Every finding on record at Loft Rehab & Nursing of Canton

Based on observation, interview, and record review, the facility failed to prevent a burn injury caused by a homemade hot pack application for one (R1) of 14 residents reviewed for incidents and accidents. This failure resulted in R1 sustaining a blister thermal burn to R1's left outer knee requiring medical treatment. Findings include: R1's medical record documents in part that R1 was admitted to the facility on [DATE] with diagnoses including COPD (Chronic Obstructive Pulmonary Disease); Mild Protein-Calorie Malnutrition; Type 2 Diabetes Mellitus; Hereditary and Idiopathic Neuropathy, and on 2/16/26 additional diagnoses of Multiple Fracture of Ribs, Bilateral Sequela and Acute Respiratory Failure. R1's medical record documents R1 has mild cognitive issues with a BIMS/Brief Interview for Mental Status score of 11 of 15. R1's medical record documents R1 had bilateral knee discomfort and complained of pain to his left knee area following a fall on 12/08/25. A Nursing Progress Note by V3 (Wound Nurse/ADON/Assistant Director of Nursing) dated 12/09/25 at 10:38 am documents: Resident (R1) has a water blister to left outer knee new tx (treatment) orders obtained and V16 (Medical Director/R1's physician) notified. V3's Nursing Progress Note dated 12/17/25 documents the following: New tx (treatment) orders - will have wound md (doctor) evaluate and treat left outer knee wound with next rounding, resident aware and son aware. The facility's Wound Log entry dated 12/09/25 documents R1 developed a blister/burn to R1's left outer knee measuring 3.5cm/centimeters long by 3 cm wide. R1's medical record includes Wound Physicians Notes (V14) dated 12/23/25 through 1/6/26. V14's Initial Wound Evaluation and Management Summary dated 12/23/25 documents V14 identified a Burn Wound of Left, Lateral Knee Full Thickness with duration of the wound documented as greater than 7 days and measuring 3.5 cm/centimeters in length by 3.0 cm wide with depth of the wound not measurable. This note also documents: (R1) was using a heating pad due to the knee pain and suffered thermal burn. On 3/13/26 at 12:30pm R1 stated he had a burn on his left leg caused by a hot pack a couple months ago. R1 stated after the hot pack was in place to his outer knee, It was burning, but I thought it was helping the pain in my knee. On 3/13/26 at 1:45pm V1 (Administrator) verified homemade hot packs should never be used and CNAs are not allowed to use any type of heat application for residents. V1 stated a physician's order is required and heat packs should be applied by Licensed Nursing staff or Physical Therapy and monitored. V1 stated, on 1/20/26, R1 identified V12 (Certified Nursing Assistant/CNA) as the staff member who applied the hot pack causing the burn. On 3/17/26 at 6:50am V14 (the facility's contracted Wound Care Physician) stated he was not aware R1's left lateral knee burn was caused by a homemade hot pack applied by a staff member to the area. V14 stated homemade hot packs should never be used. There are specific products available for safe heat application to the skin. V14 added these heating packs are applied only with a physician's order and by licensed Nursing staff only. On 3/17/26 at 9:07am V3 (Wound Nurse/ADON) stated, a CNA reported to V3, on 12/09/25, she found a blister on R1's left knee. V3 stated she immediately assessed the wound and notified the physician for orders. V3 stated she assumed the blister formed due to the severe edema inflicting R1's lower extremities. V3 stated there was no report of a hot pack application to the area and R1 stated he did not know how the injury came about. V3 stated she treated the blister wound a naturally formed fluid-filled blister due to collection of excess fluid in R1's lower leg. V3 stated she became aware of the cause of the blister when R1 told V14 of the hot pack application by an unknown Certified Nursing Assistant. On 3/17/26 at 10:45am R1 was lying in bed, R1 denied any discomfort and denied having any issues with the residual scarring present from the burn. R1 showed this surveyor the healed burn area on his left lateral lower thigh/knee area. The area was approximately 3 cm Long by 3 cm wide, with intact light purple scarring surrounded by dry skin. On 3/17/26 at 1:48pm V12 (CNA) stated she had been making and applying homemade hot packs for R1 when he asked for one. V12 stated she made the hot packs by pouring hot water from the coffee maker onto 2 washcloths and adding some cold water, sealing the hot pack inside a plastic biohazard bag, wrapping it in one or two pillowcases and placing on R1's skin where he indicated discomfort. V12 stated she was unaware CNAs were not allowed to apply hot packs to residents before being educated by facility administration when R1's burn was identified. The facility was unable to provide a policy or procedure addressing resident heat application. The facility's Certified Nursing Assistant job description dated 6/2021 documents CNA job functions include Report all complaints and grievances made by the resident and Use only the equipment you have been trained to use.

Based on interview and record review the facility failed to ensure a resident's anticoagulant therapy was maintained related to a diagnosis of Atrial Fibrillation, obtain a valid physician order prior to discontinuing the medication, and document clinical justification to discontinue a residents anticoagulant therapy for one of three residents (R1) reviewed for quality of care in a sample of three. These failures resulted in (R1) who was at high risk for thromboembolic (blood clots that form in one location and travel to another location, potentially blocking blood flow) events, experienced complications from a suspected complication of Acute Cerebrovascular Accident due to Cerebrovascular Disease and passed away after Xarelto was discontinued for 75 days without physician authorization or documented clinical justification.Findings include: R1's admission Record, dated [DATE], documents R1 was admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Chronic Obstructive Pulmonary Disease, Alzheimer's Disease, and Chronic Atrial Fibrillation. R1's Order Summary Report, dated [DATE], documents an order for Xarelto (blood thinning medication) 15mg (milligrams) on [DATE] to be taken once daily. R1's Order Summary Report, dated [DATE], documents V1 (Administrator) received a verbal order on [DATE] from V13 (Hospice Physician) to discontinue R1's Xarelto. R1's Clinical Census documents R1 started receiving Hospice Services on [DATE]. R1's Plan of Care with a review date of [DATE] documents, (R1) is on anticoagulant therapy related to Chronic Atrial Fibrillation. Administer anticoagulant medications as ordered by physician. Monitor for side effects and effectiveness every shift. This same plan of care documents (R1) has a personal history of cerebral infarction. Give Medications as ordered by physician. Monitor/document side effects and effectiveness. R1's Progress Note, dated [DATE] and signed by V12 (Licensed Practical Nurse) documents R1 passed away on [DATE] at 8:01 PM. R1's Certificate of Death, dated [DATE], documents date of death : [DATE]. Cause of Death: Complications from Suspected Acute Cerebrovascular Accident due to Cerebrovascular Disease. Xarelto's Warning Label, dated 3/2020, documents Warning: (A) Premature discontinuation of Xarelto increases the risk of thrombotic events. To reduce this risk, consider coverage with another anticoagulant if Xarelto is discontinued for a reason other than pathological bleeding or completion of a course of therapy. Indications and Usage: XARELTO is indicated to reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. R1's entire Clinical Medical Record (including Hospice Medical Record) does not include evidence of a documented clinical justification of why R1's Xarelto was discontinued. There is also no evidence in R1's Clinical Medical Record of a Physician giving the order to discontinue R1's Xarelto medication or signing an order to discontinue R1's Xarelto medication. On [DATE] at 9:28 AM V5 (R1's Power of Attorney) stated at some point (R1) was taken off her blood thinner (Xarelto). I was not aware of this until I requested (R1's) medical records (after R1 expired) and did not see Xarelto on her medication list. I could not see where a physician discontinued her Xarelto but noticed (R1) had quit receiving at some point during her stay. I am very upset (R1) wasn't receiving her Xarelto throughout (R1's) entire stay because (R1) had Atrial Fibrillation and was at high risk for strokes. I would not have wanted (R1's) Xarelto to be discontinued and the facility and hospice were aware of that. On [DATE] at 10:48 AM V14 (Registered Nurse/Owner of Hospice) stated, We (hospice) send all current orders to the facility for each resident on our hospice. (V5 R1's Power of Attorney) called me after (R1) had passed away asking why (R1's) Xarelto had been discontinued. Our orders for (R1) did not show (R1's) Xarelto had been discontinued, nor do I have any signed order by a hospice physician or hospice nurse practitioner discontinuing (R1's) Xarelto. V14 verified there is no clinical justification to discontinue R1's Xarelto in R1's hospice medical records because they (hospice) still had the order as active. On [DATE] at 2:35 PM V9 (R1's Primary Physician) stated she did not authorize for R1's Xarelto to be discontinued. On [DATE] at 5:51 PM V8 (Hospice Nurse Practitioner) I do not recall giving (V1 Administrator) an order to discontinue (R1's) Xarelto. I would not have discontinued (R1's) Xarelto without discussing it with (V5 R1's Power of Attorney or V6 R1's spouse) and (V13 Hospice Physician). On [DATE] at 11:40 AM V2 (Director of Nursing) stated she responsible for medication oversight and hospice coordination. V2 stated, if a high-risk medication is being discontinued it would be my expectation for the nurse receiving the order or discontinuing the order to document the clinical justification to discontinue the medication. V2 verified at this time that she did not see clinical justification in R1's medical record after the discontinuation of R1's Xarelto on [DATE]. On [DATE] at 1:09 PM V13 (Hospice Physician) stated, I know Xarelto was on (R1's) medication list when admitting to hospice. I was not notified (R1's) Xarelto was discontinued. I am not aware of anyone from my hospice team giving the order to discontinue (R1's) Xarelto. I never gave the order. V13 stated R1's falls were discussed but she does not remember discontinuing the Xarelto in relation to the falls. V13 stated, I do believe there is a communication gap with the facility, I know that medication reconciliation is an issue and has been an issue. (R1) was at high risk for thromboembolic events due to (R1) having Atrial Fibrillation, a history of lung cancer, being sedentary in her lifestyle, and being over the age of 75. It was possible a stroke contributed to (R1's) death and Xarelto could have prevented the stroke form occurring. On [DATE] at 1:32 PM V1 (Administrator) stated, I am the one who entered the verbal order to discontinue (R1's) Xarelto on [DATE]. I received a verbal order from (V8 Hospice Nurse Practitioner) on [DATE] but wrote the order from (V13 Hospice Physician). I did not document why the Xarelto was discontinued anywhere in (R1's) medical record. V1 verified a clinical justification of discontinuing R1's medications should have been documented in R1's medical record and wasn't. On [DATE] at 1:49 PM V14 (Medical Records) stated she oversees physician telephone orders and verbal get signed by the ordering Physician. V14 verified R1's verbal order to discontinue R1's Xarelto on [DATE] has not been signed by a physician.

Based on interview and record review the facility failed to notify a resident's representative of a significant change of medication regimen for one of three residents (R1) reviewed for notification of change in a sample of three. Findings include:The facility's Notification of Changes Policy dated 2/10/25, documents Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member of legal representative when there is a change requires such notification. Circumstances requires notification of change include: 3. Circumstances that require a need to alter treatment. This may include b. Discontinuation of current treatment due to i. Adverse consequences. ii. Acute Condition. Iii. Exacerbation of a chronic condition. 2. Residents incapable of making decisions: a. the Representative would make any decisions that have to be made. b. The resident should still be told what is happening to him or her.R1's admission Record dated 8/4/25, documents R1 was admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Chronic Obstructive Pulmonary Disease, Alzheimer's Disease, and Chronic Atrial Fibrillation.R1's Order Audit Report dated 8/4/25, documents R1's Xarelto (blood thinner) 15mg (milligram) tablet daily was discontinued on 3/31/25.R1's entire Clinical Record does not document evidence of R1 or V5 (R1's Power of Attorney) being notified of R1's Xarelto being discontinued.On 8/4/25 at 9:28 AM V5 (R1's Power of Attorney) stated, I was never notified (R1's) Xarelto was discontinued. I am very upset about this, because I feel like (R1) needed to be on the Xarelto due to (R1) having Atrial Fibrillation.On 8/4/25 at 5:51 PM V8 (Hospice Nurse Practitioner) stated I do not recall giving (V1 Administrator) an order to discontinue (R1's) Xarelto. I would not have discontinued (R1's) Xarelto without discussing it with (V5 R1's Power of Attorney or V6 R1's spouse) and (V13 Hospice Physician). I did not notify (V5) or (V6) of (R1's) Xarelto being discontinued because I wasn't aware it was discontinued.On 8/5/25 at 7:47 AM V6 (R1's Spouse) stated he was at the facility everyday with R1 and was involved in her care. V6 stated he was never made aware that R1's Xarelto was discontinued.On 8/5/15 at 11:40 AM V2 (Director of Nursing) stated if a medication has been discontinued then the resident and the resident's representative should be notified. If the resident is on hospice and the order is from hospice, then hospice would be the ones who would notify the family.On 8/5/25 at 1:32 PM V1 (Administrator) stated, I am the one who entered the verbal order to discontinue (R1's) Xarelto on 3/31/25. I received a verbal order from (V8 Hospice Nurse Practitioner) on 3/31/25 but wrote the order from (V13 Hospice Physician). I did not notify (R1), (V5 R1's Power of Attorney) or (V6 R1's Spouse) when I wrote the verbal order to discontinue R1's Xarelto on 3/31/25. Hospice should have been the ones to notify (R1) and (V5). V1 verified at this time that R1's medical record does not include documentation of R1 or V5 being notified of R1's Xarelto being discontinued.

Based on interview and record review the facility failed to ensure the resident's representative was involved with the interdisciplinary team quarterly to review and revise a resident's care plan for one of three residents (R1) reviewed for care plans in a sample of three. Findings include: R1's Care Plan Sign in Sheet, dated 5/13/25, only documents V4's (Social Service Director) signature as attending R1's care plan meeting held on 5/13/25. R1's IDT (Interdisciplinary) Care Plan Care Conference, dated 5/13/25, documents V4 (Social Service Director), R1, V6 (R1's Spouse), and V7 (R1's Family Member) attended the care conference. This same Care Conference documents (R1) had her care plan today, (V6 R1's Spouse) and her son (identified as V7 R1's Family Member) attended. Due to no other department managers being available for the care plan the family would like it rescheduled for about a month with all department managers. On 8/4/25 at 9:28 AM V5 (R1's Power of Attorney) stated (R1) admitted to the facility on [DATE]. We (the family) had a big meeting with the interdisciplinary staff on 2/18/25. During that meeting it was told to us that they schedule meetings every three months with the family to go over (R1's) progress or (R1's) care in general. The facility scheduled a meeting sometime in May and the only person from the facility that attended (R1's) care plan meeting was (V4 Social Service Director), not the whole team as promised. (V6 R1's Spouse) and (V7 R1's Family Member) were there for the meeting and ready to discuss where (R1's) care was at and how she was doing. On 8/5/25 at 7:47 AM V6 (R1's Spouse) stated I showed up to the care plan meeting on 5/13/25 with (V7 R1's Family member) to discuss (R1's) care. I had many concerns I wanted to go over with (R1's) care that I wanted different departments to answer to. When (V7) and I arrived at this meeting, the only person that was in attendance was (V4 Social Service Director). (V7) and I both voiced concerns regarding (V4) being the only one at the care plan meeting, when there were other issues in other departments that needed address to have a better plan in place for (R1's) care. (V4) told us the other departments she invited to the care plan meeting told her they were unable to attend that morning, so that is why it was just (V4). (V4) told us we would have to reschedule a care plan meeting for (R1) if we wanted more than just her in the meeting. I don't feel like that is right when we were promised to have meeting to discuss (R1's) care at least every three months with a team of people. On 8/4/25 at 11:15 AM V4 (Social Service Director) stated she is the one in charge of scheduling care plan meetings and conducting the care plan meetings with the residents, family members, and members of the interdisciplinary team including, Activities, Nursing, Dietary, and Therapy (if resident is on therapy). V4 stated when a resident arrives to the facility she will schedule an initial care plan meeting with the interdisciplinary team, the resident, and family and then schedule them quarterly after that to keep everyone on the same page. V4 stated, I set up (R1's) quarterly care plan meeting for 5/13/25 with (R1), (V6 R1's Spouse), and (V7 R1's Family Member.) (V5 R1's Power of Attorney) could not make the meeting because he lives out of state. When (V6) and (V7) arrived at the facility for (R1's) care plan meeting, I was the only available person to attend (R1's) care plan meeting from the facility. No other department was able to attend. (V6) stated he wanted everyone to be at the care plan meeting because he wanted to discuss (R1's) overall care, so I told (V6) we would have to reschedule the care plan meeting. I email all departments that are supposed to attend the care plan meetings every Monday for the scheduled resident's care plan meetings of the week. If someone out of the department cannot attend, they should make me aware as soon as possible so I can let the family and resident know ahead of time or we (the facility) can figure out someone else out of that department to attend. Whoever attends would sign the sign in sheet and the sign in sheets are accurate. V4 stated the care plan meeting was rescheduled for 6/17/25 but was never conducted because R1 passed away on 6/13/25. On 8/4/25 at 2:12 PM V3 (Vice President of Clinical Services) stated a care conference should be scheduled with the resident and (if available) the resident's representative at least every three months. The care conferences should consist of the Dietary Manager, MDS (Minimum Data Set) Coordinator, a facility Nurse, Social Services, Activities, the resident, and (if available) the resident's representative to discuss a resident's plan of care as a group and to ensure the resident's needs are being met. On 8/5/25 9:50 AM V15 (Dietary Manager) stated I get notified weekly by email of the resident care plan meetings schedule for that week. I sometimes must work in the kitchen if we have a call in or I may be ill so I can't always make the care plan meetings. I would sign the residents care plan conference sign in sheet if I attended the meeting. On 8/5/25 at 9:54 AM V10 (MDS Coordinator) stated I am the nurse they want going to the residents scheduled care plan meetings. I get notified via emails on Mondays of that week's care plan conferences for residents. I attend sometimes, but sometimes I forget to go in. I started in April 2025. I get sidetracked plugging away on MDS's. I should be going to the meetings. If I attend a meeting I would have signed the sign in sheet for that resident's care plan meeting.

Based on interview and record review, the facility failed to ensure coordination of care and communication between the facility and hospice provider for one of one resident reviewed for hospice services in a sample of three. Findings include:The facility's Agreement with Hospice Care, dated and signed [DATE], documents Coordination of Services: Hospice Provider and Facility have agreed to participate in a system of communication as described in Hospice Provider's policies and procedures to: 1. Ensure the Hospice Provider's IDG (Interdisciplinary Group) maintains responsibility for directing, coordinating, and supervising the care and services provided. 1. Ensure that the care and services are provided in accordance with Hospice Provider Plan of Care. 1. Ensure that the care and services provided are based on assessment of the Hospice Patient and family needs. 1. Provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. 1. Provide for an ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. 7. Coordination of Services for Hospice Residents. For Hospice Residents, Hospice Provider shall further coordinate services by: 1. Designating specific member of the hospice Provider IDG that will be responsible for a Hospice Resident. The designated Hospice Provider IDG member is responsible for: 1. Overall coordination of Hospice Care of the Hospice Resident with the Facility representatives. 1. Overall coordination of Hospice Care for the Resident with the Facility Representative. 1.Communicating with Facility representatives and other health care providers participating I the provision of care for the Terminal Illness and related conditions to ensure quality of care. 1. Hospice Provider must ensure that the Hospice Provider IDG communicates with the Medical Director of the Facility, the Attending Physician, and other physicians participating in the provision of care to the Hospice Resident as needed to coordinate the Hospice Care with medical care provided by other physicians.The facility's Coordination of Hospice Services, dated [DATE], documents Policy: When a resident chooses to receive hospice care and services, the facility will coordinate and provide care in cooperation with hospice staff in order to promote the resident's highest practical physical, mental, and psychosocial well-being. Policy Explanation and Compliance Guidelines. 2. The facility and hospice provider will coordinate a plan of care and will implement interventions in accordance with the resident's needs, goals, and recognized standards of practice in consultation with the resident's attending physician/practitioner and resident' representative, to the extent possible.R1's Clinical Census documents R1 started receiving Hospice Services on [DATE]. This same Census documents R1 expired on [DATE] in house.On [DATE] at 2:35 PM V9 (R1's Primary Physician) stated she did not authorize for R1's Xarelto to be discontinued and was not aware of R1's Xarelto being discontinued. I noticed while reviewed (R1's) medical records on [DATE], (R1) had medication changes including the Xarelto medication being discontinued. Hospice has not collaborated with me at all. My expectation is to be involved in my patient's medication changes while on hospice including (R1's) medication changes, that just didn't happen. On [DATE] at 5:51 PM V8 (Hospice Nurse Practitioner) stated I do not recall giving (V1 Administrator) an order to discontinue (R1's) Xarelto. I would not have discontinued (R1's) Xarelto without discussing it with (V5 R1's Power of Attorney or V6 R1's spouse) and (V13 Hospice Physician). I did not notify (V5) or (V6) of (R1's) Xarelto being discontinued because I wasn't aware it was discontinued. When I would arrive to the facility for a visit, I would get in our hospice binder that the facility should be using for communication, and the orders would be missing or not put in there or the care plan would be gone. I would take notes to put in the binder myself and then the next time I arrived at the facility they would be gone. I tried to get a printout of our medication list and match it with the facility's and let them know if there was a discrepancy, but next time I would come in, it still wouldn't be fixed.On [DATE] at 7:47 AM V6 (R1's Spouse) stated he was at the facility everyday with R1 and was involved in her care. V6 stated he was never made aware that R1's Xarelto was discontinued. V6 stated, I just felt like the facility and Hospice were never on the same page. I am not sure where the gap is, but I just want to save someone else from having to go through what we went through with (R1) with communication between the facility and hospice. Neither one could tell us who was supposed to notify us of changes or why the Xarelto was discontinued.On [DATE] at 1:09 PM Interview with V13 (Hospice Physician) stated, I never met (R1) personally. I know Xarelto was on (R1's) medication list when admitting to hospice. When we (Hospice) go through resident's medications during admission, we try to minimize what medications they are on. Usually, the only reason I keep patients on Xarelto is based on family wishes. We always explain the risks and benefits. I was not notified (R1's) Xarelto was discontinued. I am not aware of anyone from my hospice team giving the order to discontinue (R1's) Xarelto. I never gave the order. I do believe there is a communication gap with the facility, I know that medication reconciliation is an issue and has been an issue. We (hospice) have our own medical records, and the facility has their own medical records for the residents. We (hospice) have a hard time getting updates or finding records at the facility or trying to ensure our records are consistent with the facility. When our nursing team goes to the facility they try to reconcile what we are given with what they are on at facility, but they had a hard time getting facility records.On [DATE] at 1:32 PM V1 (Administrator) stated, We (the facility) and the Hospice Company have had a hard time with communication since they had started coming to our building. They are a new company that we started working with. We were having major issues with medication reconciliation and being on the same page, that's why I ended up getting involved with the orders at the end of [DATE]. I am the one who entered the verbal order to discontinue (R1's) Xarelto on [DATE]. I received a verbal order from (V8 Hospice Nurse Practitioner) on [DATE] but wrote the order from (V13 Hospice Physician). I did not document why the Xarelto was discontinued anywhere in (R1's) medical record. I did not notify (R1), (V5 R1's Power of Attorney) or (V6 R1's Spouse) when I wrote the verbal order to discontinue (R1's) Xarelto on [DATE]. Hospice should have been the ones to notify (R1), (V5), and (V9 R1's Primary Physician).

