) severe pain. There is no reason for any of my residents to be without their pain medications. The facility should have gotten ahold of me immediately to get (R2's) Norco ordered. I am always available by phone call and fax.2. R14's MDS (Minimum Data Set) assessment dated [DATE] documents R14 is cognitively intact. R14's Nursing Home Visits dated 319/25 and 4/9/25 and signed by V30 (R14's Physician) document, Chronic Pain: On Norco and Ibuprofen. R14's current Care Plan documents, Problem: Pain (R14) is at risk for chronic pain related to spinal stenosis. (R14) is no routine narcotic pain medication and PRN (as needed) non-narcotic medication for pain. 2/9/25 history of fracture o lumbar vertebrae. Goals: (R14) will verbalize reduction of pain. Approach: Administer medications as ordered. Monitor and record effectiveness. Report adverse side effects. Assess past effective and ineffective pain relief measures. Problem: (R14) has been asking for more pain medications, asking other nurses for pain \medications and telling other staff that (R14) did not get his pain medications. Approach: Nursing staff will give (R14) a sticky note of times he takes his schedules pain medications at the beginning of each shift.R14's Physician's Order Report dated 6/15/25 through 7/15/25 document R14 has the diagnoses of Spinal Stenosis of the Lumbosacral Region and Low Back Pain. This same Physician's Order Report documents, Start Date 10/16/23: Hydrocodone-Acetaminophen (Norco) 5-325 mg two tablets every six hour for low back pain. Start Date 9/1/23 Pain Scale/Evaluation every shift. Pain Scale 0-10. 0=No pain. 1=Mild Pain of uncomfortable/annoying. 4=Moderate Pain that is distressing/miserable. 10=Excruciating Pain that is the worst possible and interferes with the ability to carry on with daily routine, socialization, or sleep.R14's MARs dated 5/1/25 through 7/15/25 documents R14 did not receive his schedule Norco 5-325 mg as ordered on 13 occasions due to the Norco being unavailable.R14's MARs dated 5/1/25 through 7/15/25 document on 5/23/25 during the R14 was rating his back pain at a level 7 on a 0-10 pain scale. According to R14's MARs R14 did not receive his Norco 5-325 mg as ordered on 5/23/25 at 8:00 AM, 2:00 PM, or 8:00 PM and on 5/23/25 R14 was rating his back pain at a level 7 on a 0-10 scale.R14's MARs dated 5/1/25 through 7/15/25 document on 6/15/25 during the entire day R14 was rating his back pain at a level 7 on a 0-10 pain scale and on 6/16/25 during the night R14 was rating his back pain at a level 10 on a 0-10 pain scale. According to R14's MARs R14 did not receive his Norco 5-325 mg as ordered on 6/15/25 at 8:00 PM or 6/16/25 at 2:00 AM.R14's Electronic Medical Record does not include any pain relieving interventions, physician's notification, or comprehensive pain assessments after the 13 occasions between 5/1/25 through 7/15/25 when R14 did not receive his Norco as prescribed.On 7/15/25 at 10:05 AM R14 was walking with a walker in the dining room. R14 stated, The facility runs out of my Norco every month. I was an iron worker and hurt my back years ago. I have been on Norco for the pain in my lower back and was seeing a specialist for the pain. When I don't get my scheduled Norco I have excruciating, stabbing pain to my lower back. The pain keeps me awake. I really wish the facility would get this fixed, so I do not have to go without the Norco.On 7/16 /25 at 10:30 AM V2 (Director of Nursing) stated, (R14) did not get his Norco as ordered on 13 occasions between 5/1/25 through 7/15/25. (R14) has a lot of back pain and should not go without his scheduled Norco.On 7/16/25 at 1:20 PM V1 (Administrator-In-Training) stated, I was made aware that (R14) was running out of his Norco frequently. I know (R14) needs his Norco for lower back pain and should not ever run out of Norco.On 7/16/25 at 2:00 PM V19 (Regional Nurse Consultant) stated, (R14) has not had a comprehensive pain assessment completed since 5/13/25. V19 verified (R14) should have had a comprehensive pain assessment completed anytime (R14) went without his ordered Norco and was experiencing pain.On 7/18/25 at 11:00 AM V20 (R14's Family Member) stated, I know agency nurses do not get (R14's) medication refills done on time. (R14) has always had chronic pain and was a construction worker and hurt his back by following out of a third floor window of a building. (R14) has had multiple back surgeries. (R14) is usually out of his pain medications on the weekends and calls me when (R14) does not get his pain medication because he is having pain. If (R14) misses even one dose of Norco (R14) is in pain.On 7/18/25 at 11:10 AM V30 (R14's Physician) stated, (R14) should never have to go without his Norco. (R14) is dependent on the Norco and needs the Norco routinely to control his back pain. The facility should get ahold of me before (R14's) Norco runs out.3. R22's current Pain Care Plan documents R22 has complaints of chronic pain due related to osteomyelitis, pressure ulcer to the right ischium, tear of the hamstring tendon, and peripheral vascular disease, and is receiving hospice services for pain control management. This same care plan documents R22's pain medications should be administered as ordered and R22 will verbalize reduction of pain and/or show no signs of non-verbal pain.R22's current Physician Order Report documents R22 has the diagnoses of strain of muscle of the fascia and tendon of the posterior muscle group at right thigh level and malignant neoplasm of the large intestine and receives hospice services. This same Physician Order Report documents the following orders, Start Date 6/10/25 pain scale/evaluation every shift. Start Date: 7/7/25 MS Contin (Morphine) tablet extended release 15 mg twice daily at 8:00 AM and 8:00 PM.R22's Physician's Order dated 6/26/25 documents an order to increase R22's Hydrocodone/Acetaminophen from 5-325 mg every four hours to 10-325 mg every four hours and then discontinue on 7/7/25.R22's Medication Administration Record dated 6/10/25 through 7/15/25 documents R22's MS Contin 15 mg was not received on 7/7/25 at 8:00 AM or 8:00 PM due to the medication being unavailable.R22's Medication Administration Record dated 6/10/25 through 7/7/25 documents R22's Hydrocodone/Acetaminophen from 10-325 mg was not received as ordered on 15 occasions due to the Hydrocodone/Acetaminophen being unavailable.R22's Electronic Medical Record documents R22's last Comprehensive Pain Assessment was completed 6/26/25.On 7/16/25 at 11:00 AM R22 was lying in bed. R22 stated, I have cancer, and I hurt all over. I do not like to complaint. I have had pain all over and especially in my lower back and legs. I had no idea I was out of my pain medication. That would explain why I was hurting so bad.On 7/18/25 at 10:30 AM V12 (Hospice RN/Registered Nurse) I was not aware that (R22) was not getting his Hydrocodone/Acetaminophen 10mg-325 mg as ordered or his MS Contin 15 mg for two doses. I made (R22's) Hydrocodone/Acetaminophen 10mg-325 mg scheduled around the clock due top (R22) having wound pain, back pain, arm pain, and leg pain. It is unacceptable for (R22) to go without pain medication and (V9/Hospice Physician) was not notified. (V9) should have been notified so me or (V9) could have reached out to the pharmacy to make sure (R22) was getting his medication or we would have ordered something else to control (R22's) pain until the Hydrocodone/Acetaminophen and MS Contin was received.

Based on observation, interview, and record review the facility failed to implement a process for the timely ordering and reordering of medications, failed to notify the physician of the need for opioid analgesic medications and anti-anxiety medication prescription refill orders, failed to notify the physician of the need for an alternative to ordered Ozempic, and failed to obtain physician ordered opioid analgesic medications, anti-antianxiety medication, and weight-loss medication from the pharmacy for four of four residents (R2, R14, R18, and R22) reviewed for pharmacy services in the sample of 30. These findings resulted in R2 experiencing restlessness, increased anxiety, and unrelieved pain after seven days of going without his prescribed opioid medication and anti-anxiety medication, R14 experiencing excruciating and stabbing unrelieved pain to the lower back and withdrawal symptoms, and R22 experiencing unrelieved severe pain to the lower back and legs. Findings include: The facility's Controlled Substance Prescription Pharmacy Policy, dated 10/25/2014, documents Policy: Before a controlled drug can be dispensed, the pharmacy must be in receipt of a clear, complete, and signed written prescription from a person lawfully authorized to prescribe. To facility effective communication, documentation, and aide in prevention of medication errors, medication orders should be clear and concise and free of potentially dangerous abbreviations. Procedures: A. Elements of a controlled substance prescription: 12) Manual signature of prescriber. C. The prescriber and/or nurse are contacted for direction when delivery of a medication will be delayed, or the medication is not or will not be available. E. New Controlled Substance Prescriptions: 1) For emergency-controlled substance orders, the nurse will review the Emergency Kit list for available medications prior to contacting the prescriber. The nurse will communicate to the prescriber the emergency medications available to provide appropriate care to the patient. 4) In order to communicate Controlled II orders orally/verbally between the prescriber and pharmacist, the prescription must meet DEA's (Drug Enforcement Administration) criteria of an emergency situation. Conformance with such criteria must be discussed between the prescriber and pharmacist and documented on the prescription: a. Immediate administration of the controlled substance is necessary for proper treatment of the intended ultimate user. b. No appropriate alternative treatment is available, including administration of a drug which is not a controlled substance under Schedule II; AND c. It Is not reasonably possible for the prescriber practitioner to provide written prescription to be present to the person dispensing the substance prior to dispensing. 4) Only after verifying that the above communication has occurred and the pharmacy and facility receive a complete prescription, the nurse reviews the Emergency Kit List to assess the contents. After finding the medication list, the nurse unlocks the container seal and removes the required medication if it is available in the emergency kit. If the medication is not available in the emergency kit, the nurse contacts the pharmacy using the afterhours emergency number(s) if necessary. (See IC5: Emergency Pharmacy Service and Emergency Kits). The United States Food and Drug Administration Safety Communication Website article dated 4-9-19 documents, Opioid's are a class of powerful prescription medicines that are used to manage pain when other treatments and medicines cannot be taken or are not able to provide enough pain relief. Patients taking opioid pain medicines long-term should not suddenly stop taking your medicines without first discussing with hour health care professional a plan for how to slowly decrease the dose of the opioid and continue to manage your pain. Even when the opioid dose is decreased gradually, you may experience symptoms of withdrawal. Rapid discontinuation can result in uncontrolled pain or withdrawal symptoms. These include serious withdrawal symptoms, uncontrolled pain, psychological distress, and suicide. 1. R2's admission Care Plan dated 7/3/25 documents, (R2) is at risk of complaints of chronic pain related to infection/inflammatory reaction due to internal fixation with removal of hardware and pressure ulcers. (R2) has narcotic and non-narcotic pain medications orders prn (as needed). Approach: Administer medications as per orders. Evaluate/record/report effectiveness and any adverse side effects.R2's current Physician Order Report documents R2 was admitted on [DATE] with the diagnoses of a Pressure Ulcer of the right hip, Osteomyelitis, Pressure ulcer of the left hip, Pressure Ulcer of the right buttock, Contracture of Right Hip, Contracture of the right knee, Contracture of right lower leg muscle, Infection and inflammation reaction due to internal fixation device, and Anxiety Disorder. This same Physician Order Report documents, Start Date 6/30/25 (Admission) Hydrocodone-Acetaminophen (Norco) 10-325 mg (milligrams) one tablet every eight hours as needed.R2's admission Physician's Orders dated 6/30/25 document, Lorazepam 0.5 mg twice daily as needed for Anxiety.R2's Pharmacy Packing Slip dated 7/7/25 documents R2's Lorazepam 0.5 mg 28 tablets was not delivered until 7/7/25 (seven days after R2 was admitted to the facility).R2's Pharmacy Packing Slip dated 7/7/25 documents R2's Hydrocodone/Acetaminophen 10-325 mg 30 tablets was not delivered until 7/7/25 (seven days after R2 was admitted to the facility).R2's Medication Administration Records (MARs) dated 6/30/25 through 7/7/25 document R2 did not receive any Norco as ordered during this timeframe. R2's Electronic Health Record does not include documentation of R2's Physician (V30) being notified of the need for a prescription to fill R2's Norco or R2's Lorazepam, or documentation of pain relieving interventions utilized while R2 was not receiving his Norco as ordered from 6/30/25 through 7/7/25.R2's Progress Notes dated 7/5/25 at 3:45 PM and signed by V28 (Agency RN/Registered Nurse) documents, (R2) alert with confusion. Very confused on (R2's) whereabouts and day to day things. (R2) very restless at times. (R2) throws his legs and upper half of body out of the bed. Staff repositioned (R2) very frequently. (R2) is however contracted. (R2) has legs drawn up in a fetal position. (R2) frequently yells out for someone to get the people out of there while he points at his window. Will continue to monitor and follow current plan of care.On 7/15/25 at 1:35 PM R2 was lying in a low bed with the head of the bed up 90 degrees. R2 had multiple bruises to the right lower arm and a four by four bandage to the right lower arm. R2 had pressure ulcers to the right and left hip and right buttock. R2's legs were drawn up into a fetal position. R2 had facial grimacing and when asked if R2 was in pain, R2 replied, Yes.On 7/16/25 at 9:50 AM V27 (CNA/Certified Nursing Assistant Manager) stated, On 7/5/25 around 2:25 PM (V28/Agency RN/Registered Nurse) was working and told me (R2) seemed to be in pain and anxiety and had no medication. I called (V3/Prior Director of Nursing) and (V3) said she would take care of getting (R2's) pain medication.On 7/16/25 at 1:00 PM V28 (Agency RN) stated, I was working on 7/5/25 and it seemed throughout the shift that (R2) could not get comfortable. (R2) was seeing things and very fidgety and anxious. I looked at (R2s) MAR and noticed (R2) did not have Norco. I also did not have (R2's) Lorazepam to give (R2) to help with his restlessness. (V27) called (V3) and (V3) was supposed to take care of getting (R2's) Norco. (R2's) Norco never did come in that day.On 7/18/25 at 11:10 AM V30 (R2's Physician) stated, (R2) absolutely should not go without his Norco or Lorazepam. With all (R2's) illnesses and wounds, going without Norco would cause (R2) severe pain. There is no reason for any of my residents to be without their pain medications. The facility should have gotten ahold of me immediately to get (R2's) Norco ordered. I am always available by phone call and fax to get the prescription to pharmacy.2. R14's MDS (Minimum Data Set) assessment dated [DATE] documents R14 is cognitively intact. R14's Nursing Home Visits dated 319/25 and 4/9/25 and signed by V30 (R14's Physician) document, Chronic Pain: On Norco and Ibuprofen. R14's current Care Plan documents, Problem: Pain (R14) is at risk for chronic pain related to spinal stenosis. (R14) is no routine narcotic pain medication and PRN (as needed) non-narcotic medication for pain. 2/9/25 history of fracture o lumbar vertebrae. Goals: (R14) will verbalize reduction of pain. Approach: Administer medications as ordered. Monitor and record effectiveness. Report adverse side effects. Assess past effective and ineffective pain relief measures. Problem: (R14) has been asking for more pain medications, asking other nurses for pain \medications and telling other staff that (R14) did not get his pain medications. Approach: Nursing staff will give (R14) a sticky note of times he takes his schedules pain medications at the beginning of each shift.R14's Physician's Order Report dated 6/15/25 through 7/15/25 document R14 has the diagnoses of Spinal Stenosis of the Lumbosacral Region and Low Back Pain. This same Physician's Order Report documents, Start Date 10/16/23: Hydrocodone-Acetaminophen (Norco) 5-325 mg two tablets every six hour for low back pain. Start Date 9/1/23 Pain Scale/Evaluation every shift. Pain Scale 0-10. 0=No pain. 1=Mild Pain of uncomfortable/annoying. 4=Moderate Pain that is distressing/miserable. 10=Excruciating Pain that is the worst possible and interferes with the ability to carry on with daily routine, socialization, or sleep.R14's MARs dated 5/1/25 through 7/15/25 documents R14 did not receive his schedule Norco 5-325 mg as ordered on 13 occasions due to the Norco being unavailable.R14's MARs dated 5/1/25 through 7/15/25 document on 5/23/25 during the R14 was rating his back pain at a level 7 on a 0-10 pain scale. According to R14's MARs R14 did not receive his Norco 5-325 mg as ordered on 5/23/25 at 8:00 AM, 2:00 PM, or 8:00 PM and on 5/23/25 R14 was rating his back pain at a level 7 on a 0-10 scale.R14's MARs dated 5/1/25 through 7/15/25 document on 6/15/25 during the entire day R14 was rating his back pain at a level 7 on a 0-10 pain scale and on 6/16/25 during the night R14 was rating his back pain at a level 10 on a 0-10 pain scale. According to R14's MARs R14 did not receive his Norco 5-325 mg as ordered on 6/15/25 at 8:00 PM or 6/16/25 at 2:00 AM.R14's Electronic Medical Record does not include any pain relieving interventions, physician's notification, or comprehensive pain assessments after the 13 occasions between 5/1/25 through 7/15/25 when R14 did not receive his Norco as prescribed.On 7/15/25 at 10:05 AM R14 was walking with a walker in the dining room. R14 stated, The facility runs out of my Norco every month. I was an iron worker and hurt my back years ago. I have been on Norco for the pain in my lower back and was seeing a specialist for the pain. When I don't get my scheduled Norco I have excruciating, stabbing pain to my lower back. I know when I don't get the Norco because I start to have withdrawals and start feeling sick and jittery. The pain keeps me awake. I really wish the facility would get this fixed, so I do not have to go without the Norco.On 7/16 /25 at 10:30 AM V2 (Director of Nursing) stated, (R14) did not get his Norco as ordered on 13 occasions between 5/1/25 through 7/15/25. (R14) has a lot of back pain and should not go without his scheduled Norco.On 7/16/25 at 1:20 PM V1 (Administrator-In-Training) stated, I was made aware that (R14) was running out of his Norco frequently. I asked (V3/Prior Director of Nursing) sometime around April 10th to start doing narcotic medication audits on every Monday and Friday each week after I was made aware that narcotics were running out and residents were not getting their pain medications as ordered due to not getting renewal prescriptions in time. I wanted (V3) to make sure all residents were getting their narcotic medications as ordered. (V3) did not complete those audits as I instructed. I know (R14) needs his Norco for lower back pain and should not ever run out of Norco. If a resident does not have their narcotic the nurses should know the process and should call the physician immediately to get the prescription and call pharmacy to get a code to get the narcotic out of the facility's back-up supply.On 7/16/25 at 2:00 PM V19 (Regional Nurse Consultant) stated, (R14) has not had a comprehensive pain assessment completed since 5/13/25. V19 verified (R14) should have had a comprehensive pain assessment completed anytime (R14) went without his ordered Norco and was experiencing pain.On 7/18/25 at 11:00 AM V20 (R14's Family Member) stated, I know agency nurses do not get (R14's) medication refills done on time. (R14) has always had chronic pain and was a construction worker and hurt his back by following out of a third floor window of a building. (R14) has had multiple back surgeries. (R14) is usually out of his pain medications on the weekends and calls me when (R14) does not get his pain medication because he is having pain. If (R14) misses even one dose of Norco (R14) is in pain.On 7/18/25 at 11:10 AM V30 (R14's Physician) stated, (R14) should never have to go without his Norco. (R14) is dependent on the Norco and needs the Norco routinely to control his back pain. The facility should get ahold of me before (R14's) Norco runs out.3. R18's MDS assessment dated [DATE] documents R18 is cognitively intact.R18's Physician's Progress Note dated 5/3/25 and signed by V5 (R18's Primary Physician) documents, Chief complaint: (R18) is a [AGE] year-old who is trying to lose weight. (R18) wants to get stronger and hopefully go home. Hopefully will get (R18) started on an agent that will help (R18) lose some weight. Obesity.R18's current Physician Order Report documents R18 has the diagnoses of Severe Morbid Obesity and Type II Diabetes Mellitus. This same Physician Order Report documents, Start Date 6/16/25: Ozempic pen injector 0.25 mg subcutaneous once a day on Wednesdays.R18's Medication Administration Record dated 6/16/25 through 716/25 documents R18 did not receive Ozempic 0.25 mg as ordered on Wednesdays dated 6/18/25, 6/25/25, 7/2/25, 7/9/25, and 7/16/25.R18's Pharmacy Notice of Rejection dated 6/26/25 documents, Ozempic 2mg/3 ml quantity 3 not covered. Reason for denial: (Insurance Plan) requires additional information from medical doctor. Alternative: Trulicity 0.74 m/0.5 ml subcutaneous once a week.R18's Electronic Medical Record does not include notification or follow-up with the physician or pharmacy once insurance rejected to fill R18's Ozempic.On 7/15/25 at 11:00 AM R18 was sitting outside in a wheelchair. R18 stated, (V5/Physician) order me Ozempic so I can get my weight off and get my hip surgery. My insurance will not cover it. I really need it.On 7/16/25 at 9:00 AM V2 (Director of Nursing) stated, I was not aware that (R18) was not getting her ordered Ozempic.On 7/16/25 at 11:12 AM V31 (V5's Registered Nurse) stated, The nursing home has not called or followed up with (V5) to let us know (R18) was not getting Ozempic to get an alternative to (R18's) Ozempic or more information to get (R18's) Ozempic covered by insurance.4. R22's current Pain Care Plan documents R22 has complaints of chronic pain due related to osteomyelitis, pressure ulcer to the right ischium, tear of the hamstring tendon, and peripheral vascular disease, and is receiving hospice services for pain control management. This same care plan documents R22's pain medications should be administered as ordered and R22 will verbalize reduction of pain and/or show no signs of non-verbal pain.R22's current Physician Order Report documents R22 has the diagnoses of strain of muscle of the fascia and tendon of the posterior muscle group at right thigh level and malignant neoplasm of the large intestine and receives hospice services. This same Physician Order Report documents the following orders, Start Date 6/10/25 pain scale/evaluation every shift. Start Date: 7/7/25 MS Contin (Morphine) tablet extended release 15 mg twice daily at 8:00 AM and 8:00 PM.R22's Physician's Order dated 6/26/25 documents an order to increase R22's Hydrocodone/Acetaminophen from 5-325 mg every four hours to 10-325 mg every four hours and then discontinue on 7/7/25.R22's Medication Administration Record dated 6/10/25 through 7/15/25 documents R22's MS Contin 15 mg was not received on 7/7/25 at 8:00 AM or 8:00 PM due to the medication being unavailable.R22's Medication Administration Record dated 6/10/25 through 7/7/25 documents R22's Hydrocodone/Acetaminophen from 10-325 mg was not received as ordered on 15 occasions due to the Hydrocodone/Acetaminophen being unavailable.R22's Electronic Medical Record documents R22's last Comprehensive Pain Assessment was completed 6/26/25.On 7/17/25 at 1:00 PM V1 (Administrator-In-Training) verified R22 never received the Hydrocodone/Acetaminophen 10-325 mg as ordered due to the mediation not being delivered from the pharmacy. V1 also verified she was not aware of R22 not receiving the Hydrocodone/Acetaminophen 10-325 mg and should have been informed and the nurses should have notified the physician immediately to get a signed prescription and ensure the medication was received. V1 verified R22 did not receive the first two doses of MS Contin 15 mg due to the medication being unavailable.On 7/18/25 at 10:30 AM V12 (Hospice RN/Registered Nurse) I was not aware that (R22) was not getting his Hydrocodone/Acetaminophen 10mg-325 mg as ordered or his MS Contin 15 mg for two doses. I made (R22's) Hydrocodone/Acetaminophen 10mg-325 mg scheduled around the clock due top (R22) having wound pain, back pain, arm pain, and leg pain. It is unacceptable for (R22) to go without pain medication and (V9/Hospice Physician) was not notified. (V9) should have been notified so me or (V9) could have reached out to the pharmacy to make sure (R22) was getting his medication or we would have ordered something else to control (R22's) pain until the Hydrocodone/Acetaminophen and MS Contin was received.