Based on record review and interview the facility failed to implement Infection Prevention and Control Practices after residents were subjected to direct contact from a staff member who tested positive for COVID-19 (Coronavirus 2019) and after residents exhibited symptoms of COVID-19. These failures have the potential to affect all 67 residents residing within the facility. Findings include: The facility's Daily Census Report dated 1-21-25 documents 67 residents currently reside within the facility. The facility's COVID-19 (Coronavirus 2019) Prevention, Response, and Reporting policy dated 10-1-24 documents, It is the policy of this facility to ensure that appropriate interventions are implemented to prevent the spread of COVID-19 and promptly respond to any suspected or confirmed COVID-19 infections. COVID-19 information will be reported through the proper channels as per federal, state, and/or local health authority guidance. Staff will alert to signs of COVID-19 and notify the resident's physician/practitioner if evident fever/chills, cough, shortness of breath/difficulty breathing, fatigue, muscle or body aches, headache, loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and diarrhea. The facility will establish a process to identify and manage individuals with suspected or confirmed SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) infection to include: a. Ensuring that everyone is aware of the recommended IPC (Infection Prevention and Control) practices in the facility by posting visual alerts at the entrance and in strategic placed to include instructions about current IPC recommendations. b. Establishing a process to make everyone entering the facility aware of recommended actions to prevent transmission to others if they have any of the following three criteria: i. A positive viral test for SARS-CoV-2. ii. Symptoms of COVID-19. iii. Close contact with someone with SARS-CoV-2 infections for residents and visitors or a higher-risk exposure for healthcare personnel. 5. The facility will instruct healthcare personnel to report any of the three above criteria to the Infection Preventionist or designee for proper management. 6. The facility will provide guidance about recommended actions for residents and visitor who have any of the above three criteria. Source control is recommended for individuals in healthcare settings who have suspected or confirms SARS-CoV-2 infection or other respiratory infections or had close contact or a higher-risk exposure with someone with SARS-CoV-2 infections, for 10 days after their exposure. Source control is recommended more broadly in fete following circumstances: i. By residing or working on a unit or area of the facility experiencing a SARS-CoV-2 or other outbreak of respiratory infection; universal use of source control could be discontinued as a mitigation once the outbreak is over. 13. The facility will perform viral testing for SARS-CoV-2 as per national standards such as CDC (Center for Disease Control and Prevention) recommendations. 14. IPC practices when caring for residents with suspected or confirmed SARS-CoV-2 infection: These recommendations below also apply to resident with symptoms of COVID-19 and asymptomatic residents who have met the criteria for empiric Transmission-Based Precautions based on close contact with someone with SARS-CoV-2 infections. These residents, however, should not be cohorted with residents with confirmed SARS-CoV-2 infection unless they are confirmed to have SARS-CoV-2 infection through testing. The facility will decide to discontinue empiric transmission-based precautions for symptomatic residents being evaluated for SARS-CoV-2 infections based upon having negative results from at least one viral test. If the suspected resident is never tested , the decision to discontinue transmission-based precautions can be made based on time from symptom onset. 27. Responding to a newly identified SARS-CoV-2 infected healthcare personnel or resident: a. The facility should defer to the recommendations of the jurisdiction's public health authority when performing an outbreak response to a known case. b. A single new case of SARS-CoV-2 infection in any healthcare personnel or resident should be evaluated to determine if others in the facility could have been exposed. c. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based approach is preferred if all potential contact cannot be identified or managed with contact tracing or if contact tracing failed to halt transmission. d. Perform testing for all residents and healthcare personnel identified as close contacts or on the affected unit (s) if using a broad-based approach, regardless of vaccination status. The CDC Infection Control Guidance: SARS-CoV-2Perform SARS-CoV-2 Viral Testing dated 6-24-24 documents, Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible. Asymptomatic patients with close contact with someone with SARS-CoV-2 infection should have a series of three viral tests for SARS-CoV-2 infection. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Healthcare facilities should have a plan for how SARS-CoV-2 exposures in a healthcare facility will be investigated and managed and how contact tracing will be performed. If healthcare-associated transmission is suspected or identified, facilities might consider expanded testing of HCP and patients as determined by the distribution and number of cases throughout the facility and ability to identify close contacts. For example, in an outpatient dialysis facility with an open treatment area, testing should ideally include all patients and HCP. Depending on testing resources available or the likelihood of healthcare-associated transmission, facilities may elect to initially expand testing only to HCP and patients on the affected units or departments, or a particular treatment schedule or shift, as opposed to the entire facility. If an expanded testing approach is taken and testing identifies additional infections, testing should be expanded more broadly. If possible, testing should be repeated every 3-7 days until no new cases are identified for at least 14 days. The IPC recommendations described below (e.g., patient placement, recommended PPE) also apply to patients with symptoms of COVID-19 (even before results of diagnostic testing) and asymptomatic patients who have met the criteria for empiric Transmission-Based Precautions based on close contact with someone with SARS-CoV-2 infection. However, these patients should NOT be cohorted with patients with confirmed SARS-CoV-2 infection unless they are confirmed to have SARS-CoV-2 infection through testing. Duration of Empiric Transmission-Based Precautions for Symptomatic Patients being Evaluated for SARS-CoV-2 infection. The decision to discontinue empiric Transmission-Based Precautions by excluding the diagnosis of current SARS-CoV-2 infection for a patient with symptoms of COVID-19 can be made based upon having negative results from at least one viral test. If a patient suspected of having SARS-CoV-2 infection is never tested , the decision to discontinue Transmission-Based Precautions can be made based on time from symptom onset as described in the Isolation section below. Ultimately, clinical judgment and suspicion of SARS-CoV-2 infection determine whether to continue or discontinue empiric Transmission-Based Precautions. R7's current Physician's Orders document R7 has the diagnoses of Chronic Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, and Hypertension. R7's Progress Notes dated 12-31-24 at 7:42 AM documents, (R7) complained of a moist, wet, non-productive cough, inspiratory and expiratory wheezing, and rhonchi noted. (R7) denies SOB (Shortness of Breath) and/or chest pain. PRN (As Needed) Mucinex and inhaler utilized. Both are ineffective. (R7) has had this cough for several days now. Fax sent to (V19/R7's Physician) to inquire about a chest-Xray. Will await response. R7's Medical Record does not include evidence of R7 being tested for COVID-19 after exhibiting symptoms on 12-31-24, or evidence of R7 being placed in transmission-based precautions once exhibiting symptoms until COVID-19 could be ruled out. R8's current Physician's Orders document R9 has the diagnoses of Type II Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, and Hypertension. R8's Progress Notes dated 1-12-25 at 9:11 AM documents, (R8) is lethargic but aroused easily. (R8) complains of fatigue, SOB, lower back pain, and all over just not feeling well. Expiratory wheezing and rhonchi noted. PRN nebulizer administered. PRN Tylenol administered for pain. (R8) is refusing breakfast. R8's Medical Record does not include evidence of R8 being tested for COVID-19 after exhibiting symptoms on 1-12-25, or evidence of R8 being placed in transmission-based precautions once exhibiting symptoms until COVID-19 could be ruled out. The facility's COVID-19 Testing Log dated 12-29-24 documents V17 (CNA/Certified Nursing Assistant) tested positive for COVID-19. V17's Timecard Report dated 12-28-24 documents V17 worked on 12-28-24 from 6:05 AM through 2:13 PM. On 1-22-25 at 11:57 AM, V17 stated, I worked all day on 12-28-24 with a sore throat and runny nose. I worked with all residents on all hallways and dining rooms that day. I felt sick, so later that night I tested myself and was positive for COVID-19. The last several months staff have only had to wear surgical masks while caring for the residents. On 1-22-25 at 12:30 PM, V2 (Director of Nursing) stated, I was the infection preventionist in December 2024. We (the facility) do not test residents anymore if they are in contact with a COVID positive staff member. No residents were tested for COVID once (V17/CNA) tested positive for COVID on 12-29-24. (V17) did not report to any of the department heads on 12-28-24 that she had a runny nose or sore throat while at work. (R7 and R8) were not tested for COVID-19 once they had symptoms. I am going to have to educate staff that residents should be tested whenever exhibiting symptoms of COVID. (R7 and R8) were not placed in transmission-based precautions when they were having symptoms of COVID-19. On 1-22-25 at 12:45 PM V2 stated, I just spoke to (V18/Vice President of Clinical Operations), and (V18) said that we should have been testing all residents who were in contact with (V17) on 12-28-24.

Based on observation, interview, and record review the facility failed to use extensive assistance of two staff members during a mechanical lift sit-to-stand transfer for one of four residents (R3) reviewed for falls in a sample of eight. This failure resulted in R3 falling during a mechanical lift sit to stand transfer, sustaining a severely painful dislocated left shoulder. Findings include: The facility's Safe Resident Handling/Transfers policy, dated 12/15/22, documents Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable, experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Policy explanation: All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of a mechanical lifts are a safer alternative and should be used. Compliance Guidelines: 10. Two staff members must be utilized when transferring residents with a mechanical lift. R3's current Admission Record documents R3 has the following, but not limited to, diagnoses: Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side, Cerebral Infarction due to unspecified Occlusion or Stenosis of right middle Cerebral Artery, Hyperlipidemia, Essential Hypertension, other Abnormalities of Gait and Mobility, other Lack of Coordination, and Morbid Obesity due to excess calories. R3's MDS (Minimum Data Set), dated 10/3/24, documents R3 is cognitively intact. This same MDS documents, Mobility. 01. Dependent- Helper does all the effort. Resident does none of the effort to complete the activity or the assistance of two or more helpers is required for the resident to complete the activity. (R3) is dependent on toilet transfers and chair to bed/bed to chair transfers. R3's current Care Plan documents R3 has limited physical mobility related to Hemiplegia/Hemiparesis of Left Nondominant Side following a CVA (Cerebrovascular Accident). R3's Progress Note, dated 10/26/24 and signed by V21/RN (Registered Nurse), documents This RN was in another resident's room and was notified by (V8/CNA (Certified Nursing Assistant) that (R3) had a fall in his room. This RN walked into room and noticed (R3) laying on floor with sit-to-stand machine (mechanical lift) pulled back at the base of (R3's) feet, pillow under head. This RN began to physically assess (R3) and (R3) stated nine out of ten left shoulder pain and was unable to move arm. V8/CNA's Witness Statement, dated 10/26/24, documents I was transferring (R3) from the toilet to the bed using the sit to stand (mechanical lift). (R3) let go of the hand grips causing (R3) to slide out of the sling. Once (R3) slipped far enough, I couldn't pull (R3) up, so I lowered (R3) down to the ground. R3's Final Report, dated 10/26/24, documents R3 had a witnessed fall with injury resulting in a dislocation of R3's left shoulder. This same Final Report documents, (R3) let go from the arms of the stand aide (mechanical lift) without reporting to staff that (R3) could no longer hold onto stand aide. The support belt was still around (R3), though staff attempted to hold (R3) and call for help, due to (R3's) weight and that (R3) was starting to slide down the support belt. Staff assisted with lowering (R3) the rest of the way to the floor, during the process of getting lowered to the floor, (R3's) arms are above (R3's) head, which contributed to the dislocation. When asked why (R3) let go of the stand aide, (R3) stated that he could not hold on anymore. (R3) had c/o (complaints of) shoulder pain and decreased range of motion. (R3's) shoulder was manipulated at ER (emergency room ) by physician and returned to the facility. R3's ER Note, dated 10/26/24 documents, (R3) presents after a ground-level fall with left shoulder pain and (R3's) left arm stuck above his head. (R3) denies loss of consciousness, reports no other injury from the fall. (R3) is unable to move his left arm at the shoulder. R3's Left Shoulder X-Ray, dated 10/26/24, documents inferior shoulder dislocation. On 11/15/24 at 10:50 AM R3 was lying in his bed. R3 stated, During my last fall on the sit-to-stand (mechanical lift) my left hand became weak, and I ended up falling to the ground. (V8/CNA) was the only staff member transferring me. Usually, two people transfer me on the sit-to-stand, especially because I have had a stroke that caused my left side to be weak. I was in severe pain and was unable to move my left arm. My left arm was stuck straight up in the air. I ended up having a dislocated shoulder and had to have it put back in place at the Hospital. On 11/15/24 at 11:15 AM V3/ADON (Assistant Director of Nursing) stated V8/CNA was the only one transferring R3 during the toilet to bed transfer on 10/26/24. V3 stated, When using a sit-to-stand (mechanical lift), the staff should always use two staff members when transferring a resident for safety of the resident and themselves. On 11/15/24 at 11:22 AM V1/Administrator verified V8/CNA was the only one transferring R3 when R3's fall occurred on 10/26/24. V1 stated, It was (V8's) last scheduled day of employment at our facility on 10/26/24. I don't believe (V8) cared about anything since it was his last day, so (V8) transferred (R3) by himself with the sit-to-stand mechanical lift instead of using two people for the transfer. Staff should always have two people when transferring with any mechanical lifts.

Based on observation, interview and record review the Facility failed to provide physician ordered treatments for three of three Resident's (R1, R2 and R3) reviewed for wound care in a sample of three. Findings include: Facility Wound Treatment Management Policy, revised 8/19/24, documents: to promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders; and wound treatments will be provided in accordance with physician orders including the cleansing method, type or dressing and frequency of dressing change. Facility Physician/Practitioner Orders, revised 12/13/23, documents: the attending physician/practitioner may include, but is not limited to wound care. The Facility Administrator Job Description, dated 6/2021, documents the position purpose as leading, guiding and directing the operations of the healthcare facility in accordance with local, state and federal regulations standards and established facility policies and procedures to provide appropriate care and services to residents. The Facility Wound/Skin Log, dated 9/24/24, documents: R1's Lymphedema to R1's Left Lower Shin and Right Lower Shin; R2's Left Lateral Abdominal Fissure and R3's Right Dorsal Trauma/Injury. The Resident Council Minutes, dated 7/7/24 document concerns with day to day nursing care varies and would like care needs to be more consistent and would like (V7/Wound Nurse's) orders for care followed by other nurse caring for residents. R1's Treatment Administration Records, dated 10/1/24 through 10/25/24, do not document completion of Physician Orders for: monthly skin assessments (Braden Scale) on 10/6/24; cleanse Left and Right below the Knees with surgical cleanser (Antiseptic Skin Cleanser) and pat dry every day shift for wound care on 10/5/24, 10/6/24, 10/8/24, 10/9/24, 10/14/24 and 10/23/24; cleanse Left Lower Shin with surgical cleanser and apply dry dressing (Petroleum Gauze Dressing) and cover with a wrap (Gause Dressing) every day shift for 10/5/24 and 10/6/24; cleanse Left Medial thigh with wound cleanser and apply dry dressing (Petroleum Gauze Dressing) and cover with a wrap (Gause Dressing) every day shift for 10/5/24, 10/6/24, 10/8/24 10/9/24 and 10/14/24; ensure Left Lower Shin dressing is clean and dry every day shift for wound care for 10/5/24 and 10/6/24; apply barrier cream to Buttocks and Sacrum daily every shift on 10/5//24, 10/6/24, 10/8/24 and 10/14/24; and ensure dressing (Antimicrobial Fabric) is intact in Ankle area every shift for 10/5/24, 10/6/24, 10/8/24 and 10/14/24. R2's Treatment Administration Records, dated 9/1/24 through 10/25/24, do not document completion of Physician Orders for: topical cream to back, thigh and abdomen every day and evening for 10/4/24, 10/17/24 and 10/19/24; ensure medicated pad (calcium alginate) is in place every shift to left lateral abdominal area on 9/28/24, 10/4/24, 10/17/24 and 10/19/24; cleanse left lateral a with wound cleanser and apply thin coat of medicated ointment (Gentamicin Sulphate) around the peri-wound and middle of wound, then topical cream (clotrimazole-betamethasone) around peri-wound and cover with dressing (Alginate Calcium) on 9/28/24; topical cream (clotrimazole-betamethasone) around left upper abdominal wound for 9/5/24, 9/6/24, 9/14/24 and 9/20/24 and left lateral Abdominal peri-wound on 9/25/24, 10/8/24; medicated powder (Nystatin) to bilateral breast folds topically every shift for 9/5/24, 9/6/24, 9/14/24, 9/20/24 and 9/28/24; and ensure dressing (silver calcium alginate) is in place every shift to the left lateral upper abdominal area. R3's Treatment Administration Records, dated 10/1/24 through 10/25/24, do not document completion of Physician Orders for: barrier cream to buttock and coccyx every shift on 10/5/24, 10/6/24 and 10/14/24; and external cream to bilateral lower legs topically every day and evening shift for stasis dermatitis on 10/5/24, 10/6/24, 10/8/24 and 10/14/24. On 10/25/24 at 11:23 am, V7 (Wound Nurse/Assistant Director of Nursing/ADON) stated, I am the wound nurse and I monitor the skin issues in the building. This includes the treatment order. If there is no signature/initials in the date on the Treatment Administration Record, then the treatment was not done. On 10/25/24 at 11:53 am, V8 (Wound Doctor) stated, If there is a Physician Treatment order, then the Nursing Department should be following those orders for skin treatments and completing them according to the orders. On 10/25/24 at 1:40 pm, V2 (Director of Nursing) stated, Looking at (R1's, R2's and R3's) Treatment Administration Record/TAR, I do see that treatments were missed getting done and not documented. The nurses should be signing completion of the Treatment Administration records when there is a Physician Order for treatment. On 10/25/24 at 11:57 am, V1 (Administrator/ADM) stated, The nurse on duty should be following the physician orders for (R1's, R2's and R3's) treatment and they should also be signing out that the treatment was completed.

Based on observation and record review, the facility failed to ensure food is prepared under sanitary conditions by not using Personal Protective Equipment (PPE) properly to prevent hair from contacting food. This failure has the potential to affect all residents with a current census of 65 residents. Findings include: The Hair Restraint; Jewelry; Nail Polish; False Eyelashes policy, dated 11/10/21, documents Food and nutrition services employees shall wear hair restraints and beard guards. Hairnets will be worn at all times in the kitchen. [NAME] guards or masks will be worn as indicated. Dietary staff must wear hair restraints to prevent their hair from contacting exposed food. If a hat is worn, a hairnet must be worn under the hat if any hair is exposed from under the hat. On 8/21/24 at 11:15 AM, two maintenance men (vendor) were observed to be in the kitchen working on an ice machine without hair or beard restraints donned. On 8/21/24 at 11:20 AM, V13 (Cook) was observed to have multiple pieces of hair exposed from under the hair restraint while preparing lunch trays. On 8/21/24 at 11:22 AM, V11 (Dietary Manager) stated the maintenance men should have donned hair restraints and beard guards prior to entering the kitchen and the cook should've had all hair covered by the hair restraint.

This citation has 2 deficient practice statements. A. Based on record review, observation and interview, the facility failed to wear Personal Protective Equipment (PPE) appropriately, failed to disinfect patient use items and failed to conduct hand hygiene per policy for one of three residents (R41) reviewed for infection control practices in a sample of forty residents. B. Based on observation, interview and record review the facility failed to pass medications in a manner to prevent contamination. This failure has the potential to affect the 19 residents who reside on the 400 hall (R1,R5,R6,R12,R16,R19,R23,R26,R27,R31,R32,R36,R29,R46,R50,R54,R56,R60 and R61) in a total sample of forty. Findings include: A. The Enhanced Barrier Precautions policy, dated 1/1/24, documents Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multi-resistant organisms that employ targeted gown and gloves use during high contact resident care activities. b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO (Methicillin-drug Resistant Organism). The Morbidity and Mortality Weekly Report Vol. 51 / No. RR-16 Guideline for Hand Hygiene in Health-Care Settings, Recommendations of the Healthcare Infection Control Practices, Advisory Committee and the HICPAC/[NAME]/APIC/IDSA, Hand Hygiene Task Force, 10/25/22, documents G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin and wound dressings if hands are not visibly soiled J. Decontaminate hands after removing gloves. R41 was admitted on [DATE] with sacral and ankle wounds, a gastrostomy tube, indwelling urinary catheter and a history of urinary tract infections. 08/20/24 12:10 PM and 8/21/24 at 9:08 AM, an Enhanced Barrier Precaution sign was posted outside of R41's room door. On 8/21/24, V12 (Registered Nurse) and V10 (Certified Nurse Aide) were observed to provide wound care without donning a gown. V12 was observed to clean stool from R41's buttocks and removed the dressing, which was soiled with stool, removed gloves and donned new gloves without conducting hand hygiene. After the dressing change, V12 removed gloves and proceeded to pick up the tube of ointment used during treatment, applied the lid to the tube of ointment and put the ointment back into the ointment box without conducting hand hygiene or wearing gloves. On 8/22/24 at 10:00 AM V2 (Director of Nursing) stated PPE gowns should be secured with both ties, hand hygiene should have been conducted before and after glove application and removal. V2 stated the tube of ointment should have been considered dirty and should have been disinfected prior to replacing the ointment back into the ointment box with clean gloves donned. 33970 B. The Facility's Medication Administration policy dated 01/04/24 documents Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. On 8/21/24 at 8:05 AM V2 (Director of Nursing) prepared R5's scheduled morning medications in a medicine cup. V2 knocked the medicine cup over on top of the medication cart and used her gloved hand to scoop up the pills that came out onto to cart and put them back in the cup and then administered the medications to R5. On 8/22/24 at 10:00 AM V2 (Director of Nursing) stated I don't remember doing that, yesterday was crazy, if I did, I shouldn't have. V2 confirmed that the top of the medication cart would not be considered a clean surface and that all medications that came out of a medicine cup during medication preparation should be discarded. V2 confirmed that the medication cart she had been working out of on 8/21/24 contained all the medications for the 400 hall. The Facility's Room Roster dated 8/20/24 documents that the following residents reside on the 400 hall: R1,R5,R6,R12,R16,R19,R23,R26,R27,R31,R32,R36,R39,R46,R50,R54,R56,R60 and R61.

Based on record review and interview the facility failed to provide a completed transfer document for one resident (R68) of 2 residents reviewed for discharge in a total sample of forty. Findings Include: The Facility's Transfer and Discharge policy dated 1/30/24 documents Orientation for transfer or discharge must be provided and documented to ensure safe and orderly transfer or discharge from the facility, in a form and manner that the resident can understand. Depending on the circumstances, this orientation may be provided by various members of the interdisciplinary team. The Facility's Transfer and Discharge policy dated 1/30/24 documents for Emergency Transfers/Discharges that the nurse will Complete and send with the resident (or provide as soon as practicable) a Transfer Form which documents: Resident status, including baseline and current mental, behavioral and functional status and recent vital signs; Current diagnosis, allergies and reason for transfer/discharge; Contact information of the practitioner responsible for the care of the resident; Resident representative information including contact information; Current medications (including when last received), treatments, most recent relevant lab and. or radiological findings and recent immunizations; Special instructions or precautions for ongoing care to include precautions such as isolation or contact; special risks such as risk for falls, elopement, bleeding or pressure injury and/or aspiration precautions, comprehensive care plan goals, and any other documentation, as applicable, to ensure a safe and effective transition of care. R68's Electronic Medical Record documents that R68 was admitted on [DATE] after a Cerebral Vascular Accident for therapy with an anticipated return to home after therapy was completed. R68's Physician Order Sheet for May 2024 documents that R68 was receiving Skilled Therapy during his stay, R68's Physician Order Sheet for May 2024 document that R68 was receiving Apibaxin 5 mg (milligrams) (anti-coagulant medicine) daily. R68's Nurse's Notes dated 5/24/24 at 9:24 AM document that R68 left the physical therapy department independently in his wheelchair and staff attempted to redirect him to finish his therapy due to his repeated refusals to complete the whole sessions. The Nurse's Note documents Resident sitting in middle of hallway, resident is having behaviors. Resident purposefully sliding out of his wheelchair as he did not want to wheel himself back to his room. Resident asking female staff for their personal phone number. Resident assisted back up in his chair using gait belt and several staff members. Resident taken to his room and started demanding we send him out to hospital because he wants to leave. Several minutes later he reported to staff he had facial numbness (of) bilateral arms (and) legs numbness. (Doctor) was notified and he gave an order to send resident to (Local emergency room ) for evaluation. R68's SNF/NF (Skilled Nursing Facility/Nursing Facility) to Hospital Transfer Form dated 5/24/24 has area for Reason for transfer that was blank, area Primary Care Clinician in SNF/NF was blank, Risk Alerts area was blank, Immunizations area was blank, Behavioral Issues and Interventions area was blank, Rehabilitation Therapy: Is the Resident/Patient currently receiving Rehabilitation Therapy? was not answered. On 8/21/24 at 10:30 AM V2 (Director of Nursing) stated she didn't know why the areas were blank because she was not the one who filled out the form. V2 provided R68's eInteract Transfer Form dated 5/24/24 and stated that the form could be considered R68's transfer form/discharge summary. R68's eInteract Transfer Form dated 5/24/24 has area Primary Diagnosis for Admission to your Facility that was blank, Transfer/Discharge Details area was blank, Risk Alerts: Precautions: currently on isolation precautions? was not answered, Risk Alert: Other Risks area was blank, Behavior area was blank, Immunizations area was blank, Rehabilitation Therapy Is the resident/patient currently receiving Rehabilitation Therapy? was not answered, Primary Care Clinician in SNF/NF area was blank. R68's Acute Care Transfer Document Checklist documents Documents Recommended to Accompany Resident/Patient: Resident/Patient Transfer Form, Personal Belongings identified on Resident/Patient Transfer Form are enclosed, Face Sheet, Current Medication List or Current MAR (Medication Administration Record), SBAR (Situation, Background, Assessment and Recommendation) and/or other Change in Condition Progress Note (if completed), Advance Directives (Durable Power of Attorney for Health Care Living Will), Advance Care Orders. None of the listed documents are marked as sent with R68 to the emergency room . On 8/22/24 at 9:15 AM V2 stated she did not know why the forms were not completed because she was not the person who transferred R68 to the hospital. On 8/22/24 at 9:20 AM V1 (Administrator) confirmed that the forms should have been filled out in their entirety and V1 confirmed that R68 had documented behaviors that should have been noted, and that R68 was on an anticoagulant and that should have been noted in the other risk areas where available on the forms.

Based on observation, interview and record review the facility failed to perform personal care for one resident (R20) of twenty residents reviewed for clean and well kempt appearance in a total sample of forty. Findings Include: The Facility's Activities of Daily Living Policy dated 12/5/23 documents Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care. The policy also documents A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal hygiene and oral hygiene. R20's Electronic Medical Record documents that R20 was admitted for Hospice Care due to adult failure to thrive and muscle wasting. R20's Point of Care Response History documents that on 8/17/24 R20 was totally dependent for bathing and grooming. On 8/20/24 at 9:00 AM R20 was lying in bed in a hospital gown with full beard stubble with a longer mustache that covered his entire lips. R20's fingernails were also long. R20 stated I've been asking (staff) to shave me, I want the mustache trimmed and I don't want all of this (motioned to full beard stubble on cheeks and neck). I need my damn nails cut too, I told the girl last night she said she would come back later and do it but never did. I could cut paper with my nails. On 8/22/24 at 10:00AM V8 (R20's family) stated (R20) needs shaved badly and he has told me a couple of times about his nails, I keep trying to remember some clippers so I could do it for him. I don't know why they (staff) haven't done it. R20's Point of Care Response History documents that R20 received a shower on 8/20/24 by V6 (Certified Nurse Aid). On 8/22/24 at 10:05 AM R20 stated I told her (V6/Certified Nurse Aid) that I wanted shaved, and my nails cut, and she said she would come back and do it and she never did. On 8/22/24 at 11:00 AM V1 (Administrator) confirmed that it would be her expectation that unless there was documentation of a resident refusing that all residents receive personal grooming to include being shaved and nails clipped during a shower. V1 confirmed that R20's shower was marked as given and that there was no documentation of R20 refusing personal grooming.

Based on record review and interview, the facility failed to complete diabetic monitoring and care for one of two residents (R41) reviewed for quality of care in a sample of 40 residents. Findings include: R41's Minimum Data Set (MDS) documents R41 was admitted on [DATE] with Type 2 Diabetes Mellitus with Insulin Dependence. R41's Physician's Standing Orders, undated, documents Diabetes: Unless otherwise indicated: blood glucose monitoring before meals and at bedtime. If no sliding scale ordered, may use the following scale . R41's hospitalization Discharge Summary, dated 8/16/24, documents Insulin to be administered per sliding scale every four hours. R41's Progress Note document R41 returned to the facility post hospitalization on [DATE] at 3:45 PM. R41's Blood Glucose Monitoring log documents a blood glucose level was conducted on the facility's admission assessment on 8/16/24 at 5:30 PM and not again until 8/19/24 at 11:06 AM. R41's Progress Note dated 8/19/24 at 10:09 AM documents Resident had been yelling out in the morning, currently lethargic and slightly diaphoretic (sweating). Blood glucose levels checked, and resident is currently at 471 (per sliding scale 60-150 blood sugar levels require no treatment). Twelve units of insulin Lispro administered in reference to sliding scale standing order. Discharge orders (Hospital's Discharge Orders) checked prior to administration, order for insulin Lispro on sliding scale noted in discharge orders (Hospital's Discharge Orders). Doctor notified of elevated blood glucose levels. R41's Progress Note dated 8/19/24 at 11:06 AM documents 1 (one) hour recheck blood glucose at 413, 15 units (Insulin) administered. On 8/19/24 at 12:00 PM, a Physician's Order for Insulin administration per sliding scale was obtained. R41's Progress Note dated 8/19/24 at 12:08 PM documents Second blood glucose level at one hour after insulin administration, 413. Second dose of insulin administered via sliding scale guidelines. One hour post second dose administration blood glucose level 311. On 8/22/24 at 12:45 PM, V14 (Registered Nurse) confirmed R41's blood glucose levels were not monitored per standing order nor where insulin orders obtained upon return to the facility post hospitalization on [DATE] until 8/19/24.

Based on record review and interview, the facility failed to ensure catheter care was conducted for one of nine residents (R41) with indwelling catheters in a sample of forty residents. Findings include: R41's Care plan, dated 7/29/24, documents Indwelling Catheter for wound healing. Monitor/record/report to Medical Doctor for signs and symptoms Urinary Tract Infection: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. R41's Progress Notes, dated 8/3/24 at 9:49 PM, documents Husband concerned that R41 may be getting a Urinary [NAME] Infection. New Catheter bag in place for clean catch (urine sample). Will pass on to next nurse to collect urine if signs and symptoms for urinalysis to be collected. R41's Progress Notes, Physician Orders and Laboratory Results lacks documentation a urinalysis was obtained. R41's Progress Notes, dated 8/6/24 at 9:48 AM, documents R41 was sent to the hospital for evaluation for a change in condition. R41's hospitalization Discharge Summary, dated 8/16/24, documents During R41's admission (8/6/24 through 8/16/24), R41 was treated with Intravenous antibiotics for pneumonia and a urinary tract infection. R41's urine culture did have Pseudomonas Aeruginosa, Enterococcal Faecalis and Coag-negative Staphylococcus. On 8/16/24, the Progress Notes documents R41 returned to the facility with an indwelling urinary catheter. R41's Treatment Administration Record (TAR) documents a Physician's Order for Catheter Care every shift was obtained to start on 8/20/24 at 10:00 PM. The TAR documents catheter care was not conducted until night shift on 8/20/24, 4 days after return to the facility post hospitalization . On 8/22/24 at 12:45 PM, V14 (Registered Nurse) stated R41's (spouse) told me R41 said R41 felt like R41 had a kidney infection. R41 can be very cognizant at times. At home, R41 always told R41's (spouse) when R41 felt the symptoms of an UTI (Urinary Tract Infection) and the spouse would call R41's doctor, get a urinalysis and start antibiotics. R41's spouse said R41 always knew (when UTI was starting). So, when R41's spouse told me that (R41 reported signs and symptoms of kidney infection) I changed the catheter bag so we could get a clean catch specimen (urine). I don't know why it (urine sample) was never gotten. I think R41's urine looked ok until the day R41 went to the hospital. It doesn't look like physician orders were addressed until Monday, the 19th (8/19/24). Probably because it was a weekend.

Based on observation, interview and record review the facility failed to identify specific triggers of re-traumatization for two residents (R1, R6) reviewed for PTSD (Post Traumatic Stress Disorder) of three residents reviewed for Trauma Informed Care in the sample of 40. Findings include: Facility Policy/Trauma Informed Care dated 1/30/24 documents: A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization. The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident and will be added to the resident's care plan. While most triggers are highly individualized, some triggers may include, but not limited to: Experiencing a lack of privacy or confinement in a crowded or small space. Exposure to loud noises, or bright/flashing lights. Certain sights, such as objects that are associated with their abuser. Sounds, smells, and physical touch. Trauma-specific care plan interventions will recognize the interrelation between trauma and symptoms of trauma such as substance-abuse, eating disorders, depression, and anxiety. In situations where a trauma survivor is reluctant to share their history, the facility will still try to identify triggers which may re-traumatize the resident and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident. Current Physician Order Summary Report indicates R1 was admitted to the facility on [DATE]. Trauma Informed Care assessment dated [DATE] indicates R1 had no history of trauma. Trauma Informed Care Assessments dated 5/4/23 and 1/4/24 indicate R1 did have a history of trauma described as child, sexual abuse/assault (including rape) - non-consensual sexual contact which caused emotional harm. Assessments indicate symptoms exhibited are anger and tearfulness. R1's current Care Plan indicates R1 has a history of trauma (child abuse/sexual abuse). Care Plan interventions (dated 10/20/23) indicate (R1) will come and talk to Social Services or Nursing if she is having triggers due to her history of sexual abuse until she restarts therapy. Care Plan does not identify triggers for potential re-traumatization. On 8/22/24 at 12:20pm V15, Social Services/Care Plan Coordinator stated triggers should have been identified and documented in R1's care plan. 2) Current Physician Order Summary Report indicates R6 was admitted to the facility on [DATE]. Trauma Informed Care Assessments dated 8/17/23 and 2/16/24 indicate R6 has a history of trauma identified as sexual abuse/assault (including rape). Assessment indicates no symptoms or triggers per resident. R6's current Care Plan does not include PTSD or Trauma Informed Care including triggers/interventions. On 8/22/24 at 12:25pm V15, Social Services/Care Plan Coordinator stated R6's care plan should have included her diagnosis of PTSD and thinks it got overlooked.

Based on observation, interview and record review, the facility failed to identify an appropriate indication for use and identify target behaviors for the use of an antipsychotic medications for three of five residents (R28, R32, R39) reviewed for unnecessary medications in a sample of forty residents. Findings include: Facility Policy/Use of Psychotropic Medication dated 9/27/23 documents Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication. Enduring Conditions (i.e., non-acute, chronic, or prolonged):The resident's symptoms and therapeutic goals shall be clearly and specifically identified and documented. An evaluation shall be documented to determine that the resident's expressions or indications of distress are:Not due to a medical condition or problems that can be expected to improve or resolve as the underlying condition is treated or the offending medications(s) are discontinued;Not due to environmental stressors alone, that can be addressed to improve the symptoms or maintain safety;Not due to psychological stressors, anxiety, or fear stemming from misunderstanding related to his or her cognitive impairment that can expected to improve or resolve as the situation is addressed; and Persistent, negatively affect his or her life. 1. The Medication Administration Record (MAR), dated 8/1/24 - 8/31/24, documents R28's has the following diagnoses: Unspecified Mood Disorder and Unspecified Dementia, Unspecified Severity, without Behavioral Disturbances, Psychotic Disturbances, Mood Disturbances and Anxiety. The MAR's Physician's order, dated 6/11/24, documents Olanzapine (Antipsychotic medication) oral tablet 5 mg (milligram) at bedtime related to unspecified mood disorder is administered daily. R28's Careplan, dated 7/23/24, documents R28 uses Antipsychotic medication related to diagnosis of Mood disorder and Dementia. The Psychiatric Evaluation, dated 5/29/24, 6/7/24, 7/5/24 and 8/1/24, documents Psychiatric History: No history of inpatient or out patient psychiatric care. No history of Suicidal Ideation. No history of TMS (Transcranial magnetic stimulation), ETC (Electroconvulsive therapy) or any known psychotropic trials. Staff report no acute concerns or agitation. Staff deny any new or worsening non redirectable dementia related to behaviors. Staff deny noting any signs or symptoms of anxiety, depression, suicidal or homicidal ideation. No indication of delusions, visual hallucinations, auditory hallucinations, mania or paranoia. Patient remains at baseline mood without fluctuations. There are no indications of psychotic or manic features. On 8/20/24, 8/21/24 and 8/22/24, R28 was observed and did not display any inappropriate behaviors or signs/symptoms of psychosis. On 6/10/24, the Progress Note documents (Primary Care physician) was notified R28 is on a antipsychotic for Dementia related behaviors. However, R28 is not having any current behaviors per staff and per chart review. R28 has also been noted to be very drowsy in the morning during our visits. If R28 is having behaviors that i am unaware of please let me know. No Behaviors noted since being with us per nursing. On 8/22/24 at 12:45 PM, V3 (Assisting Director of Nursing) stated V28 has not exhibited any behaviors since admission and confirmed R28 did not have a psychiatric diagnosis. V3 stated R28 was admitted on Olanzapine and it has not been changed. V3 stated I will ask for them to discontinue it. 30899 2) Current Physician Order Summary Report indicates R32 is [AGE] years old and was admitted to the facility on [DATE]. Physician Order Summary Report dated 4/1/24 to 4/30/24 indicates Quetiapine 25 mg (milligrams) twice daily was initially ordered on admit 4/2/24, for Unspecified Mood Disorder. Current Order Report indicates R32 currently has orders for Quetiapine (antipsychotic) 50 mg (milligrams) twice daily for Unspecified Mood Disorder was increased/ordered on 6/20/24. Progress Note dated 6/7/24 indicates R32's family Would like the physician to do a face to face with (R32) so she can determine whether (R32) is competent or not since she talks to family members about relatives that are no longer alive. Progress Note dated 6/11/24 at 6:42 PM indicates (R32's) family keeps calling staff demanding that he wants (R32) to be deemed incompetent. Progress Note dated 6/19/24 at 8 PM indicates R32 was showing signs of increased anxiety and increased sadness. Note indicates R32's family called facility with same concerns and requested medication change. Progress Note dated 6/20/24 at 1:24 PM indicates R32's family was wanting R32's medications adjusted however, R32's antidepressant was just increased. Note indicates R32 Recently had a flare up of CHF (Congestive Heart Failure) so she's been increase (ingly) complaining about everything and more whining (more) than usual, (which) would be expected. Progress Note dated 6/20/24 at 2:24pn indicates R32's PCP (Primary Care Physician) ordered (increased) R32's Quetiapine to 50 mg twice daily. Progress Note dated 8/4/24 at 11:58 AM indicates R32 was verbally aggressive, yelling and demanding to go home. Progress Note dated 8/7/24 3:29 PM indicates R32 very upset, yelling out that she wanted to go home while receiving care from staff. Consent for Psychotropic Medications dated 4/3/24 and 6/20/24 indicates Quetiapine was ordered for Bipolar. Review of R32's current diagnosis list and psychiatry notes found no diagnosis of Bipolar Disorder. Most recent psychiatry note dated 8/1/24 indicates R32 has no audio/visual hallucinations or delusions. Current Care Plan indicates R32 uses antipsychotic medication related to diagnosis of Mood disorder and Depression. Care Plan indicates R32 is upset with placement and wants to go home. Care Plan interventions indicate to monitor occurrence of target behavior symptoms - withdrawn, tearful, refusal of cares, agitation. Pharmacy Recommendations dated 6/12/24 indicates a Gradual Dose Reduction was recommended by pharmacy for R32's Quetiapine. Physican response to recommendations indicated Condition is not well controlled/stable and a reduction is likely to impair the resident's function and/or cause psychiatric instability. On all dates of the onsite survey 8/20/24, 8/21/24, 8/22/24 - R32 was seen self-propelling her wheelchair through the facility and easily engaging with staff. On 8/20/24 R32 did have a concern regarding her family taking over her finances, then later stated she spoke with staff and it was no longer a concern. R32 did not exhibit any distress related to her concerns. On 8/22/24 at 12:30 PM V15, Social Services/Care Plan Coordinator acknowledged R32's behaviors are only being occasionally verbally aggressive and resistive to cares at times. V15 stated R32 has never been physically aggressive. On 8/22/24 at 12:40 PM V3, ADON/Psychotropic Nurse (Assistant Director of Nursing) stated R32's behaviors are outbursts, yelling at staff and resistive to cares. V3 acknowledged she was not in agreement with increasing R32's Quetiapine acknowledged R32's behaviors did not meet requirements for an antipsychotic. V3 also acknowledged Bipolar was not the correct diagnosis documented on R32's psychotropic consents. 3) Current Physician Order Summary Report indicates R39 is [AGE] years old and was admitted to the facility on [DATE]. Current Order Report indicates R39 has orders for Quetiapine (antipsychotic) 25 mg (milligrams) in the afternoon for verbal aggression, crying uncontrollably related to Vascular Dementia with Agitation (order date 8/14/24). Progress Note dated 8/7/24 at 2:40 PM indicates R39 was outside of the nursing office yelling and crying out. Note indicates staff attempted to give R39 pain medication which R39 refused at that time. Progress Note dated 8/7/24 at 3 PM indicates R39 Up at the nurses's desk upset and yelling out and crying. Note indicates multiple staff unable to determine reason R39 was upset due to R39's word salad. Note further indicates when R39 was able to calm down, staff able to determine that R39 was constipated and wanted something to help. Progress Note dated 8/11/24 9:10 AM indicates R39 had an unwitnessed non-injury fall in her room. Progress Note dated 8/11/24 at 10:38 AM indicates R39's hearing aide was broken. Progress Note dated 8/11/24 at 11:58 AM indicates a new order was received from psychiatry services to start Quetiapine (antipsychotic) 25 mg daily. Progress Note dated 8/12/24 at 11:28 AM indicates R39 had an unwitnessed non-injury fall in her room. Progress Note dated 8/19/24 at 4:28 AM indicates R39 came out of her room and was crying and stating I can't stand this pain! and requesting nurse call the physician. R39's current Care Plan reviewed and found no care plan area to address Quetiapine/antipsychotic use or identified target behaviors. On all dates of the onsite survey 8/20/24, 8/21/24, 8/22/24 - R39 was seen sleeping or in her room in her recliner chair. R39 did not exhibit any inappropriate behaviors. On 8/22/24 at 12:40 PM V3, ADON stated Hospice ordered the Quetiapine for R39 and stated she advised Hospice the current diagnosis was not appropriate for its use. V3 stated R39 gets frustrated and mad due to not being able to express herself and not being understood by staff. V3 stated that a lot of R39's behaviors are due to R39's pain and medication seeking. V3 stated there has been a disconnect between nursing and care planning and R39's Quetiapine should have been care planned along with target behaviors. V3 stated R39's behaviors are not constant or dangerous to herself or others.

Based on interview and record review, the facility failed to follow the Care Plan to ensure a fall did not occur for one (R1) resident of three residents reviewed for falls/accidents in a sample of three Findings include: The facility's Incidents and Accidents Policy, dated 12/6/22, documents: It is the policy of this facility for staff to utilize (Electronic Health Record)/Risk Management to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. The purpose of incident reporting can include: Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care. R1's diagnoses included: Dementia, psychotic disturbance, mood disturbance, chronic kidney disease, malignant neoplasm of bladder, chronic obstructive pulmonary disease, retention of urine, urinary tract infection, cerebrovascular disease, weakness, other abnormalities of gait and mobility, history of falling, acute kidney failure. R1's Care Plan documents: The resident has an Activities of Daily Living/ADL self-care performance deficit related to weakness. The resident has limited physical mobility related to muscle weakness, dementia. The resident has impaired cognitive function/dementia or impaired thought processes related to dementia diagnosis. R1's Fall Risk assessment dated [DATE], documents: (R1) is at high risk for falling; (R1) overestimates or forgets limits. R1's Progress Note Dated 1/20/24 documents: Ground level fall at 200 hall nursing station, resident ambulating unassisted and fell , struck right side of head with laceration noted. Resident made comfortable and will let Emergency Medical Transport/EMTs lift resident up due to head injury. R1's Report to (State) Department of Public Health, Incident Date 1/20/24, documents: R1 Attempted to self-ambulate which resulted in fall, sent to emergency room /ER for evaluation. Investigation initiated. Type of Injuries: Six centimeter laceration to right forehead closed with five staples. R1's Hospital Notes, dated 1/22/24 documents: Assessment: Acute nondisplaced fracture involving the right posterior lamina; acute nondisplaced fractures involving the temporal process of the right zygomatic bone and the right greater wing of the sphenoid. Plan: No surgery needed to facial fractures. R1's Minimum Data Set (MDS), dated [DATE], documents: R1 has a BIMS (Brief Interview of Mental Status) score of 12. (MDS indicates that on a scale of 0 - 15, 13 to 15 cognitively intact; 8 to 12 moderate impairment; and 0 to 7 severe impairment.) On 2/13/24 at 10:45am, V3 Assistant Director of Nursing/ADON) stated when R1 was admitted to the facility on [DATE], he resided on the facility's 100 Hall close to the nursing station; and stated that R1 was initially rehab to home but became long term and was transferred to the 200 Hall. At this time, V3 ADON stated, The 200 Hall has two Certified Nursing Assistants/CNAs; most of the residents with dementia would go to the 200 hall; (R1) had dementia. Someone should have had eyes on him at all times because he is high risk for falls. On 2/8/24 at 1:35pm, V8 Licensed Practical Nurse/LPN stated that she was R1's nurse when he fell on [DATE]; stated that at the time of his fall, she was doing Accu-checks and the two staff Certified Nursing Assistants/CNAs (V9 and V13) assigned to the 200 Hall were passing meal trays to the room residents. On 2/8/24 at 1:35pm, V8 LPN stated, Most of the residents were in the dining area across from the nursing station and I would be able to keep an eye on them. (R1) was at the back door near the nursing station, sitting in his wheelchair and looking out; I went to do another Accu-check and heard a resident say, 'that man just fell '. (R1) tried to ambulate unassisted; has a history of falls, no safety awareness. We like to keep an eye on him; the fall happened so quickly. I felt terrible. At this time, V8 LPN stated that R1 had lots of blood coming from his head; stated that she notified the EMT/Emergency Medical Transport right away. V8 LPN stated, (R1) did not come back to the facility; was transferred to a (local hospital) for head injury and brain bleed, then went to hospice. On 2/9/24 at 12:25pm, V9 Certified Nursing Assistant/CNA stated she worked on the 200 Hall where R1 resided and was his CNA when he fell ; stated that when she saw him on the floor, he was not saying anything. At this time, V9 CNA stated, (V13 CNA) and I were passing the lunch trays at the other end of the hall; it takes both of us; and V8 LPN was watching the residents in the dining room. If V8 LPN was not watching them, either me or (V13 CNA) would have been watching. On 2/9/24 at 12:30am, V13 CNA stated when R1 fell , R1 was face down on the floor and breathing funny; bloody from head; did not respond to them when they talked to him. At this same time, V13 stated, The nurse (V8 LPN) was watching (R1); think he popped up and tried to walk; he is fast. There were a room full of residents down there (dining area/nursing station); he was not by himself. Someone has to watch residents at all times, and the nurse (V8 LPN) was there.

Based on interview and record review, the facility failed to provide the service of a Registered Nurse (RN) eight hours a day seven days week. This has the potential to affect all 65 residents residing in the facility. Findings include: The facility's Facility assessment dated ,d+[DATE] documents, At least 10% must be provided by RN. V1, Administrator, verified that out of the 100% direct care staffing hours needed per 24 hours, at least 10% of those hours have to be completed by an RN equaling a minimum of eight hours a day. The facility's daily nurse staffing schedules dated 9/23/23 through 10/25/23, documents the facility did not have an RN scheduled on 9/23, 9/24, 10/1, 10/7, 10/8, and 10/22. On 10/25/23 at 1:17 PM, V1, Administrator, verified there was no RN coverage of the before mentioned dates and stated, We don't have an RN right now to cover all the weekends. We're trying to get some hired. The facility's resident roster report dated 10/24/23 and verified by V1, Administrator, documents 65 residents residing in the facility.