Based on interview and record review the facility failed to issue a written notice of room moves for three of four residents (R13, R14, and R27) reviewed for room moves in a sample of 30. Findings include: The facility's Room Changes Policy, dated 1/2025, documents Policy: To make room changes when requested by the resident or as may become necessary to meet the resident's medical and nursing care needs. Policy Specifications: 2. Unless medically necessary for the safety and well-being of the resident(s), a resident will be provided with advance notice of the room change, at least two days before relocation, however, the resident has the right to relocate prior to the expiration of the two-day notice. Such notice will include the reason(s) why the move is recommended. 3. Prior to the room change, the resident, his or her roommate (if any), and the resident's representative will be provided with information concerning the decision to make the room change. 1. R13's current Census Sheet documents R13 had room moves on 2/8/25, 2/13/25, 2/19/25, 3/7/25, and 5/1/25. R13's MDS (Minimum Data Set) Assessment, dated 7/11/25, documents R13 is cognitively intact. R13's Electronic Medical Record does not include a notice of room change issued to R13 for R13's room moves on 2/8/25, 2/13/25, 2/19/25, 3/7/25, and 5/1/25. On 7/16/25 at 11:04 AM R13 stated, I am never made aware of reasons for room moves and they (the facility) make us change rooms a lot. I do not like it.2. R14's current Census Sheet documents R14 moved rooms from the [NAME] Hall to the [NAME] Hall on 5/8/25. R14's MDS Assessment, dated 5/13/25, documents R14 is cognitively intact. R14's Electronic Medical Record does not include a notice of room change issued to R14 or R14's representative. On 7/17/25 at 11:56 AM R14 stated he was never made aware of the reason why they moved him to another room and never received a written notice of room change. 3. R27's current Census Sheet documents R27 moved rooms on 2/1/25, 2/28/25, and 5/19/25. R27's MDS Assessment, dated 7/3/25, documents R27 is cognitively intact. R27's Electronic Medical Record does not include a notice of room change issued to R27 or R27's representative. On 7/17/25 at 11:07 AM V2/Director of Nursing stated R27 is alert and able to answer questions appropriately by shaking his head yes or no.On 7/17/25 at 11:11 AM R27 was asked by this surveyor if he has moved rooms in the facility a few times in the past 6 months. R27 shook is head yes. R27 was asked if they ever let him know the reasons why he was moved rooms and R27 shook his head no. On 7/17/25 at 11:20 AM V6/R27's Family Member stated they called her on one room move (2/28/25) and told her they moved R27 to a different room, but never told her a reason why. V6 stated the facility never let her know about the room moves on 2/1/25 or 5/19/25.On 7/17/25 at 11:24 AM V1/Administrator in Training verified R13, R14, and R27 did have multiple room moves and they (the facility) did not issue any written notice of room moves to R13, R14, R27 or their representatives. V1 stated, I was unaware we were supposed to issue a written notice to the resident or representative of the room moves and the reason we (the facility) are moving the resident(s) to a different room.

Based on interview and record review the facility failed to notify a resident's responsible party after a significant weight loss was identified for one of four residents (R1) reviewed for notifications of change in a sample of 30.Findings include:The facility's Weight Assessment and Intervention Policy, dated 1/2025, documents The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month- Five percent weight loss is significant; greater than 5% is severe. b. 3 months- 7.5 percent weight loss is significant; greater than 7.5% is severe. c. 6 months- 10 percent weight loss is significant; greater than 10 percent is severe.The facility's Notification of Consumer Change in Condition Policy, dated 1/2025, documents Policy: It is the policy of this facility to promptly notify the consumer, their legal representative(s) and attending physicians of changes in the consumer's health condition. Policy Specifications: To establish guidelines for assuring consumers, their legal representative and attending physicians are informed of changes in the consumer's condition. As per the Guidelines for Reporting to Physicians as per INTERACT Change in Condition Guidelines. Responsibility: Director of Nursing and Licensed Nurses. Standards: 3. Clinical change in condition is determined by consumer visualization, medical record review, clinical assessment findings and care plan review. Review of high-risk clinical issue such as skin breakdown, falls, weight loss, dehydration and others are conducted on a daily basis. 12. Consumer representative(s) notifications and attempts will be made promptly and documented in the nurses' notes. In the event the licensed nurse is unable to contact the consumer's representative, after a reasonable time period, the director of Nursing will be notified.The facility's Notification of Change Guidelines, dated 1/2025, documents Purpose: It is the practice of this facility that changes in a resident condition or treatment are immediately shared with the resident and/or resident representative, according to their authority, and are reported to and consulted with the attending physician. The resident and/or the resident representative will be educated about treatment options and supported to make an informed decision. Responsible Party: Clinical. Physician Notification and Consultation- Notification is provide to residents and/or the resident representative(S) to promote the right to make informed decisions regarding choices for care and treatment while keeping them informed about their current health status.1. R1's Face Sheet, dated 7/16/25, documents R1 is a [AGE] year-old male that admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Cerebral Palsy, Epilepsy, Unspecified Intellectual Disabilities, Hypothyroidism, Bradycardia, and Dysphagia, and Gastrostomy Status Placed 4/30/25.R1's MDS (Minimum Data Set) Assessment, dated 7/1/25, documents R1 had a significant weight loss of five or more percent in one month and/or ten percent or more in six months and is not on a physician-prescribed weight loss regimen.The facility's Weight Variance Report, dated 1/1/25 through 7/9/25, documents R1 weighed 126.2 pounds on 6/3/25 and 109.60 pounds on 7/1/25 indicating R1 had a severe weight loss of 13.2 percent weight loss in one month.R1's Electronic Medical Record does not include notification to V22/R1's Guardian of R1's severe weight loss of 13.2 percent identified on 7/1/25.On 7/15/25 at 9:35 AM V22/R1's Guardian stated she was never notified of R1's significant weight loss identified on 7/1/25 or any weight loss prior to that date. V22 stated, I would have liked to have known about (R1's) severe weight loss. I am very involved in (R1's) care and want him to be able to return to where (R1) lived prior to admitting to (this facility).On 7/15/25 at 10:12 AM V18/Regional Director stated it is the responsibility of the Director of Nursing to notify the family after a significant weight loss is identified. V18 stated, I cannot find any documentation of anyone notifying V22/R1's guardian of R1's significant weight loss identified on 7/1/25.

Based on record review and interview the facility failed to protect a resident from staff-to-resident verbal abuse for one of three residents (R13) reviewed for staff-to-resident abuse in the sample of 30. Findings include:The facility's Abuse Prevention Policy, undated, documents The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of the individual's age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never to be able to see his/her family again.R13's MDS (Minimum Data Set) assessment dated [DATE] documents R13 is cognitively intact.On 7/16/25 at 2:45 PM R13 stated, One night about a month ago a CNA (Certified Nursing Assistant/unknown name) picked up a trash can and wanted to throw it at me and cussed me out. I reported this to (V3/Prior Director of Nursing). (V3) told me she fired the CNA because of abusing me. I felt threatened.On 7/17/25 at 11:00 AM V1 (Administrator-In-Training) stated, I was on maternity leave around a month ago, so (V18/Regional Director) was covering for me. A CNA should not cuss or threaten to throw a trashcan at (R13). (R13) would know if this happened and would know if the CNA still works here. I have not been able to figure out who the CNA was, as (R13) said she no longer works here.

Based on interview and record review the facility failed to obtain consent prior to administering psychotropic medications for one of three residents (R1) reviewed for psychotropic medications in a sample of 30.Findings include:The facility's Psychotropic Medication Policy, dated 2/2014, documents Policy: To establish the process for monitoring the use of and the Reduction of doses of psychotropic medications without compromising the resident's health and safety, ability to function appropriately, or the safety of others. Policy Specifications: Psychotropic medication shall not be prescribed without the informed consent of the resident, the resident guardian, or other authorized representative.R1's Face Sheet, dated 7/16/25, documents R1 admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Unspecified Intellectual Disabilities and Epilepsy.R1's current Physician Order Sheet documents R1 receives Risperidone (psychotropic medication) 0.5 mg (milligram) tablet twice a day and Clobazam (psychotropic medication) 5mg twice a day.On 7/15/25 at 9:35 AM V22/R1's Guardian stated she never verbally gave consent or signed an informed consent for R1's psychotropic medications.On 7/15/25 at 2:24 PM V1/Administrator in Training stated, We (the facility) could not locate an informed psychotropic consent for (R1). We should have obtained one prior to administering (R1's) psychotropic medication.On 7/17/25 at 10:07 AM V19/Regional Nurse Consultant verified an informed psychotropic consent could not be produced for the use of R1's Psychotropic medication.

Based on record review and interview the facility failed to implement their Abuse Policy to immediately report an allegation of resident abuse to the State Agency and Administrator for one of seven residents (R13) reviewed for Abuse in the sample of 30.Findings include:The facility's Abuse Prevention Policy, undated, documents The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. V. Internal Reporting Requirements and Identification of Allegation: Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer. In the absence of the administrator, reporting can be made to an individual who has been designated to act in the administrator's absence. Reports will be documented, and a record kept of the documentation. Supervisors shall immediately inform the administrator or person designated to act in the administrator's absence of all reports of incidents, allegations or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property. Any allegation of abuse or any incident that results in a serious bodily injury will be reported to the Illinois Department of Public Health immediately, but not more than two hours of allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported withing 24 hours. External Reporting- 1. Initial Reporting of Allegations: When an allegation of abuse, exploitation, neglect, mistreatment or misappropriation of resident property has been made, the administrator or designee, shall notify Department of Public Health's regional office immediately by telephone of fax. Public health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property has been reported to the administrator and is being investigated. 2. Five-day Final Investigation Report: Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health.R13's MDS (Minimum Data Set) assessment dated [DATE] documents R13 is cognitively intact.On 7/16/25 at 2:45 PM R13 was lying in bed. R13 stated, One night about a month ago a CNA (Certified Nursing Assistant/unknown name) picked up a trash can and wanted to throw it at me and cussed me out. I reported this to (V3/Prior Director of Nursing). (V3) told me she fired the CNA because of abusing me. I felt threatened.R13's Electronic Health Record and the facility's Abuse Investigations do not include evidence of the administrator or the State Agency being notified of R13 alleging a CNA cursed at R13 and threatened to pick up a trash can and throw the trash can at R13.On 7/17/25 at 11:00 AM V1 (Administrator-In-Training) stated, I was on maternity leave around a month ago, so (V18/Regional Director) was covering for me.On 7/17/24 at 11:25 AM V18 (Regional Director) verified V3 did not report R13's allegation that a CNA cursed at R13 and threatened to throw a trash can at R13. V18 stated V3 should have reported the allegation to V18 immediately.

Based on record review and interview the facility failed to immediately investigate an allegation of resident abuse for one of seven residents (R13) reviewed for Abuse in the sample of 30.Findings include:The facility's Abuse Prevention Policy, undated, documents The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. VII. Internal Investigation- 2. Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation. 8. Final Investigation Report: The investigator will report the conclusions of the investigation in writing to the administrator or designee within five working days of the reported incident.R13's MDS (Minimum Data Set) assessment dated [DATE] documents R13 is cognitively intact.On 7/16/25 at 2:45 PM R13 was lying in bed. R13 stated, One night about a month ago a CNA (Certified Nursing Assistant/unknown name) picked up a trash can and wanted to throw it at me and cussed me out. I reported this to (V3/Prior Director of Nursing). (V3) told me she fired the CNA because of abusing me. I felt threatened.R13's Electronic Health Record and the facility's Abuse Investigations do not include evidence of an investigation being conducted regarding R13 alleging a CNA cursed at R13 and threatened to pick up a trash can and throw the trash can at R13.On 7/17/25 at 11:00 AM V1 (Administrator-In-Training) stated, I was on maternity leave around a month ago, so (V18/Regional Director) was covering for me.On 7/17/24 at 11:25 AM V18 (Regional Director) verified V3 did not report R13's allegation that a CNA cursed at R13 and threatened to throw a trash can at R13, therefore an investigation has never been done.

Based on interview and record review the facility failed to provide residents with a bed hold and written notice of transfer when transferring to the hospital for three of three residents (R3, R13, and R14) reviewed for hospital transfers in a sample of 30. Findings include: The facility's Transfer and Discharge Policy, un-dated, documents Policy: To assure resident transfers and discharges will be conducted in accordance with residents' rights, physician orders, and in such a manner as to maintain continuity of care for the resident. Policy Specifications: 2. When the facility transfers or discharges a resident under any circumstances, the resident/authorized legal representative must be notified verbally and in writing at least 30 days prior to the intended discharge unless the resident waives the notification period or in an emergency. (including situations where the safety of other residents may be compromised). The facility must also: b. Include a written notice to the resident/authorized legal representative the following. i. reason for transfer/discharge; ii. Effective date of transfer, iii. Location to which the resident will be transferred/discharged ; iv. A statement that the resident has the write to appeal the action to the State; v. the name, address, and telephone number of the State long term care ombudsman; and vi. Any other appropriate advocacy or protective services agency as required by the state. The facility's Bed Hold Policy Notification, undated, documents This Bed Hold Policy will be given to you at the time of admission and a copy will be given to you each time you are transferred from the facility. 1. R3's current Census Sheet, documents R3 was sent to the hospital on 1/13/25 and 7/5/25. R3's medical record did not contain documentation of a written notice of the facility's bed hold policy or notice of discharge was given to R3 or R3's representative for 1/13/25 and 7/5/25. 2. R13's current Census Sheet, documents R13 was sent to the hospital on 6/26/25. R13's medical record did not contain documentation of a written notice of the facility's bed hold policy or notice of discharge was given to R13 or R13's representative for 6/26/25. 3. R14's current Census Sheet, documents R14 was sent to the hospital on 2/9/25. R14's medical record did not contain documentation of a written notice of the facility's bed hold policy or notice of discharge was given to R14 or R14's representative for 2/9/25. On 7/16/25 at 10:30 AM V1/Administrator in Training verified R3 or R3's representative was not given a bed hold or notice of transfer on 1/13/25 and 7/5/25 when transferred to the hospital, R13 or R13's representative was not given a bed hold or notice of transfer on 6/26/26 when transferred to the hospital, and R14 or R14's representative was not given a bed hold or notice of transfer on 2/9/25 when transferred to the hospital. V1 stated When any resident goes out to the hospital, they should receive a bed hold and a written notice of transfer.

Based on interview, observation and record review, the facility failed to provide supervision and implement fall prevention interventions to prevent resident falls for two of three residents (R1 and R4) reviewed for falls in the sample of 24. These failures resulted in R1 falling and sustaining an injury to right eyelid and R4 falling and experiencing left hip pain. Findings include: The facility's Fall Reduction Program (revised April 2019) documents the following: It is the policy of this facility to have a Fall Reduction Program that promotes the safety of residents in the facility. The program's intent is to assist clinical staff in determining the needs of each resident through the use of standard assessments, the identification of each resident's individual risks, and the implementation of appropriate interventions, supervision, and/or assistive devices deemed appropriate. Quality Assurance will monitor the program to assure ongoing effectiveness. This same policy documents, Safety interventions will be determined and implemented based on the assessed, individualized risks and in accordance with standards of care; interventions to be documented in the resident's care plan. This policy also documents, Examples of Standard Fall/Safety Precautions that May be Applicable: Call lights answered in a timely manner; Supervision of residents who require staff assistance with bathing, showering, or toileting. If resident is not able to maintain proper sitting balance, staff shall remain with resident allowing as much privacy as is safe for the resident. 1. R1's Fall Risk Observation (dated 05/09/25) documents a score of 20, indicating R1 is at high risk for falls. R1's current Fall Prevention Care Plan documents the following: (R1) is at risk for falling related to polyneuropathy, generalized muscle weakness and cognitive deficit related to progression of Parkinson's. R1's current Functional Status Care Plan documents the following focus: (R1) requires extensive assistance with bed mobility due to weakness related to Parkinson's. R1's Functional Status Care Plan also documents the following intervention currently in place: Never leave (R1) in a position that is unsafe or uncomfortable to him. R1's Minimum Data Set Assessments (dated 02/11/25 and 05/09/25) document in Section GG, R1 is dependent (helper does all of the effort, or the assistance of two or more helpers is required) in the following areas: Roll left and right, Sit to lying, and Lying to sitting on bed. R1's Fall Investigation (dated 04/15/25) documents, IDT (Interdisciplinary Team) met to discuss alleged fall. (R1) was receiving cares in bed when CNA (Certified Nursing Assistant) turned away and (R1) rolled out of bed and onto the floor. (R1) has discoloration to right eyelid. Neurological checks initiated. (R1) not complaining of pain at this time. All notifications made, care plan updated. Root cause: Extensive assistance needed for all cares provided while in bed. Intervention: Two staff present during cares in bed at all times. On 05/14/25 at 11:15 AM, V2 (Director of Nursing) stated that V16 (former Certified Nursing Assistant), Was the only one in with (R1) at the time of his fall. (V16) walked away and left (R1) unattended in his bed to obtain supplies while she was providing cares to him, and he fell out of his bed while he was unattended. (R1) ended up with a black eye. (V16) should not have walked away from (R1) at any time. She knew better than that. She was terminated and no longer works at the facility. 2. R4's current Fall Prevention Care Plan documents the following: (R4) is at risk for falling and repeat falls related to spinal stenosis, generalized edema, history of falls, generalized muscle weakness accompanied by poor safety awareness. This same care plan documents the following fall prevention interventions in place: CNAs (Certified Nursing Assistants) will assist (R4) to the bathroom and back using a wheelchair; Staff will frequently check on (R4) and anticipate her needs. R4's Fall Investigation (dated 03/14/25) documents the following: (R4) stated she needed to use the bathroom and was in a hurry, so she attempted to get up alone. She lost balance and lowered herself to her knees. (R1) stayed on her knees until CNA (Certified Nursing Assistant) and Nurse entered room and were able to transfer resident back into the bed. No injury. This same investigation documents that R4's call light was on at the time of R4's fall. On 05/14/25 at 10:00 AM, R4 was sitting in a recliner in her room watching television. When asked about falling in the facility, R4 stated the following: My legs are weak, so I do fall a lot. I'm supposed to ask for help and wait for them to come, but it usually takes too long. There're times I've had an accident in my pants waiting for help to go to the bathroom. I feel like this happens constantly. It takes a really long time for someone to answer the call light at nighttime. I've waited several hours. They try to get to you during the day, but at times you wait 30 to 45 minutes. They definitely need to schedule more nurses and CNAs. R4 was able to recall her 03/14/25 fall and stated the following: I needed to use the bathroom, and I had my call light on. I waited and waited, and no one ever came, so I attempted to get up by myself. That was a mistake because I fell on to my knees. I stayed on my knees for several minutes until someone finally came to help. On 05/14/25 at 11:25 AM, V2 (Director of Nursing) verified that R4's call light was on at the time of her 03/14/25 fall, and stated staff should be checking on R4 frequently, especially since she is a high risk for falls. R4's Fall Investigation (dated 04/10/25) documents the following: Resident experienced an unwitnessed fall around 07:30 AM. After the fall, she stated she had left hip pain, and she stated she hit her head. Writer assessed resident after falling. No bleeding, resident alert, neuro (neurological) check done and normal, MD (Medical Doctor) and POA (Power of Attorney) notified. Resident is being sent to ED (emergency department) to be evaluated. This same investigation documents: Resident statement of what happened: I was trying to use the bathroom. This investigation also documents the following conclusion: Root cause: Staff did not follow plan intervention. Staff education and discipline. On 05/14/25 at 11:30 AM, V2 (Director of Nursing) stated, After (R4's) fall on 04/10/25, (V18, Certified Nursing Assistant) received discipline because she did not check on (R4) frequently. I watched the camera that records the entrance to (R4's) room, and it was an extended period of time before (V18) checked on (R4) since she had last been checked. (R4) is supposed to be checked on frequently, at least every 15 minutes.