Based on observation, interview, and record review the facility failed to immediately assess a newly acquired wound, implement new skin interventions, obtain a treatment order upon wound identification, revise a wound care plan, and follow physician orders for wound care for two of three residents (R2, R3) reviewed for wounds in the sample of five. Findings include: The facilities Wound Treatment Manage policy dated, 8/22/2023, documents, Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders, or the assigned licensed nurse in the absence of the treatment nurse. This same policy also documents Treatments will be documented on the Treatment Administration Record. The facilities Notification of Changes Policy dated, 12/13/22, documents, Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. The facilities Care Plan Revisions Upon Status Change policy, dated 1/25/23, documents The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. The comprehensive care plan will be reviewed and revised as necessary when a resident experiences a status change. 1. R3's Skin and Wound Evaluation dated, 9/8/23, documents R3's wound was found on 9/7/23, but not evaluated until 9/8/23. The same form documents the area is a blister to the rear right malleolus measuring 0.2 cm (centimeters), length of 0.4 cm, and width 0.8 cm, with a wound bed that contains slough and light serous exudate. R3's Initial Wound Evaluation and Management Summary dated, 9/13/23, and signed by V11 (Wound Physician) documents, Diabetic wound of the right, posterior, upper heel full thickness. This same form documents, Nurse had listed this as posterior ankle, but it does involve the upper posterior calcaneal fat pad and would be considered heel site. R3's care plan dated, 8/28/23, documents, The resident has potential skin integrity of the (right heel r/t (related to) immobility.) This same care plan does not document any revision or new interventions after the heel wound was identified on 9/7/23. R3's physician order dated, 7/28/23, documents orders to Float heels on pillow or use (heel protectors) for pressure relieving every shift for wound care. On 9/11/23 at 11:35 am, R3 was sitting in her wheelchair in her room. R3's left and right heels were observed for 15 minutes resting on R3's foot petals on her wheelchair. R3 had nonslip socks on at this time. R3's (heel protectors) were not on R3's feet and were located on R3's side table. On 9/11/23 at 12:20 PM, R3 was in her room in R3's wheelchair eating lunch. R3 did not have her heel protectors on. R3 stated, I am supposed to wear my heel protectors, but staff doesn't always put them on me, and I need them on for the hole on my right foot. On 9/11/23 at 12:35 PM, V8 (Assistant Director of Nursing/Wound Nurse) stated, Staff (unknown) reported to me on 9/7/2023 that (R3) had an area to the back of her right ankle. I was very busy and I wear multiple hats, so I didn't evaluate the wound or notify the doctor (V7, R3's Physician) until 9/8/2023. V8 confirmed that no new interventions were put into place when R3's wound was identified on 9/7/23 and that R3 did not receive a wound treatment until 9/8/23. V8 stated, (R3) should always have her (heel protectors) on while in her wheelchair. 38396 2. R2's Wound Evaluation Management Summary, dated 8/16/23, and signed by V11 (Wound Physician) documents R2 was seen on 8/16/23 by V11 for a chief complaint of a wound on his left lateral fifth toe. A new order for skin prep to the wound was recommenced at that visit. R2's Treatment Administration Record, dated 9/1/23-9/30/23, documents R2 has a Treatment order to Apply Betadine (topical antiseptic) to left second and fourth toes and left lateral fifth toe daily and PRN (as needed) every day shift for wound care. This order has a start date of 8/26/23. On 9/11/23 at 1:15 PM, V4 (Licensed Practical Nurse) completed R2's wound treatment while R2 remained in bed. V4 cleansed R2's toes and applied Betadine to the 2nd and 4th toe on R2 left foot. A pencil eraser sized scab was noted on the side of R2's left foot (Lateral 5th toe location). V4 stated, There is not a treatment for that site. It has been there for a couple of weeks but there is nothing in place for that one. V4 completed the drying of R2's toes and reapplied a heel protection boot to his foot, without completing any treatment to the left lateral fifth toe site. R2's current care plan, dated 2/2/23, documents, The resident has actual impairment to skin integrity of the left fourth toe and second toe related to diabetic. This care plan does not document any revision since the development of a new wound on R2's left lateral fifth toe. On 9/13/23 at 1:30 PM, V8 (Assistant Director of Nursing/ Wound Nurse) confirmed R2 has a treatment order for his left lateral fifth toe. V8 stated, The Betadine treatment should be done to all three sites when doing his wound care not just the second and fourth toes. On 9/14/23 at 10:10 AM, V16 (Care Plan Coordinator) stated, Some areas of the care plan are done by me and some by other staff. The wound nurse (V8) does the wound care plans. New wound sites should be added to the wound care plan. Anything new for residents should be updated on the care plan within 24 hours. Both CNA's (Certified Nursing Assistants) and Nurses use and look at the care plans for resident cares.

Based on interview and record review, the facility failed to follow physician orders and administer a newly ordered laxative and antibiotic to help reduce the risk of Hepatic Encephalopathy (altered level of consciousness as a result of liver failure) for one of three residents (R1) reviewed for medication errors in the sample of three. Findings include: The facility's Medication Error policy dated 1/4/23, states, Significant medication error means one of which causes the resident discomfort or jeopardizes his/her health and safety. The facility shall ensure medications will be administered as follows: a. According to physician's orders. Medication errors, once identified, will be evaluated to determine if considered significant or not by utilizing the following three general guidelines: a. Resident's Condition: If the resident's condition requires rigid control, such as strict intake and output measurement, daily weights, or monitoring of lab values. b. Drug Category: If the medication is from a category that usually requires the resident to be titrated to a specific blood level such as a medication with a narrow therapeutic index. c. Frequency of Error: If an error is occurring repeatedly such as an omission of a resident's medication several times. R1's Hospital Progress Notes dated 6/5/23-6/12/23, documents R1 was admitted with a primary diagnosis of Hepatic Encephalopathy triggered by constipation related to Hepatic Cirrhosis. R1's Hospital re-admission orders dated 6/12/23, document new orders for Senna 8.6 mg (milligram) by mouth two times per day for a diagnosis of constipation and Xifaxan 550 mg by mouth two times per day for a diagnosis of Hepatic Encephalopathy. R1's Medication Administration Record dated 6/2023, documents R1 was not administered Senna 8.6 mg or Xifaxan 550 mg until 6/17/23. Xifaxan.com states Xifaxan is a non-systemic antibiotic that slows the growth of bacteria in the gut that are believed to be linked to symptoms of overt HE (Hepatic Encephalopathy). Xifaxan is the only FDA- (Food and Drug Administration) approved medicine indicated for the reduction in risk of overt HE recurrence in adults. It was also proven to help reduce the risk of HE-related hospitalization s. Expert guidelines strongly recommend that doctors use Xifaxan together with lactulose as part of a plan to help manage overt HE. R1's Medication Error Report Form dated 6/16/23, documents R1's physician ordered Xifaxan (antibiotic to help prevent recurrence of certain liver problems) 550 mg tablet twice a day was omitted between 6/13/23 and 6/17/23 (9 missed doses). This same form states the Xifaxan was missed during readmit (6/12/23 at 11:57 p.m.)/contributing factor (readmit) was at midnight). V3 (Minimum Data Set (MDS) Coordinator) and V4 (Licensed Practical Nurse) were responsible for the medication error. R1's Medication Error Report states, (R1) had no change in condition. (R1) was seen in the (emergency room ) on 6/14/23 (after a fall with no injury). On 6/23/23 at 12:43 p.m., V3 (MDS Coordinator) stated, I was working 6 p.m. to 6 a.m. when (R1) was readmitted on [DATE] at almost midnight. We had two admissions on that shift. One earlier than (R1). I had medication pass and everything else I needed to do during my shift on top of two new admissions. I went through the other new resident's chart. In the middle of that is when R1 came in around midnight. We got him admitted and to bed. I told him I would be back in to assess everything, and he just wanted to go to bed. I started processing R1's admission but was not able to get it all completed and handed it off to the next shift, who was (V4/Licensed Practical Nurse). On 6/23/23 at 12:47 p.m. V4 (Licensed Practical Nurse) stated she was the day shift on 6/13/23 following the night shift of V3. V4 stated, I didn't have time to even look at (R1's) admission check list. I wasn't aware of (R1) having orders that had not been transcribed or sent to pharmacy. I simply didn't have time on my shift. The admission policy says that two nurses will go over the admission check list to be sure that all orders are entered correctly. In this case, (V3) didn't have time to get the new orders in and I didn't even have a chance to look at what she had completed on the checklist to see that orders had not been processed. (R1) did have new orders for Xifaxan and Senna that were not processed or given as ordered. On 6/23/23 at 9:30 a.m., V6 (R1's family member) stated on 6/16/23, V6 realized R1 was not receiving his Xifaxan and Senna that had been ordered at the hospital. V6 stated R1 returned from the hospital on 6/12/23 and he did not receive either one of those medications until the morning he was discharged . V6 stated R1 ended up in the hospital on 6/17/23 with Hepatic Encephalopathy. V6 stated no physician has told her that R1 not receiving the Xifaxan, or Senna resulted in R1's hospitalization on [DATE]. V6 stated, But that was the reason that the new medications were ordered was to help control the Hepatic Encephalopathy and constipation due to R1's liver failure. R1's Progress Notes dated 6/13/23 through 6/16/23, do not document any change in R1's condition. R1's Progress Notes dated 6/17/23 at 10:15 a.m., document the following: R1's wife was requesting R1 be sent to the hospital to have his ammonia levels checked because she thought R1 was not doing well. (R1) alert with confusion per his norm. Took meds whole this (morning). Voiced no (complaints) at this time. (R1's physician) paged. R1 was sent to the hospital via ambulance. R1's Progress Note dated 6/18/23, states the Hospital called to notify them that R1 has been admitted with a diagnosis of Hepatic Encephalopathy.

Based on interview and record review, the facility failed to identify safety risks for a new admit for one resident (R1) out of three residents reviewed for falls in a sample of three. This failure resulted in R1 falling and sustaining an acute mildly displaced and comminuted fracture involving the surgical neck of the left humerus. Findings include: The facility's Incidents, Accidents and Supervision policy dated 1/1/2020 documents The resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). R1's medical record documents R1 was admitted to the facility on [DATE] for skilled therapy services due to a postoperative open reduction and internal fixation of the left intertrochanteric femur fracture. Fracture of left femur due to fall at home. R1's medical record documents and admitting diagnosis of Fracture of neck of Left femur, [CONDITION(S)], psychotic disturbances, mood disturbance and anxiety. R1's minimum data set (MDS) dated [DATE] documents R1's cognitive skills for daily decision making as Severely impaired. R1's admission MDS scores R1's brief interview of mental status (BIMS) as a 99. R1's neurological admission screen dated 8/29/22 documents Resident is very confused and can verbalizes some things however cannot verbalizes her needs. R1's medical record dated 8/29/22 documents Resident arrived via family transport from hospital. Two person total assist to assist resident out of car. Staff instructed via this nurse to use full mechanical lift until therapy evaluates and states otherwise. Left hip fracture with post surgical wound. Resident is alert with confusion. Regular diet and physically can feed herself however family states she will not feed herself and will want staff to feed her. CNA's (Certified Nursing Assistant) instructed to have resident out to dining room for meals. R1's medical record dated 8/29/22 documents, Resident is very confused respirations easy non labored, lung sounds clear, active bowel sounds in all four quadrants. Post surgical to left hip with [CONDITION(S)] noted to left lower extremity 3 plus pitting, pedal pulses present. Groin red, open wound to sacrum. R1's medical record dated 9/4/22, documents Found resident on floor face down, with left arm underneath her next to her bed, incontinent of bowel, pulled out indwelling catheter, soiled (incontinence brief) in chair next to bed. R1's medical record dated 9/5/22, documents Called primary care physician regarding X-ray results of left humerus. Findings was proximal humeral fracture presumable acute. New orders to call orthopedic office to set up an appointment for outpatient orthopedics. No therapy today. Sling to left arm for comfort only. continue with pain management as ordered. If pain medication is not helping call doctor for further orders. Family was here and spoke with doctor as well on the phone. R1's hospital record dated 9/8/22, documents Acute mildly displaced and comminuted fracture involving the surgical neck of the left humerus. On 9/23/22 at 9:58 AM, V3, Registered Nurse (RN) stated, (R1) was here for physical therapy because she had a fall at home and had hip surgery. I don't think she understood how to use the call light. She was very confused. We don't have an alternate call light method that I know of, just the push button call light and the tap call light. She wasn't on any type of increased monitoring. She was very restless, but we gave her medication for it. On 9/23/22 at 1:45 PM, V4, Licensed Practical Nurse (LPN) verified she was the nurse that found R1 on the floor on 9/4/22 and stated, (R1) had taken of her soiled (Incontinence brief) and threw it in the chair next to her bed. She had an indwelling catheter that she also ripped, probably when she took off the depends. I think (R1) was trying to get up herself cleaned up when she fell . (R1) always thought she had to go to the bathroom. Her confusion got worse toward evening time because I think she was sundowning. (R1) had the tap call light, but she didn't understand how to use it. She was too confused. She had poor safety awareness. She thought she could get up and walk on her own, but her hip surgery prevented her from walking. She was on the standard two hour checks and there was no adjustment to her environment. On 9/23/22 at 2:08 PM, V2, Director of Nursing (DON) stated Ok, so about that. I'll be completely honest with you, there was no baseline care plan done for (R1). It was discovered during (R1)'s fall investigation. I've educated the staff to make sure one is completed for all new admits, but unfortunately there wasn't one completed for (R1) to address her safety concerns. R1 did have the push pad call light, but no, I don't think that's an appropriate intervention for someone who is too confused to understand how to use it.

Based on observation, record review and interview, the facility failed to administer pain medication as ordered by the physician, for one of three residents (R1) reviewed for pain, in a sample of four. This failure resulted in R1's pain being uncontrolled for over 48 hours and experiencing discomfort related to recent spinal surgery, described as a 7-8 on a pain scale of 1-10 (with 1 being the least amount of pain and 10 being the worst pain) and affecting R1's sleep. Findings include: The facility policy, titled Pain Management (12/01/2020), documents, The Facility must ensure that pain management is provided to residents who require such services consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences. The facility policy, titled Medication Reordering (01/01/20), documents, It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident. The electronic medical record documents R1 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Pain Interview completed upon R1's 6/13/22 admission documents R1 has daily, frequent, and severe pain that limits her day-to-day activities. A Minimum Data Set assessment, dated 6/20/22, documents R1 as without cognitive impairment, having no short/long-term memory loss, and experiencing frequent, moderate pain. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Controlled Drug Receipt/Record/Disposition forms, for the months of June 2022 and July 2022, document R1 consistently received [MEDICATION(S)] 5-325 mg two tablets two-four times per day to control her pain. However, the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/13/22 at 10:34 am, R1 was sitting up in her wheelchair, wearing a rigid upper body back brace. R1 grimaced as she adjusted herself in the wheelchair and stated she has suffered from chronic back pain for many years. R1 stated she came to the facility following a recent back surgery, because she lives alone and needed therapy. R1 stated she had an issue about a week and a half prior, where staff were unable to get her [MEDICATION(S)] refilled and they would not pull [MEDICATION(S)] from their Emergency Medication Box for her. R1 stated, since her back surgery, she suffers from constant back pain that varies in intensity. R1 stated she needs to stay on top of her pain, or it will get worse. R1 stated her pain medication is not scheduled as routine, but she tries to take it as routinely as possible, so the pain doesn't get unbearable. R1 stated the nurse gave her Extra Strength Tylenol when they couldn't get her [MEDICATION(S)] refilled, but that didn't touch it. R1 described the pain as a 7-8 on a scale of 1-10 when she didn't have her [MEDICATION(S)]. R1 described the pain as being bad and stated, (I) could not sleep and it was impossible to get comfortable. On 7/13/22 at 1:23 pm, V4 (Registered Nurse) stated on the evening of 7/02/22 the facility ran out of R1's [MEDICATION(S)] 5-325 mg and could not pull any [MEDICATION(S)] from the Emergency Medication Box because they could not get a signed prescription from V8 (Medical Director). V4 explained that R1's prescription for [MEDICATION(S)] needed refilled and in order to take [MEDICATION(S)] from the Emergency Medication Box, they need a signed (electronically) prescription. V4 stated she actually attempted to obtain a refill of R1's [MEDICATION(S)] on the Wednesday prior (6/29/22) to the holiday weekend, because she knew R1 routinely takes her pain medication and would likely run out by that Saturday (07/02/22). V4 stated other nursing staff also attempted to contact V8 regarding the [MEDICATION(S)] refill, on 6/30/22 and 7/01/22, per the correspondence given from shift change; however, staff were unable to obtain the refill authorization from V8 via phone or fax. V4 stated, by 7/04/22, R1 was pretty uncomfortable, very emotional and upset over being in pain and the unavailability of her pain medication. V4 continued to attempt to reach V8 by phone, as her office was closed for the weekend, but was only able to leave messages. V4 stated she gave R1 Extra Strength Tylenol, but it did not touch R1's pain. V4 stated she tried to reposition R1 and attempted to calm her so her pain would not get worse, but nothing worked. V4 stated R1 was extremely concerned about staying on top of her pain symptoms, since she routinely took [MEDICATION(S)] for chronic back pain prior to her back surgery, when she was at home. V4 stated V2 (Director of Nursing) came into the facility on the afternoon of 7/04/22, and she expressed concern over still being unable to reach V8 to refill R1's [MEDICATION(S)]. V4 stated V2 called V8 herself, and within 20 minutes, the refill was authorized, and she was able to access the [MEDICATION(S)] in Emergency Medication Box for R1. On 7/13/22 at 2:09 pm, V5 (Licensed Practical Nurse) stated it is difficult to obtain a signed prescription from the physician over the weekend, whether it is V8 or the physician on call. V5 stated the physician has the ability to electronically sign for narcotic refills through the pharmacy system and staff have access to V8's cell phone number but getting V8 to make those authorizations is hard. V5 stated that due to the difficulties they have obtaining electronic signatures for medication refills on the weekend, they try to be proactive and make their refill requests a few days in advance. On 7/13/22 at 1:55 pm, V2 (Director of Nursing) stated there is no reason a resident should go without their pain medication. V2 stated staff should reach out to V8 or the on-call physician to obtain refills, as they can provide an electronic signature directly to the pharmacy to authorize any refill. V2 confirmed that V4 asked her to contact V8 the afternoon of 7/04/22, because V4 needed to access the Emergency Medication Box to administer R1 her [MEDICATION(S)], which she did. V2 stated she was unaware that nursing staff had been attempting to reach V8 since 6/29/22 to authorize a refill of R1's pain medication, and nursing staff should have informed her of the issues they were experiencing.