Based on observation, interview, and record review the facility failed to obtain physician orders for use and care of an indwelling urinary catheter (R1), failed to notify a physician of a resident's abnormal urine laboratory testing results (R1), failed to timely treat a urinary tract infection/UTI (R1), and failed to obtain a physician ordered urine laboratory test (R4) for two of three residents (R1 and R4) reviewed for indwelling urinary catheters and UTIs in the sample of six. These failures resulted in R1 experiencing lower abdominal pain; urine with increased sediment in R1's indwelling urinary catheter tubing and bag; abnormal urine laboratory test results with a delay of physician notification and treatment. R1 was subsequently transferred to two different local area hospitals and admitted to the intensive care unit with a diagnosis of UTI with septic shock. Findings include: The facility's Urinary Tract Infections/Bacteriuria revised April 2007 states, 1. As part of the initial assessment, the physician will help identify individuals who have a history of symptomatic urinary tract infections, and those who have risk factors (for example, an indwelling urinary catheter, urinary outflow obstruction, etc.) for UTIs. 2. The staff and practitioner will identify individuals with signs and symptoms suggesting a possible UTI. 1. The physician will order appropriate treatment for verified or suspected UTIs based on a pertinent assessment. The facility's Lab, Diagnostic Test Results and Change in Resident's Condition-Clinical Protocol (undated) states, Policy: To establish guidelines for physician notifications concerning resident lab and diagnostic test results and change(s) in resident conditions. 1. A licensed nursing will review all diagnostic test results: b. if the staff member who first receives or reviews lab and diagnostic test results is unable to follow the remainder of this procedure (i.e., reporting and documenting the results and their implications), another nurse in the facility should follow and coordinate procedural compliance. 2. The person who is to communicate results to a physician will review and compile the information and be prepared to discuss the following: the individual's current condition and any recent changes in status, including vital signs and mental status; b. major diagnoses, allergies, pertinent current medications, other recent pertinent lab work, actions already taken to address the results and treat the resident, and pertinent aspects of advanced directives; c. Why the test results were obtained, d. How the test results might relate to the individual's current status, treatments, or medications; e. any concerns the physician will be expected to address upon receiving the results. 3. The attending physician is responsible for responding in a timely manner to nurses regarding prompt notification calls or emergencies. The attending physician is also responsible for communicating the results of assessments and medical plans to a licensed nurse when appropriate. 4. Nurses should promptly notify the physician of any significant abnormal laboratory results. In such situations, direct communication with the physician is required and may not be faxed. Prompt calls must be made after office hours or when physician offices are closed. The following symptoms, signs and laboratory values should prompt the nurse to notify the physician as soon as possible: c. any of the following abnormal reports: Positive urine culture > (greater than) 100,000 colonies/ml (per milliliter) of a pathogen only if 1. Resident has symptoms and is not on treatment; or 2. The pathogen is not sensitive to the antibiotic which has been prescribed. 5. If a response from an attending physician concerning abnormal lab results is not obtained, the designated alternate physician should be called. If a response is still not received, the Director of Nursing/Designee should be notified for further instructions. 8. The following documentation should be entered into the resident's clinical record: a. Any calls to and from the physician indicating information conveyed or received, b. All orders taken from the physician or his designee (i.e., physician extender); c. Ongoing conversations with the physician regarding response to notification(s) of changes in condition and/or laboratory/diagnostic test results. The facility's Urinary Catheter Care Policy revised September 2005 states, The purpose of this procedure is to prevent infection of the resident's urinary tract. General Guidelines are documented as: Should the resident indicate that his or her bladder is full or that he or she needs to void (urinate), report it immediately to your supervisor; Observe the resident for signs and symptoms of urinary tract infection and urinary retention. Report findings to the supervisor immediately; Report to the supervisor any complaints the resident may have of burning, tenderness, or pain in the urethral area. Documentation: The following information should be recorded in the resident's medical record: 1. The date and time that catheter care was given. 2. The name and title of the individual(s) giving the catheter care. 3. All assessment data obtained when giving catheter care. 4. Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor. 5. Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain. 6. Any problems or complaints made by the resident related to the procedure. 7. How the resident tolerated the procedure. 8. If the resident refused the procedure, the reason(s) why and the intervention taken. 9. The signature and title of the person recording the data. 1. R1's Resident Census documents R1 admitted to the facility on [DATE] and was placed on hospital leave on 4/10/24. R1's Admission Minimum Data Set assessment dated [DATE] documents the following: R1 is cognitively intact; R1 has impairment to both upper and lower extremities; R1 is dependent on staff assistance for all activities of daily living (ADLs); and R1 has an indwelling urinary catheter. R1's Admission Bladder Observation dated 3/22/24 documents R1 admitted to the facility with an indwelling urinary catheter. R1's Care Plan documents the following with a start date of 3/25/24: R1 requires an indwelling urinary catheter; R1 will have catheter care managed appropriately as evidenced by: not exhibiting signs of urinary tract infection or urethral trauma; Change catheter per MD (Medical Doctor) order; Provide Catheter Care during peri-care and as needed; and Report signs of UTI (acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain/difficulty urinating, nausea, emesis, chills, fever, low back/flank pain, malaise, foul odor, concentrated urine, blood in urine). R1's Physician's Order documents a written order dated 4/3/24 and signed by V14 (Advanced Practice Nurse for UA C&S/Urinalysis with Culture and Sensitivity. R1's Order History documents an order with a start date of 4/4/24 to collect a Urinalysis with Culture and Sensitivity with special instructions as Chronic (Indwelling Urinary Catheter). As of 4/25/24, this same Order History did not document an order for: R1's Indwelling Urinary Catheter, including what size catheter and balloon to be used; Indwelling Urinary Catheter bag changes; or treatment orders for the care of R1's Indwelling Urinary Catheter. On 4/25/24 at 11:37 AM, V18 (Licensed Practical Nurse) verified R1 did not have orders for R1's Indwelling Urinary Catheter or Catheter Care and should have. V18 stated catheter care is completed minimally on each shift daily and would be on the resident's administration record to be completed each shift and as needed. As of 4/25/24, R1's medical record did not contain documentation that R1's indwelling catheter care was completed daily. R1's Resident Progress Notes dated 4/5/24 at 2:55 PM and signed by V7 (Licensed Practical Nurse/LPN) states, UA obtained and sent to (name of local area hospital). R1's Resident Progress Notes dated 4/8/24 at 2:38 PM and signed by V7 is recorded as a late entry on 4/12/24 at 11:45 AM. This note states, Writer (V7) called (name of local area hospital) lab to obtain UA C&S results that were sent to lab on 4/5/24. (Name of local area hospital) lab faxed preliminary results to writer (V7) and writer (V7) then calls back to (name of local area hospital) lab to get the final result faxed to facility. Writer (V7) then faxed C&S final results to PCP/Primary Care Physician. Awaiting response. R1's Resident Progress Notes dated 3/22/24-3/30/24 documents R1 with the presence of an indwelling urinary catheter draining yellow urine. R1's Resident Progress Notes dated 3/30/24 at 10:52 PM documents R1 complained during the shift of R1's indwelling urinary catheter not feeling right. V19 (LPN) attempted to irrigate R1's indwelling urinary catheter without success. V19 replaced R1's indwelling urinary catheter with an immediate return of yellow urine. R1's Resident Progress Notes dated 4/3/24 and signed by V15 (R1's Physician) states, Assessment: (indwelling urinary catheter) with yellow urine with sediment. This same note states, Plan: UA C+S (Urinalysis Culture and Sensitivity). R1's Resident Progress Notes dated 4/9/24 at 5:45 AM and signed by V10 (LPN) states, (R1) requesting catheter to be flushed; states he has been feeling some discomfort and pressure in his lower abdomen. Noted to have about 50 cc (cubic centimeters) of urine in the drainage bag. Abdomen distended and hard. Attempt to flush met with resistance. Catheter changed using size 14 fr (french) with 30 cc NS (normal saline). Upon insertion of new catheter, urine return of 1200 cc noted in the drainage bag right away. R1's Resident Progress Notes dated 4/10/24 at 1:21 PM and signed by V9 (LPN) states, (R1) complained of lower abdomen pain and states he can't pee. Moderate amount of sediment present in the (indwelling urinary catheter tube). Attempted to flush indwelling urinary catheter and was not effective. Changed indwelling urinary catheter #14 30 cc with scant amount of yellow sediment urine. Spoke with V14 (R1's Advanced Nurse Practitioner) and to send to ER (emergency room ) for evaluation. Call placed to 911 for transport to (name of local area hospital). R1's Urinalysis Laboratory Result dated 4/5/24 documents the following results: Color: Amber; Appearance: Cloudy (with a normal result being clear); pH (potential of Hydrogen): 9 (with a normal result being 5-7); Leukocyte esterase: 2+ (with a normal result being negative); Nitrite: Positive (with a normal result being negative); Protein: 1+ (with a normal result being negative-trace); [NAME] Blood Cells 6-10 (with normal range being 0-5); Bacteria: 3+. This same lab result contains a handwritten note on the bottom corner that it was sent to V14 and V16 (R1's Physician). R1's Urine Culture Laboratory Result documents it was collected on 4/5/24 and resulted on 4/8/24. The Final Report states, > (greater than) 100,000 col/ml (colonies per milliliter) Proteus mirabilis. The Sensitivity report of susceptible antibiotics is listed at the bottom of the page. R1's History and Physical (H&P) from the local area hospital dated 4/10/24 documents R1 presented to a local area hospital from the skilled nursing facility for evaluation of a UTI (Urinary Tract Infection), but R1 was not started on any antibiotics and R1 had complaints of lower abdominal pain. (R1) reports that he has had some abdominal pain the past few days. His blood pressure was on the lower side on arrival with a bp (blood pressure) in the upper 70s. (R1's) labs demonstrated mild leukocytosis and urinalysis consistent with UTI. A CT (Computed Tomography) of (R1's) abdomen and pelvis was performed (on 4/10/24) and demonstrated abnormal appearance of urinary bladder with mucosal hyperenhancement bladder wall thickening, findings of cystitis. This same H&P states, Impression/Plan: Severe Sepsis secondary to complicated UTI (Urinary Tract Infection), Leukocytosis, Sepsis protocol. R1's Discharge Summary from the local area hospital dated 4/19/24 documents R1 was initially evaluated at a local area hospital closer to the facility and transferred to a second hospital where R1 remained until R1's discharge. R1 was admitted to the Intensive Care Unit/ICU on 4/10/24. R1 was discharged from the hospital on 4/19/24 after a nine-day hospital stay. R1 required blood pressure support medication while in the ICU. R1's significant problems are again stated as: Severe Sepsis (with) shock secondary to complicated UTI and Leukocytosis-Source appears to be r/t (related to) UTI in the context chronic (indwelling urinary) catheter. On 4/23/24 at 10:06 AM, V20 (R1's Spouse/Power of Attorney) stated that R1 had been complaining about lower abdominal pain and not feeling well for almost a week. V20 stated, I kept pointing out that (R1) had what looked like thick strands of mucous in his (indwelling urinary catheter) tubing and bag and the staff just kept brushing me off. (R1) is immunocompromised and he gets UTIs easily. I knew he was getting an infection, and no one was listening. They were telling me the way his catheter looked was 'expected.' V20 stated V20 was aware a urine sample was taken and V20 reported never being made aware what R1's urine test results were. V20 stated R1 was in the hospital for nine days and discharged to another skilled nursing facility. On 4/24/24 at 11:59 PM, during a third shift telephone interview with V10 (LPN), V10 stated when V10 came onto shift on 4/8/24, V10 received a report from V7 (LPN) that R1 was complaining of bladder burning and that the V7 had sent R1's UA C&S results to V14 (APN) and V16 (R1's Physician) earlier in the shift with no response. V10 stated that V7 had not received an answer back from V14 or V16 on V7's shift. V10 denied following up with V14 (APN), V15 (R1's Physician) or V16 (R1's Physician) regarding R1's UA C&S results. V10 denied being aware of R1's urine lab test results. V10 stated, I was just told (V7) faxed them. V10 stated during V10's shift, R1 had complained of abdominal pain and that R1 had expressed R1 felt as if R1's indwelling urinary catheter wasn't draining. V10 stated V10 attempted to flush R1's catheter and was not able to, so V10 replaced R1's urinary catheter with a new one. V10 denied speaking to any of R1's physicians or nurse practitioner (V14-V16) regarding R1's complaints of pain, issues with R1's indwelling urinary catheter, or R1's abnormal urine test results during V10's shift. On 4/24/24 at 2:22 PM, V7 (LPN) stated that V7 was the admitting nurse when R1 arrived at the facility. V7 stated that R1 had an indwelling urinary catheter in place at the time of R1's admission to the facility. V7 stated that V7 recalls V20 stating that R1 goes septic quickly with UTIs. V7 stated that V20 was requesting a urine sample be ordered for R1 as V20 was concerned about R1's urine. V7 stated on 4/5/24, V14 gave a verbal order to obtain a UA C&S and V7 sent the sample out on that same day. V7 stated when V7 returned to work on 4/8/24, V7 followed up with the lab regarding R1's urine C&S results. V7 stated V7 faxed the urine test results to V14 and V16 on 4/8/24. V7 stated V14 and V15 were taking over as primary care of R1, but V16 was still overseeing in the transitional period, so V7 sent the results to both. V7 denied getting a physician response regarding R1's abnormal urine test results and V7 denied speaking with V14, V15, or V16 directly regarding R1's abnormal urine test results. V7 stated V7 faxed the results and nothing further. On 4/24/24 at 10:30 AM, V9 (LPN) stated that V9 was off work for a couple of days before returning to work on 4/9/24. V9 denied speaking with any physician or getting new orders on 4/9/24 regarding R1's abnormal urine test results. V9 stated V9 was aware R1's test results were faxed to a provider on 4/8/24, but V9 was not aware R1's test results were abnormal requiring a physician response. V9 stated if V9 had been aware of R1's urine test results were positive for a UTI, V9 would have attempted to speak with a physician directly. V9 stated, I would have sent the fax and immediately followed up with a phone call. V9 stated on 4/10/24, V9 was handed R1's UA C&S results and there was a sticky note on the results stating to call R1's daughter. V9 stated the UA was positive for a UTI. V9 stated, I went to (V2/Director of Nursing) and I asked who is taking care of this? V9 stated V14, V15, and V16, but V14 and V15 did not end up coming to the facility on [DATE] to see the residents. V9 stated on 4/10/24, R1 was complaining of severe abdominal pain with a lot of sediment in R1's indwelling urinary catheter tubing and bag. V9 stated V9 tried to irrigate R1's catheter and was unable to. V9 stated that V9 then replaced R1's urinary catheter and V9 still did not get much urine return, stating it was mostly sediment. V9 stated V9 asked about bladder scanning R1, but the equipment was broken and not able to be used. V9 stated, I thought ok, it's time to go. V9 stated V14 gave orders for R1 to be transferred to the local area emergency room for evaluation. On 4/23/24 at 12:57 PM, V2 (Director of Nursing) stated that the facility was in transition between two different lab companies and that in the interim, all lab samples had to be transported to the local hospital to be tested . V2 stated that since the hospital was running the lab tests, the results did not automatically show up in the system at the facility. V2 stated the hospital was not faxing over results once they were available; the facility was having to call to get them causing delays. V2 also stated that V14 and V15 were new providers to the facility and were going to be taking over as primary care for the respiratory care residents, including R1. V2 stated that V16 remained primary in the two-week transitional period while V14 and V15 got to know the residents and meet families. V2 stated V14 ordered the UA C&S on R1 during rounds and that the results were given to V14 and V16 on 4/8/24. V2 stated the nursing staff should have called V14, V15, or V16 to immediately notify of R1's UA C&S results. V2 stated V14 and V15 did not come to the facility on [DATE] as originally planned, so R1's urine lab tests were not reviewed then either. V2 stated R1's UA results were positive for a UTI and as soon as the C&S results were available, the nurses should have called to get treatment orders that day. V2 stated R1's UA resulted on 4/5/24 and that on 4/8/24, new orders should have been received based off the culture and sensitivity. V2 verified treatment orders were not obtained at the facility for R1's abnormal urine test results and should have been. V2 verified residents with indwelling urinary catheter should have orders for the catheter indicating the size catheter and balloon to be used and orders for catheter care to be completed. V2 stated the residents' electronic administration record would document the catheter care was completed. On 4/24/24 at 11:30 AM, V14 (Advanced Practice Nurse) stated that during rounds on R1 on 4/3/24, it was noted that R1's urine in R1's indwelling urinary catheter bag was yellow and cloudy so V14 ordered a UA C&S to be obtained. V14 stated R1's initial UA result was sent to the wrong doctor as the nurses were not sure where to send results in the facility's transition period of primary care doctors changing. V14 stated, I was not able to be apprised what to do because I did not know. V14 stated V14 never saw the results from R1's 4/8/24 urine culture and sensitivity. V14 stated V14 would have expected to be made aware of R1's abnormal UA C&S result as soon as it was resulted. V14 stated V14 did not round in the facility on 4/10/24. V14 stated R1's UTI would have been easy to treat if V14 had been made aware of R1's lab findings. V14 stated if V14 had been made aware of R1's C&S result on 4/8/24, R1 would have had a full day or two of good relief and that it is possible R1 may not have needed to be sent out to the hospital. V14 stated, With UTI infections, the inflammation in R1's urinary tract is worsened, and antibiotics would have helped decrease that swelling. V14 stated R1's urinary sediment increases problems with obstruction, further leading to the importance of reducing the swelling and getting antibiotics started quickly. 2. On 4/24/24 at 2:56 PM, R4 was lying in bed with R4's eyes closed. R4's indwelling urinary catheter bag was hanging from the left side of R4's bed and was draining clear yellow urine. R4's current Physician Orders documents an order for an Indwelling Urinary Catheter for a diagnosis of urine retention. R4's Resident Progress Note dated 4/17/24 at 4:34 PM and signed by V3 (Assistant Director of Nursing) states, V14 (Advanced Nurse Practitioner) was here for weekly rounds and ordered UA C&S (Urinalysis and Culture and Sensitivity). Awaiting Progress Notes from NP (Nurse Practitioner). Order placed in computer. The facility's Lab Due Report documents a one-time order dated 4/19/24 for R1 for a Urinalysis; Urine Culture to rule out a urinary tract infection. As of 4/24/24, R4's medical record did not contain a result for R1's 4/19/24 physician ordered UA and C&S. On 4/24/24 at 2:36 PM, V2 (Director of Nursing) stated, I am not going to lie to you. V3 (Assistant Director of Nursing) placed the order for the UA and C&S to be completed, but it was never done. Whether the lab never picked it up or the staff never collected it, I don't know, but either way, it wasn't done. At this time, V2 verified R4's UA and C&S should have been collected on 4/19/24 and it was not.