Based on observation, interview and record review the facility failed to ensure an electronic wander management system/door alarm system was in working order, failed to re-assess (R1) as high risk for elopement once (R1) started to exit seek, failed to revise/update (R1's) elopement care plan after (R1) eloped, and failed to provide adequate supervision for one of three residents (R1) reviewed for elopement risk in the sample of three. These failures resulted in R1, a moderately cognitively impaired resident with the diagnosis of Dementia, eloping from the facility on two different occasions and on 4-24-22 R1 eloping from the facility up a grassy embankment, across a street between the facility and a church, and entering into a church 250 feet away from the facility. The facility was unaware of R1 missing until (V7/Pastor) located R1 and contacted the facility. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 5-6-22, the facility remains out of compliance at a severity Level II as the facility continues to investigate R1's elopement in February, 2022; provide in-servicing to all staff on R1's updated care plan interventions including providing one on one staff supervision and diversional activities; provide in-servicing of all staff on identified residents at risk for elopement and how to provide adequate supervision for those at risk to prevent elopement; and assess all residents quarterly who wander/exit seek and with any changes in behavior. The facility's IDT (Inter-Disciplinary Team) will review 24- and 72-hour notes to assess for changes in resident behaviors and needs for completion of a wandering risk assessment. Findings include: The facility's Elopements and Wandering Residents policy dated 1-1-2020 documents, Policy: This facility ensures that residents who exhibit wandering behavior and/or at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Definitions: Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. Policy Explanation and Compliance Guidelines: 1. The facility is equipped with door locks/alarm to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risk, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 4. Monitoring and managing residents at risk for elopement and unsafe wandering. a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize the risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements. e. The effectiveness of interventions will be communicated to relevant staff. The facility's Wander Guard (electronic alarm monitoring) System Inspection dated 4-21-22 at 8:30 AM and signed by V6 (Maintenance Director) documents all door alarms, including 100-hallway, 200-hallway, 300-hallway, and 400-hallways were last inspected on 4-21-22 and working. The facility's Maintenance Checklist Full Service dated 4-22-22 documents the generator's manufacturer's technician provided the facility with a full generator service. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is moderately cognitively impaired and wanders one to three days per week that does not put the resident at significant risk of getting to a potentially dangerous place (outside of the facility). This same MDS documents R1 requires supervision when walking in his room, walking in the corridor/unit, and locomotion off and on of the unit. R1's Physician's Order Sheets (POS's) dated 5-4-22 document R1 has the diagnoses of unspecified dementia without behavioral disturbance, unsteadiness on feet, cognitive communication deficit, history of falling, muscle weakness, and generalized anxiety disorder. These same POS's document, Order date 3-11-22: Check wander guard (electronic monitoring bracelet) function on Saturdays for safety. R1's Morse Fall Scale dated 3-3-22 documents R1 is a high risk for falling. R1's Wandering Risk assessment dated [DATE] documents, Category: Moderate risk for wandering. Score: 7. Orientation: Disoriented times two. Forgetful/short attention span. Diagnosis: Early Dementia. History of wandering unchecked (meaning R1 does not have a history of being a wanderer/history of wandering. R1's Progress Notes dated 1-28-21 document, (R1) wandering and exit seeking this shift. R1's Progress Notes dated 1-30-21 document, (R1) alert with confusion. (R1) frequently ask this nurse to take him home. Exit seeking out 200 hall door. Easily re-directed. R1's Progress Notes dated 2-4-21 document, (R1) ambulates with wheeled walker. Tried to exit building multiple times. Reminded (R1) that he lives here now. Resident stated that he could not remember anything now. R1's Progress Note dated 4/7/2022 at 5:54 PM documents, (R1) having increased confusion. (R1) wanting to leave and is difficult to redirect. (R1) becomes agitated with staff when redirected and was slamming walker on the ground. (R1) usually redirects easily. R1's Progress Note dated 4/7/2022 at 4:59 AM document, (R1) wandering and exit seeking this shift. Staff redirected with minimal difficulty. R1's Progress Notes dated 1-28-21 through 4-24-22 document multiple occurrences of R1 trying to exit seek and wander. R1's Wandering Risk Assessment has not been updated from 8-20-20 through 4-23-22 to address R1's wandering and exit seeking that started according to R1's Progress notes on 1-28-21. R1's Progress Notes dated 4-24-22 at 9:45 AM and signed by V3 (Licensed Practical Nurse) document, (R1) outside of building. CNA's (Certified Nursing Assistants) went and got (R1) and (R1) came back inside without difficulty. Wander guard (electronic monitoring bracelet) in place. On call nurse notified as well as maintenance to come and check door alarms. 15-minute checks started at this time. R1's Progress Notes dated 4-24-22 at 10:00 AM and signed by V3 document, Full body assessment completed, and no injuries noted. (V4/R1's Physician) and (V5/R1's Family Member) notified. R1's Final State Report dated 4-28-22 and signed by V1 (Administrator) documents, (R1) is an [AGE] year-old male. On 4-24-22 at approximately 9:45 AM it was reported that (R1) was out of the facility and a Lakeland Community Church. Staff member went to the church and assisted (R1) back to the facility. Type of Injuries: No injuries. Summary of Investigation: (R1) ambulates with a wheeled walker and exhibits both wandering and exit seeking behaviors. Due to being assesses as high risk for wandering/elopement, resident has a wander guard in place. At approximately 9:45 AM the facility received a call from the (V7/Pastor) at Lakeland Community Church, located on the south side of the building, to report that (R1) was at the church and wanted to return back to the facility. Staff members went to the church and assisted (R1) back to the facility. (V5/R1's family member) and (V4/R1's Physician) were notified. (V1/Administrator) was contacted and informed of (R1) exiting the building at 9:30 AM. No staff members heard any door alarms going off including the wander guard alarm system. (V6/Maintenance Director) was immediately notified of alarm system no working. (V6) came to the facility and checked alarm system and found a fuse had blown. At approximately 10:30 AM on 4-24-22 (V6) replaced the fuse and alarm system was functioning properly. R1's Elopement Risk Care Plan dated 3-16-22 documents, Created on 1-8-21 Focus: (R1) is an elopement risk at times related to disoriented to place. Goal: (R1's) safety will be maintained. Interventions: Distract (R1) from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Provide structured activities: toileting, walking inside and outside, and re-orientation strategies including signs, pictures, and memory boxes. Wander guard in place. This same Care Plan has not been updated to address R1's elopement from the facility on 4-24-22. R1's Medical Record does not include any other Wandering Risk Assessments from 8-12-20 (R1's) admission through 4-24-22 at 9:45 AM (R1's elopement date). The Google Maps website page dated 5-4-22 documents the church where R1 was found on 4-24-22 is 262 feet from the facility with Buckeye Street running in-between the facility and the church on the South side of the facility. These same website documents Main Street is located in the front of the building. On 5-4-22 at 8:00 AM, R1 was sitting in the dining area across from the nurse's desk. R1 was pleasantly confused and was unaware of date, time, and place. R1 had a Wander guard bracelet to his left ankle and a walker to the right side of him. On 5-4-22 at 10:30 AM this surveyor noted the front door of the facility goes out to a parking lot where staff and visitor's park. In front of this parking lot is a grassy ditch with a steep embankment that goes up to a main street which is the main route of vehicles within [NAME], Illinois. In-between the facility and the church where R1 was found is a steep grassy embankment and then a side street (Buckeye Street) that R1 would have had to went up and crossed to get to the church. The church shares a parking lot with Walmart (a department store). On 5-4-22 at 8:15 AM V10 (LPN) stated, (R1) looks outside frequently and goes to the doors frequently. (R1) always states 'I am going home now. On 5-4-22 at 8:30 AM V11 (CNA) stated, (R1) walks up to the doors all of the time. (R1) does not have good safety awareness. (R1) sets off the door alarms when he tries to leave, and that is when we know (R1) is attempting to go outside unattended. On 5-4-22 at 9:00 AM V6 (Maintenance Director) stated, I have been at the facility for two months. I test the door alarms once a week. On 4-22-2022 the generator had its annual inspection all day long. I did not know that by turning the generator off and on that it blew a fuse to the wander guard system. On 4-24-22 I got a call that the alarms were not working on the doors and (R1) had gotten out of the facility, I came into the facility on [DATE] around 10:20 AM and checked the Wander guard system. When I came in none of the exit door wander guard alarms were working. That is when I found a fuse was blown and replaced the fuse. The wander guard alarms have worked since I changed the fuse. On 5-4-22 at 9:35 AM V3 (LPN) stated, On 4-24-22 I saw (R1) sometime between 8:00 AM to 8:30 AM I saw (R1) across from the front nurse's station. (R1) tries to exit seek at times. (R1) will try to open doors and the alarms go off. When the alarm goes off it startles (R1), and he stops trying to go outside. (R1) tried to open doors and exit seek a couple times daily. Around 9:45 AM I got a call from (V7/Pastor) that (R1) was at the church and (V7) wanted someone to pick (R1) up. (V8 and V9) went to the church and brought (R1) back to the facility. The weather was chilly and rainy that day. (R1) had clothes, a jacket, and shoes on and had no visible injuries. No alarms had gone off within the facility to let us know that (R1) exited the facility. (R1) is very confused and would not know to watch for cars before crossing the street. (R1) would not be safe outside by himself. I believe (R1) exited out of the front door. All other exit doors have another delayed response alarm that would have sounded had (R1) tried to exit out of them. The front door alarm is shut off every day from 8:00 am to 4:30 PM. (R1) also wanders to the front lobby and is always looking for his car and wanting to go home. On 5-4-22 at 9:55 AM V8 (CNA) stated, I have to re-direct (R1) back to 200 hallway a lot. (R1) tried to exit seek every day. (R1) tries to open doors and the alarm will sound which frightens him. (R1) is always asking staff if they are going to [NAME], or if they can take (R1) home. On 4-24-22 the last time I saw (R1) was around 8:45 AM. I re-directed (R1) from the front lobby back down to 200 hallway. (R4) had told me that she saw (R1) go past her outside window and I did not think (R4) knew who (R1) was. I saw a visitor was at the facility with a walker and though (R4) must have saw the visitor. I went to the desk to report this to the nurse, and (V3) was already on the phone with (V7) who was reporting (R1) was at the church. (R1) would have had to exited out of the front door if (R4) saw him walk by her window. No alarms were sounding. (R1) would not be safe walking outside alone or trying to walk up a ditch. (R1) would fall very easily. The roads around here are very busy and (R1) could get hit by a car. There is also a small lake across the road from the facility where (R1) could drown. I went with (V9/CNA) to pick up (R1) from the church. (R1) had clothes on, a jacket, and shoes. It was pouring down rain that day. I got soaked going to my car. (R1) was not that wet. (R1) did not have any injuries. On 5-4-22 at 10:00 AM V9 (CNA) stated, On 4-24-22 around 9:30 AM I re-directed (R1) to 200 hallway from the front nurse's station. (R1) was adamant that he was going home that day. (R1) exit seeks and tries to open doors daily. (R1) is very homesick. Around 9:45 AM me and (V8) had to go to the church next door to pick up (R1). I was down-pouring when we went to pick up (R1). (R1) was not injures and had clothes and shoes on. No alarms were sounding that day. I do not know what door (R1) exited out of. (R1) would be unsafe to go outside unattended. (R1) would not know where he was or how to watch for cars. On 5-4-22 at 12:45 PM R4 stated, I saw (R1) go by window outside (on 4-24-22) in the parking lot. I told staff. On 5-4-22 at 1:00 PM V2 (Assistant Director of Nursing/ADON) stated, (R1's) wandering risk assessment should have been completed quarterly with the MDS schedule. (R1) has only had one wandering risk assessment done on admission 8-20-20. When (R1) started wandering and exit seeking in February 2021, a wandering risk assessment should have been done to assess (R1) as being high risk for elopement and assess for hazards and interventions to prevent (R1) from eloping. On 5-5-22 at 7:45 AM V2 verified that R1's elopement care plan has not been updated since R1 to address R1 eloping from the facility on 4-24-22. On 5-5-22 at 7:20 AM V5 (R1's Family Member) stated, (R1) had gotten out in the front parking lot in the wintertime this last February. I know a visitor saw him and the staff were able to bring him back in. (R1) is not safe to go outside unattended and would not know where he is going. (R1) could get hit by a car, fall, or get lost. It scares me to think that (R1) could get out of the facility without staff knowing. On 5-5-22 at 8:00 AM V12 (RN/Registered Nurse) stated, I was told in report by (V8/CNA) that one day earlier this year in the wintertime (R1) was outside unattended in the front parking lot trying to get into cars. By the time (V8) had found (R1) his walker was cold with frost on it. (R1) is always trying to go outside and I know the front door doesn't always latch right. On 5-5-22 at 9:35 AM V13 (CNA) stated, I know visitors have let (R1) outside before because they thought (R1) was a visitor and not a resident. I do not remember when this was. (R1) is constantly trying to exit seek. On 5-7-22 at 10:15 AM V1 stated, I completed an investigation today regarding (R1) exiting the building in February 2022. After reviewing nursing schedules (R1) had to have exited the building on February 16, 2022. (V15) had found (R1) outside unattended and had brought him back inside. (V15) thought that she had informed me of finding (R1) outside and had thought she filled out a witness statement. I do not recall (R1) ever telling me about (R1) being found outside and have not located a witness statement. On 5-7-22 at 10:45 AM V15 (Activity Director) stated, One day in the middle of February 2022 I was in the front lobby and saw (R1) outside in the cold. (R1) was trying to get back into the facility was shaking the door trying to open the door. No alarms were sounding, and no staff were with (R1). I am not sure how (R1) got outside unattended. I brought (R1) back into the facility. (R1's) walker was cold. The Immediate Jeopardy was identified on May 5, 2022, to have started on February 16, 2022, when the facility failed to provide adequate supervision and implement elopement interventions after R1 was found outside of the facility, unattended by staff, resulting in R1 eloping from the facility a second time up a grassy embankment, across a street between the facility and a church, and entering into a church 250 feet away from the facility. V1 (Administrator) and V2 (Assistant Director of Nursing) were notified of the Immediate Jeopardy on 5-6-22 at 12:05 PM. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 4/24/22 V1 instructed that a staff member be placed at each door to monitor until V6 (Maintenance Director) assessed the problem and replaced the fuse. 2. On 4/24/22 V6 checked all doors to ensure that the Wander guard system was working. 3. On 4/24/22 each Wander guard was checked to ensure proper functioning by nursing staff. 4. On 4/24/22, V1 in-serviced all staff on the Elopement & Wander guard policy. 5. On 4/24/22, V6 in-serviced all staff regarding contacting V6 when the generator is operating. 6. On 4/25/22, V2 (ADON) and V14 (MDS/Minimum Data Set Coordinator) conducted an audit to ensure current a wandering risk assessment was completed for all residents with a Wander guard. 7. On 4/25/22, V2 and V14 conducted care plan and treatment administration record audits for all residents with a Wander guard. 8. On 4/25/22, V1 reviewed the elopement communication book to ensure that it was updated. 9. On 4/26/22, an electrician completed an inspection of fuse box. 10. On 4/28/22, a six-amp (ampere) fuse and outlet suppressor were installed. 11. On 5/5/22, V1 provided an in-service to nursing staff regarding checking doors to ensure that exit doors are alarmed at all times and ensure exit doors are checked by anytime electricity is interrupted to ensure alarms are on and in working order. 12. On 5/5/22, daily exit door and Wander guard door audits were initiated by nursing staff. 13. On 5/5/22, V1 sent an initial report to IDPH (Illinois Department of Public Health) regarding R1's possible elopement in February 2022 and an investigation was initiated. 14. On 4/24/22, a wandering risk assessment was completed for R1. 15. On 5/6/22, V1 provided an in-service to V14 regarding assessing all residents quarterly who wander/exit seek and who have any changes in behavior. 16. On 5/5/22, one on one staff supervision of R1 was initiated by V1. 17. On 5/5/22, R1's care plan was updated by V14 to include the one-on-one staff supervision and on 5/6/22 R1's care plan was updated with additional diversional activities. 18. On 5/5/22, all staff were in-serviced on R1's updated care plan interventions of providing one on one staff supervisor and diversional activities, on identified residents at risk for elopement, and on how to provide adequate supervision for those at risk to prevent elopement. Abatement completion date: 5/6/20

Based on record review and interview, the facility failed to obtain treatment orders for a surgical wound and provide wound care, for one of five residents (R3) reviewed for wound care in sample of five. These failures resulted in R3's surgical chest wound not being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: The facility policy, titled Wound Treatment Management (dated 12/01/2020), documents, To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physicians orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. The electronic medical record documents R3 was admitted to the facility on [DATE] after undergoing a parotidectomy and neck resection due to malignancy. Nursing Progress Notes document R3 was re-hospitalized from 1/07/22 to 1/11/22 due to complications and infection of her neck wound. An Admission/Readmission Nursing Assessment, dated 1/11/22, documents R3 had a total of four surgical incisions on her body at that time, including one located on her chest. The Physicians Orders and Treatment Administration Records fail to document any treatment that was provided to the wound on R3's chest from 1/11/22 to 1/18/22. Nursing Progress Notes, dated 1/18/22, document V7 (Registered Nurse) contacted R3's Surgeon to obtain treatment orders for surgical wounds located on R3's left breast and clavicle. On 1/19/22, Nursing Progress Notes by V7 document, This (Nurse) called and updated (Surgeon's) nurse about (R3's) wound on her left breast and her condition. Wound is draining yellow/green fluid, red and inflamed, warm to the touch and smells like necrotic tissue. (R3) is very drowsy, reporting that she does not feel good and is very week. Staff reported that resident could not hold self-up when they tried to get her up this (morning). Subsequent documentation in the Nursing Progress Notes on 1/19/22, indicates the Surgeon ordered R3 to go to the emergency room for evaluation of a change in condition. An emergency room Note Report, dated 1/19/22, documents upon arrival, R3 had an incision with staples under the left breast with a (Jackson Pratt) drain which has some purulent drainage. (R3) is sent from the nursing home. Medics did not really know why she was being transported other than there is some drainage in the (Jackson Pratt) drain which would be expected. Nursing home staff did not give a clear cut indication for her being seen today. I looked on the (Hospital) website and found the communication from today that the dressing under the left breast was just changed for the first time yesterday, which was 10 days post (operation), so the dressing looked yellow and dirty. Further emergency room documentation, from 1/19/22, indicates R3 was returned to the facility the same day with instructions to continue ordered oral antibiotic therapy. Nursing Progress Notes, dated 1/21/22, document R3's Surgeon ordered a culture of the wounds on the left breast and clavicle, due to continued signs of infection. On 1/25/22, Nursing Progress Notes document R3's left breast and clavicle wound culture was positive for [CONDITION(S)] ([CONDITION(S)]-resistant Staphylococcus Aureus) infection that would require treatment with intravenous [MEDICATION(S)]. Nursing Progress Notes, dated 1/26/22, document R3 was hospitalized on that day for ongoing treatment and medical management of the left breast and clavicle wounds. On 1/26/22 at 10:40 am, V6 (Certified Nursing Assistant) stated, when she came to work on 1/18/22, she could smell a foul odor, like infection or necrotic tissue. V6 stated the Nurse on duty, V7 (Registered Nurse), smelled the same odor and went room to room looking for the source. V6 indicated the odor came from R3's room. According to V6, it was at that time that V7 found a dressing on R3's chest that had been there for 10 days, saturated with drainage. V6 stated, the next day R3 had to be sent out to the hospital and she had an infection in the wound. On 1/26/22 at 12:13 pm, V7 (Registered Nurse) stated at the start of her shift on 1/18/22, V6 told her they could smell necrotic tissue on the hall. V7 stated she noticed the odor coming from R3's room. V7 stated she assessed R3, who had a wound vacuum to a large surgical wound on her left jaw and ear, a Jackson Pratt Drain, and a dressing to a wound on her back. V7 stated those wounds all looked good and had no evidence of infection. V7 then noted a dressing on R3's left clavicle and a surgical dressing under the left breast. V7 stated the surgical dressing under the left breast smelled like necrotic tissue, the dressing was black, and the wound appeared horribly infected. V7 stated she looked for the treatment order for the clavicle and wound under the left breast. V7 could not find any evidence of a treatment or treatment order for those wounds and noted that R3 had returned from the hospital on 1/11/22, one full week prior. V7 stated she told V2 (Director of Nursing) that R3 chest wounds had not been treated or assessed since she returned from the hospital on 1/11/22. V7 stated the dressing under the left breast was not dated, but she was familiar with the surgical dressing R3's Surgeon used from her previous job, and the dressing under the left breast was not one that they use at the facility. V7 contacted the Surgeon's office and obtained orders to cleanse and treat the wounds on the left clavicle and under the left breast. V7 stated the next day, R3 indicated she was not feeling well and appeared weak. V7 stated R3 could normally ambulate to the bathroom and she was too weak to do so. V7 assessed R3's wounds and noted the wound under the left breast was very red and inflamed, draining purulent drainage, so she contacted the Surgeon again. V7 stated R3 was later sent out to the hospital for evaluation. On 1/26/22 at 12:55 pm, V8 (Registered Nurse) stated she completed R3's 1/11/22 readmission nursing assessment and does recall that R3 had a dry dressing in place over a surgical wound under her left breast and on her clavicle. V8 stated it is protocol to notify the physician, if a resident does not have a treatment ordered for a wound that they have upon admission. V8 was unable to answer as to why she did not notify the physician on 1/11/22 that R3 had surgical wounds with no treatment orders. V8 stated R3 had to be admitted to the Hospital today (1/26/21), so she could be treated with intravenous [MEDICATION(S)] for a [CONDITION(S)] infection of the wound under the left breast.

Based on observation, interview and record review, the facility failed to properly transfer residents, ensure supervision was provided to prevent additional falls, document the root cause analysis of falls and implement additional interventions to decrease the risk of future falls for three of three residents (R28, R39, R47) reviewed for resident injury in the sample of 23. These failures resulted in R28 falling at the facility on 1/31/21 and sustaining a left femur fracture, as well as R47 falling at a local dentist office on 12/22/20 during an improper transfer by a facility staff member and sustaining a left tibia fracture. Findings include: The Facility's Incidents, Accident and Supervision policy dated 1/1/20, states The resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary. 2. Evaluation and Analysis-the process of examining data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents. Interdisciplinary involvement is a critical component of this process. a. Data collection includes documents that are for review of the QAPI (Quality Assurance and Performance Improvement) Committee only: Risk Management Report, Post Fall Huddle Summary, etc. b. Analysis may include, for example, considering the severity of hazards, the immediacy of risk, and trends such as time of day, location, etc. Both the facility-centered and resident-directed approaches include evaluating hazard and accident risk data, which includes prior accidents/incidents, analyzing potential causes for each hazard and accident risk, and identifying or developing interventions based on the severity of the hazards and immediacy of risk. d. Evaluations also look at trends such as time of day, location, etc. 3. Implementation of Interventions-using specific interventions to try to reduce a resident's risk from hazards in the environment. The process includes a. Communicating the interventions to all relevant staff. b. Assigning responsibility. c. Provide training as needed. d. Documenting interventions (e.g. plans of action developed by the QAPI team or care plans for the individual resident). e. Interventions are based on the results of the evaluation and analysis of information about hazards and risks and are consistent with relevant standards, including evidence-based practice. f. Development of interim safety measures may be necessary if interventions cannot immediately be implemented fully. g. Facility-based interventions may include, but are not limited to: i. educating staff, ii. repairing the device/equipment, iii. developing or revising policies and procedures. h. Resident-direct approaches may include i. implementing specific interventions as part of the plan of care, ii. supervising staff and residents, etc. iii. facility records document the implementation of these interventions. 5. Supervision-Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. 1. R28's Minimum Data Set assessments dated 10/18/20 and 1/13/21, document R28 has severely impaired cognition, requires extensive assistance with transfers and is unable to ambulate. R28's Fall Risk assessment dated [DATE], documents R28 is at high risk for falls. R28's Fall Report dated 12/10/20 at 7:30 p.m., documents R28 was observed on the floor, sitting in front of the wheelchair next to the bed. R28's Fall Investigation dated 12/10/20, does not document a root cause analysis of the fall or new interventions to prevent future falls. R28's Care Plan dated 6/3/21, was not revised to reflect R28's fall on 12/10/20. R28's Fall Report dated 12/11/20 (unknown time), documents R28 was walking without assistance and the nurse attempted to assist back to bed and R28's knees gave out and R28 was lowered to the floor. R28's Fall Investigation dated 12/11/20, does not document a root cause analysis of the fall or new interventions to prevent future falls. R28's Care Plan dated 6/3/21 was not revised to reflect R28's fall on 12/11/20. R28's Fall Report dated 1/30/21 at 8:30 a.m., documents R28 fell in front of her wheelchair with no injuries. R28's Fall Investigation dated 1/30/21, does not document a root cause analysis of the fall or new interventions to prevent future falls. R28's Care Plan dated 6/3/21, was not revised to reflect R28's fall on 1/31/21. R28's Fall Report dated 1/31/21 at 3:30 p.m., documents R28 was found on the floor in the doorway of her room. R28 complained of right upper leg pain. R28's same fall report dated 1/31/21 at 4:15 p.m., documents R28 fell again after transferring self from her wheelchair to another resident's bed. R28 complained of right upper leg pain. X-ray results were received at 3:36 p.m., and documented R28 had a fracture of the neck of her right femur. R28's Fall Investigation dated 1/31/21, does not document a root cause analysis of either fall or new interventions to prevent future falls. R28's X-Ray report dated 2/1/21, documents a right hip fracture. On 07/1/21 11:30 a.m., V2 (Director of Nursing) stated R28's fall reports dated 12/10/20, 12/11/20, 1/30/21, and 1/31/21 did not document a root cause analysis or any new interventions to help prevent future falls. V2 verified R28's care plan dated 6/3/21, was not revised to reflect R28's falls/interventions after falls on 12/10/20, 12/11/20, 1/30/21, or 1/31/21. 2. On 06/29/21 at 11:25 AM, R47 was alert sitting up in her wheelchair with a mechanical sling underneath of her. R47 stated, I can't wait to not be a mechanical lift anymore. Now that I'm a lift I can't use the restroom. I have to go to the bathroom in my adult incontinent brief, and its awful. I was doing therapy and only using the sit to stand assist lift; however, I fell on [DATE] at a dentist appointment and broke my tibia. So now I'm a mechanical lift. I was even at the point of taking steps in therapy. My wheelchair wouldn't fit thru the door at the dentist office, so the one (V8 CNA-Certified Nursing Assistant) who took me told me I had to walk. I told them I could only walk six steps and I didn't feel comfortable doing it. So, on the 7th step I ended up falling. I had pain when it happened, but then as it went on it got worse and worse. I have a high pain tolerance and normally just tolerate pain. Before this I barely took any pain medication, so to take pain medication it took a lot. Initially it was an aching pain. After the x-ray came back negative the staff continued to transfer me with the sit to stand assist lift, so I was still putting weight on that leg. It would send shooting pains in my leg. I ended up staying in bed for a while because I was in so much pain and didn't want to get up because of having to put weight on it. They didn't increase my pain medication until I suggested it to them. I requested the appointment with the orthopedic doctor as well because I knew something was wrong. It was the orthopedic doctor who finally found the fracture. Then, I had to be a mechanical lift. I've been a mechanical lift ever since then. I just got orders that I can put weight on that leg again so I'm crossing my fingers that I can at least be a sit to stand assist again so I can go back to using the actual bathroom, and maybe take steps eventually. R47's Care plan, dated 6/3/21, documents that at the time of R47's fall, R47 was a two person assist with a sit to stand lift. R47's Post Fall Observation, dated 12/22/20, documents, Resident stated that staff at dental office was attempting to have R47 ambulate from wheelchair to dental chair when she had to be lowered to the ground. R47's left leg was under her bottom during lowering. Was there a deviation from usual status: Yes, dental office staff attempted to assist resident in walking from wheelchair to dental chair. Summarize potential factors that could have contributed to the fall: Staff unfamiliar with R47 at other facility. Describe measures to be taken to prevent further falls: Ensure transfer status is known among other facilities. R47's Fall Investigation, dated 12/22/20, documents, 10:10 a.m. (R47) returns from dentist appointment and reports that she had fallen at the dentist office. (R47) states that she was lowered to the floor during transfer from the wheelchair to dental chair. Complains of pain in left leg, states leg was under bottom. The Investigation also documents, (R47) is alert and oriented with a BIMs (Brief Interview of Mental Status) score of 15 (cognitively intact). (R47) requires assistance with transfers and cares. On 12/22/20, (R47) was transferring from wheelchair at dentist appointment to dental chair and was lowered to the floor, resulting in left leg bending back and being under her bottom. Physician did a telehealth visit with (R47) due to fall at the dentist. (R47) complaining of pain to left lower leg and bruising noted. Physician ordered an x-ray at this time. Mobile x-ray done; no fracture noted. R47's Nurses' note, dated 12/22/2020 at 12:20 p.m., documents, Physician did a telehealth visit with R47 due to fall at the dentist. R47 complaining of pain to left lower leg and bruising noted. physician ordered an X-ray at this time. R47's Staff Statement, dated 12/22/20, documents an interview with V8 stating, During transfer at dentist resident was lowered to the floor. R47's Fall Care plan, dated 6/3/21, documents that R47's care plan was not revised with new interventions to prevent further accidents. R47's Nurses' note, dated 1/5/2021 at 07:59 a.m., documents, Warmth, bruising, pain and swelling noted to left lower extremity. V7 (R47's family) requests x-ray of knee and lower leg. R47's Orthopedist note, dated 1/13/21, documents, After her distal femur fracture, she was never really able to ambulate for any sustained distances. She spends most of her time in a wheelchair and often times will use a mechanical lift and staff assistance for transfers at the skilled facility. She presented today for a visit though, as unfortunately she sustained another ground level fall on December 22, 2020 or approximately 3 weeks ago. She was at the dentist's office and was required to get out of her wheelchair and walk a certain distance to the dental chair. After a few steps, she became fatigued given her deconditioning and fell on to the left knee. She had discomfort and some swelling and bruising since that time. X-rays were apparently ordered at the skilled nursing facility upon her return, which showed a left proximal tibia periprosthetic fracture. She presents today in the office for further evaluation. Assessment: Left knee proximal tibia periprosthetic fracture. A facility State Reportable, dated 1/14/21, documents, on 12/22/20, (R47) went out of building to dentist and staff at dental office attempted to have resident ambulate from wheelchair to dental chair. (R47) was lowered to the floor and left leg was bent under her bottom. Facility CNA (V8) also assisted resident at dentist appointment. Type of Injuries: Proximal Tibial Fracture. Disposition: 12/22/20: (R47) had fall during transfer with staff at dentist office. (R47) complained of pain, with swelling to left knee area. MD notified of fall and did telehealth visit on 12/22/20 with order for x-ray. X-ray of tibia/fibula shows no acute fracture or dislocation in left tibia and fibula. Ice pack and Tylenol. (R47) continued to have pain in left knee area, staff continued to monitor. On 1/2/21 continued left leg pain and bruising noted. On 1/5/21 physician notified of request for second x-ray. Order received for x-ray and doppler knee shows old healing distal femur left knee fracture (this was original diagnosis on admit 1/4/19). Venous doppler performed 1/6/21 negative for DVT (Deep Vein Thrombosis). Per resident and V9 request resident had appointment with orthopedic doctor. On 1/13/21 reported new tibula fracture. Order received for non-weight bearing of left lower extremity, no left knee ROM (Range of Motion), hinged knee immobilizer locked on extension, ok to open brace while in bed for skin care. Follow up in four weeks. On 06/29/21 at 03:17 PM, V1 (Administrator) stated, (V8) went with (R47). (R47's) wheelchair would not fit into dentist exam room. So, they (dental office) asked if she could walk from the wheelchair to the exam chair. They were asking her to walk, which she is not really able to do. On 06/29/21 at 03:38 PM, V7 stated, When she went to the dentist appointment, (R47) was a sit to stand lift. The dental place asked her if she could walk just a few steps from her wheelchair to the chair. (V8) was with her the whole time. (V8) was the one who assisted (R47) to walk to the chair. (V8) was aware of her abilities and took care of her so he should have known not to walk with her. The dentist office called 911 and the fire department transferred her back to her wheelchair. (R47) was not transported to the hospital. After it happened, (V8) called me to let me know. (R47) continued to complain of pain. (R47) is very tolerant of pain. At that time, she would say it was uncomfortable, swollen, and it hurts. (R47) would say it was around a 5 or 6 (on a pain scale of 0-10) but with her tolerance that would be extremely high for myself. A normal person it would probably be rated a 30. I knew something was wrong with her complaining because she didn't complain. As it went on, I wondered if something else was going on because she continued to complain. One day I went in there she pointed out to me that it was swollen. I spoke with the nurse and asked if there was anything we could do, and that is when the second X-ray was ordered. On 06/30/21 at 10:54 AM, V12 (Dental Office) stated, (R47's) wheelchair would not fit thru the exam room doorway. (V8) had a gait belt on (R47) and attempted to walk (R47) to the exam chair, but she ended up going down. Both (R47) and (V8) sat on the ground for a while because he couldn't get her up off of the floor by himself. We don't help patients with transfers to the chair or walking. We couldn't help with getting her up off of the floor even, so we had to call the fire department for lift assistance. On 07/01/21 at 09:47 AM, V2 (Director of Nursing) stated, (R47) was a sit to stand lift transfer status. If (R47) was a sit to stand lift transfer, then she was not able to ambulate. We should follow the same transfer/ambulation status at the appointments as what she is in the facility. It is my understanding that she went to the dentist before and was not able to see her because she couldn't transfer into the exam chair so that appointment was rescheduled. (R47) and (V8) worked to do a pivot transfer, and that is what it was supposed to be a pivot transfer from the wheelchair to the exam chair. My understanding is (V8) attempted to ambulate (R47) from the doorway to the exam chair when (R47) fell . (R47) reported to the nurse that she had fallen when she had gotten back from the appointment. The dentist office called to reschedule the appointment and notified us that she had fallen. I don't recall (V8) calling the facility to report the fall. Initially, (V8) was interviewed and never said he attempted to ambulate (R47) so I didn't know she was ambulated. I didn't interview the dental office; at the time I was told I didn't need to. I wasn't even aware the fire department was called for lift assist. I don't know if there is any direction as to what to do when a resident falls in this situation. If at a doctor appointment ultimately that staff can make that judgement, but she was at a dentist office with a CNA, and CNAs cannot make that judgement. On 7/1/21 at 11: 49 a.m., V11 (Physical Therapy Assistant) stated, (R47) was working with therapy at the time of the fall. The staff were only to use the sit to stand lift. The therapy staff were working with standing and taking 5-6 steps maximum at a time. She wasn't even close to the point that we would release her to allow the staff to ambulate her. (R47) was only to be walking in therapy. After the fall, we held a few treatments because of the pain and swelling in her left leg prior to knowing her left tibia was fractured. Therapy stopped initially when we got the non-weight bearing status and she was switched to a mechanical lift only. We just got the orders to start bearing weight, but she is still a mechanical lift. On 7/1/21 at 12:00 p.m., V4 (Minimum Data Set Coordinator) stated, (R47's) use of the sit to stand lift for all transfers was on her ADL (Activities of Daily Living) care plan, but I did not revise the care plan following the incident. 3. The facility's Safe Lifting and Movement of Residents policy dated 9/1/20, states In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. 4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belt, lateral boards) and mechanical lifting devices. R39's Physician Wound Evaluation and Management Summary dated 6/30/21, documents R39 has superficial frictional abrasive injuries to the left sacrum and the left buttock. On 7/01/21 at 9:54 a.m.,V4 (Minimum Data Set Coordinator), stated R39 has friction wounds on his sacrum and left buttock that developed in house. V4 stated (R39's) wounds were caused by the slide board. On 7/1/21 at 11:15 a.m., V14 (Certified Occupational Therapy Assistant) stated she was notified by V2 (Director of Nursing) that V2 suspected R39's friction injuries to the buttocks and sacral area (first documented on 6/9/21). V14 stated I educated the staff on allowing (R39) to do the sliding board transfer himself while using a gait belt and (stand by assistance) and not to simply pull him across the board causing skin injuries. On 7/1/21 at 11:22 a.m., V4 (Minimum Data Set Coordinator) stated R39's wounds on his sacrum and buttock were cause by the staff pulling R39 across the sliding board rather than allowing him to slowly scoot himself across the slide board as intended. R39's Occupational Therapy Daily Treatment note dated 6/16/21 and written by V14 (Certified Occupational Therapy Assistant), states Slide board transfer completed with (Certified Nurse Aid) staff to decrease pulling (R39), cues to provide patient time required in order to complete transfer (with contact guard assistance). R39's Occupational Therapy Daily Treatment note dated 6/17/21, stated (V14) addressed slide board transfer from edge of bed to wheelchair (contact guard assistance) cues for hand placement and appropriate scooting to decrease skin breakdown. On 7/1/21 at 11:50 a.m., V13 (Wound Doctor) stated that providing staff education on proper use of a sliding board could have possibly prevented the development of R39's friction injuries to the left buttock and sacrum.