Based on observation, interview and record review, the facility failed to ensure a resident with a history of falling was supervised while toileting for one of three residents (R2) reviewed for falls in the sample of three. This failure resulted in R2 getting out of the bathroom on her own and suffering a fall that resulted in head injury and required transfer to the local emergency room for treatment of a headache and a six centimeter hematoma to the right frontal scalp. Findings include: The facility's Fall Reduction Program policy, dated 4/2019, documents It is the policy of this facility to have a fall reduction program that promotes the safety of the residents in the facility. The program's intent is to assist clinical staff in determining the needs of each resident through the use of standard assessments, the identification of each resident's individual risks, and the implementation of appropriate interventions, supervision, and/or assistive devices deemed appropriate. This policy also documents Standards: A fall risk assessment will be performed by a licensed nurse at the time of admission; staff will obtain additional information from resident, family, or legal representative when possible. The assessment tool will incorporate current clinical practice guidelines. Safety interventions will be determined and implemented based on the assessed, individualized risks and in accordance with standards of care; interventions to be documented within the resident's care plan. Assigned nursing personnel are responsible for ensuring that the ongoing precaution(s) are put in place and consistently maintained per the individual's plan of care. Supervision of residents who require staff assistance with bathing, showering, or toileting. If resident is not able to maintain proper sitting balance, staff shall remain with resident allowing as much privacy as is safe for the resident. R2's current care plan, dated 11/29/23, documents R2 has diagnoses of Dementia, Osteoarthritis, Difficulty walking, Weakness and Pain in unspecified joint. This plan of care documents R2 has care plans of Restorative: (R2) requires supervision with ambulation due to weakness related to dementia. Falls: (R2) has a history of falling related to unsteady gait and transfers self without staff. R2's Fall Risk Observation, dated 11/29/23, documents R2 is at High Risk for falling. R2's Nursing progress notes, dated 2/19/2024 at 11:56 PM, documents R2 was found at 11:15 PM sitting on the floor on buttocks next to the bed in R2's previous room. This note documents (R2) stated she came out of the bathroom and got confused about where to go and tried to get into the bed and lost her balance and fell on to her buttocks. R2's Fall Risk Observation, dated 2/20/24, documents R2 has Intermittent confusion, balance problems while standing and walking, requires use of assistive devices, requires assistance to/from and on/off the toilet for elimination, has suffered three or more falls in the last three months and (is labeled as) High Risk for falling. R2's Nursing progress notes, dated 2/22/24 at 8:50 AM and signed by V4 (Licensed Practical Nurse), documents Observed (R2) sitting on buttocks on floor by bed in another room that use to be her room. Resident stated she was using the bathroom and came out and fell down. Noted with a large hematoma to right side of forehead, measures seven cm (centimeter) by six cm. No bleeding noted. Complaining of pain to head. Does have chronic pain to bilateral knees, but denies pain during range of motion. This same note also documents (R2) is alert with confusion per usual. Ambulance was called for transport to (local hospital). R2's hospital Radiology Report, dated 2/22/24 at 11:35 AM, documents (R2) fell today hitting the right side of her head. Patient complains of headache. Hematoma to the right frontal aspect of head. No known loss of consciousness. This report result documents Impression: A six cm right frontal scalp hematoma. On 3/22/24 at 1:55 PM, R2 was laying in bed in her room. R2 had yellow/light green bruising above her right eye and on her upper right forehead, as well as a quarter sized raised area at the top of her forehead near her hair line. At this time R2 stated she did have a fall and hit her head on the floor. R2 stated she cannot recall what made her fall or what she had been doing before the fall. R2 stated it gave her a headache and she got a big bruise. R2 stated she isn't sure if she is supposed to push her call light to get up but she can do most things on her own without staff helping her. On 3/22/24 at 1:10 PM, V4 (Licensed Practical Nurse) confirmed sending R2 out to the hospital on 2/22/24 after she fell . V4 stated When I found (R2), she had a big hematoma on her head. She wasn't able to say what she hit it on. (R2) is forgetful. She was on another hall and she had been recently moved. As soon as (R2) got (her room) moved, that really threw her off. Staff might have put her in the bathroom but I am not sure if that's the case. I don't remember that part because why would they put her on the toilet and then leave? They should be staying in there with her for assistance. Like she needs help with hygiene, dressing and such. On 3/22/24 at 1:33 PM, V6 (Certified Nursing Assistant) confirmed she was the one who assisted R2 up to the bathroom on 2/22/24. V6 sated I went in her room, she has Dementia, (R2) got on the toilet and I stepped away to get a clean brief due to her being soiled. I was out of the bathroom to get this. When I came back in the bathroom she was no longer in there and had went through the opposite door and was on the floor in the other room. (R2) hit her head and developed a hematoma. Prior to this she was someone who got up on her own but would forget her limitations. (R2) always just needed help to pull pants up and do perineal care. She just has to be heavily watched because she is impulsive, she has been impulsive like that since admission to the facility. On 3/22/24 at 2:00 PM, V2 (Director of Nursing) stated (R2) moved rooms and was on antibiotics for a respiratory infection. Her family thinks the fall may be more related to the room change and confusion. She has intermittent confusion. (R2) has days when she's good and so independent but days when she has more confusion.

Based on interview and record review, the facility failed to keep a resident's pain in control following a hip fracture with surgical repair for one of three residents (R1) reviewed for pain management in the sample of six. This failure resulted in R1 experiencing excruciating pain for over 48 hours causing R1 to cry, not eat and scream in distress. Findings include: The facility's Pain Management policy dated 5/2017, states It is the policy of this Facility to screen all residents for pain; identify those who are experiencing pain; and assess and develop an effective individualized pain management care plan. R1's Hospital Discharge Orders dated 11/27/23 at 11:21 a.m., states Start Norco (narcotic pain medication) 7.5/325 mg (milligram) 1-2 tabs every six hours as needed for pain. Stop Norco 5/325 mg 1 tab every twelve hours as needed for pain. R1's Medication Administration Record dated 11/25/23 through 11/30/23, documents R1 did not get the physician ordered Norco 7.5/325 mg to start on 11/27/23 until 11/29/23 at 2:11 p.m. R1's Pain Care Plan dated 11/18/23, documents an updated approach on 11/27/23 was implemented for Staff to increase monitoring of pain management (due to) recent right hip surgery. This same Care Plan documents to Administer medication as ordered and monitor for effectiveness of relief, complete pain assessment, notify R1's physician if current pain medication is not effective. On 12/12/23 at 10:45 a.m., R1 stated she fell and broke her hip on 11/21/23 and had to have the hip surgically repaired. R1 stated she was readmitted on [DATE] with orders for a new higher dose of Norco (narcotic pain medication) 7.5/325 mg (milligram) 1-2 tablets every six hours as needed for pain. R1 stated for an unknown reason the nurses did not receive the Norco from the pharmacy until 11/29/23 in the afternoon. R1 stated she was in excruciating pain for over 48 hours with no relief and nothing was done about it. R1 stated she didn't want to eat due to the pain. R1 stated she tried to hold still and sleep to keep her hip from hurting. R1 stated it was a long 48 hours. R1 stated she had a mild pain pill ordered but it didn't touch the pain. R1 stated the hospital ordered the increased dose of Norco because of the severe pain she was experiencing after the hip fracture and surgical repair. On 12/12/23 at 11:00 a.m., R6 stated she has been R1's roommate for a long time and they know each other very well. R6 stated when R1 returned from the hospital on 11/27/23 she had a lot of pain that progressively got worse as the day went on because she did not receive any pain medications. R6 stated R1 was crying and moaning in pain. R6 stated I tried to get her to eat her meals, but she didn't feel like it. I felt so helpless. The nurses didn't seem too concerned about it for some reason. They said they were working on getting the pain medications delivered yet they didn't come. R6 stated it was the afternoon of 11/29/23 before R1 finally received her prescribed Norco pain medication. R6 stated R1 would try to lie still and sleep to keep from hurting but she would wake up moaning. On 12/13/23 at 2:10 p.m., V3 (R1's Representative) stated she had spoken to R1 and knew she was in horrible pain since she returned from the hospital, but no one could tell her why her pain medications had not been delivered. V3 stated then on 11/29/23, V2 (Director of Nursing) called and told V3 that there was confusion with R1's name on the prescription and that had to be clarified. V3 stated that was ridiculous to take over 48 hours to clarify the name of a resident that has resided in the same facility for almost four years. V3 stated the nurses gave her a mild pain medication but it was not good enough to help the pain of her hip repair. On 12/12/23 at 1:00 p.m., V2 DON stated V2 was notified that R1 had not received her Norco as ordered on 11/29/23 when she came in to work. V2 stated she went down to see R1. V2 stated R1 was crying in pain and visibly in distress.V2 stated R1 should have received her pain medication in a timely manner and not gone over 48 hours without her newly ordered Norco for the hip pain. V2 stated the nurses should have intervened and got something done with the pain medications whether it was through the pharmacy or R1's physician. V2 stated R1 should have had her new pain medications from the pharmacy delivered the night of 11/27/23 into 11/28/23. V2 stated the medications could have been ordered emergency service and they would have been at the facility in four hours or less or they could have acquired them from a local pharmacy with a different prescription from R1's physician.

Based on interview and record review, the facility failed to ensure narcotic pain medication was available upon a resident's readmission following hip surgery for one of three residents (R1) reviewed for pain in the sample of six. This failure resulted in R1 experiencing excruciating pain for over 48 hours causing R1 to cry, not eat and scream in distress. Findings include: The facility's Pharmacy Receiving Controlled Substances policy dated 10/25/2014, states 5) A nurse notifies the pharmacist if controlled substance orders or doses are missing or incorrect. The facility's Pharmacy Emergency Pharmacy Service and Emergency Kits policy dated 10/25/14, states Emergency pharmacy service is available on a 24-hour basis. Emergency needs for medication are met by using the facility's approved Emergency Medication Kit/Box or by special order from (the pharmacy). (The pharmacy) supplies emergency medications including emergency drugs, antibiotics, controlled substances, and products for infusion in limited quantities in compliance with applicable state and federal regulations to serve the immediate clinical needs of the residents. A. Telephone/fax numbers for emergency pharmacy service are posted at nursing stations. C. The dispensing pharmacy supplies emergency or 'stat' medications according to the dispensing pharmacy provider, noncontract, or infusion therapy products agreement. R1's Hospital Discharge Orders dated 11/27/23 at 11:21 a.m., states Start Norco (narcotic pain medication) 7.5/325 mg (milligram) 1-2 tabs every six hours as needed for pain. Stop Norco 5/325 mg 1 tab every twelve hours as needed for pain. R1's Progress Notes dated 11/27/23 at 3:54 p.m., state (R1) returned from (local hospital to the facility) at 12:15 p.m. (R1) returned with a new order for (Norco) 7.5/325 mg 1-2 tabs every six hours for pain. R1's Progress Notes do not include any further documentation about R1's pain or that R1's Norco 7.5/325 mg had not been received from pharmacy on 11/27/23 per physician orders. R1's progress notes do not document the pharmacy was notified until 11/29/23 at 8:35 a.m. R1's Progress Notes completed by V2 (Director of Nursing) dated 11/29/23 at 8:35 a.m., state Called (the pharmacy) about (R1's) pain medication. Pharmacy reported the signed (prescription) was in (R1's legal name) and not (R1's nickname). The error has been corrected as of this time. We are unable to pull from the (automated medication dispensing cabinet), therefore, the medication will be (rushed) delivered today. (R1)/Floor nurse were updated. R1's Progress Notes dated 11/29/23 at 8:46 a.m., states (R1 complains of) pain to right hip (10 on a scale of 10). (R1's as needed) Tramadol (pain medication) and extra strength Tylenol administered by floor nurse. R1's Progress Notes dated 11/29/23 at 4:47 p.m., states Spoke to (V3/R1's representative) regarding her (new prescription for Norco 7.5/325 mg). Explained to her that the Norco has arrived and R1 has received her first dose around 2:00 p.m. and is able to get it every six hours. R1's Pain Care Plan dated 11/18/23, documents an updated approach on 11/27/23 was implemented for Staff to increase monitoring of pain management (due to) recent right hip surgery. This same Care Plan documents to Administer medication as ordered and monitor for effectiveness of relief, complete pain assessment, notify (R1's physician) if current pain medication is not effective). R1's Medication Administration Record dated 11/25/23 through 11/30/23, documents R1 did not get the physician ordered Norco 7.5/325 mg to start on 11/27/23 until 11/29/23 at 2:11 p.m. The Pharmacy Timeline received from V6 (Pharmacy Director of Nursing), dated 12/14/23, documents the following: Original order for Norco was faxed to pharmacy on 11/28/23 at 1:50 p.m.; The prescription was written for R1's legal name in which the pharmacy had never seen in their system; On 11/28/23 at 10:22 p.m. R1's name was confirmed and the Norco order was processed but missed the 10 p.m. cutoff for delivery that night; On 11/29/23 the facility sent an order to pharmacy for R1's Norco STAT (Immediately) at 8:35 a.m.; R1's Norco was delivered to the facility on [DATE] at 12:49 p.m. The Pharmacy Packing Slip Proof of Delivery form documents R1's Norco 7.5/325 mg 12 tablets was delivered to the facility on [DATE] at 12:49 p.m. R1's Controlled Drug Record form documents R1's Norco 7.5/325 mg was started on 11/29/23 at 2:00 p.m. On 12/12/23 at 10:45 a.m., R1 stated she fell and broke her hip on 11/21/23 and had to have the hip surgically repaired. R1 stated she was readmitted on [DATE] with orders for a new higher dose of Norco (narcotic pain medication) 7.5/325 mg (milligram) 1-2 tablets every six hours as needed for pain. R1 stated for an unknown reason the nurses did not receive the Norco from the pharmacy until 11/29/23 in the afternoon. R1 stated she was in excruciating pain for over 48 hours with no relief and nothing was done about it. R1 stated she didn't want to eat due to the pain. R1 stated she tried to hold still and sleep to keep her hip from hurting. R1 stated it was a long 48 hours. R1 stated she had a mild pain pill ordered but it didn't touch the pain. R1 stated the hospital ordered the increased dose of Norco because of the severe pain she was experiencing after the hip fracture and surgical repair. On 12/12/23 at 11:00 a.m., R6 stated she has been R1's roommate for a long time and they know each other very well. R6 stated when R1 returned from the hospital on 11/27/23 she had a lot of pain that progressively got worse as the day went on because she did not receive any pain medications. R6 stated R1 was crying and moaning in pain. R6 stated I tried to get her to eat her meals, but she didn't feel like it. I felt so helpless. The nurses didn't seem too concerned about it for some reason. They said they were working on getting the pain medications delivered yet they didn't come. R6 stated it was the afternoon of 11/29/23 before R1 finally received her prescribed Norco pain medication. R6 stated R1 would try to lie still and sleep to keep from hurting but she would wake up moaning. On 12/13/23 at 2:10 p.m., V3 (R1's Representative) stated she had spoken to R1 and knew she was in horrible pain since she returned from the hospital, but no one could tell her why her pain medications had not been delivered. V3 stated then on 11/29/23, V2 (Director of Nursing) called and told V3 that there was confusion with R1's name on the prescription and that had to be clarified. V3 stated that was ridiculous to take over 48 hours to clarify the name of a resident that has resided in the same facility for almost four years. V3 stated the nurses gave her a mild pain medication but it was not good enough to help the pain of her hip repair. On 12/12/23 at 3:30 p.m., V8 (Pharmacist) stated R1's Norco was not delayed due to the name needing clarified. V8 stated the order wasn't received by pharmacy until 11/28/23 at 1:49 p.m. On 12/12/23 at 12:45 p.m., V9 (Licensed Practical Nurse) stated she sent R1's Norco order to the pharmacy on 11/27/23 when she was readmitted from the hospital. V9 stated when she got to work on 11/28/23 R1 told her she still had not received her Norco and was in a lot of pain. V9 stated I called the pharmacy and they told me they didn't received the prescription for (R1's Norco) so I had them stay on the phone and verify they got the fax while I was talking to them. I did not have them send it STAT. I probably should have. The Norco should have arrived early morning on 11/29/23 but I guess it still wasn't here when (V2/Director of Nursing) got to work. The nurse on night shift 11/27/23 did not document any attempts to notify the pharmacy that I can see. On 12/12/23 at 1:00 p.m., V2 stated V2 was notified that R1 had not received her Norco as ordered on 11/29/23 when she came in to work. V2 stated she went down to see R1. V2 stated R1 was crying in pain and visibly in distress. V2 stated R1 should have received her pain medication in a timely manner and not gone over 48 hours without her newly ordered Norco for the hip pain. V2 stated the nurses should have intervened and got something done with the pain medications whether it was through the pharmacy or R1's physician. V2 stated R1 should have had her new pain medications from the pharmacy delivered the night of 11/27/23 into 11/28/23. V2 stated the medications could have been ordered emergency service and they would have been at the facility in four hours or less or they could have acquired them from a local pharmacy with a different prescription from R1's physician.

Based on observation, interview, and record review, the facility neglected to follow their Resident Rights Protocol and Answering the Call Light policy for one of four residents (R2) reviewed for abuse/neglect and resident rights in the sample of eight. This neglect resulted in R2 exhibiting sustained and intense crying, moaning, and yelling. Findings include: The facility's Resident Rights Protocol for All Nursing Procedures (revised August 2008) document resident rights including 1.b. Resident dignity and respect, 1.f. Resident right of refusal, and 1.h. Resident freedom of choice. The facility's Answering the Call Light policy (revised August 2008) documents the following: 3. Ask the resident to return the demonstration so that you will be sure that the resident can operate the system, 5. When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident, and 6. Some residents may not be able to use their call light. Be sure to check these residents frequently. R2's face sheet and admission record documents he was admitted to the facility on [DATE] to the Respiratory unit for treatment and care required for [CONDITION(S)] and ventilator dependence. R2's progress notes and census sheet document he was moved from the Respiratory unit to a general care room on 1/14/22 due to weaning off the ventilator. R2's medical records document diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Minimum Data Set (MDS) assessment dated [DATE] documents R2's speech is not clear, he sometimes understands and is sometimes understood, is moderately cognitively impaired, totally dependent on staff for all Activities of Daily Living (ADL), receives enteral feedings, and has bilateral impairment of upper and lower extremities. R2's current Care Plan documents the following: Include resident's preference in rendering care and services, (R2) total dependence on staff for all ADL, encourage to use bell to call for assistance, call light within his reach when in room, monitor and record any nonverbal signs of pain (crying, moaning), monitor for psychosocial changes, observe and report any changes in mental status caused by situational stressor, and provide support for expression of feelings related to situational stressor. R2's Care Plan does not document any behaviors or any transmission-based precautions to be observed. On 2/8/22 at 9:30am, R2 was lying in his bed on his back. R2 had contractures of his upper extremities with his fists drawn tightly up to his shoulders and his lower extremities with heels drawn up near buttocks, requiring padding to prevent pressure on this area. R2 was unable to form words but was able to moan and nod 'yes' and 'no' and look to the right and left to indicate things in his room (example- where his letter board was mounted on the wall above the head of his bed). There was no call light within R2's reach. At 11:00am, 1:30pm, and 2:00pm, R2's door was closed, he was yelling, and no staff were in his room. There were no transmission-based precautions in place for R2. On 2/9/22 from 8:30am-9:00am, and 9:30am, R2's door was closed and R2 was yelling and crying. There were no staff present in R2's room. Upon entering R2's room at 9:30am, R2 was sobbing/crying, face red, trying to talk/mouth moving but unable to speak, his face was covered with tears, he was shaking. and moving his head back and forth. R2 indicated to V9 (Certified Nursing Assistant/CNA) that his butt hurt. At this time, R2 was asked if he wanted his door closed and he shook his head no back and forth repeatedly. R2 nodded yes repeatedly when asked if he wanted his door kept open. There was no call light or alternative call light within resident reach at this time. On 2/9/22 at 9:00am, V9 (CNA) stated, (R2) screams all day. We keep his door closed so the other residents aren't bothered. He yells all day. When asked how R2 alerts staff when he needs something or is in pain, V9 shrugged. On 2/9/22 at 9:40am, V5 (Licensed Practical Nurse/LPN)/Wound Nurse) stated staff should not close R2's door because R2 cannot use a touch pad call light for assistance due to his contractures. On 2/10/22 at 8:15am, V3 (Director of Nursing/DON) stated and confirmed that the only call light in R2's room was a push button call light which R2 was unable to use, which was over the head of the bed and on the floor, and not within R2's reach. V3 stated staff should not be keeping R2's door closed because of his yelling. V3 stated R2 was used to receiving more socialization/interaction from the increased number of staff in the Respiratory unit which he does not receive on the general unit, and R2's yelling is a behavior. On 2/8/22 at 2:13pm, V12 (R2's family member) stated facility staff do not let R2 keep his door open because they do not want to hear when he needs help.