Based on interview and record review, the facility failed to monitor and establish control of severe pain following a fall with suspected fracture for one of three residents (R47) reviewed for injuries in the sample of 23. These failures resulted in R47 experiencing severe pain following a fall on 12/22/20. Findings include: The facility's Pain Management policy, dated 2020, documents, The facility will utilize a systematic approach for recognition, assessment, treatment and monitoring of pain. Recognition: In order to help a resident attain or maintain his/her highest practicable level of physical, mental, and psychosocial well-being and to prevent or manage pain, the facility will: Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. Evaluate the resident for pain upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs (e.g. after a fall, change in behavior or mental status, new pain or an exacerbation of pain). The policy also documents, Pharmacological interventions will follow a systematic approach for selecting medications and doses to treat pain. The interdisciplinary team is responsible for developing a pain management regimen that is specific to each resident who has pain or who has the potential for pain. The following are general principles the facility will utilize for prescribing analgesics: Evaluate the resident's medical condition, current medication regimen, cause and severity of the pain and course of illness to determine the most appropriate [MEDICATION(S)] therapy for pain. Consider administering medication around the clock instead of PRN (as needed) or combining longer acting medications with PRN medications for breakthrough pain. Use lower doses of medication initially and titrate slowly upward until comfort is achieved. Reassess and adjust the medication dose to optimize the resident's pain relief while monitoring the effectiveness of the medication and work to minimize or manage side effects. Facility staff will notify the practitioner, if the resident's pain is not controlled by the current treatment regimen. On 06/29/21 at 11:25 AM, R47 was alert sitting up in her wheelchair with a mechanical sling underneath of her. R47 stated, I fell on [DATE] at a dentist appointment and broke my tibia. So now I'm a mechanical lift. I was even at the point of taking steps in therapy. My wheelchair wouldn't fit thru the door at the dentist office, so the one (V8 CNA-Certified Nursing Assistant) who took me told me I had to walk. I told them I could only walk six steps and I didn't feel comfortable doing it. So, on the 7th step I ended up falling. I had pain when it happened, but then as it went on it got worse and worse. I have a high pain tolerance and normally just tolerate pain. Before this I barely took any pain medication, so to take pain medication it took a lot. Initially it was an aching pain. After the x-ray came back negative the staff continued to transfer me with the sit to stand assist lift, so I was still putting weight on that leg. It would send shooting pains in my leg. I ended up staying in bed for a while because I was in so much pain and didn't want to get up because of having to put weight on it. They didn't increase my pain medication until I suggested it to them. I requested the appointment with the orthopedic doctor as well because I knew something was wrong. It was the orthopedic doctor who finally found the fracture. R47's Order Summary Report, dated 7/1/21, documents that since 5/9/2019 R47 had an order to receive Tylenol 500 mg (milligrams) by mouth two times a day as needed for pain rated a 1-4 on a scale of 0-10. Then, on 1/4/21 this order was increased to 1000 mg by mouth two times a day as needed for pain. R47's Pain Care plan, dated 6/3/21, documents an intervention to notify the physician if pain frequency/intensity is worsening or if current [MEDICATION(S)] regimen is ineffective. R47's MDS, dated [DATE], documents that R47 rarely has pain and the worst pain she has had in the last five days would be a 2. R47's Fall Investigation, dated 12/22/20, documents, 10:10 a.m. (R47) returns from dentist appointment and reports that she had fallen at the dentist office. (R47) states that she was lowered to the floor during transfer from the wheelchair to dental chair. Complains of pain in left leg, states leg was under bottom. The Investigation also documents, (R47) is alert and oriented with a BIMs (Brief Interview of Mental Status) score of 15 (cognitively intact). (R47) requires assistance with transfers and cares. On 12/22/20, (R47) was transferring from wheelchair at dentist appointment to dental chair and was lowered to the floor, resulting in left leg bending back and being under her bottom. Physician did a telehealth visit with (R47) due to fall at the dentist. (R47) complaining of pain to left lower leg and bruising noted. Physician ordered an x-ray at this time. Mobile x-ray done; no fracture noted. R47's Nurses' note, dated 12/22/2020 at 12:20 p.m., documents, Physician did a telehealth visit with R47 due to fall at the dentist. R47 complaining of pain to left lower leg and bruising noted. physician ordered an X-ray at this time. R47's MAR (Medication Administration Record), dated 12/2020, documents that R47 received PRN Tylenol on the following dates: 12/22/20 at 12:02 p.m. for pain rated at a 5; 12/22/20 at 6:14 p.m. for pain rated at a 6; 12/23/20 at 12:11 a.m. for pain rated at a 5; 12/24/20 at 9:17 a.m. for pain rated at 4; 12/24/20 at 4:04 p.m. for pain rated at a 5; 12/28/20 at 10:04 a.m. for pain rated at a 5; 12/29/20 at 8:16 a.m. for pain rated at a 5; 12/30/20 at 10:23 a.m. for pain rated at a 4. R47's Physician telephone encounter, dated 12/29/20, documents, Advise that (R47) needs to be out of bed to chair three times daily as she has not gotten out of bed in the past week. R47's MDS, dated [DATE], documents that R47 frequently has pain that limits her day to day activities and the worst pain she has had in the last five days would be a 4. R47's MAR, dated 1/2021, documents that R47 received Tylenol 500 mg prn on the following dates: 1/2/21 at 12:05 a.m. for pain rated at a 4; 1/2/21 at 8:39 p.m. for pain rated at a 6; 1/3/21 at 8:30 a.m. for pain rated at a 4; 1/4/21 at 1:17 p.m. for pain rated at an 8. R47 received Tylenol 1000 mg prn for pain on the following dates: 1/6/21 at 9:04 a.m. for pain rated a 6; 1/6/21 at 7:12 p.m. for pain rated a 5; 1/7/21 at 7:28 p.m. for pain rated a 6; 1/9/21 at 5:30 a.m. for pain rated at a 5; 1/9/21 at 5:56 p.m. for pain rated a 10; 1/10/21 at 7:44 p.m. for pain rated a 4; 1/10/21 at 7:44 p.m. for pain rated a 4; 1/11/21 at 7:57 p.m. for pain rated a 4; 1/13/21 at 3:40 p.m. for pain rated a 4. R47's Nurses' note, dated 1/2/2021 at 4:03 p.m., documents, Complains of left leg pain and bruising. R47's Nurses' notes, dated 1/4/2021 at 6:51 p.m., documents, This nurse spoke to physician about residents continued pain in her left lower extremity. Physician gave new orders for ice to knee every shift for 20 minutes for two days. R47's Nurses' note, dated 1/5/2021 at 07:59 a.m., documents, Warmth, bruising, pain and swelling noted to left lower extremity. V7 (R47's family) requests x-ray of knee and lower leg. R47's Wound Doctor Visit Summary, dated 1/6/21, documents, (R47) has limited mobility with left leg pain, bruising and swelling after a fall. R47's Orthopedist note, dated 1/13/21, documents, After her distal femur fracture, she was never really able to ambulate for any sustained distances. She spends most of her time in a wheelchair and often times will use a mechanical lift and staff assistance for transfers at the skilled facility. She presented today for a visit though, as unfortunately she sustained another ground level fall on December 22, 2020 or approximately 3 weeks ago. She was at the dentist's office and was required to get out of her wheelchair and walk a certain distance to the dental chair. After a few steps, she became fatigued given her deconditioning and fell on to the left knee. She had discomfort and some swelling and bruising since that time. X-rays were apparently ordered at the skilled nursing facility upon her return, which showed a left proximal tibia periprosthetic fracture. She presents today in the office for further evaluation. Assessment: Left knee proximal tibia periprosthetic fracture. A facility State Reportable, dated 1/14/21, documents, on 12/22/20, (R47) went out of building to dentist and staff at dental office attempted to have resident ambulate from wheelchair to dental chair. (R47) was lowered to the floor and left leg was bent under her bottom. Facility CNA (V8) also assisted resident at dentist appointment. Type of Injuries: Proximal Tibial Fracture. Disposition: 12/22/20: (R47) had fall during transfer with staff at dentist office. (R47) complained of pain, with swelling to left knee area. MD notified of fall and did telehealth visit on 12/22/20 with order for x-ray. X-ray of tibia/fibula shows no acute fracture or dislocation in left tibia and fibula. Ice pack and Tylenol. (R47) continued to have pain in left knee area, staff continued to monitor. On 1/2/21 continued left leg pain and bruising noted. On 1/5/21 physician notified of request for second x-ray. Order received for x-ray and doppler knee shows old healing distal femur left knee fracture (this was original diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Per resident and V9 request resident had appointment with orthopedic doctor. On 1/13/21 reported new tibula fracture. Order received for non-weight bearing of left lower extremity, no left knee ROM (Range of Motion), hinged knee immobilizer locked on extension, ok to open brace while in bed for skin care. Follow up in four weeks. On 06/29/21 at 03:38 PM, V7 stated, When she went to the dentist appointment, (R47) was a sit to stand lift. The dental place asked her if she could walk just a few steps from her wheelchair to the chair. (V8) was with her the whole time. (V8) was the one who assisted (R47) to walk to the chair. (V8) was aware of her abilities and took care of her so he should have known not to walk with her. The dentist office called 911 and the fire department transferred her back to her wheelchair. (R47) was not transported to the hospital. After it happened, (V8) called me to let me know. (R47) continued to complain of pain. (R47) is very tolerant of pain. At that time, she would say it was uncomfortable, swollen, and it hurts. (R47) would say it was around a 5 or 6 (on a pain scale of 0-10) but with her tolerance that would be extremely high for myself. A normal person it would probably be rated a 30. I knew something was wrong with her complaining because she didn't complain. As it went on, I wondered if something else was going on because she continued to complain. One day I went in there she pointed out to me that it was swollen. I spoke with the nurse and asked if there was anything we could do, and that is when the second X-ray was ordered. On 07/01/21 at 09:47 AM, V2 (Director of Nursing) stated, It is not normal for (R47) to complain of pain, but she continued to complain of having that pain to her left leg. The only pain medication she took was Tylenol. Staff were documenting pain scale higher than four even though (R47's) order is for a 1-4. The Tylenol 500 mg one tablet only was administered at those time. As a nurse they should have been notifying the doctor to try and get something stronger since she was requesting the pain medication more often and her pain levels were higher. On 12/29/20, (R47's) doctor called to say (R47) needs to get out of bed since she hadn't been out of bed for a week after the fall. I don't know why the doctor wasn't called sooner to address (R47's) pain changes. The doctor wasn't notified until 1/4/21 when she ordered the ice packs for two days. The wound doctor saw her on 1/5/21 and noted the limited mobility and pain in her R47's left leg. She was still a sit to stand bearing weight on that leg until she was seen on 1/13/21 by the orthopedic doctor who diagnosed the fracture. On 7/1/21 at 11: 49 a.m., V11 (Physical Therapy Assistant) stated, After the fall, we held a few treatments because of the pain and swelling in her left leg prior to knowing her left tibia was fractured. On 07/01/21 at 11:50 AM, V10 (Licensed Practical Nurse) stated, (R47) complained of more pain and was taking her Tylenol more frequent. She didn't complain of pain much prior to that (fall 12/22/20) maybe an occasional headache.

Based on observation, record review and interview, the facility failed to thoroughly assess a resident's skin while using compression wraps to splint a femur fracture, notify the Physician after a pressure ulcer/injury was identified to obtain treatment, and failed to accurately assess and identify the stage of multiple pressure injuries, for one of one residents (R1) reviewed with pressure ulcers/injury, in a sample of three. This failure resulted in R1 developing an unstageable pressure ulcer on the right inner knee and a unstageable pressure injury to the back of the left knee. Findings include: The facility policy, titled Wound Treatment Management ([DATE]), documents To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and Physician orders. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with Physician orders, including the cleansing method, type of dressing and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify Physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. The policy further documents, 5. Treatment decisions will be based on: a. Etiology of the wound: i. Pressure injuries will be differentiated from non-pressure ulcers, such as arterial, venous, diabetic, moisture or incontinence related skin damage. ii. Surgical. iii. Incidental (i.e. skin tear, medical adhesive related skin injury). iv. Atypical (i.e. dermatological [MEDICAL CONDITION] lesion, pyoderma, [DIAGNOSES REDACTED]). b. Characteristics of the wound: i. Pressure injury stage. ii. Size-including shape, depth, and presence of tunneling and/or undermining. iii. Volume and characteristics of exudate. iv. Presence of pain. v. Presence of infection or need to address bacterial bioburden. vi. Condition of tissue in the wound bed. vii. Condition of peri-wound skin. A Nursing Note dated [DATE] at 4:22 pm by V2 (Director of Nursing) documents, (R1) returned to facility. (V8 - Physician) notified and orders received to admit with transfer order, hospice (services), regular diet, resume previous medication. (Indwelling) catheter in place and draining yellow urine. (Compression) wrap to lower extremities to splint left to right leg due to fracture and non-surgical candidate. Family aware of [DIAGNOSES REDACTED]. Reddened area noted on outside of left great toe, IV (intravenous) site left wrist. Admission physician's orders [REDACTED]. Check (every) shift and PRN (as needed). The Treatment Administration Record for [DATE] does not indicate that this order was processed to be included in the scheduled treatments for R1. A Braden Skin Assessment For Predicting Pressure Sore Risk tool, dated [DATE], identifies R1 as being high risk for skin breakdown. The Nursing Progress Notes do not document any information regarding any ongoing assessments of R1's legs and use of compression wraps. The first documented assessment of R1's legs is on [DATE] at 12:02 pm, when V2 documents in the nursing notes, Resident resting in bed with (compression) wraps to bilateral legs at the knees. Hospice nurse in facility and (compression wraps) removed. (Right) anterior knee area (#1) - (4.5) x 1.5 (centimeters). (#2) area 12 x 1.5 (centimeters). (#3) area 0.7 x 1 (centimeters). Outer aspect of right knee 3.7 x 2 (centimeters). (Left) heel 1.5 x 2.7. Left anterior knee 6.5 x 5 (centimeters). Left knee posterior 2.5 x 8.5 (centimeters) with open area surrounding bruised area. (Left) hip 4 x 4 centimeters. Posterior left knee skin is pushed back (no measurement of area). (V8) notified of skin issues and waiting orders. The documented measurements fail to identify the specific characteristics of the pressure injury, including Stage, shape, color or condition of wound bed and there are no further documented skin assessments through [DATE], the day R1 expired. On [DATE] at 11:30 am, R1 was sleeping in bed and being assessed by V11 (Hospice Registered Nurse). At that time, V11 removed the blanket covering R1's legs, which were not bound with a compression wrap, but open to air. R1's right anterior knee had a dark red and black circular area on the bony prominence, measuring 6.0 x 4.3 centimeters and a large open, weeping, red area the shape of a rectangle directly behind the left knee at the crease, measuring 14 x 7 cm. V11 stated she would consider these wounds to both be unstageable pressure injuries. V11 stated she first saw the wounds on [DATE], when she was doing her hospice rounds. On that day, V11 stated she observed R1's legs to be bound together with a compression wrap, and once she removed it, she found a diaper folded in between her knees, a large reddened area on the inner right knee over the bone where it would touch the left inner knee, and a large open area behind the left knee where the wrap had been. V11 stated that V2 measured all of the abnormal findings on R1's skin and indicated she would get treatment orders. V11 confirmed at that time that Hospice had not given any orders regarding the compression wraps used to splint R1's legs together. On [DATE] at 1:38 pm, V3 (Registered Nurse) stated she worked the day shift on [DATE], and was present when R1 was readmitted from the hospital. V3 stated V2 entered in all of R1's admission orders [REDACTED]. When R1 arrived from the hospital, V3 observed R1's legs wrapped together with a compression wrap and a towel was between her knees. V3 stated the wrap looked tight, but was not digging into her skin. V3 stated she did see an order in the physician's orders [REDACTED]. V3 stated she was not clear on what that order meant exactly and if the wraps were actually to be removed every shift or just checked for placement. On [DATE] at 3:50 pm, V6 (Licensed Practical Nurse) stated she worked the first shift on [DATE], [DATE] and [DATE] and cared for R1. V6 stated she was told in report the morning of [DATE] that R1's compression wraps were in place and Hospice staff were supposed to tell them what exactly to do with them, such as removing or cleansing the skin. V6 stated V10 (Hospice Nurse) came in on [DATE] and assessed R1, but gave no orders regarding the compression wraps. V6 stated she just checked them for placement and never removed them on [DATE] and [DATE]. On [DATE] at 2:10 pm, V4 (Licensed Practical Nurse) stated she worked the second shift on [DATE], [DATE] and [DATE] and cared for R1. V4 stated on either [DATE] or [DATE], she told V6 about R1's legs being wrapped and V6 did loosen the wraps, but didn't remove them completely. V4 stated she was under the impression V6 was going to get an order for [REDACTED]., because they appeared wet. V4 stated when she removed the wrap there was a towel folded between her upper thighs and R1's inner knees had been touching, bone on bone, with the wrap holding them in place. V4 stated R1's inner knees had obvious areas of purple and redness where they had been touching and described the right inner knee to have a baseball size open wound with sloughy skin on the bony prominence. V4 stated the area behind R1's left knee had an open area the exact spot of the wrap, with a visible line where the wrap had stopped. V4 stated this area was weeping and had an odor. V4 stated she immediately called V9 (Wound Nurse) and informed her of what R1's legs looked like. According to V4, V9 instructed her to not chart anything and V9 indicated she would look at the wounds the next morning ([DATE]). V4 asked about some foam padding to place between R1's knees when she rewrapped them or a treatment order, and V9 informed her the facility did not have anything like that to protect her knees. V4 stated she decided to take a incontinence brief and cut it, folding it so the absorbent/padded part was on the outside of both sides, and placed it between R1's knees as padding, prior to re-splinting the the legs together with the compression bandage. On [DATE] at 1:25 pm, V2 (Director of Nursing) stated she had never observed a resident having her legs splinted in the manner R1's were splinted, when R1 returned from the hospital on [DATE]. V2 stated she would expect staff to obtain orders from the Physician as to exactly how they are to manage that type of splinting/wrap. At 2:16 pm, V2 pointed out that there was an order from the admitting Physician (V8) on [DATE], that she entered into the computer system, advising staff to buddy splint R1's legs together with compression wraps and to check them every shift and as needed. V2 stated, regarding that order, In my mind, I thought the staff would unwrap R1's legs every shift, but (staff) obviously didn't read the order that way. Additionally, V2 confirmed that specific order never made it to R1's Treatment Administration Record. On [DATE] at 2:30 pm, V2 stated she would expect staff to measure and document on wounds as soon as they are identified, to obtain a baseline, and call the Physician to get treatment orders. On [DATE] at 1:24 pm, V9 (Wound Nurse) confirmed that V4 did call her on [DATE] and reported that R1's compression wraps had been wet, so she removed them and found skin breakdown on R1's inner knees and behind the left knee. V9 stated she did not advise V4 as to what treatment could be provided for the wounds at that time, but notified V2 (Director of Nursing) so she could measure the wounds the next day. On [DATE], V8 (Medical Director) stated she did give an order on [DATE] for staff to check R1's compression wraps every shift, and assumed that staff would be doing some type of skin assessment at that time. V8 indicated she saw R1 on [DATE], during a telehealth visit, but R1 was sleeping and V8 did not see how R1's legs were wrapped during that visit. V8 indicated she was under the impression Hospice staff would be addressing how R1's compression wraps were to be managed. V8 stated it was reported to her on [DATE] that R1 just had blistered areas on her knees and legs, not as a pressure injury, and staff wanted to treat the areas with [MEDICATION NAME] ointment, which she ordered. V8 indicated she was not given measurements or any additional description of the wounds.