Based on observation, interview, and record review, the facility failed to implement a physician ordered pressure ulcer treatment, failed to identify wounds as pressure ulcers, failed to properly evaluate pressure ulcer risk factors to determine individualized pressure ulcer preventive measures, and failed to implement care planned pressure ulcer treatment, and prevention measures for three of three residents (R1, R2, R3) reviewed for pressure ulcers in a sample of three. These failures resulted in R1 developing two stage four pressure ulcers which required hospitalization and surgical debridement, R2 developing a stage three pressure ulcer, and R3 developing a stage four pressure ulcer. Findings include: 1. R1's list of current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set (MDS) assessment dated [DATE] documents R1 is cognitively intact and requires extensive assistance for bed mobility, is totally dependent on two staff for transfers, and uses a wheelchair for mobility. R1's pressure ulcer risk assessment dated [DATE] documents R1 is at high risk of developing pressure ulcers related to R1's very limited ability to respond meaningfully to pressure-related discomfort, is chairfast and must be assisted into a chair or wheelchair, has a very limited ability to change and control his body position, and requires moderate to maximal assist with moving to prevent shearing of skin. R1's pressure ulcer risk assessment dated as completed 6/24/21 documents that R1 was at moderate risk of developing a pressure ulcer. R1's pressure ulcer care plan intervention dated 3/10/21 states, Assess (R1) for presence of risk factors. Treat, reduce, eliminate risk factors to extent possible, and Use padded heel boots to relieve pressure on the heels. R1's care plan intervention dated 6/21/21 states, Assess pressure ulcer for stage. R1's care plan interventions dated as created 7/15/21, after R1's discharge to the hospital 7/14/21, by V3 (Wound Nurse) document's that R1 refuses to see the facility wound physician and Instruct (R1) to not use straps on foot pedals to secure feet due to increase friction/pressure. R1's care plan does not include a pressure ulcer prevention measure to ensure R1's wheelchair footrests don't cause pressure to R1's feet. R1's nursing progress notes dated 6/21/21 state, Callous/Blister-like area noted on bottom/outer right foot. He states that he had a similar event happen on the bottom of his left foot & (and) it opened and became a callus. R1 states he wears the same shoes every day. On his w/c (wheelchair), he places his shoes in a black strap that keeps them from slipping off, his footrests. R1's nursing progress notes dated 7/2/21 documents there was a change in condition of R1's right foot wound, Right plantar foot blister rupture and wound noted to have an odor, redness and maceration around edges, slough/necrotic tissue noted. R1's nursing progress notes dated 7/7/21 documents V12 (R1's Physician) examined R1 on that date at which time R1 informed V12 that he had an appointment with a Wound Clinic on 7/9/21 to evaluate R1's right plantar foot wound. R1's nursing progress note dated 7/14/21 documented by V3 (Wound Nurse) states, Resident refusing care/orders from facility wound MD (V4). (R1) stated he has his own wound MD he is seeing and would not like any recommendations from facility wound physician. R1's Wound Management notes dated 6/21/21 through 7/9/21 documented by V3 (Facility Wound Nurse) shows that R1 developed a fluid filled blister to the bottom of R1's right and left feet on 6/21/21. Those notes were entered into R1's medical record on 7/2/21. These notes also documented on 7/2/21 R1's, right foot blister wound had a decline in which the blister ruptured and was draining a purulent (Pus) drainage which had an odor. R1's left foot Wound Management note from 7/2/21 documents R1's left foot wound had redness, and warmth, but does not describe whether the original blister was still intact. These same wound notes documented on 7/9/21 R1's right and left foot wounds were improving with each wound containing 100% (percent) Eschar (dead tissue) with a light amount of drainage. None of V3's wound notes document whether R1's wounds were pressure ulcers or what stage they were. On 8/17/21 at 3:48p.m. and 8/19/21, at 8:05a.m. R1 stated he is no longer a resident at the facility. R1 stated he did not receive appropriate pressure ulcer prevention measures while at the facility. R1 stated he is paralyzed from the waist down and has no feeling in his legs. R1 stated on 6/21/21 his nurse found blisters on the bottom of his right and left foot. R1 stated he asked the facility for an appointment to be evaluated by their wound physician. R1 stated the facility did not make him an appointment to see their wound physician until after he had made his own appointment for 7/9/21 with a wound clinic not associated with the facility. R1 stated his physician at the facility (V12) came into his room on 7/7/21 to listen to his heart but never looked at R1's feet. R1 stated he told V12 he had made an appointment with a wound clinic to address the wounds on his feet. R1 stated he had to beg the wound clinic to see him right away because he was worried about the condition of his feet. R1 stated on 7/9/21 he went to the wound clinic and was evaluated by V9 (Wound Physician's Assistant). R1 stated V9 told him he had an unstageable pressure ulcer to his right foot. R1 stated V9 sent him back to the facility with new treatment orders and an appointment to return to the wound clinic on 7/14/21. R1 stated no two nurses ever changed his dressings the same way. R1 stated the wound clinic orders did not include any ointments to be applied to his wounds but most of the time the facility nurses were applying an ointment or cream as part of the dressing change. R1 stated because of his paralysis he is unable to keep his feet on the pedals of his wheelchair. R1 stated he had to use straps to secure his feet in place on the wheelchair pedals or else they would fall off. R1 stated his plan was to discharge to an independent living environment which required he be independently mobile. R1 stated he can be independently mobile in his wheelchair if he has a means of preventing his feet from falling off the pedals. R1 stated the facility never recommended using different foot pedals to keep his feet in place. R1 stated when he returned to the wound clinic on 7/14/21, his right foot wound had worsened to a stage 4 pressure ulcer and his left foot had developed a stage 4 pressure ulcer on the bottom of his foot. R1 stated during his wound clinic appointment on 7/14/21, V9 was concerned enough about his right and left foot wounds she recommended sending R1 to the hospital for surgery with V8 (Wound Specialist). R1 stated he was admitted to the hospital on 7/14/21 and never returned to the facility. R1 stated on 7/13/21 or 7/14/21, V3 came into his room at the facility and said, I hear you went out on your own to see a wound doctor. R1 stated he told her it was because she didn't make him an appointment to see the facility wound physician. R1 stated even though he is paralyzed and unable to use his legs, he wants to keep his legs and feet and expected the facility to help prevent him from developing pressure ulcers and to properly treat pressure ulcers if any did develop. On 8/18/21 at 9:40a.m., 10:15a.m., 3:10p.m. and on 8/19/21 at 1:15p.m. V3 stated on 6/21/21 R1 developed two blisters, one on the bottom of his right foot and one on the bottom of his left foot. V3 stated she wasn't sure whether R1's blisters were pressure ulcers at that time because the wounds were on the bottom of R1's feet. V3 stated she thought R1's wounds may have developed because of the tennis shoes R1 liked to wear. V3 stated on 7/2/21 R1's right foot blister had ruptured and was draining a purulent (Pus) drainage. V3 stated R1's right foot wound had a foul odor and the wound bed contained eschar and slough (non-viable and dead tissue). V3 stated at the time R1 went to the wound clinic on 7/9/21, she thought R1's right foot wound was improving and R1's left foot wound was just a scab. V3 verified that at the time R1's right and left foot wounds developed, R1 was using a wheelchair with foot pedals with straps to keep R1's feet in place. V3 verified R1 liked to strap his feet tightly in the wheelchair foot pedals so his feet would not fall off. V3 stated R1's right and left plantar foot pressure ulcers could have resulted from the foot straps pressing the bottoms of R1's feet against the foot pedals of his wheelchair. V3 stated R1 did have pressure relief boots but R1 did not like to where them when he was in his wheelchair. V3 stated although she developed R1's pressure ulcer prevention and treatment interventions, she did not evaluate R1's foot pedals or refer R1 to Occupational Therapy to have his wheelchair foot pedals evaluated for an alternative means to support his feet without using straps in order to prevent pressure to the bottoms of R1's feet. V3 verified R1's treatment orders were not correct based on the orders received from V9 on 7/9/21. V3 stated R1 should not have had Santyl applied to R1's wounds but instead R1 should have only had the application of treatments and dressings as ordered by V9 on 7/9/21 with any previous treatment orders discontinued. V3 stated she did not know R1's left plantar foot wound had worsened. V3 stated the last time she examined R1's right and left foot wounds was on 7/9/21 at which time she thought the wounds were improving.

Based on interview, and record review, the facility failed to perform routine blood glucose monitoring for one (R1) of three residents reviewed for receiving insulin in a sample of three. This failure resulted in R1 receiving incorrect doses of insulin causing an alteration in mental status and subsequently being admitted to the hospital with high blood glucose readings and Diabetic Ketoacidosis. Findings include: R1's current Care Plan dated 6-10-21 documents R1 is at risk for potential complications related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Face sheet documents R1 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Nursing notes dated 6-9-21 at 2:12 pm document R1 returned from the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Another order documents R1 is to receive [MEDICATION(S)]/[MEDICATION(S)] (short acting insulin) 18 units before each meal and correction dose of one unit for every 25 mg/dl (milligrams per deciliter, unit of measurement for blood glucose) above 150 mg/dl up to 100 units a day. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's POS/Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's POS does not contain any orders for blood glucose monitoring or the correction doses of [MEDICATION(S)]/[MEDICATION(S)]. R1's MAR/Medication Administration Record for June 2021 documents that R1's [MEDICATION(S)]/[MEDICATION(S)] was given four times a day starting at 8:00 pm on 6-9-21. R1's MAR does not contain the correction dose of one unit for every 25 mg/dl above 150 mg/dl up to 100 units a day. There are no blood glucose monitoring values documented on the MAR or anywhere in R1's medical record from readmitted [DATE] until the morning of 6-13-21 when it was documented in the progress notes as reading HI meaning blood glucose level too high to register on the machine. R1's Nursing progress notes dated 6-13-21 document at 9:38 am that R1 was experience increased lethargy, had a glucometer reading at 8:00 am of HI and was given his ordered 18 unit of [MEDICATION(S)]. R1's glucose was rechecked at 8:30 am and again at 9:00 am with continued readings of HI. These Progress notes document that V9 NP/Nurse Practitioner ordered R1 to be sent out to the hospital for evaluation and treatment. R1's Hospital Critical Care History and Physical dated 6-13-21 documents that R1 was found to have mental status changes and an extremely high glucose on his finger stick (at the facility). R1 was taken to a local hospital and found to be in DKA (Diabetic Ketoacidosis) and was transferred to (present hospital) for further care. On 6-23-21 at 10:20 am, V8 LPN stated he worked with R1 on 6-10-21 and 6-11-21. V8 stated it is best practice to complete blood sugar monitoring when receiving R1's type of insulin. V8 stated he does not remember if he checked R1's blood sugar or not since there was no order and it was not documented. V8 stated R1 was not experiencing any symptoms that would indicate high blood sugar when he worked with him. On 6-23-21 at 5:20 pm, V10 LPN stated he worked with R1 on 6-12-21 and 6-13-21 and gave him several doses of insulin. V10 stated since R1 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6-23-21 at 11:00 am, V7 LPN stated she worked with R1 on 6-12-21 and 6-13-21. V7 stated she noticed there was no order for blood glucose monitoring for R1 but did not feel comfortable giving him is insulin without first checking it. V7 stated she checked his blood sugar on 6-12-21 before giving both his 7:00 am and 4:00 pm doses of insulin. V7 stated she should have documented the results somewhere in his medical record but did not. V7 stated R1's blood sugar was running in the 180s. That reading would have required another unit of [MEDICATION(S)]/[MEDICATION(S)] if that order had been transcribed. V7 stated she came in the next day, 6-13-21, heard R1 had two emesis and seemed to have an altered mental state. V7 completed blood glucose monitoring receiving a HI reading, gave his [MEDICATION(S)] insulin 18 units and rechecked it another two times receiving HI readings. V9 NP then sent R1 out the hospital.

Based on interview and record review, the facility failed to transcribe and administer all insulin orders for one (R1) of three residents reviewed for receiving insulin in a sample of three. This failure resulted in R1 experiencing an alteration in mental status and subsequently being admitted to the hospital with high blood glucose readings and Diabetic Ketoacidosis. Findings include: The facility's Insulin Administration policy dated 2007 documents, The type of insulin, dosage requirements, strength, and the method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The facility's Medication Administration Policy dated March 2014 documents, Drugs will be administered in accordance with orders of licensed medical practitioners of the State in which the facility operates. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] R1's face sheet documents R1 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Nursing notes dated 6-9-21 at 2:12 pm document R1 returned from the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview, and record review, the facility failed to ensure a resident's choice to discharge home was honored for one of three residents (R3) reviewed for discharge in the sample of 26. This failure resulted in R3 arranging his own transportation and leaving the facility AMA (Against Medical Advice) causing R3 emotional distress for not getting home in time before losing his dying significant other. Findings include: R3's Social Service note, dated 11/12/18, documents, R3 is a new admit from an acute care facility. He is alert and orientated and able to voice his needs. He has a history of a right ankle fracture and requires extensive assistance with ADLS (Activities of Daily Living) and ambulates by wheelchair. R3 was previously receiving disability income. He is a full code with limited treatment and responsible for self. He uses oxygen, Bi-Pap, nebulizer, and is diabetic. R3 reports he has oxygen concentrator, Bi-Pap, Bariatric Walker, Cane, Life Alert already in place at home. He had skilled Nursing two times week and a home health Aide six hours a week through Home health. He is receiving skilled therapy at this time. R3 previously lived in an apartment with his girlfriend. He would like to discharge to home with services resuming. The facility's Discharge Summary Policy, dated 4/24/19, documents, A discharge summary shall be prepared for each resident discharged from our facility. When the facility anticipates a resident's discharge to a private resident or to another nursing care facility (i.e. skilled, intermediate care, etc) a discharge summary will be developed which will assist the resident to adjust to his or her new living environment. R3's MDS (Minimum Data Set), dated 11/18/18, documents that R3 has a BIMS (Brief Interview for Mental Status) score of 15 (cognitively intact), and that R3 expects to be discharged to the community but no active discharge plan is in place. R3's Social Service note, dated 12/19/18, documents, R3 would need to be transported by the facility at discharge. R3's Nurse's notes, dated 1/18/19 at 10:36 a.m., document, Physician rounding today: new orders R3 may discharge home with current medications and therapy services. A facility Concern form, dated 4/18/19 and signed by V1 (Administrator), documents, R3 came to express concerns about his significant other declining. R3 stated that she was not doing well, but said she was fighting and that they (R3 and significant other) wanted to be together. R3's Social Service Note, dated 4/19/19 at 5:00 p.m., documents, R3 left the facility AMA (Against Medical Advice). R3 asked a family member in the facility to take him home; R3 did wait for oxygen to come from local oxygen company. R3 did not agree to sign the AMA form before exiting the facility. R3's Nurse's notes, dated 4/19/19 at 5:39 p.m., document, R3 discharged home AMA at 5:00 p.m. R3 left with his own oxygen. R3 left with a wheel chair. It is unknown who the wheel chair belongs to. No medication were sent with R3. R3's current medical record has no documentation of a discharge summary that was sent with R3 upon discharge. On 4/23/19 at 10:15 a.m., R3 stated, I was given a release from the doctor to go home back in January, however the facility kept telling me I needed more therapy. I stayed but I didn't want to. Then, about three weeks ago I got a call that I needed to get home because my girl friend wasn't doing well and they didn't think she would live that long. So I told V1 she needed to help me get this set up for me to go home. V1 told me she would help me with home health services, oxygen, a wheel chair, and a ride home in the facility van. Then, nothing was happening they kept putting me off and kept putting me off not setting anything up for me to go home. Then all of a sudden they told me they couldn't provide transportation when I went home. On 4/19/19 while I was in bible study I got a phone call saying that they thought my girlfriend only had 24-48 hours to live so I knew I had to leave that day. I spoke with V1 about it and she told me there was no way she could get everything ready for me even though she was suppose to be working on it the last three weeks. I'm a very religious man and I needed to be there for my girlfriend so I started working on it myself. Another resident's husband offered to give me a ride home so the facility no longer had to worry about transport. However, the facility said if I left with this gentleman then I would have to sign out AMA (Against Medical Advice) because they could only release me to a family member. I don't need a family member I have my mind and make all my decisions. The gentleman was still willing to give me a ride so I had to sign AMA papers because my family didn't come to pick me up, and the facility wasn't going to help with my transportation. R3 paused and got silent. Then, R3 started crying and stated, I was praying I would get to my girlfriend in time. She needed me there during this time. R3 began crying again and was unable to speak. Then, R3 stated, She passed away 40 minutes prior to me arriving. We are both very religious and I know she is in a better place, but I'm heart broken I couldn't be there with her all because of the facility. I'm struggling dealing with this. I've been very depressed. It's been so hard on me. I've been home about a week now and the facility never did set up home health for me. On 4/29/19 at 11:23 am, was verified that the facility did not send any medications with him when he went home on 4/19/19 and that he did not get a list of medications to know what he needed to try to get from a pharmacy. R3 stated I am totally out of several medications and can't get some of them refilled because they paid for the medications that were left at the facility. I don't know why they (the facility) can't give me my medications. On 4/23/19 at 9:00 a.m., V20 (Social Services Director) stated, About a week ago, R3 wanted to leave but since he didn't have transportation we didn't feel safe with letting him discharge to home. I was aware when I took over that he had an order to go home in January. On 4/24/19 at 1:20 p.m. V1 stated, No documentation including medication prescriptions were sent with R3 nor were any medications sent with him. R3 didn't have a wheel chair or home health services set up. We were aware from admission that he planned to discharge home. On 4/23/19 at 11:30 a.m., V8 (APRN Advance Practice Registered Nurse) stated, I feel like with home health assistance he would have been ok with going home. I thought he was set up to go home last Thursday (4/18/19) or Friday (4/19/19). On 4/29/19 at 1:11 p.m., V26 (R3's Physician) stated it was important for R3 to get his medications. V26 also stated he would have liked the facility to have sent R3's medications with him. V26 also verified that he did give an order for [REDACTED].

Based on interview, and record review, the facility failed to discharge a resident according to physician's orders for one of three residents (R3) reviewed for discharge in the sample of 26. This failure resulted in R3 being depressed and crying over missing the death of his significant other. Findings include: R3's Social Service note, dated 11/12/18, documents, R3 is a new admit from an acute care facility. He is alert and orientated and able to voice his needs. He has a history of a right ankle fracture and requires extensive assistance with ADLS (Activities of Daily Living) and ambulates by wheelchair. R3 was previously receiving disability income. He is a full code with limited treatment and responsible for self. He uses oxygen, Bi-Pap, nebulizer, and is diabetic. R3 reports he has oxygen concentrator, Bi-Pap, Bariatric Walker, Cane, Life Alert already in place at home. He had skilled Nursing two times week and a home health Aide six hours a week through Home health. He is receiving skilled therapy at this time. R3 previously lived in an apartment with his girlfriend. He would like to discharge to home with services resuming. R3's MDS (Minimum Data Set), dated 11/18/18, documents in Section C Cognitive Patterns that R3 has a BIMS (Brief Interview for Mental Status) score of 15 (cognitively intact), and in Section Q Participation in Assessment and Goal Setting that R3 expects to be discharged to the community but no active discharge plan is in place. R3's Social Service note, dated 12/19/18, documents, R3 is alert and orientated and able to voice needs. He is a full code with limited treatment and responsible for self. He uses oxygen, Bi-Pap, Nebulizer, and is diabetic. R3 reports he has oxygen concentrator, Bi-Pap, Bariatric Walker, Cane, Life Alert, grab bars, and ramp already in place at home. He reports has a new powered wheelchair being delivered. He had skilled Nursing two times a week and a home health Aide six hours a week through Home health. R3 is receiving skilled therapy at this time. R3 previously lived in a home with his girlfriend. R3 would like to discharge to home with services resuming. He would need to be transported by the facility at discharge. R3's Nurse's notes, dated 1/18/19 at 10:36 a.m., document, Physician rounding today: new orders R3 may discharge home with current medications and therapy services. R3's MDS (Minimum Data Set), dated 3/30/19, documents in Section C Cognitive Patterns that R3 has a BIMS (Brief Interview for Mental Status) score of 15 (cognitively intact), and in Section Q Participation in Assessment and Goal Setting that R3 expects to be discharged to the community but no active discharge plan is in place. R3's Care plan, dated 4/12/19, documents, R3 would like to discharge to home with Home Health services. R3 previously lived in a home with his girlfriend. R3 uses oxygen, Bi-Pap, Nebulizer, and is diabetic. R3 self-reports he has oxygen concentrator, Bi-Pap, Bariatric Walker, Cane, and Life Alert already in place at home. R3 had skilled Nursing two times a week and a home health Aide six hours a week through Home health. R3's Social Service Note, dated 4/19/19 at 5:00 p.m., documents, R3 left the facility AMA (Against Medical Advice). R3 had discharge orders in place, home health setup, but resident did not have a ride home. R3 asked a family member in the facility to take him home; R3 did wait for oxygen to come from local oxygen company. R3 did not agree to sign the AMA form before exiting the facility. R3's Nurse's notes, dated 4/19/19 at 5:39 p.m., document, R3 discharged home AMA at 5:00 p.m. R3 left with his own oxygen. R3 left with a wheel chair. It is unknown who the wheel chair belongs to. No medication was sent with R3. On 4/23/19 at 10:15 a.m., R3 stated, I was given a release from the doctor to go home back in January, however the facility kept telling me I needed more therapy. I stayed but I didn't want to. Then, about three weeks ago I got a call that I needed to get home because my girlfriend wasn't doing well, and they didn't think she would live that long. So, I told V1 she needed to help me get this set up for me to go home. V1 told me she would help me with home health services, oxygen, a wheel chair, and a ride home in the facility van. Then, nothing was happening they kept putting me off and kept putting me off not setting anything up for me to go home. Then all of a sudden, they told me they couldn't provide transportation when I went home. On 4/19/19 while I was in bible study I got a phone call saying that they thought my girlfriend only had 24-48 hours to live so I knew I had to leave that day. I spoke with V1 about it and she told me there was no way she could get everything ready for me even though she was supposed to be working on it the last three weeks. I'm a very religious man and I needed to be there for my girlfriend, so I started working on it myself. Another resident's husband offered to give me a ride home, so the facility no longer had to worry about transport. However, the facility said if I left with this gentleman then I would have to sign out AMA (Against Medical Advice) because they could only release me to a family member. I don't need a family member I have my mind and make all my decisions. The next problem was getting oxygen. The facility kept telling me they wouldn't have oxygen in time. So, I asked them if I could take a portable tank for the drive and the gentleman would bring the tank back since his wife is a resident. Again, they told me no. The facility also never had a wheel chair for me. I got lucky though and a resident here who no longer needed his wheel chair donated his wheel chair to me. Right before I was getting to leave the oxygen company showed up with my portable oxygen, so I was able to leave. The gentleman was still willing to give me a ride, so I had to sign AMA papers because my family didn't come to pick me up, and the facility wasn't going to help with my transportation. R3 paused and got silent. Then, R3 started crying and stated, I was praying I would get to my girlfriend in time. She needed me there during this time. R3 began crying again and was unable to speak. Then, R3 stated, She passed away 40 minutes prior to me arriving. We are both very religious and I know she is in a better place, but I'm heartbroken I couldn't be there with her all because of the facility. I'm struggling dealing with this. I've been very depressed. It's been so hard on me. I've been home about a week now and the facility never did set up home health for me. On 4/23/19 at 9:00 a.m., V20 (Social Services Director) stated, About a week ago, R3 wanted to leave but since he didn't have transportation we didn't feel safe with letting him discharge to home. I was aware when I took over that he had an order to go home in January. On 4/23/19 at 11:30 a.m., V8 (APRN Advance Practice Registered Nurse) stated, I'm not sure what happened with a discharge order back in January. I feel like with home health assistance he would have been ok with going home. I thought he was set up to go home last Thursday (4/18/19) or Friday (4/19/19). On 4/24/19 at 1:20 p.m. V1 stated, No documentation including medication prescriptions were sent with R3 nor were any medications sent with him. He received his oxygen prior to leaving, but he didn't have a wheel chair or home health services set up. We told him he couldn't leave without a proper wheel chair. On 4/19/19 he insisted on leaving that day and he didn't have family to transport him, so he had to sign AMA papers if he wanted to leave. We were aware from admission that he planned to discharge home.