Based on observation, interview, and record review, the facility failed to identify a pressure ulcer and have a physician ordered treatment that was clinically indicated for a unstageable necrotic pressure ulcer for one of two residents (R46) reviewed for pressure ulcers in the sample of 20. This failure resulted in R46's pressure ulcer worsening from a Stage two to unstageable. Findings include: The facility's Skin Practice Guide, dated 2013, documents, Dressing selection is based upon: wound type, tissue type, need to contain exudate, need to protect wound bed, need to minimize pain, treatment goals, protection of peri-wound area, and manufacturer recommendations for product utilization and frequency of change. According to the National Pressure Ulcer Advisory Panel: Prevention and treatment of [REDACTED]. Category/Stage II: Partial Thickness Skin Loss: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured serum filled blister. Unstageable: Depth Unknown: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Guide also documents, Wound Dressings For treatment of [REDACTED]. Select a wound dressing based on the: Ability to keep the wound bed moist; Need to address bacterial bioburden; Nature and volume of wound exudate; Condition of the tissue in the ulcer bed; Condition of periulcer skin; Ulcer size, depth and location; Presence of tunneling and/or undermining; Goals of the individual with the ulcer. According to Gentell Total Wound Care Solution (Gentell.com), MASD (Moisture Associated Skin Damage) versus Pressure Ulcers, dated 7/13/2017, Moisture Associated Skin Damage: L[NAME]ATION: Diffusely distributed; COLOR: Pink or red; DEPTH: Partial thickness, or blistering; TISSUE: NO slough or eschar. Pressure Ulcers: L[NAME]ATION: Usually over a bony prominence, or under a medical device/including brief; COLOR: Red or bluish/purple; DEPTH: Partial or full thickness; TISSUE: With or without slough or eschar. According to Merck Manual Professional Version, Pressure Ulcers, dated (YEAR), Direct ulcer care. Appropriate ulcer care involves cleaning, debridement, and dressings. Debridement is necessary to remove necrotic tissue. Necrotic tissue serves as a medium for bacterial growth and blocks normal wound healing. Dressings are helpful for protecting the wound and facilitating the healing process (Dressings should be used for stage I pressure ulcers that are subject to friction or incontinence and for all other pressure ulcers. R46's Braden risk assessment, dated 5/1/18, documents a score of 15 putting R46 at risk for developing pressure ulcers. R46's Nurse's notes, dated 5/15/2018 at 3:29 p.m. documents, This nurse called to R46's room by CNAs who reported open area to buttocks. Right buttock skin fold red open area approximately 2.0 cm (centimeters) x 1.0 cm no drainage, no bleeding, peri wound area light red. On 05/22/18 at 01:55 PM, R46 was incontinent of urine. V22 (Certified Nursing Assistant-CNA) rolled R46 to his right side. Clear bloody drainage was on R46's bed sheets. R46 had an irregular shaped open area to R46's right ischial tuberosity area (buttock crease) with clear bloody drainage. R46's wound bed was dark red partial wound area then dark brown tissue (eschar) scattered throughout the wound. R46's wound was uncovered and remained uncovered following R46's incontinent care. On 05/23/18 at 08:50 AM, R46 was incontinent of a soft light brown feces. R46 had an irregular shaped open area to his right ischial tuberosity area (buttock crease). The wound had a dark red wound bed with small areas of dark brown tissue. V18 (Wound Nurse) stated that the area of the open area is a pressure point when R46 is sitting, and that R46 sits quite a bit for long periods. V18 also stated that they don't consider it a pressure ulcer, they are calling it MASD (Moisture Associated Skin Damage). (V18) also confirmed that the wound had necrotic areas in it, and needs a physician prescribed treatment because the treatment now is preventative barrier cream. R46's Nurse's notes, dated 5/23/18 at 9:07 a.m., documents, R46 has the following wound moisture related area below right buttock measuring 3.8 cm x 3 cm. No drainage noted. Area bright red with some darkened area. The facility's in house stock preventative cream product information sheet, dated 5/23/18, documents that the cream is indicated for the relief of discomfort associated with diaper rash caused by wetness, urine, and/or stool and other macerated skin conditions. R46's physician's orders [REDACTED]. R46's Current Electronic Care plan documents that R46 is at risk for alteration in skin integrity related to incontinence and dementia. The care plan has no documentation of revision to include R46's current area. On 05/23/18 at 02:45 PM, V16 (V46's physician) stated she was notified when the area developed and informed them to continue using the barrier cream. I was notified today (5/23/18) about the change in the wound, and I ordered to continue the barrier cream. 05/23/18 02:53 PM V2 (Director of Nursing) stated, If the area has necrotic tissue, then it wouldn't be an MASD wound. Barrier cream would not be appropriate to treat an open area with necrotic tissue.

This failure resulted in two deficient practices. A. Based on observation, record review, and interview the facility failed to maintain R26's bed in a low position and failed to re-evaluate R26's fall risks and interventions after removing a planned fall reduction assistive mattress for one of two residents (R26) reviewed for falls in the sample of 20. These failures resulted in R26 falling out of bed at a higher plane and sustaining a right [MEDICAL CONDITION]. B. Based on observation, interview, and record review, the facility failed to provide supervision and implement new interventions to prevent resident to resident altercations for one of three residents (R47) reviewed for behaviors in the sample of 20. This also had the potential to affect one resident (R41) in the sample and three residents (R4, R41, R51, R53) not in the sample. Findings include: A. The facility's Falls Practice Guide dated 12/2011 documents, Fall interventions are clear, specific, and individualized for a patient's needs. Regardless of the interventions that are put in place, a key factor to success is the timely review of the interventions as the patient's conditions and needs change. Environmental risk factors which may be associated with falls may need to be reviewed and considered as ongoing fall preventions strategies. These factors may include the bed height and assistive devices. On 05/22/18 at 2:00 PM, R26 was lying in bed. R26's right leg was approximately two inches shorter than R26's left leg and R26 had an approximate 4 inch diameter faded purple bruise to the right knee. R26's current [DIAGNOSES REDACTED]. R26's Incident Report dated 12-2-17 at 9:00 PM, documents R26 was found on the floor on R26's buttocks parallel to the bed. This same report documents a scoop mattress (mattress with raised sides) will be applied to R26's bed as a fall intervention. R26's Incident Reports and Progress Notes do not include R26 having any further falls out of bed since the incident on 12-2-17, until 5-13-18. R26's Incident Investigation Report dated 5-13-18 at 2:33 AM and signed by V8 (Licensed Practical Nurse) documents R26 was found on the floor beside the bed on R26's bottom, with no complaints of pain. This same report documents R26 later complained of pain to the right leg on 5-14-18 and an order was given to obtain an x-ray. R26's current Fall Care Plan documents a scoop mattress was re-applied to R26's bed on 5-15-18. R26's X-Ray report dated 5-15-18 documents R26 sustained an acute displaced fracture to the right hip. R26's Clinical Record does not include documentation of R26's scoop mattress ever being removed off of R26's bed between the fall on 12-2-17 and 5-13-18. This same record also does not include a re-evaluation of R26's risks of falls and fall interventions once the scoop mattress was removed. The Manufacturer's Description of a scoop mattress (undated), documents, The Defined Perimeter Mattress creates a raised fall, defined perimeter for enhanced fall prevention, without using patient restraints. On 05/22/18 at 3:41 PM, V7 (CNA/Certified Nursing Assistant) stated, (R26) just got a scoop mattress back last week when (R26) rolled out of bed and got the right [MEDICAL CONDITION]. (R26) use to have a scoop mattress but they (the facility) took it off and put a regular air mattress on that did not have raised sides like the old scoop mattress. On 05/22/18 at 3:24 PM, V8 (Licensed Practical Nurse/LPN) stated, I worked the night (5-13-18) when (R26) rolled out of bed. The CNA (V9) got me and said (R26) landed on the floor around 2:30 am. On 05/22/18 at 3:27 PM, V9 (CNA) stated, I worked 5-13-18. I heard (R26) yelling for help. I went in (R26's) room and (R26) was on the floor on the left side of the bed with her back against the bed and both legs out. I could see that (R26's) right leg was injured and was twisted. (R26) did not want her right knee touched because she had pain. Not excruciating. I thought her leg was fractured. Before the fall, the head and the feet of (R26's) bed were raised up and (R26's) bed was not in the lowest position. Sometimes (R26) gets restless at night. (R26) needs a mattress with raised sides. The air mattress (R26) has at the time of the fall is thicker than a regular mattress and would have made her fall from a higher level. On 05/23/18 at 8:46 AM, V2 (Director of Nursing/DON) stated, On 12-2-17 we (the facility) applied a scoop mattress because (R26) rolled out of bed. On 4-10-18 (R26) developed an area on the heel and needed an air mattress. We (the facility) discontinued (R26's) scoop mattress at that time (4-10-18). We (the facility) did not re-evaluate (R26's) fall interventions at that time when (R26's) fall intervention of a scoop mattress was removed. We should have re-evaluated (R26's) fall interventions at that time. (R26) rolled out of bed and that is when (R26) sustained the fracture. (R26) did not have any falls out of the bed when (R26) had the scoop mattress. The scoop mattress would most likely have prevented (R26) from rolling out of bed. The first thing I said when (R26) rolled out of the bed was that we (the facility) need to get a scoop mattress back on (R26's) bed to prevent further falls. (R26's) bed should have been in the lowest position when (R26) fell . On 05/23/18 at 3:00 PM, V8 (LPN) stated, When (R26) fell out of bed on 5-13-18, (R26's) bed was not in the lowest position. It should have been. B. The facility's Behavior Practice guide, dated (YEAR), documents, As with other behavior symptoms, the interdisciplinary team works to identify the trigger and structures the plan of care to meet the need of the patient specific trigger, preferably prior to the onset of wandering or exit seeking. The guide also documents, Interventions are continually evaluated for effectiveness and updated as the patient's condition and needs change. R47's Behavior Care plan, dated 7/18/17, documents that R47 is at risk for behavior symptoms (physically combative, verbally aggressive, refusal of medications and cares, wandering, impulsivity) related to dementia with behaviors and anxiety. R47's Care plan does not have any documentation of R47's Care plan being revised after altercation incidents. R47's Wandering care plan, dated 1/26/18, documents that R47 is at Wandering/Pacing/elopement risk related to: cognitive impairment. The care plan has the intervention to allow R47 to wander in the facility. R47's Wandering care plan has no documentation of being revised after altercation incidents. R47's Incident Report, dated 11/9/17, documents, After lunch, residents were in the activity room-one resident (R41) had a banana and another resident (R47) came to this resident and took the banana and started to eat it. The activity director witnessed this and went to the kitchen to get another banana. When she returned to the activity room she witnessed both residents slapping hands. Incident Statement, dated 11/9/17, documents a statement from R41, I witnessed R47 eating another resident's banana and getting into her crackers. I told R47 that those were not hers to eat. R47 started yelling and hitting me. Incident Statement, dated 11/9/17, documents a statement from V11 Activity Director, I came into the room to R41 and R47 yelling. R47 started hitting R1 and I tried to wheel R47 away. Incident Statement, dated 11/9/17, documents a statement from R256, He was in the activity room when R47 came into the room. She picked up another resident's food to eat it. The activity director went into the kitchen to get this resident a banana. While the activity director was gone, R47 attempted to pick up the other residents crackers at that time R41 began to verbally attempt to redirect R47 who then reached out and hit R41 on the arm. R47's Nurse's notes, dated 12/26/2017 at 3:00 p.m., documents, Report from 100 hall nurse, R47 was in another residents (R51) room and R51 claims there was a physical altercation. The facility's state report, dated 12/28/17, documents, R47 entered R51's room in her wheelchair. R47 stood up when she was by R51's closet and was attempting to hang a coat up. R47 has [DIAGNOSES REDACTED]. R47 has a BIMS score of 5 (severely impaired). R47 does not recall the incident. R51 confronted R47 and stood up by front of her bed. R51 has a BIMS score of 13 (Cognitively Intact). R51 stated that R51 yelled at R47 to get out, and R47 yelled back and then struck R51 hard across her face, glasses, and her right eye. R47's Nurse's note, dated 3/26/2018 at 3:45 p.m., documents, A male resident (R53) stated that this resident hit him in the mouth on Saturday. When this resident was interviewed, she stated that she did not understand what we were asking and denied any wrongdoing. A facility state report, dated 3/27/18, documents, On 3/26/18 at approximately 2:00 p.m. R53 stated that R47 hit R53 in the jaw on 3/24/18 around breakfast time. R53 stated that R47 struck him on his right jaw on 3/24/18. R53 said he didn't' know why R47 hit him. R53 said he was going down the hall in his motorized scooter, and was looking to his left. R53 said R47 was on his right side and he came near her with his chair but didn't know if he hit her or her chair. R53 has a BIMs (Brief Interview for Mental Status) score of 14 (Cognitively Intact). V20 (Housekeeper) said she saw R53 and R47 in what appeared to be an altercation on the 200 Hall. V20 said the two residents were in the hall with their wheelchairs against each other. R47's Nurse's note, dated 4/6/2018 at 5:42 p.m., documents, R47 has been in and out of other resident's rooms and beds and when told its not R47s bed resident's states 'I know its not my bed, I don't give a[***] R47's Nurse's note, dated 5/2/2018 at 7:45 p.m., documents, another nurse notified this nurse that R47 entered R4's room and hit R4 when R4 asked R47 to leave the room. On 05/23/18 at 03:54 PM, R4 stated, I was sitting in my room when (R47) came in. She doesn't belong in my room so I asked her to leave. (R47) got pissed off when I asked her to leave and (R47) yelled at me then hit me in the arm. (R47) shouldn't have been in my room I didn't ask her to come in and then she hits me. R47's Nurse's notes, dated 5/3/2018 at 9:17 a.m., documents, R47 has climbed in and out of all beds as she chooses. Will not allow staff to redirect her. R47's Nurse's notes, dated 5/4/2018 at 3:12 a.m., documents, R47 up out of bed several times start of shift wandering hallways in wheelchair. R47's Nurse's note, dated 5/5/2018 at 8:16 p.m. documents, R47 up and around in wheel chair all shift, getting into other resident's beds. On 05/22/18 03:08 PM, V25 (Licensed Practical Nurse) stated, R47 wanders, exit seeks, goes into other peoples rooms, and climbs in their beds. She can get mad and combative. Sometimes she is easily directed sometimes not. She hits. Threatens to bite. (R47) cusses and hits at the other residents sometimes unprovoked and sometimes when asked to leave their rooms. (R47) is allowed to self propel throughout the facility. We just try to keep an eye on her and redirect as needed. On 05/24/18 at 09:09 AM, V5 (Licensed Practical Nurse) stated that R47 wanders throughout the facility and she gets in and out of other residents beds frequently. On 05/24/18 at 09:10 AM V24 (Licensed Practical Nurse) stated that R47 is confused wanders into rooms and lays in the beds, and that R47 has gotten aggressive with other residents when they confront her. On 05/24/18 at 09:34 AM, V22 CNA stated, (R47) wanders throughout the facility in her wheelchair and climbs in and out of residents beds. (R47) has been aggressive with residents. On 05/22/18 at 02:51 PM, R47 was in the 200 hall dining room self propelling. On 5/22/18 at 3:45 pm, R47 was self propelling in main lobby area heading towards dining room. On 05/22/18 at 04:08 PM, R47 was self propelling in main lobby area. On 05/23/18 at 03:55 PM, R47 was self propelling self in wheelchair down 400 hall with no staff member present. On 05/23/18 at 10:50 AM, V2 DON (Director of Nursing) stated, We just try to redirect R47 because of her dementia. Sometimes R47 is easily redirected. R47 doesn't like hands on and doesn't like touched. No interventions have been implemented following R47s incidents. R47 is able to self propel in the wheelchair. We can not reeducate R47 to not go into other resident rooms. R47 frequently visits the 400 hall because that is where she previously had a room. R47 is able to propel throughout the whole facility, not limited on where she can go. When R47 leaves 200 hall she propels wherever she would like without staff supervision.

Based on record review and interview the facility failed to assess and obtain treatment of [REDACTED]. These failures resulted in R1 developing a painful left hip abscess that became infected and required surgical drainage, antibiotics, and a [DEVICE]. Findings include: The facility's Skin Practice Guide dated 01/2013 documents, Risk factors for the development of skin alterations are dependent on the type of alteration: Trauma (skin tear, laceration, bruise), fall risk, and coagulation disorders. A weekly skin evaluation is completed by the licensed nurse for those patients identified as at risk for skin breakdown. Skin evaluations are documented in the clinical record. If non-pressure related ulcers or other skin alteration are identified, a skin alteration record is initiated. Patients who develop new skin alterations are ideally evaluated by a qualified health professional (physician, physician's assistant, or a certified wound specialist) within 24 hours or as soon as practicable upon a new skin alteration identification. Treatment orders shall be obtained by the physician and should include: site location, type of skin alteration, cleansing agent, primary dressing, secondary dressing, frequency of treatment, and as needed orders. R1's Incident Description and Investigation dated 1-21-18 at 5:30 p.m. documents, (R1) was observed sitting on the floor next to the wheelchair. Lying on right side next to wheelchair. No injuries noted. R1's Physical Therapy (PT) Treatment Notes dated 1-23-18 documents, (R1's) left hip a little sore from fall. Several rest breaks needed. R1's PT Treatment Note dated 1-24-18 and signed by V9 (Physical Therapist/PT) documents, (R1) left lean new onset. Bruising to left hip and left knee observed. Reported to nursing. R1's PT Treatment Note dated 1-26-18 and signed by V9 documents, Drainage observed to (R1's) left posterior/lateral hip area of pants. Certified Nursing Assistant notified who has notified nursing. R1's Progress Notes and Plan of Care dated 1-19-18 (Admission) to 1-31-18 (Discharge) do not include any documentation or nursing assessment related to R1's bruising to the left hip/left knee, or the drainage noted to R1's left hip area. R1's physician's orders [REDACTED]. hip skin alteration. These same POS's and TAR's document R1 is to have weekly skin checks every Friday. R1's TAR's and Electronic Medical Record dated 1-19-18 to 1-31-18 do not include a weekly skin check assessment as ordered. R1's Progress Notes dated 1-31-18 and signed by V12 (Nurse Practitioner) document, Reason for appointment: Sore on hip for past couple weeks from a fall. Left hip. Just released from (facility) today. Family reports that nursing home reported that (R1) had a fall approximately two weeks ago and developed a sore area to (R1's) left hip. Family reports that nursing home staff have been placing bandages on the site and for the past few days the wound has started to drain. Severe dark purple bruising extending from the lumbar area to bottom of bilateral buttocks. Left lateral hip abscess measuring approximately 10 cm (centimeters) in diameter. Center of wound is a soft, stage two wound. Partial thickness loss of dermis tissue in the center and area is warm to touch. Wound draining serosanguineous (blood and liquid colored) drainage. Purulent (milky colored) discharge on bandage present upon arrival. Ecchymosis (bruising) extends down entire left leg with moderate swelling from the hip to toes. Approximately a four cm ecchymotic area to the left temple. Moderate swelling and extensive ecchymosis to the entire left lower extremity. Assessment: Cutaneous abscess of the left lower extremity. Injury of the left hip. Fall from ground level. Treatment: Wound Culture to the left lower extremity abscess. (R1) to see V17 (Surgeon) tomorrow for evaluation and possible incision and drainage of abscess. R1's Progress Notes dated 2-1-18 and signed by V17 (Surgeon) document, (R1) fell and developed a mass to the left hip area upper thigh one week ago. (R1) is on [MEDICATION NAME] (blood thinner). (R1) started to have pain and discomfort in the area and also started to drain purulent material from the area. Significant bruising and abscess formation noted to the left lateral hip. Local infection of the skin and subcutaneous tissue. Orders include [MEDICATION NAME] (antibiotic) tablet 500 mg (milligrams) daily for 10 days and schedule an incision drainage. R1's Surgical Services dated 2-5-18 and signed by V17 documents R1 had an incision, drainage, and debridement of the hematoma and abscess of the left thigh measuring 10 cm (centimeters) by 6 cm in diameter. R1's Culture Results dated 2-5-18 document R1 [MEDICAL CONDITIONS] to the left hip abscess. R1's Discharge Instructions dated 2-6-18 and signed by V17 documents the following orders: [MEDICATION NAME] 5/325 mg (milligrams) one or two tablets every four to six hours as needed for discomfort. Home Health to evaluate and treat the left hip wound. Wound clinic to apply a [DEVICE] (vac) to the left hip wound. Dressing changes daily to the left wound until wound vac applied. On 2-13-18 at 9:05 a.m., V3 (R1's Family Member) stated, On 1-31-18 when (R1) was getting discharged I noticed a bandage on (R1's) left leg. The bandage was hanging off of (R1's) left thigh. (R1's) leg looked infected. (R1's) leg was swollen to his ankle. (R1) had smelly drainage to the left thigh. I took (R1) to the hospital on 1-31-18 and (R1) had to have surgery to that leg. (R1's) leg was also infected [MEDICAL CONDITION]. On 2-13-18 at 9:20 a.m., V7 (Certified Nursing Assistant/CNA) stated, (R1) had a large brown bandage to his left thigh. I am not sure how long the bandage was there. It might have been there around a week. The left hip area would weep with bloody discolored drainage onto (R1's) pants. The drainage smelled a little bit. I thought the nurses knew about the bandage to (R1's) left hip so I didn't report it to them. On 2-13-18 at 1:05 p.m., V10 (CNA) stated, (R1) had a bandage to the left hip from a fall. The nurses had the leg wrapped. The bandage had some clear drainage on it. I know (R1) had a bandage on for at least a week. On 2-13-18 at 1:25 p.m., V9 (Physical Therapist) stated, I noticed drainage on (R1's) pants on 1-26-18. I noticed bruising to (R1's) left hip and left knee on 1-24-18. On 1-23-18 (R1) complained of soreness to the left hip. On 2-13-18 at 2:15 p.m., V14 (CNA) stated, I know (R1) had a bruise on the left hip around soft ball size. It looked like it hurt. It was a purplish/blackish color. The bruise was there maybe a week or so. On 2-13-18 at 2:30 p.m., V16 (Licensed Practical Nurse/LPN) stated, I am not sure if (R1) had a treatment order for the left hip. (R1) had a layer of skin missing to the left hip the size of a baseball. The area was pink. I changed the dressing on the day the family picked (R1) up for discharge. The dressing had serosanguineous drainage on it and was coming off, so I changed it. I am not sure how long (R1) had the area. I thought the area to the left hip was related to (R1's) fall. On 2-13-18 at 2:40 p.m., V2 (Director Of Nursing) stated that no one reported to V2 that R1 had an area to the the left hip or bruising to the left hip, no one did an assessment of the area, and no one obtained a treatment order for the left hip. V2 stated that an investigation into the left hip area and bruising was not done and that the nurses should not have applied a dressing without a physician's assessment and order. V2 also stated that the nurses did not do R1's weekly skin checks as ordered and a skin alteration form was not initiated. On 2-13-18 at 10:20 a.m., R1 stated, I fell and got an abrasion to the left hip. The nurses put a bandage on the area once or twice while I was there. My left hip hurt. It (left hip) did not get enough attention and had drainage coming out of it. I told them (facility staff) that my hip was hurting, but they didn't care. Now I am laid up at home from surgery. On 2-13-18 at 1:45 p.m., V12 (Nurse Practitioner) stated, (R1) was brought to the hospital on 1-31-18, after being discharged from the facility. (R1) had a soft abscess to the left hip that had been there for awhile. The abscess was large and about the size of a softball. (R1's) top layer of skin was missing. The abscess was warm to touch. (R1) had bruising to the entire left leg and the left leg was purple and swollen. The nurses should have gotten (R1) treatment before the abscess had gotten that bad. (R1) complained of his hip hurting. (R1's) abscess had foul smelling drainage. I ordered a culture to be done of the abscess. The culture results [MEDICAL CONDITION]. (R1) had a significant amount of swelling to the left leg, left groin, and toes. The facility should have gotten a treatment for [REDACTED]. The facility let the abscess go for too long. The abscess had to have been there for at least a week. I referred (R1) for a surgical consult with (V17). On 2-14-18 at 2:30 p.m., V17 (Surgeon) stated, (R1's) abscess was related to an injury such as a fall. An abscess does not form within 24 hours. The abscess had to be forming for at least a week.