Based on observation, interview, and record review the facility failed to safely transfer one of three residents (R12) reviewed for resident injury on the sample of 26. This failure resulted in R12 sustaining a [MEDICAL CONDITION] and a left ear laceration requiring emergency care for sutures. Findings include: On 4/24/19 at 10:33 AM, R12 was sitting in the dining room. R12 had a sutured laceration above the left eyebrow. R12 had bruising under the left eye and a laceration to the left ear. R12's emergency room report dated 4/21/19 at 8:26 AM documents R12 presented to the Emergency Department after a fall from the mechanical lift, approximately four feet off the ground. This report documents R12 has a four-centimeter laceration to the left forehead which required 13 sutures and a one-centimeter laceration to the left ear which required two sutures. On 4/24/19 at 10:25 AM, V5 LPN stated V5 was called into R12's room on 4/21/19 at 6:30 AM. R12 was face down on the floor at the base of the mechanical lift. V5 stated there was lots of blood on the floor. V5 stated V5 rolled R12 over and R12 had a huge laceration on the forehead. V5 stated V5 put gauze over the laceration. V5 stated V7 Certified Nurse's Assistant (CNA) was unsure how but during a transfer R12 came out of the mechanical lift sling and fell on to the floor. V5 stated V7 had attempted to transfer R12 by herself. V5 stated there is always supposed to be two staff when doing a mechanical lift transfer. The facility's Final Report dated 4/26/19 documents, Staff (V7 CNA) was interviewed regarding incident. CNA was transferring resident using mechanical lift. As per staff CNA placed sling under (R12), rolled the lift to the (R12's) bedside and placed it so that overhead bar is directly over the (R12). While attaching sling loops properly to mechanical lift, (V7) did need to instruct (R12) not to touch them as (R12) was trying to help. (V7) started to raise (R12) in the sling and right bottom loop came undone and (R12) started to slip out. (V7) attempted to catch (R12) but was unable to do so. (V7) immediately called for help and (V5) responded. On 5/01/19 at 1:41 PM, V7 CNA stated on 4/21/19 at 6:30 AM, V7 put the mechanical lift sling under R12. V7 denied hooking the sling loops to the mechanical lift as documented on the facility's Final Report dated 4/26/19. V7 stated V7 was the only staff person in the room and R12 offered to help and R12 attached the sling loops to the mechanical lift. V7 stated R12 would attach the sling loops to the mechanical lift all the time. V7 denied checking the loops and denied instructing R12 to not touch the loops to the mechanical lift as per the facility's report. V7 stated V7 was the only staff person in the room. V7 stated there is supposed to be two staff to do a mechanical lift. V7 stated V7 did not ask another staff member to come into the room to help because the nurses get mad at the CNAs when they go into the rooms together. V7 stated the CNAs have to do mechanical lifts by themselves all the time. V7 stated when V7 raised the mechanical lift, V7 thinks one of the loops came undone and then R12 fell out of the sling onto the floor. V7 also denied trying to catch R12. V7 stated R12's head hit where the legs split on the mechanical lift. On 4/30/19 at 5:00 PM, V11 (R12's physician) stated R12's laceration were caused by a fall from the mechanical lift on 4/21/19. V11 stated V11 expects two staff to operate the mechanical lift for safety.

Based on interview and record review the facility failed to develop a program for offloading while in the wheelchair, and implement a turning and repositioning program for one of three residents (R1) reviewed for pressure ulcers in a sample of three. These failures resulted in R1, a resident with new onset of paralysis, developing an unstageable pressure ulcer to the sacrum which required debridement and hospitalization . Findings include: A Skin Assessment Policy and Procedure dated 5/2017 states, Intact healthy skin is the body's first line of defense. It is the policy of this facility to monitor skin integrity for signs of injury and irritation. In addition to ongoing assessment of the skin, the facility will implement measures to protect the resident's skin integrity and to prevent skin breakdown. A Pressure Ulcer Prevention Protocol dated 5/2018 states, Interventions necessary to maintain skin integrity or to promote healing will be incorporated into the plan of care based on each resident's individual needs and risks, which may include: A. Daily skin checks conducted either by the CNA or Licensed Nurse to ensure identification of potential problem areas. B. Plan of Care to address mobility status and ability to reposition self. This same protocol documents, The resident's care plan will indicate the resident's risk factor(s) and include individualized interventions as needed for a comprehensive pressure ulcer prevention program. R1's list of current [DIAGNOSES REDACTED]. R1's Minimum Data Set (MDS) assessment dated [DATE] documents R1 is totally dependent on staff for bed mobility, transfers, and locomotion on and off the unit. This same MDS documents R1 had functional limitation in range of motion to both upper and lower extremities. This MDS further documents that R1 was at risk of developing pressure ulcers and at the time of the assessment had a stage one pressure ulcer with intact skin but with non-blanchable redness of a localized area. R1's MDS also documents that R1 was on a turning and repositioning program. R1's new admission Skin Integrity Observation sheet dated 1/17/19 documents R1 had redness to the buttocks with barrier cream ordered. R1's physician's orders [REDACTED]. This same POS does not include an order for [REDACTED]. R1's care plan dated 1/21/19 states that R1 is at risk for developing pressure ulcers related to [MEDICAL CONDITION]. This same care plan instructs staff to, Turn and reposition as resident (Resident) tolerates. R1's care plan does not address R1's lack of mobility related to R1's paralysis, and does not include a program to turn and reposition R1 every two hours, or a plan to off load R1 while R1 is up in the wheelchair. R1's Braden Scale assessment for pressure ulcer risk dated 1/17/19 documents that is able to R1 respond to verbal commands but can't always communicate discomfort or need to be turned or has some sensory impairment that limits R1's ability to feel pain or discomfort in one or two extremities. This same assessment documents R1 is chair fast with R1's ability to walk severely limited or nonexistent, is able to make occasional slight changes in body or extremity position, but unable to make frequent or significant changes independently, and requires moderate to maximum assist in moving as well as frequent repositioning with maximum assist. R1's Braden Scale score indicates R1 is at moderate risk for the development of a pressure ulcer, however, this same Braden Scale assessment further instructs that if other major risk factors are present to consider the resident as the next higher risk category. R1's CNA (Certified Nurse Aide) Monitoring Form dated 1/24/19 documents R1 had redness to the buttocks and sacral area. R1's Tissue Tolerance assessment dated [DATE] documents that R1 had redness to the buttocks on that date and required an every two hour repositioning schedule. R1's New Site Wound documentation dated 1/27/19 documents that a 5cm (centimeters) long x 3.5cm wide wound was found on R1's buttocks which had a black-brown wound bed. R1's Initial Wound Evaluation & (and) Management Summary dated 1/30/19 and signed by V5 (wound Physician) documents R1 developed an unstageable pressure ulcer due to necrosis to the sacrum, a boney area in the center of the back just above the buttocks which measured 5cm long x 3.5cm wide with a depth not measurable. This Summary further document that R1's wound bed was 100% (percent) devitalized necrotic tissue which required surgical excisional debridement of the wound. This same summary documents that after the debridement R1's wound was considered a stage three pressure ulcer for R1's MDS assessment. On 2/11/19 at 11:23a.m. and 2:15p.m. and on 2/13/19 at 1:30p.m. V3 (Wound Nurse) stated that staff reported that R1 developed an unstagable pressure ulcer to the sacrum on 1/30/19. V3 stated that V3 documented the assessment on R1's new admission Skin Integrity Observation sheet dated 1/17/19, R1's Braden Scale assessment for pressure ulcer risk dated 1/17/19 and R1's Tissue Tolerance assessment dated [DATE]. V3 also stated that V3 also serves as the facility's Care Plan Coordinator and developed R1's care plan for pressure ulcer prevention. V3 verified that R1 had a reddened area to the buttocks at the time of admission and a non-blanchable area which was documented as a stage one pressure ulcer during the seven day look back period of the MDS assessment dated [DATE]. V3 stated that she did not document any additional assessments of R1's reddened area or non-blanchable stage one pressure ulcer to the sacrum following her initial assessments. V3 stated that R1 was not on a scheduled every two hours turn and reposition program stating, I don't like to put a specific schedule on the care plan for turning because the resident may not follow that schedule and so I care planned to turn him as he tolerates. V3 stated that there was no specific plan to off load R1 while he was in the wheelchair but instead he was to be off loaded as tolerated. On 2/11/19 at 3:58p.m. V6 (Registered Nurse) stated that on 1/27/19 V6 was R1's nurse until 6:00a.m. that morning at which time V7 (Licensed Practical Nurse) took over as R1's day shift nurse. V6 stated that on the morning of 1/27/19 she was just about to leave the facility at approximately 6:30a.m. to 6:45a.m. when a CNA (Certified Nurse Aide) approached her stating that R1 had a new wound to the sacral area. V6 stated that she decided to look at R1's wound then reported what she observed to V7. V6 stated R1's wound was a large blackened area on the sacrum with a stripe-like pattern down each side of the wound. V6 stated that when she cared for R1, He was cooperative with care and didn't like to lie down and he would negotiate to stay up longer. We knew he would be on the call light if he layed down because he liked a lot of attention. V6 stated that every time V6 was R1's nurse, R1 would lie down and turn to his side when asked. On 2/13/19 at 3:20p.m. V1 (Administrator) stated that V1 did an investigation into why R1 developed an unstageable pressure ulcer on 1/27/19. V1 stated that staff reported R1 spent a great deal of his time in the wheelchair. V1 stated that whenever staff asked R1 to lay down R1 would cry so staff would leave R1 in his wheelchair. On 2/13/19 at 10:30a.m. V2 (Director of Nurses) verified that R1's Braden Scale assessment dated [DATE] documents that if a resident has other major risk factors then that resident should be moved up to the next level of risk. V2 stated that R1 did not fall into the category of having additional risk factors that would increase his risk of developing a pressure ulcer, despite being paraplegic and totally dependent on staff for turning and repositioning. V2 stated that R1's [MEDICAL CONDITION], and dependence on staff for positioning was built into the Braden score which showed R1 was only at a moderate risk for developing pressure ulcers. V2 stated that even though R1 had a stage one pressure ulcer documented on his MDS on 1/23/19 and redness to the buttock at the time of admission on 1/16/19, R1 still would not have been at a higher risk to develop an open pressure ulcer. V2 also stated that R1 was not nutritionally compromised at 225 lbs (pounds) and 74 inches tall. V1 also stated she thought that R1's pressure ulcer was unavoidable because he was a paraplegic and had Autism. V2 stated that the facility does not have a policy for how often to offload a resident who spends a lot of time in the wheelchair. On 2/11/19 at 2:55p.m. V5 (Wound Physician) stated that he considered R1 a moderately high risk for the development of a pressure ulcer. V5 stated he examined and treated R1 for an unstageable pressure ulcer to the sacrum on 1/30/19. V5 stated that R1's sacral wound was very large and required debridement. V5 stated that if V5 had been able to completely debride R1's wound it would have been considered, At least a stage three if not a stage four pressure ulcer. V5 stated that R1's wound was the result of unrelieved pressure of at least two to four hours of duration. V5 stated that the only way R1's pressure ulcer would have been unavoidable was if the facility had put every possible preventive measure in place and R1 developed a pressure ulcer despite those preventive measures. R1's emergency physician progress notes [REDACTED]. This progress note further states, Patient does have foul-smelling stage IV (four) sacral decubitus (pressure) ulcer present. which required antibiotic treatment.

Based on observation, record review, and interview, the facility failed to ensure a resident was safely transported in a wheelchair utilizing foot pedals and failed to investigate falls as directed in the facility policies, for two of four residents (R2, R5) reviewed for accidents, in a sample of seven. This failure resulted in R2 being pushed in a wheelchair with no foot pedals attached and his stabilization boot became caught underneath him, causing a right medial meniscus (knee tendon) tear. Findings include: 1. The facility policy, titled Wheelchairs (5/17) documents, Procedure: 1. Explain procedure to resident and bring wheelchair to bedside. Lock wheels. 2. Adjust footrests. They can be folded or swung to the side for easy access to bed, toilet or tub. The electronic medical record documents R2 was admitted to the facility 11/09/18 for therapy services following a right fibula fracture at his home. On 1/28/19 at 9:00 a.m., R2 was laying on his bed with his right lower extremity in a stabilization boot. At that time, R2 stated, Around New Year's (V4 - Certified Nursing Assistant) was getting ready to take me from the shower room in my wheelchair, when I asked (V4) to put the foot rests on due to my broken leg and having to wear this heavy boot. (V4) told me she didn't have time to do that, and to just lift my feet. On the way from the shower room, (V4) was pushing me pretty fast, when my feet got caught under the wheelchair, and injured my knee. I now have a torn Meniscus in my knee and might need surgery. I haven't progressed in therapy since my injury. A Nursing Progress Note, dated 12/28/2018 at 9:00 AM, documents CNA was pushing (R2) in his (wheelchair) back from the shower (and R2's right) leg went underneath his (wheelchair and) twisted back. (R2) does have swelling noted to the knee. (Complaint of) pain noted. No bruising at this time. (Medical Director) notified. A Physical Therapy note for R2 dated 12/31/18, documents, Improvements in activity tolerance, strength, and balance allows patient to tolerate higher levels of challenges in transfer training to reduce fall risk and maximize mobility independently. Was able to stand for a (minute) holding onto parallel bars with 50% (weight bearing) but now unable to transition sit to stand due to increased knee pain. A Physical Therapy note for R2 dated 1/07/18 documents, The patient is unable to stand due to increased pain with transfers in (right) knee and 50% (weight bearing) on (right lower extremity). A MRI (Magnetic Resonance Imaging) report for R2, dated 1/18/19 documents, Reason for study: Pain in the right knee throughout the entire knee after twisting injury two weeks ago and Impression: Diffuse [MEDICAL CONDITION] tearing of the lateral meniscus with undersurface tearing of the posterior horn and body of the medial meniscus. A Correspondence Note from V6 (Advanced Nurse Practitioner), dated 1/22/19, addresses R2's MRI results and documents, There is severe arthritic changes to the knee in all 3 compartments, greatest to the lateral aspect. Medial and lateral meniscus tears. No ligament tears. Recommend follow up with an orthopedic surgeon to discuss options. On 1/29/19 at 10:17 am, V4 stated (on 12/28/18) she was returning R2 to his room via wheelchair. V4 stated, while pushing R2 in his wheelchair, his right foot became entangled underneath. According to V4, R2 did have his stabilization boot on his right foot when it got caught under the wheelchair and V4 had to get assistance from the nurse to untangle R2's foot. V4 stated R2 yelled out in pain when the incident occurred. V4 stated R2 did have footrests for his wheelchair, but she did not put them on. On 1/28/19 at 2:55 p.m., V6 stated R2 has never complained of knee pain until the incident when his foot was caught under a forward moving wheelchair. V6 stated she ordered the 1/18/19 MRI due to R2's ongoing right knee pain after that incident. V6 stated R2's MRI showed medial and lateral meniscus tears, with the medial tear being an acute injury. V6 concluded that the mechanism of R2's foot, with the stabilization boot on, being pulled under a wheelchair as it is propelling, would be consistent with this type of injury. V6 stated R2's meniscus tear has set him back in his recovery for the right fibula fracture and hindered his physical therapy and timeframe for discharge. 2. The facility Fall Reduction Program (7/18) policy documents, It is the policy of this facility to have a Fall Reduction Program that promotes the safety of residents in the facility. The program's intent is to assist clinical staff in determining the needs of each resident through the use of standard assessments, the identification of each resident's individual risks, and the implementation of appropriate interventions, supervision, and/or assuasive devices deemed appropriate and In the even a fall incident occurs, nursing staff will complete an assessment of the resident and obtain the facts surrounding the fall, and report findings to the resident's physician and responsible party and document findings and notification within the resident's clinical record. 7. Post fall monitoring shall be completed by the nursing staff every shift for 72 hours and findings documented within the clinical record. 8. Attempts shall be made to implement new or modified interventions as needed to enhance safety and consistent with root cause analysis; new interventions to be communicated to the facility staff through revision of resident care plan and profile to maintain continuity of care. The facility policy, titled Post Fall Investigation (5/17), documents, It is the policy of this facility to investigate falling incidents as part of the Quality Assurance Process in efforts to determine possible causative factors and to develop an individualized prevention plan in attempts to prevent further occurrences. Procedure: 1. A Post Fall Investigation form will be completed by staff within seventy two hours of the occurrence. 2. After the completion of the form, information will be reviewed to determine, if possible causative factors and include interventions that are currently being used and those interventions that will be implemented as a result of the investigation. An Event Report, dated 12/29/2018 at 9:00 PM, by V13 (Licensed Practical Nurse), documents R5 fell in his room from his bed, did not complain of pain and no injury was noted; however, a Witness Report by V15 (Licensed Practical Nurse), dated 12/29/18 at 9:15 PM, documents (R5) was laying between bed and wall (with) heater on his left side. (R5) stated that he hit his head, left arm & leg on the floor and that they hurt. An Event Report, dated 1/01/19 at 8:05 PM, by V13, documents R5 fell in his room from his bed and sustained redness, bruising and bump to right wrist/elbow. The Electronic Medical Record contains no corresponding Resident Progress Notes detailing any information regarding the 12/29/18 or 1/01/19 fall. On 1/29/19 at 2:05 pm, V1 (Administrator) stated, she did not have investigations, which are to be completed by V1 or V2 (Director of Nursing) for R5's falls, as the nurse who was caring for R5 at the time of each incident (V13) did not notify Administrative Staff of the falls, so an investigation could be initiated and potential cause determined. V1 concluded that V13 was reprimanded for not following the facility Fall Reduction Program.

Based on observation, record review and interview, the facility failed to accurately assess multiple pressure ulcers at the time of admission and failed to provide treatment and/or pressure ulcer prevention interventions, for two of four residents (R78, R132) reviewed with pressure ulcers in a sample of 24. This failure resulted in R132's left ear wound not being treated for [REDACTED]. Findings include: The facility policy, titled Wound Assessment Policy and Procedure (5/17), documents, Objective: 1. It is the policy of this facility to do a systemic, ongoing wound assessment on all wounds in order to determine the response to nursing care and treatment modalities. 2. To promote a systemic, comprehensive approach to the assessment of wounds. 3. To document an accurate, ongoing assessment of wounds in the medical record. Procedure: 1. The presence of wounds, ulcers, and/or other skin abnormalities will be indicated on the admission nursing assessment. 2. A complete wound assessment will be done weekly by a licensed nurse for all wounds, ulcers, and impairments in the skin integrity. 3. The comprehensive or complete wound assessment will be documented on the Nursing Admission Assessment form during the initial admission skin assessment and on the Treatment Administration Record weekly thereafter. Facilities using the (electronic health record) will complete the initial skin assessment on the Admission/Readmission Observation Packet and a Weekly Pressure Ulcer Documentation Observation thereafter. The wound assessment will contain the following information: a. Wound classification b. Wound location c. Pressure ulcer staging OR description of the extent of tissue damage d. Description of the wound bed, drainage, margins/surrounding skin and odor e. Wound measurements f. Wound related pain. The facility policy, titled Skin Assessment Policy and Procedure (5/17), documents, Resident's who are determined 'AT HIGH RISK' for the development of pressure ulcers will have a head-to-toe skin assessment done by a licensed nurse or CNA (Certified Nursing Assistant) daily and documented on the Treatment Administration Record (TAR) or Daily Skin Assessment Sheet. Hospital Discharge Summary, dated 10/02/18, documents R132 was transferred to the facility with a Pressure Ulcer to the Left Medial Knee, Right Medial Knee, Left Heel, Right Heel, Left Plantar Foot, Left Ear and Sacrococcygeal area (no measurements provided). R132's Admission Nursing Assessment, on 10/02/18 at 7:23 pm, documents, under Pressure Ulcers - Include Measurement and Location - Yes, describe - See progress notes. A Resident Progress Note, dated 10/03/18 at 5:38 am, documents (R132) has wounds to heels, knees, (coccyx) and to left ear. Wound nurse to assess. The Electronic Medical Record fails to document any wound measurements or assessments at the time of R132's admission, as instructed in the Wound Assessment policy. Resident Progress Note, dated 10/03/18 at 4:59 pm by V16 (Wound Nurse) documents, R132's Right Heel, Left Heel, Right Medial Knee, Left Medial Knee, and Sacral wounds were assessed and measured by V16; however, it fails to document an assessment or measurement of the left ear wound. A Initial Wound Evaluation and Management Summary, dated 10/08/18, documents the facility's Wound Doctor assessed R132 Right and Left Heel, Right and Left Medial Knee and Sacral Wounds, but R132's Left Ear Pressure Ulcer was not assessed. R132's Plan of Care, dated 10/05/18, documents R132 has impaired skin integrity related to a Left Heel Pressure Ulcer, Right Heel Deep Tissue Injury, Left and Right Medial Knee Pressure Ulcers and a Sacral Pressure Ulcer, with corresponding pressure ulcer prevention interventions related to those specific wounds. R132's 10/05/18 Plan of Care fails to identify the presence of a Left Ear Pressure Ulcer or associated treatments/interventions for that wound. R132's Treatment Administration Record and physician's orders [REDACTED]. The Electronic Medical Record documents R132 was admitted to the hospital on [DATE], discharging back to the facility on [DATE]. Hospital Wound Measurements, dated 10/11/18, documents R132 presented with a Stage III Pressure Ulcer to the Left Ear, measuring 0.6 cm (centimeters) x 0.5 cm x 0.2 cm with part of the ear missing. Hospital Discharge Instructions, dated 10/19/18, document R132 has a left ear wound that is to be treated with [MEDICATION NAME] daily. R132's Re-admission Progress Notes, dated 10/19/18 at 12:20 pm, document, Stage 4 wounds to bilateral inside of knees, bilateral heals, at greater right toe, and at coccyx along with wound at left hip. R132's has excoriated bilateral inner upper thighs. The Resident Progress note fails to document R132's left ear wound was assessed at the time of re-admission. R132's Admission Nursing Assessment, dated 10/20/18 at 5:32 pm (over 24 hours after R132's re-admission), documents, Pressure Ulcer - Include measurement and location - Yes, describe: Sacrum 6 x 7 (cm), left hip abrasion, (left) knee (2.5 cm x 1.5 cm), (right) knee (3.5 cm), (left) heel 6 x 7 (cm), (right) heel 6 x 4 (cm). The Pressure Ulcer section of the Admission Nursing Assessment fails to identify R132's left ear pressure ulcer. The Electronic Medical Record documents treatment orders for R132's Sacrum, Right and Left Knee, and Right and Left Heel pressure ulcers were not obtained and initiated until 10/21/18, two days after R132's readmission. The Electronic Medical Record documents a treatment order for R132's Left Ear pressure ulcer was not obtained and initiated until 10/22/18, three days after R132's re-admission. On 10/22/18, R132's Current Plan of Care did not address any interventions to prevent the left ear wound from worsening. On 10/22/18 at 10:15 am and 12:30 pm, R132 was laying in bed, with her head leaning to the left and the left ear against her left shoulder. R132 did not have any positioning device/pillow to prevent her head from leaning onto the left shoulder. On 10/22/18 at 2:20 pm, V16 (Wound Nurse) provided wound care to R132. R132 had a large open wound of the mid left ear, with a portion of the outer ear missing. V16 stated at that time, it was the first time she had seen any wound on R132's left ear and indicated that the wound was new, since her most recent hospitalized from [DATE] to 10/19/18. V16 was unaware that R132 had the left ear pressure ulcer at the time she was originally admitted to the facility on [DATE]. V16 identified R132's left ear pressure ulcer as a Stage III at that time. On 10/25/18 at 12:00 pm, R132's Electronic Medical Record still did not contain documentation of a wound assessment for R132's Stage III left ear pressure ulcer. On 10/25/18 at 1:14 pm, V16 provided documentation of wound measurements that were obtained at 11:51 am 10/25/18. V16 stated all of R132's wounds should have been measured by the nurse re-admitting R132 on 10/19/18, but true measurements of all R132's wounds were not made until today. A Wound Assessment Details Report, dated 10/25/18 at 11:51 am, documents R132 has a Stage III left ear pressure ulcer, measuring 1.2 cm x 0.5 cm x 0.3 cm. On 10/25/18 at 10:10 am, V13 (Medical Director) stated all resident pressure ulcers/wounds need to be assessed and treated upon the resident's admission to prevent the wounds from deteriorating. V13 stated staff are required to obtain treatment orders for any wounds/pressure ulcers, if one is not provided at the time of admission. V13 stated he was unaware R132 had a wound on her left ear, but was aware of R132's other pressure ulcers. V13 concluded R132's may have been acquired prior to her admission on 10/02/18, but a lack of treatment for [REDACTED]. The National Pressure Ulcer Advisory Panel's Pressure Injury Prevention Points, dated 4/16, documents, Inspect the skin at least daily for signs of pressure injury, especially nonblanchable [DIAGNOSES REDACTED]. The facility's Skin Assessment Policy and Procedure, dated 5/17, documents, Intact, healthy skin is the body's first line of defense. It is the policy of this facility to monitor the skin integrity for signs of injury and irritation. In addition to ongoing assessment of the skin, the facility will implement measures to protect the resident's skin integrity and to prevent skin breakdown. On admission, a head-to-toe assessment of the resident's skin will be completed by a licensed nurse along with the admission nursing history. Resident's who are determine 'AT HIGH RISK' for the development of pressure ulcers will have a head-to-toe skin assessment done by a licensed nurse or CNA (Certified Nursing Assistant) daily and documented on the Treatment Administration Record (TAR) or Daily skin Assessment sheet. R78's POS (Physician order [REDACTED]. R78's Observation Report, dated 7/16/18, documents R78's Sensory perception as slightly limited and responds to verbal commands but can't always communicate discomfort or need to be turned or has some sensory impairment that limits ability to feel pain/discomfort in 1-2 extremities. This same report also documents R78 as Chair fast and very limited on ability to change and control body position. Requires moderate to maximum assist in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assist. [DIAGNOSES REDACTED], contractures, or agitation leads to almost constant friction. Baden score as 12 (High Risk). R78's MDS (Minimum Data Set) assessment dated [DATE], documents R78 as extensive assist for bed mobility and impairment on lower extremities on both side for Range of Motion. This same MDS documents R78 has one unstageable pressure ulcer. R78's Wound Assessment Details Report dated 7/24/17, documents left heel pressure ulcer, unstageable, facility acquired, 5.00 cm (centimeters) x 5.00 x 0.00, identified on 7/17/18. According to the Wound assessment dated [DATE] this same wound now measures 3.00 x 3.00 x 0.30cm On 10/24/18 at 2:18 p.m., V16 (Wound Nurse) and V20 (LPN/License Practical Nurse) performed wound care on R78's left heel. While taking off the old dressing a new open area was identified on the left medial aspect of the foot. The new area was approximately quarter size. V16 stated she didn't know if it was from friction or a blister that had popped but was not aware of the area prior to. V16 also stated that skin checks were not performed daily prior to 10-17-18 as directed by the facility policy. R78's progress notes dated, 10/23/18 documents, While doing dressing change to left heel, an open blister to left medial foot was noticed. Area measures 1.5 cm round. No drainage noted. Clean, dry dressing applied. Also redness proximal to foot noted. (V13 (Medical Director) notified. A new order was received for R78 for this new area on 10/23/18 for Triple Antibiotic Ointment to left lateral foot every day for pressure ulcer to left heel, unstageable. R78's (TAR/Treatment Administration Record) dated 9/25/18 to 10/22/18, documents an order for [REDACTED]. R78's pressure ulcer plan of care documents an intervention of observe skin every shift and report any changes to nurse immediately.

Based on observation, record review and interview, the facility failed to provide pain management for one of one residents (R132) reviewed for pain, in a sample of 24. This failure resulted in R132, who is non-verbal, receiving treatment to multiple pressure ulcers, without any pain control and R132 expressing physical signs of pain during wound care. Findings include: The facility policy, titled Pain Management (2/28/13), documents, It is the policy of this Facility to screen all residents for pain; identify those who are experiencing pain; and assess and develop an effective individualized pain management care plan. A Plan of Care, dated 10/12/18, documents R132 is at risk for alteration in comfort/pain (related to) multiple wounds, non-ambulatory, contractures, [MEDICAL CONDITION], diabetes, osteo[DIAGNOSES REDACTED], (and) pancreatitis and instructs staff to notify (physician) if current pain medication management is not effective and offer (as needed) [MEDICATION NAME] prior to (Activities of Daily Living). A Braden Scale (Skin Risk Assessment), dated 10/05/18, documents R132 Responds only to painful stimuli. Can't communicate discomfort except by moaning, or restlessness. Resident Progress Notes, dated 10/19/18, documents R132 was readmitted following a hospitalization with Stage 4 wounds to bilateral inside of knees, bilateral heels, great right toe and coccyx, along with wound at left hip. R132's Current physician's orders [REDACTED]. On 10/22/18 at 2:20 pm, R132 was laying in bed, non-verbal and unable to move/reposition herself in bed independently. V16 (Wound Nurse) removed R132's bilateral heel dressings which revealed large open wounds on each heel. As V16 began cleansing the wounds R132 began grimacing and then made a face as though she was crying. R132 continued to have intermittent looks of distress on her face throughout the wound care on the heels and with repositioning of her lower extremities. V17 (Licensed Practical Nurse) was assisting V16 and began reassuring and consoling R132 when they noticed R132 was in distress. V17 stated at that time, she thought R132 had a order for [MEDICATION NAME] to manage pain, but V17 was unsure if R132 had any that day. V16 then stated she did not pre-medicate R132 before initiating wound care. On 10/23/18 at 12:50 pm, a physician's orders [REDACTED]. On 10/24/18 at 10:20 am, V21 (Registered Nurse) provided wound care to R132. As V21 removed R132's right heel dressing, R132 went from resting quietly to opening her eyes and grimacing. V21 acknowledged R132's change in facial expression and stated You can feel that, can't you?. V21 continued to perform R132's right heel wound care, as V22 (Certified Nursing Assistant) held R132's leg. As V22 extended R132's leg for V21 to visualize the heel, R132 continued to make a grimacing facial expression. V21 then removed the dressing covering R132's left heel, which caused R132 to breathe more rapidly and grimace. V22 consoled R132 when she appeared to be in pain, as the wound care was provided. After R132's bilateral heel wounds were dressed, V21 stated she did not give R132 any medication for pain prior to the treatments, and concluded that's a good idea, because she needs it. On 10/25/18 at 10:00 am, V13 (Medical Director) stated any resident experiencing pain with cares should be discussed with the physician, so appropriate pain management can be achieved.

Based on record review and interview, the facility failed to administer medication as prescribed by the physician upon transfer, for one of one residents (R132) reviewed for admission medication orders, in a sample of 24. This failure resulted in R132 becoming unresponsive and and developing a critically high sodium level and a critically low glucose level, requiring hospitalization . Findings include: A Hospital History and Physical dated 8/24/18, documents R132 has a history of Diabetes Insipidus and was receiving [MEDICATION NAME] IV three times per day during the course of her hospitalization . 10/02/18 Hospital Discharge Orders list under Discharge Medications [MEDICATION NAME] 3 mcg (Micrograms) to be given IV push every 8 hours. R132's Medication Administration Record [REDACTED]. Resident Progress notes, dated 10/11/18 at 1:55 pm document R132 was not usual self, had low blood sugar, and physician orders [REDACTED]. R132's Resident Progress notes on 10/11/18 at 2:00 pm document I was alerted that resident wasn't responding so I did a (respiratory check), gave my results to nurse. She stated that (R132's) blood sugar was low so [MEDICATION NAME] was given and resident did start breathing at a faster rate but very shallow. (Peripheral Capillary Oxygen Saturation) maintained at 98%, but resident still did not respond to sternal rub. (R132) was then sent to the hospital. The 10/11/18 Hospital Admission Laboratory reports document R132 had a critical high sodium level of 178 mmol/L (normal rang 133 - 145 mmol/L) and critical low glucose level of 44 mg/dl (normal range of 70 - 105 mg/dl) at the time of her admission. A Hospital History and Physical, dated 10/11/18, documents, R132 was brought in from (transferring hospital emergency room ) for management of severe [MEDICAL CONDITION] (elevated sodium level) of 180 mEq/L, [DIAGNOSES REDACTED] (low blood sugar) of 31 mg/dL, elevated procalcitonin and a left lower lobe infiltrate. The History and Physical later documents, (R132) has a history of central diabetes insipidus, for which she is taking [MEDICATION NAME]. From records, she has not gotten [MEDICATION NAME] since she has been admitted (to nursing home.) Hospital notes, dated 10/12/18, documents (R132) is severely hypernatremic and has abnormal renal function, azotemia from dehydration and/or from not receiving [MEDICATION NAME], which she was to have received in the nursing home. A Hospital Discharge Summary, dated 10/19/18, documents R132's [MEDICAL CONDITION] as resolved, and R132 was discharged back to the facility with orders to receive [MEDICATION NAME] 0.1 mg (milligram) twice per day. On 10/25/18 at 10:00 am, V13 (Medical Director) stated the facility is responsible for pre-screening residents before they are transferred from the hospital, and part of that includes reviewing resident medication to determine if there are medication orders that need to be addressed. V13 stated R132 was admitted to the hospital on [DATE] with a altered level of consciousness and high sodium level. V13 stated [MEDICATION NAME] is a medication that can not be abruptly stopped and this would be the reason for R132 having elevated sodium and low glucose levels on 10/11/18 and needing hospitalization . V13 stated, if the facility had contacted him regarding R132's order for [MEDICATION NAME] to be given IV push, V13 could have ordered an alternate route that the facility staff could administer. On 10/24/18 at 8:05 am, V2 (Director of Nursing) stated the facility does not administer IV push medications; therefore, the admitting nurse should have clarified that order with the physician. V2 was unable to locate any documentation that the physician was contacted to clarify R132's order for [MEDICATION NAME] or a physician's orders [REDACTED]. On 10/25/18 at 10:32 am, V2 (Director Of Nursing) stated she will review the list of medications a resident is taking prior to their admission to the facility, but she doesn't even look at them if they are IV push drugs because the facility does not give those medications. V2 stated she would have expected the admitting nurse to clarify the order with a physician at the time of admission. On 10/24/18 at 12:30 pm, V25 (Consultant Pharmacist) stated he would expect nursing staff to contact the physician to clarify the order for [MEDICATION NAME], as there are alternate routes besides IV push that could have possibly been given to R132. V25 stated all resident medications are to be reconciled upon their admission to the facility and any in question would need to be addressed by the Physician. V25 stated these circumstances put (R132's) safety at risk.

Based on interview and record review, the facility failed to complete daily skin assessments and implement pressure relieving interventions for one of three residents (R2) reviewed for pressure ulcers in the sample of four. These failures resulted in R2 developing two avoidable pressure ulcers to R2's left and right heels, that subsequently progressed to an unstageable status before being identified. Findings include: The National Pressure Ulcer Advisory Panel's Pressure Injury Prevention Points, dated 4/16, documents, Inspect the skin at least daily for signs of pressure injury, especially nonblanchable [DIAGNOSES REDACTED]. The facility's Skin Assessment Policy and Procedure, dated 5/17, documents, Intact, healthy skin is the body's first line of defense. It is the policy of this facility to monitor the skin integrity for signs of injury and irritation. In addition to ongoing assessment of the skin, the facility will implement measures to protect the resident's skin integrity and to prevent skin breakdown. On admission, a head-to-toe assessment of the resident's skin will be completed by a licensed nurse along with the admission nursing history. Resident's who are determined 'AT HIGH RISK' for the development of pressure ulcers will have a head-to-toe skin assessment done by a licensed nurse or CNA (Certified Nursing Assistant) daily and documented on the Treatment Administration Record (TAR) or Daily skin Assessment sheet. R2's POS (Physician order [REDACTED]. R2's Admission Observation Report, dated 8/3/18, documents R2 has pressure ulcers present on R2's left buttock and coccyx area. This same report documents R2 is not able to verbalize complaints, not able to verbalize illness, requires two assist or mechanical lift for transfer, and R2 is not able to bear weight. This report also documents R2's Sensory perception as very limited and responds only to painful stimuli, cannot communicate discomfort except by moaning, or restlessness or has sensory impairment that limits ability to feel pain/discomfort over half of body. This same report also documents R2 as Bedfast, completely immobile does not make even slightly changes in body or extremity position without assist, no history of foot ulcers, and no pressure ulcers present on R2's left or right heels. R2's Braden Assessment's dated 8/7/18 and 8/12/18 document a score of 10, indicating R2 is High Risk. R2's MDS (Minimum Data Set) assessment dated [DATE], documents R2 as total dependent for all cares and impairment on upper and lower extremities on both sides for Range of Motion. R2's (TAR/Treatment Administration Record) dated 8/1/18 to 8/31/18, documents an order for [REDACTED]. Place heel boots and float heels. (MONTH) remove heel boots for hygiene, laundry, treatments and skin checks. R2's plan of care dated 8/7/18, documents R2 requires Total staff participation to reposition in bed and R2's pressure ulcer plan of care documents an intervention of observe skin every shift and report any changes to nurse immediately. R2's progress notes dated 8/3/18 documents, (R2) arrived to facility via ambulance. (R2) noted to have open area on left buttock and another open area on his coccyx. R2's progress notes dated 8/13/18 documents, Wound rounds today per (V14) Wound Physician and (V18) Wound Nurse. Two new areas assessed to right and left heels DTI (deep tissue injury), soft boots placed and foam dressings to heels per physician orders. R2's Wound Evaluation and Management Summary, signed by V14 (Wound Physician) and dated 8/13/18, documents, Unstageable DTI of the left heel measuring 5 cm (centimeters) x 3 cm x not measurable. Also Unstageable DTI of the right heel measuring 3 cm x 3 cm x not measurable. Recommendations as heel protectors when in bed . On 10/17/18 at 9:40 a.m., V14 (Wound Physician) stated, (R2's) pressure ulcers to his right and left heels were acquired at the facility and found during our wound rounds. The wounds could have been avoided if preventative interventions were provided. He did not have heel protectors on the day that they were discovered when (I) was there. (R2) can not move himself. The ulcers should have been identified by the facility before they had progressed to unstageable. On 10/17/18 at 11:47 a.m., V23 (RN/Registered Nurse) stated, (I) was the nurse for (R2) on 8/13/18. (I) helped turn (R2), along with V18 and V14, and that is when (R2's) pressure ulcers were found. (R2) did not have heel protectors on prior to finding the pressure ulcers and (I) got an order at that time to apply the heel protectors. On 10/17/18 at 9:38 a.m., V2 (DON/Director of Nursing) stated, We do skin checks as ordered or weekly. CNAs (Certified Nursing Assistants) don't do actual skin checks, they just report if they see any areas during cares. On 10//17/18 at 12:19 p.m., V18 (Wound Nurse) stated, (I) do skin checks twice a week most of the time, the ulcers found on (R2) were from pressure, and if daily skin checks would have been completed, (R2's) heel pressure ulcers would have been identified earlier.

Based on interview and record review, the facility failed to administer diuretic medication in accordance with Physician order [REDACTED]. This failure resulted in R1 experiencing an acute exacerbation of [MEDICAL CONDITION] resulting in hospitalization . Findings include: Nurses Notes, dated 1/17/15, note R1 was a new admission to the facility. admitted for "Recuperate from cardiac surgery, new ICD (Internal Cardiac Defibrillator)." Progress Notes, dated 1/17/15, document R1 with medical [DIAGNOSES REDACTED].." Minimum Data Set (MDS), dated [DATE], notes R1 to be free of any cognitive deficits or memory impairments. R1's "Discharge Medication Instructions" to the skilled nursing facility, (no date), document, "[MEDICATION NAME] 60 milligrams (mg) three times a day." Physician Orders, dated 1/17/15, documents, "[MEDICATION NAME] ([MEDICATION NAME]) 60mg by mouth three times a day for [MEDICAL CONDITION] related to [MEDICAL CONDITIONS]." R1's Medication Administration Record [REDACTED]. On 3/19/15 at 10:00 A.M., R1 stated, "I had two doses of my [MEDICATION NAME] before coming to the facility. I told them (facility staff) over and over that I really needed my last dose of [MEDICATION NAME] and a pain pill. I never did get any medications that night. They (facility staff) kept telling me that my medications had not been delivered yet, and they did not know how long it would take." On 3/19/15 at 11:05 A.M., Z4 (R1's relative) stated, "I told the nurse (R1) needed [MEDICATION NAME] and a pain pill when we admitted to the facility (on 1/17/15), and the staff told me that they had to wait for the medications to be delivered, and that it may take at least a couple hours. The nurse told me that if I wanted to get his medications from home to give him, that I could do that, but not to let the nurse know that we were doing that. I didn't feel comfortable doing that, so I told the nurse we would try and wait. (R1) never did get medications that night. I called (R1) the next morning and (R1) said (R1) never got any medications last night and that (R1) was hurting and could not breathe. I called the nurse right away to check on (R1) and (R1) went to the hospital shortly after that." On 3/19/15 at 2:35 P.M., E2 (Director of Nursing) stated, "No medications were given on 1/17/15 to (R1)." E2 stated, "I would expect the staff to contact the physician if a medication was ordered and unavailable to be given." R1's Nurses Notes, dated 1/18/15 at 10:42 A.M., states, "Resident complains of shortness of breath (SOB). Respirations 28, shallow..." R1's Nurses Notes dated 1/18/15 at 10:49, states,"...orders received to send to emergency room ." On 3/19/15 at 8:28 A.M., Z1 (R1's Cardiac Surgeon) stated, "We really had to baby (R1) post-operatively. (R1) was very sensitive to fluid overload. [MEDICATION NAME] was important for (R1) because (R1) had Mitral Valve surgery. The facility should have at least called and communicated that a dose was missed. No communication was made to me. I could have made adjustments to the [MEDICATION NAME] that day. Even if (R1) only missed one 60mg dose of [MEDICATION NAME], receiving this missed dose could have prevented (R1's) hospitalization ." R1's Radiology Report from emergency room visit, dated 1/18/15 at 11:33 A.M., documents, "Clinical Impression: [MEDICAL CONDITION]" Local area hospital discharge instructions, dated 1/18/15, state R1 was treated for [REDACTED]. Discharge instructions further read to "Take [MEDICATION NAME] three times daily as prescribed by Z5's (R1's surgeon) orders."

Based on observation, interview, and record review, the facility failed to implement pressure relieving methods to help prevent the development of new pressure ulcers, and failed to treat two newly acquired pressure areas within a timely manner for one of five residents (R1) reviewed at risk for developing pressure ulcers in the sample of twenty. This failure resulted in two new pressure areas developing for R1. Findings include: According to the Physician order [REDACTED]. According to R1's Minimum Data Set ((MDS) dated [DATE], R1 is totally dependent on two staff for bed mobility and transfers. R1's pressure ulcer risk assessment dated [DATE], documents R1 is at high risk for pressure sores and should be on a turning and positioning program. R1's MDS dated [DATE], documents R1 is cognitively intact and is on a turning and repositioning program. R1's skin care plan reviewed 1-30-13, documents R1 is to be turned and repositioned every 2 hours and as needed. According to R1's turning and positioning evaluation done on 1-11-13, R1 should be on a two hour repositioning schedule, with padding on bony prominences. On 2-25-13 at 9:30a.m., R1 was sitting up, in (R1's) room, in a specialized wheelchair. On 2-25-13 from 10:00a.m. to 1:15p.m., R1 was observed every 15 minutes to be up in the specialized wheelchair. Facility staff did not assist R1 with turning and repositioning or off loading pressure from R1's left buttock and left gluteal fold, where two new pressure areas developed. On 2-28-13 at 11:30a.m., E7 (Certified Nursing Aide) verified she did not put any repositioning device under R1's buttock to off load pressure or redistribute R1's weight from her left buttock on 2-25-13 from 10a.m. to 1:15p.m. On 2-25-13 at 1:15p.m., E7 and E11 (Certified Nursing Aide) transferred R1 out of her wheelchair to her bed using a mechanical lift. On 2-25-13 at 1:22p.m., E12 (Licensed Practical Nurse) verified R1 had been up in her wheelchair from 9:30a.m. until 1:15p.m. On 2-25-13 at 1:22p.m., R1 had two pressure ulcers noted to her left buttock and left gluteal fold (left ischium). Both the left buttock and left ischium pressure ulcers did not have dressings covering them. R1's left buttock ulcer appeared dark pink, with a small amount of blood tinged drainage, and measured approximately 2.8cm (centimeters) long, by 0.9cm wide, by less than 0.2cm deep. R1's left ischium ulcer appeared dark pink, with a small amount of blood tinged drainage, and measured approximately 1.5cm long, by 0.7cm wide, by 0.1cm deep. On 2-25-13 at 1:22p.m., E12 (LPN/Licensed Practical Nurse) states, "The certified nursing aides told me that around 9:30a.m., R1 had two new open areas to her buttock, but I could not look at it or treat the open areas because R1 was up in her wheelchair, and was not laid down to bed until now (1:15p.m)." On 2-25-13 at 1:30p.m., R1 states, " The staff do not reposition me when I am in my wheelchair and if I was asked to lay down between breakfast and lunch today, I would have." On 2-27-13 at 9:15a.m., R1 states, " My tilt on my wheelchair has been broken since at least September 2012, and I use the tilt to relax and relieve pressure to my bottom." On 2-27-13 at 1:30p.m., R1 states, "My original bottom wheelchair cushion has been gone since September 2012, and the cushion the facility provided me does not fit my wheelchair correctly, and my legs rub the tray where there is no cushion." On 2-27-13 at 9:15a.m., R1's wheelchair tilt did not function to allow the specialized wheelchair to move out of one position. On 2-27-13 at 9:20a.m., E7 (Certified Nursing Aide) verified that R1's wheelchair tilt has been broken since "at least" September 2012, and the tilt was used to "relieve pressure" on R1's buttock. At this time E7 also verified that R1's bottom cushion does not fit R1's wheelchair, and we (the staff) try to put foam on the edges of the tray of the seat, but R1's legs still rub the edges because the foam moves." On 2-27-13 at 10:05a.m., E14 (Certified Occupational Therapy Assistant) verified that E14 has only been aware that R1's tilt was broken on her wheelchair for approximately two weeks. On 2-28-13 at 11:12a.m., E14 verified that R1's bottom wheelchair cushion did not fit the seat of the specialized wheelchair. E14 stated that the wheelchair vendor is either ordering a new cushion or ordering a piece to make the current wheelchair cushion fit properly. On 2-27-13 at 10:15a.m., E13 (Maintenance Director) verified he was notified about R1's wheelchair tilt being broken around two weeks ago, and that he looked at the tilt. E13 stated that he did not fix the wheelchair tilt because he was told that a new wheelchair was being ordered for R1. On 2-28-13 at 11:12a.m., E14 (Certified Occupational Therapy Assistant) verified approximately two weeks ago, E13 (Maintenance Director) asked E14 for a piece of foam for the front of R1's wheelchair bottom cushion plate because R1's legs were rubbing against the front of the wheelchair bottom that holds the cushion in place. On 2-28-13 at 10:45a.m., E2 (Director of Nursing) verified that if the facility staff could tilt R1's wheelchair back, that would relieve pressure off of R1's buttock. E2 stated, "It should have been reported to the nurses and documented in the Interdisciplinary Communication book that R1's wheelchair tilt does not work, so I would have known before two weeks ago." E2 also stated, "The facility would have rented R1 a new chair if the facility knew R1's wheelchair tilt was broken and bottom cushion was not fitting properly." The facility's pressure ulcer management for residents at risk policy dated September 2010, documents that, "Residents should be turned and repositioned every two hours or more frequently, " and that, " Residents should be assisted to change position when up in their chair."

A. Based on observation, record review, and interview, the facility failed to ensure a resident infected with MRSA (Methicillin Resistant Staphylococcus Aureus) of the nose and sputum maintained a covered airway while amongst other staff/residents, failed to educate family on proper precautions to take for Respiratory Isolation, failed to perform handwashing after coming in contact with body secretions, and failed to remain up to date on current standards of Infection Control practices, for one of seven residents (R4) reviewed on Isolation Precautions, in a sample of 23. On 3/07/12, R4, who has MRSA of the sputum and nose, was ambulating freely throughout the facility with his airways uncovered, openly coughing, touching his tracheostomy opening and then touching handrails and the Nurses Station Desk. R4 has [DIAGNOSES REDACTED] and can roam freely throughout the facility. The lack of infection control measures and lack of knowledge regarding current recommended standards of infection control has the potential to effect all residents in the facility, including 25 residents (R5, R6, R7, R16, R17, R25, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39, R40, R41, R42, R43, R44, R45) which were identified as being immunocompromised. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 3/08/12, the facility remains out of compliance at a Severity Level II as the facility continues to monitor the effectiveness of training regarding Infection Control Prevention. Findings Include: A physician's orders [REDACTED]. Microbiology Reports dated 1/05/12 document R4 was positive for MRSA infection of the nares and sputum. Follow up Microbiology Reports dated 2/13/12 document R4 continued to be positive for MRSA infection of the nares. A Plan of Care, dated 6/15/11, indicates R4 has "severe (Mental Retardation) and Downs Syndrome and has decreased safety awareness. He pulls at his (tracheostomy), (ventilator) tubing ." The Plan of Care further identifies that R4 has MRSA of the sputum and requires isolation, but did not identify specific precautions to take for covering R4's airways. The Facility Policy and Procedure, titled "Universal Precautions/Infection Control", indicates for "Airborne Precautions" that respiratory precautions are to be used and that patient transport in the facility is to be limited. The Facility Policy and Procedure, titled "Handwashing/Cleansing", indicates "Handwashing/Cleansing is done before and after resident contact, before and after any procedure, after using a Kleenex or the restroom, before eating or handling food, when hands are obviously soiled and regardless of glove use." The Facility Policy and Procedure, titled "Protocol for the Care of Residents with MDRO'S (Multi-Drug Resistant Organisms)", identifies MRSA as a MDRO and indicates that "Residents are permitted out of their room as long as precautions are maintained to contain secretions and excretions." The Facility Policy and Procedure, titled "Infection Control Guidelines", indicates "A resident who is infected with MRSA in the respiratory tract, such as pneumonia or bronchitis, should wear a mask when leaving the room ....Those residents who are colonized with MRSA in their sputum and who have a chronic, uncontrollable cough should wear a mask when leaving the room." On 3/06/12 at 9:05 a.m., while touring the facility, the door to R4's room had a sign indicating the resident is currently on Respiratory Isolation. On 3/07/12 at 8:40 a.m., R4 was ambulating through the facility independently and unsupervised by staff, with only a mask on the opening to his trachea and no mask on his face. R4 wandered into the Conference Room and had mouth secretions expelling from his bottom lip. At 9:42 a.m., R4 continued to wander the facility independently and unsupervised and was coughing in the main hallway with his mouth uncovered. On 3/07/12 at 1:30 p.m., R4 was at the Respiratory Nurses Station openly coughing and secretions could be heard rattling. R4 was not wearing a mask over his mouth and nose. On 3/08/12 at 8:15 a.m. R4 was walking down the hallway with E21 (Respiratory Therapist), with the opening to his trachea, mouth and nose uncovered. R4 touched the opening to his trachea multiple times and then touched the handrail and the counter at the Nurses Station. While standing at the Nurses Station, E21 wiped eye secretions from R4's face with her bare hand and did not perform handwashing. E21 then walked R4 back to his room, went to the kitchen to obtain a sugar packet and gave that sugar packet to another resident. At 9:22 a.m., R4 had a mask on his trachea opening while sitting in his private room. E21 was sitting next to R4, when R4 started to take the mask off of the trachea opening. E21 told R4, if he removed his mask, she would need to put a mask on herself. On 3/08/12 at 12:55 p.m., R4 was being pushed in a wheelchair up and down the hallway by Z2 (Family). R4 did not have a mask covering the opening to his trachea or his mouth and nose. At 2:05 p.m., Z2 stated he frequently takes R4 for walks throughout and outside the building. Z2 stated R4's trachea opening is usually not covered, "because he's (R4) picky and doesn't like to wear a mask." Z2 stated staff have not discussed with him under which circumstances R4's airways are to be covered. On 3/08/12 at 1:15 p.m., E2 (Director of Nursing) stated R4 does like to wander the facility and trade books with people. E2 stated "they have discussed" the fact that R4 is out among the general population with an open airway and MRSA infection, but R4 wouldn't "tolerate a mask on his face." E2 further sated, "He (R4) is a problem. The only other choice they would have is to put him in a four point restraint." E2 confirmed that the facility currently had 25 residents that would be considered immunocompromised due to their medical condition (R5, R6, R7, R16, R17, R25, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39, R40, R41, R42, R43, R44, R45). On 3/13/12 at 9:30 a.m., E5 (Infection Control Coordinator) stated R4 has been on isolation for MRSA since he was admitted in June 2011. E5 stated R4 initially stayed in his room most of the time. E5 stated R4 eventually became more likely to leave his room and staff would just have R4 cover the opening to his trachea. E5 stated the facility failed to address the fact that R4 was out amongst the general population and MRSA positive. E5 stated R4 does not have the cognitive ability to understand the importance of handwashing or covering his airway. E5 stated she has been the Infection Control Coordinator for the last six years and has never had any special training on Infection Control Prevention/Interventions. E5 stated she had not stayed current with what the CDC (Centers for Disease Control) recommends for infection control in the Long Term Care Setting. On 3/12/11 at 11:07 a.m., Z1 (Infectious Disease Physician) stated, his recommendations regarding R4 would be that the facility "control respiratory secretions as much as possible, with either a mask or room isolation, and use diligent handwashing." On 3/08/12 an Immediate Jeopardy was identified to have begun on 03/06/12 when staff failed to ensure R4's airway was covered while he was out amongst the general population. E1, Administrator, was informed of the Immediate Jeopardy on 3/08/12 at 3:00 p.m. The surveyor confirmed through observation, interview and record review that the facility took the following action to remove the Immediate Jeopardy: 1. Z2 (Family) was immediately educated on isolation procedures for MRSA, on 3/08/12. Z2 was advised on gown and glove use and handwashing procedures. 2. On 3/08/12, R4 was immediately placed on continuous 1:1 supervision to ensure mask use when outside of his room and compliance with routine handwashing. 3. On 3/08/12, facility equipment and handrails that R4 could have potentially come into contact with were cleaned with appropriate disinfectant. 4. On 3/08/12, all employees were counseled and educated on the different types of isolation, isolation precaution policies and procedures, MDRO's (Multiple Drug Resistant Organisms), transmission based precautions, use of Personal Protective Equipment, equipment cleaning, isolation garbage disposal, and where to locate current resident isolation intervention information. This inservicing was mandatory for all staff. 5. On 3/09/12, E25 (Licensed Practical Nurse) was made acting Infection Control Nurse. E25 was educated on Infection Control Management and how to conduct the Infection Control Program, including: Facility Infection Control Policies and Procedures, Infection Tracking and Surveillance, Data Analysis, Action Plans, Quality Assurance Tools, infection rounds, Employee Infection Tracking, Types of Isolation, tracking results of cultures, communicating infections and isolation information to all Departments, Personal Protective Equipment, isolation waste, and equipment disinfection. The training was conducted by E23 (Senior Administrator) and E26 (Registered Nurse). E25 is to directly report to E1, E2, and the Medical Director and have a monthly Infection Control Committee Meeting. 6. On 3/08/12, staff in the Housekeeping, Laundry and Dietary Departments were trained on environmental and dietary measures to prevent and manage infections, with emphasis on care of residents with MDRO's. 7. A Quality Assurance Tool will be completed daily to ensure compliance with infection control management and prevention, starting 3/09/12. B. Based on observation, record review and interview, the facility failed to ensure proper personal protective equipment was worn by staff when providing cares, failed to ensure the dedication of non-critical medical equipment (gait belt), and failed to properly disinfect multi-resident use equipment for residents on Isolation Precautions for a MRSA infection, for four of seven (R17, R14, R16 and R11) residents reviewed on Isolation Precautions, in a sample of 23 and one additional resident (R23) in the supplemental sample. Findings include: 1. An Admission Summary, dated 1/18/12, documents R17 has the current [DIAGNOSES REDACTED]. A Plan of Care, dated 12/19/11, documents R17 is on Isolation for MRSA of the nares. Microbiology reports, dated 12/14/11 and 2/14/12, document R17 as positive for a MRSA infection in the gastrostomy tube site. On 3/06/12 at 9:10 a.m., while touring the facility, the door to R17's room had a sign, which indicated "everyone who enters must wear gloves" and "wear a gown if contraindication is possible." On 3/08/12, at 11:30 a.m., E9 (Respiratory Therapy Nurse) was wearing only gloves and verified the placement of R17's gastrostomy tube and administered medication and water through the gastrostomy tube, while leaning against the resident's bed and sheets. E9 lifted R17's gown to observe the gastrostomy tube insertion site, which was open to air. E9 stated R17 had a MRSA infection of the nares and a drug resistant proteus of the urine and a gown was not necessary when handling R17's gastrostomy tube, because the infection was contained. The facility Policy and Procedure, titled "Universal Precautions/Infection Control", indicates for "Contact Precautions" that staff are to "(4.) Wear a gown when entering the room if contamination is at all possible" and "(6.) Dedicate the use of personal, noncritical medical equipment to a single patient." The facility Policy and Procedure, titled "Infection Control - Equipment and Supplies Used During Isolation Policy", indicates "(4.) Nursing Services will notify environmental services staff regarding equipment that needs sanitizing after use in the care of an individual with isolation precautions" and "(6.) Environmental services staff or designee shall be responsible for cleaning and sanitizing such equipment before it is returned to Central Supply or to designated storage areas." 2. A physician's orders [REDACTED]. A facility Universal Precautions/Infection Control Policy dated 7-15-02, indicates that residents with MRSA, VRE, or clostridium difficile (C-Dif) infections be placed in contact isolation. The facility policy also indicates that anyone entering a contact isolation room must wear gloves "upon entrance to the room and at all times" and to wear an isolation gown "when entering the room if contamination is at all possible." On 3-06-12 at 12:55 p.m. E6 (CNA) and E7 (CNA) applied gloves and entered R14's room to transfer R14 from the wheelchair to the bed and to provide R14 with incontinence care. Neither E6 or E7 (CNAs) wore isolation gowns while providing incontinence care to R14 or while touching R14's soiled linens. On 3-06-12 at 3:15 p.m., E13 (CNA) and E14 (CNA) entered R14's room after applying only gloves then provided R14 with incontinence care. E13 and E14 then lifted R14 from the bed using a mechanical lift device and transported him into the hall onto shower stretcher. E13 and E14 left the mechanical lift in the hall outside of R14's room without sanitizing it. E13 stated that R14 is "only in contact isolation and gowns don't need to be worn." On 3-06-12 at 3:30 p.m. E14 transported R14 by stretcher to the "Redwood" shower room. E14 removed R14's gown and placed it on a second bath stretcher located in the shower room. E14 stated that she was going to place R14's gown into one of the soiled linen barrels in the shower room but did not indicate the gown would be doubled bagged or separated from the non isolation soiled linen. On 3-08-12 at 2:15 p.m. E18 (Housekeeping Supervisor) stated that the staff are suppose to keep isolation linens separate from regular soiled linens by putting the isolation linens in a double bag before placing them in a biohazard (red) barrel. 3. A physician's orders [REDACTED]. On 3-08-12 at 1:30p.m., R16 had an isolation sign posted on the door frame of R16's room but R16 did not have isolation supplies readily available outside the room. E15 (CNA) entered R16's room without wearing gloves or a gown and raised R16's bed rail. E15 then walked out of R16's room without washing her hands and stated that she did not know what kind of isolation R16 was in. On 3-08-12 at 1:40p.m. E15 and E16(CNA) transferred R16 from the wheelchair to the bed using a mechanical lift. E16 removed the mechanical lift from R16's room and without first sanitizing the mechanical lift and placed it into another resident's room. E16 stated that he did not know under what circumstances the mechanical lift should be cleaned, stating, " I don't know, I just pushed it here." On 3-07-12 at 11:00 a.m. E2 (Director of Nursing) stated that "contact isolation does not necessarily mean that staff need to wear gowns when entering an isolation room unless the staff member is sure they will get contaminated." E2 also stated that staff would not necessarily wear a gown in a resident's room who has MRSA or VRE in the urine even if staff are performing incontinence care unless there was urine "spilled all over the floor." E2 also stated that even though the facility policy indicates to "wear a gown when entering the room if contamination is at all possible," that "still means," that staff " don't necessarily need a gown for incontinence care for residents with MRSA in their urine." 4. On 3-9-12 at 2:00 pm R23 was in bed and incontinent of stool. E11 and E22 (CNAs/Certified Nursing Assistants) starting cleaning R23. While cleaning R23's stool, E11 ran out of washcloths, went to the door of R23's room and opened the door placing her dirty gloved hand on the door latch to ask someone for more linens. E11 and E22 finished cleaning R23 and transferred him with E11's gait belt from the bed to the wheelchair. E11 then removed her gait belt from around R23's chest and put it back on her own waist, finished in the room, washing her hands and then leaving the room. R23's care plan dated 2-19-12 states R23 has MRSA (Methicillin Resistant Staphylococcus Aureus) of the gastrostomy tube ([DEVICE]). R23's care plan states to "follow facility isolation protocol." On 3-9-12 at 2:10 pm, E11 (CNA) stated she didn't realize she had touched the door handle with her dirty gloved hand. E11 also stated the staff use their own gait belts to transfer R23 instead of keeping one in the room for transfers. At 2:20 pm, E11 stated she talked with E2 (Director of Nursing) and was instructed to place a gait belt dedicated to R23's room to use for transfers. E11 also stated they cleaned the door handle to R23's room. 5. The sputum culture laboratory report for R11 dated 11/04/11 documents the following: "Moderate growth of MRSA (Methicillin Resistant Staph Aureus)". Facility policy on Contact Isolation (undated) documents that contact isolation precautions include wearing gloves upon entering the room and to wear gowns if physical contact with the resident will occur. On 03/06/12 at 9:30AM R11 was sitting in the room in the wheelchair. R11 was wearing a face mask. There was no isolation set up outside R11's room. On 03/07/12 at 10:00AM E2 (DON/Director of Nursing) stated. "Oh, there isn't an isolation set up outside (R11's) door? There should be one there, so the staff can put on the right protective equipment." 6. On 3-7-12 at 2:40 pm, E5 (Infection Control Coordinator) described the infection control program as follows: E5 gets a house report of who has started on antibiotics and logs those residents. E5 also gets a monthly log from the pharmacy for antibiotic use. E5 then attempts to determine what organism causes the infection. When asked how she monitors for trends or clusters, E5 stated she looks back from year to year. E5 verified there are 11 residents on her isolation log for 3-6-12. The facility provided a log for 2011 that listed only the number of nosocomial infections, urinary tract infections and upper respiratory infections by month. There is no indication of what organisms or other form of infections have been in the facility. E5 stated she does not track employee illness or have knowledge that employee illnesses are being tracked in the facility. E5 (Infection Control Coordinator) stated she has been in charge of the infection control program for approximately six years. E5 stated she has only recently started attending quality assurance meetings and has attended only two. E5 stated she takes her wound and infection reports to the meetings but states they have not really discussed anything related to infection control. On 3-9-12 at 11:00 am, E2 (DON/Director of Nursing) stated that when staff call in with an illness, the Department heads take the information and then E2 logs it on a form. E2 stated she does not necessarily share/correlate this information with E5 (Infection Control Coordinator). (A)