Based on interview and record review, the facility failed to implement a fall intervention by failing to add an anti-rollback device to a wheelchair for one of four residents (R4) reviewed for falls in the sample of six. This failure resulted in R4 having subsequent falls which resulted in R4 sustaining a Left Clavicle Fracture. Findings include: R4's Minimum Data Set ((MDS) dated [DATE] documents that R4 has short and long term memory problems and moderately impaired decision making. The MDS documents that R4 requires extensive assistance with transfers and ambulation. The MDS documents that R4's balance is not steady when moving from a seated to standing position and that R4 is only able to stabilize with staff assistance. The MDS documents that R4 uses a wheelchair and walker for mobility. R4's Care Plan dated 5/02/15 documents that R4 is at risk for falls due to impaired balance, poor coordination, unsteady gait, and history of falls. The Care Plan documents an intervention for anti-lock brakes (anti-rollback device) dated 5/12/15. R4's Incident Report dated 5/12/15 documents that at 4:45 PM, R4 was found on the floor in front of the wheelchair. R4's wheelchair brakes were not locked. The intervention documented to prevent future falls was adding anti-lock brakes (anti-rollback device) to the wheelchair. R4's Incident Report dated 5/22/15 documents that at 4:00 PM, R4 was found on back in room between wheelchair and recliner. Resident attempted to transfer self to recliner without assistance. R4's Incident Report dated 5/31/15 documents that at 3:43 PM, R4 was observed to be sitting on the floor in front of the wheelchair and that R4 was bending over to pick something up off of floor. R4's Nursing Notes dated 6/1/15 at 8:03 AM document that R4 was complaining of pain to the left side of chest and was using accessory muscles to breath. R4 was sent to the emergency room for an evaluation. R4's Radiology Report dated 6/1/15 documents that R4 had a recent fall and that R4 has left anterior chest pain and bruising. The Report documents that R4 has an acute medial left clavicle fracture. On 6/2/15 at 3:41 PM, Z1 (R4's Primary Care Physician) stated that the fracture to the left clavicle is consistent with R4 falling from the wheelchair on 5/31/15. On 6/2/15 at 11:20 AM, E3 (Maintenance Supervisor) stated that there was a request for an anti-rollback device to be put onto R4's chair. E3 stated that the device was ordered and that it had been delivered to the facility on [DATE]. E3 stated that the anti-rollback device has not been put on R4's wheelchair. On 6/2/15 at 12:00 PM, Z2 (Customer Representative of the company who sold the Anti-rollback Device) stated that the Anti-rollback device was ordered by the facility on 5/20/15. The Packing List dated 5/21/15 show that the anti-rollback device was packed and shipped on 5/21/15. On 6/2/15 at 11:45 AM, E4 (Director of Care Delivery) stated that on 5/12/15, E3 was told to put the anti-rollback device onto R4's wheelchair. E4 stated that E4 would expect that the device be placed by the next day or when available. E4 stated that E3 had said the anti-rollback device had to be ordered. E4 stated that there was not a new fall related intervention documented for R4 until the anti-rollback device was available but E4 would have wanted staff to keep R4 in direct sight until the anti-rollback device was added to the wheelchair. E4 stated R4 is impulsive and that R4 would not lock the wheelchair and that is the reason the anti-rollback was recommended. On 6/2/15 at 12:30 PM, E5 (Physical Therapist) stated that R4 has poor safety awareness and that posture is poor when standing. E5 stated that when standing up from the wheelchair and when sitting down into the wheelchair that R4 would not place hands in the appropriate place. E5 stated that R4 would not reach back to grab the wheelchair arms when standing or sitting and the anti-rollback brakes would keep the wheel chair from rolling back. E5 stated that the anti-rollback device would prevent the wheelchair from rolling out from under R4.

Noncompliance resulted in four deficient practice statements. 1. Based on interview, observation,and record review, the facility failed to use a gait belt during resident transfer for one of one residents (R3) reviewed for resident injury in the sample of 16. This failure resulted in R3 having a sprained shoulder and overall functional decline. Findings include: On 6-16-14 at 9:00 am, R3 stated R3 has pain in right shoulder due to a CNA(Certified Nursing Assistant) transferring R3 a few months ago by holding R3 under the arms and lifting R3 to the bed. R3 told the CNA that "there is a belt in the drawer to use," but the (CNA) continued lifting under (R3's) arms. (R3) was then sent to the ER (emergency room ) with pain to right shoulder. On 6-18-14 at 9:00 am, E3 CNA (Certified Nursing Aide) stated with regards to R3's transfer, E3 and E4 (CNA) were transferring R3 from R3's wheelchair to R3's bed. E3 and E4 picked R3 up under R3's arms without using a gait belt. R3 then complained of pain to R3's right shoulder. E3 notified the nurse of R3's pain. An Investigation Report dated 2-13-14, documents, "it was reported that when two CNA's were transferring (R3) from (R3's) wheel chair to (R3's) bed that (R3) complained of right shoulder pain rating pain at an 8 out of 10. PRN (as needed) pain medication was given at that time. emergency room physician stated R3 had a right shoulder sprain and ordered an immobilizer. Staff education provided regarding proper transferring techniques." A local hospital's discharged physician's orders [REDACTED]. The local hospital ED (Emergency Department) Visit Summary dated 2/13/14 documents, "(R3) has to be picked up to be put in bed and the nursing home staff tried to pick him up under (R3's) arms and (R3's) right shoulder popped out." R3's Physical Therapy Summary dated 2-21-14 documents, "(R3) has a decline in gait due to right shoulder injury. (R3) has immobility on right upper extremity which limits weight bearing on platform wheeled walker." On 6-19-14 at 8:30 am, E3 (DON/Director of Nursing) verified (E3) and (E4) should have used a gait belt when transferring E3 from E3's wheelchair to bed. R3's plan of care dated 1-21-14 documents, transfer with two person extensive assist. The facility's Transfer: Bed-Chair/Wheelchair Policy dated 01/2011 documents under One Person - Stand Pivot: "apply gait belt to patient." 2. Based on observation, interview, and record review, the facility failed to follow care plan interventions to prevent falls for two of ten residents (R8, R19) reviewed for falls in the sample of sixteen. Findings include: A. An Incident Report dated 1/24/14 at 12:50 p.m., documents R19 fell next to bed. An Investigation Report dated 1/24/14, documents a new care plan intervention was implemented to lay R19 down after meals. An Incident Report dated 2/17/14 at 6:30 p.m., documents R19 fell after leaving the dining room and attempting to put self to bed. The Investigation Report dated 2/17/14, documents R19 becomes impatient to be laid down after meals and will propel self to any vacant bed and attempt to place self in bed, "which usually leads to falls." An Investigation Report dated 2/17/14, documents staff were educated on following care plan interventions for R19. On 6/18/14 at 11:30 a.m., E2 (Director of Nursing) stated staff did not follow R19's care plan intervention to lay R19 down after meals on 2/17/14, when R19 fell . B. R8's current care plan dated 4/17/14 states R8 is at risk for falls due to impaired balance/poor coordination and a history of falls. R8's MDS (Minimum Data Set) assessment dated [DATE] shows R8 requires extensive assist of two staff for all transfers. An Incident Report dated 1/24/14 at 3:30 p.m., states, "Nurse was walking by (R8's room) and (saw R8) on the floor by (R8's) bed; no fall mats noted and only one sock on." The 1/24/14 incident report does not include any recommendations for new fall interventions. Prior to R8's fall on 1/24/14, a fall intervention was added to R8's care plan on 12/24/13 stating, "Fall Mats beside bed." R8's care plan shows no revisions after R8's fall on 1/24/14. R8's Progress Notes from 1/01/14 through 1/30/14 do not include an entry documenting R8's 1/24/14 fall. 3. Based on record review and interview, the facility failed to develop and implement care plan interventions to prevent resident to resident altercations for two of seven residents (R8, R7) reviewed for behaviors in the sample of sixteen. Findings Include: A. R7's Physician order [REDACTED]. The facility document titled Incident Report-Patient Involved dated 12/12/2013 8 p.m. indicates R7 was kicking another resident. R7's care plan dated 3/20/14 shows no behavioral interventions. R7's Incident Report, dated 12/25/2013, stated, "Resident slapped another resident." R7's care plan contained no further new behavioral interventions. Incident reports for continued aggressiveness by R7 were dated 12/26/2013, 1/14/2014, 1/21/2014, 2/24/2014,3/14/2014, and 4/2/2014. R7's care plan contained no further interventions or approaches. E2 (Administrative Director of Nurses/ ADNS) stated on 6/17/14 at 10:45 AM, "The prior Delivery Care Director (E14) was over the care of the patient (R7) at the time of the incidents, so (E14's) interventions were questionable. At this time I don't see where interventions were put in place to prevent further behaviors." E6 (Director of Care Delivery/ DCD ) stated on 6/17/14 at 10:45 AM, "This patient was not mine. I don't see any different approaches or interventions to keep resident safe." B. R8's MDS (Minimum Data Set) assessment dated [DATE] shows R8 has short term and long term memory problems with severe cognitive impairment. R8's current care plan dated 4/17/14 documents R8 is at risk for behavior symptoms related to Alzheimer's Disease/Dementia and exhibits behaviors which include grabbing at staff and peers as they pass by. An Incident Report dated 1/21/14 at 4:30 p.m., states, "Patient's Name: (R8). Resident to resident altercation without injury. Resident was moved away and a small open area was noted on right pinky (little finger)." R8's Progress Notes from 1/01/14 through 1/30/13 do not contain an entry for 1/21/14 at 4:30 p.m. An Investigation Report dated 1/21/14, documents R8 and R34 had a hold of each other's hands when staff intervened and separated the residents. The report states, "New intervention is to have medications reviewed for R8. R8's care plan dated 4/17/14 includes an entry for an intervention related to behaviors on 1/03/14 but no new behavior interventions were added to R8's care plan until 2/16/14. R8's progress notes and Incident Reports from 1/01/14 through 1/30/14 document six incidents of resident to resident altercations involving R8 on 1/01/14; 1/02/13; 1/17/14; 1/21/14; 1/22/14; and 1/29/14. R8's care plan does not include new interventions to address resident to resident altercations on 1/17/14, 1/21/14, 1/22/14, and 1/29/14. Incident Reports document the following: On 1/17/14 at 9:44 a.m., R8 grabbed R19 wheelchair as the resident passed by and staff had to separate R8 and R19; On 1/21/14 at 4:30 p.m., staff had to separate R8 from R34; On 1/22/14 at 12:00 p.m., R8 grabbed R29's arm while sitting at the dining room table; and on 1/29/14 at 11:00 a.m., R8 grabbed R33's arm while sitting at the dining room table. No new interventions were developed for R8's behaviors with peers until 2/15/14 when an Incident Report dated 2/15/14 at 10:25 a.m. documented R8 hit R2 closed handed to the right side of R2's face. 4. Based on observation, interview, and record review, the facility failed to properly secure a side rail for one of one residents (R13) reviewed for side rails in a sample of 13. Findings include: R13's admission face sheet dated 6/6/14 notes R13 to be [AGE] years of age with [DIAGNOSES REDACTED]. On 6/17/14 at 9:25 a.m., E13 (LPN/Licensed Practical Nurse) was performing a treatment to R13's sacral wound. E13 told R13 to grab the left side rail with his left hand to turn onto the left side. As R13 did so, the rail popped off the bed. E13 took the rail to replace it on the bed, stating, "The bottom end was not locked." R13's care plan dated 6/7/14, includes the intervention to encourage R13 to reposition as needed and to use assistive devices as needed. It states under the problem of self care deficit, "use one side rail for turning and positioning purposes only. To be left on left side (of R13's bed) at all times". E2 (DON/Director of Nursing) stated at 9:45 am on 6/17/14, "We have other side rails here for (R13's) bed but I will call the manufacturer to be sure there is not a problem with it."

Based on observation, interview, and record review the facility failed to provide treatment for [REDACTED]. These failures resulted in R1 having unrelieved pain from 9-17-13 to 9-23-13. Findings include: R1 ' s hospital discharge orders dated 9-16-13 document R1 has a [DIAGNOSES REDACTED]. R1 ' s admission Physician order [REDACTED]. R1's Progress Notes dated 9-23-13 at 2:47 a.m. and signed by E7, document R1 continues to complain of back and knee pain and R1 stated R1 does not get R1's pain medications. The Notes document the Tylenol given at 11:30 p.m., was ineffective and R1 continued to push the call light approximately every half hour. On 9-23-13 at 2:30 p.m., E9 stated throughout last night (9-23-13), nothing relieved R1 ' s pain and R1 did not sleep at all. E9 stated R1 kept saying " I hope no one has to go through this. " E9 stated R1 was even crying out in pain when the staff was "not messing " with R1. E2 stated R1 would only use the bedpan instead of getting up to the bathroom, because R1 was in too much pain. On 9-23-13 at 9:10 a.m., R1 was yelling "I am hurting so bad. I can't take it." E5 (Physical Therapy Assistant/PTA) was assisting R1 from a lying to sitting position on the bed. R1 states, " I am hurting so bad. I cannot stand it. There is something wrong. I need to go to the hospital. My right leg and hip is killing me. " E5 continued to stand and pivot R1 from the bed to the wheelchair. R1 states, " I have asked for pain pills, but the nurse says it is not time yet. " A large purple bruise was noted on R1's right lower back area. On 9-23-13 at 9:15 a.m., E4 (Registered Nurse) stated R1 last had [MEDICATION NAME] two tablets at 3:15 a.m. and Tylenol at 7:45 a.m. E4 stated R1 is just now due to receive [MEDICATION NAME]. E4 administered [MEDICATION NAME] 10-325 mg, two tablets orally to R1. On 9-23-13 at 9:50 a.m., R1 was sitting upright in the wheelchair, and continuing to moan in pain. R1 states, "I am just so tired of being in pain." On 9-23-13 at 11:15 a.m., E4 (RN) stated E4 R1 is still complaining of pain at a "9" on a 1-10 scale. E4 stated R1 keeps stating, "it hurts." E4 stated a daily pain score is suppose to be done, but ".... (R1's) is not being done." On 9-23-13 at 11:00 a.m., R1 stated R1 was admitted to the facility to get help following a surgery to R1 ' s back. R1 stated when R1 was admitted to the facility, the facility did not have R1 ' s [MEDICATION NAME] ( pain medication). R1 states, " My pain will not go away. It feels like my right knee is broke." R1's Progress Notes on 9-23-13 at 11:30 a.m. and signed by E4, document R1 rated R1's pain at a "10" on a 1-10 scale, and Tylenol was given. E4 documents the on call Physician was notified again with no response. E4 documents E4 paged the on call Physician, and at 11:30 a.m., orders were given to send R1 to the emergency room . The 9-23-13 Progress Notes document R1 was sent to the emergency room by ambulance at 11:45 a.m. On 9-24-13 at 12:00 p.m., R1 was lying in bed, at the Hospital, resting. Z4 (RN/Director of Hospital Extended Care Unit) stated R1 is comfortable on Dilauded (pain [MEDICATION NAME]) and is following up with Z3 (R1's Surgeon) today regarding newly found fractures to R1's back. A Hospital Progress Note dated 9-23-13 and dictated by Z5 (Hospital emergency room Physician), documents R1's X-ray shows a compression fracture to the anterior L3 (back) which is new since the last MRI (magnetic reasonance image) done. On 9-25-13 at 10:00 a.m., Z4 stated Z2 (R1's Physician) assessed R1 this a.m. and ordered a [MEDICATION NAME] Patch for pain. Z4 stated Z2 informed Z4 that Z2 had never been informed of R1's pain while at the facility. Z4 stated R1 is going to have surgery to fix the fractures to R1's back, on 9-30-13. On 9-22-13 at 8:10 p.m., Z1 (R1 ' s daughter) stated R1 was admitted to the facility on 9-16-13 around 9:00 p.m. Z1 stated that On 9-17-13 at 10:00 a.m., R1 reported to Z1 that R1 had pain the entire night and did not receive any pain medication. Z1 stated on 9-17-13 at 10:00 a.m., R1 was in a lot of pain. Z1 stated the facility should have notified Z1, so Z1 could try to get R1 some pain medication. Z1 stated on 9-17-13 around 10:00 a.m., Z1 reported to E1 (Administrator) that R1 was in a lot of pain and did not receive pain medication all night on 9-17-13 from 12:00 a.m. to 10:00 a.m. On 9-23-13 at 12:50 p.m., E1 (Administrator) stated E1 was informed that there were care forms filled out regarding R1 ' s pain concerns, but the concerns were assigned to E2 (Director of Nursing). On 9-23-13 at 12:50 p.m., E1 stated R1 is alert and orientated. On 9-23-13 at 9:30 a.m., E2 (Director of Nursing/DON) stated on 9-17-13 at approximately 10:00 a.m., Z1 reported to E2 that R1 did not have pain medication all night long on 9-17-13. E2 stated, upon investigation, R1 had not received [MEDICATION NAME] ([MEDICATION NAME] 10-325 mg (milligram)/ pain [MEDICATION NAME]) since 12:00 a.m. on 9-17-13, because the nurses thought they did not have a signed prescription order to obtain the [MEDICATION NAME]. At this time E2 stated R1 was probably in a lot of pain since R1 had not received [MEDICATION NAME] since 12:00 a.m. E2 stated R1 reported to E2, at approximately 10:00 a.m. on 9-17-13, that R1 was still in a lot of pain. E2 stated the nurses gave R1 Tylenol on 9-17-13 in the a.m., but was unsure of the time. E2 also stated the nurse should have called R1 ' s Physician or the facility ' s Medical Director to get a signed prescription to obtain the [MEDICATION NAME]. E2 stated if the night shift nurse would have called E2, E2 would have ensured R1 ' s Physician was notified to obtain a signed prescription to obtain R1 ' s [MEDICATION NAME]. On 9-23-13 at 2:20 p.m., E7 (RN) stated on 9-17-13 at 12:00 a.m., the pharmacy gave E7 the authorization to pull a [MEDICATION NAME] from the facility ' s supply and administer the [MEDICATION NAME] to R1, since R1 was complaining of back pain. On 9-23-13 at 11:30 a.m., E6 (Registered Nurse/RN) stated on 9-17-13 at 6:30 a.m., the night shift nurse (E7/RN) informed E6 that R1 did not have signed prescriptions to obtain R1 ' s [MEDICATION NAME] and R1 was awake all night in pain. E6 stated E7 did not try to notify R1 ' s Physician to get signed prescriptions for R1 ' s [MEDICATION NAME]. On 9-23-13 at 11:30 a.m., E6 stated E6 left a message with Z2 (R1 ' s physician) that E6 needed signed prescriptions. E6 stated E6 had two halls on 9-17-13 to take care of, and did not see R1 until around 8:00 a.m. E6 stated by that time R1 was " crying out in pain " and was stating, " I just want to die. " E6 stated E6 gave R1 Tylenol around 8:00 a.m., but the Tylenol did not help and R1 continued to rate the pain at an " 8 " on a 1-10 scale. E6 stated E6 then faxed Z2 to obtain a signed prescription to obtain and administer [MEDICATION NAME] to R1. E6 stated on 9-17-13 around 10:00 a.m., R1 ' s pain was " way over a 10 on a 1-10 scale. " E6 stated E6 found signed prescriptions for [MEDICATION NAME] on 9-17-13 around 10:30 a.m., that were place inappropriately behind the MAR (medication administration record) , so E6 administered [MEDICATION NAME] two tabs to R1. E6 stated R1 ' s daughter came to the facility around on 9-17-13 around 10:00 a.m., and was really upset with E6 for not administering administering R1 [MEDICATION NAME]. E6 stated R1 ' s pain was still " over the top " at 11:30 a.m. E6 stated the Physician was not notified of R1 continuing to complain of pain after receiving the [MEDICATION NAME] at 10:00 a.m. On 9-23-13 at 2:45 p.m., E8 (CNA) stated R1 complains of pain in R1 ' s back all of the time and nothing gives R1 relief. E8 stated the first night R1 was admitted to the facility, R1 was awake the entire night, complaining of pain. On 9-23-13 at 2:20 p.m., E7 (RN)stated R1 complained of pain all night on 9-22-13, even after receiving all of the PRN (as needed) pain medications ordered. E7 stated R1 kept stating " my knee and back hurts. " E7 stated R1 reported R1 ' s pain level at a 7 or 8 on a 1-10 scale, even after receiving all PRN pain medications. E7 stated E7 faxed R1 ' s Physician on 9-22-13 around 3:00 a.m., reporting R1 complaints of pain, even after receiving the PRN pain medications. E7 stated E7 would only call a Physician if a resident complained of a pain level of " 12 " on a 1-10 pain scale. On 9-23-13 at 2:30 p.m., E9 (CNA/Certified Nursing Assistant) stated R1 complains of pain every night and E9 can tell R1 is not getting relief. On 9-23-13 at 2:25 p.m., E8 stated on Saturday night (9-22-13) R1 kept saying over and over " I am hurting. " E8 stated nothing gave R1 relief Saturday night. R1's Progress Notes dated 9-20-13 at 3:16 p.m. and signed by E10 (RN), document R1 complained of unmanaged pain after medication regimen, and Z2 was notified. The Notes document Z2 stated Z3 (R1's Surgeon) needed to be notified regarding the pain R1 was experiencing. The Notes document Z3 was notified and Z3 stated R1 probably had a tolerance to the medications, as R1 was on the same medications prior to surgery. The Progress Notes document Z3 would see R1 in the office on Tuesday (9-24-13) and use ice as needed for pain. R1's Progress Notes and Treatment Administration Records from 9-20-13 to 9-23-13, do not document use of ice for R1's pain. On 9-24-13 at 10:10 a.m., E2 stated E10 (RN) received an order from Z2 on 9-20-13 to apply ice to R1 as needed for pain. E2 stated E10 should have written a telephone order to apply ice and should have documented the order on the Treatment Administration Record (TAR), but did not. On 9-24-13 at 10:10 a.m., E2 stated E10 is the only staff that has used ice for R1 ' s pain. On 9-25-13 at 10:45, Z2 (R1's Physician) stated Z2 was unaware that R1 had even been admitted to the facility and the facility does not notify Z2 frequently of patients being admitted there. Z2 stated Z2 had never been notified by the facility that R1 was in pain. Z2 stated Z2 would have expected the facility to have notified Z2 about R1's pain. Z2 stated a fax had been sent on Saturday night regarding R1's pain, but the facility should have called the on call Physician instead of sending a fax, because Z2 did not even receive the fax until Tuesday 9-24-13. Z2 stated that if Z2 would have known R1 was having pain, Z2 would have ordered X-rays, consulted with Z3 (R1's Surgeon), and tried to figure out where R1's pain was coming from. R1's Nurse's Medication Notes document R1 received Tylenol 650 mg for pain on 9-17-13 at 7:55 a.m., 9-19-13 at 11:00 a.m., and 9-23-13 at 7:00 a.m., but do not include a follow up result/response to the medication. R1's Nurse's Medication Notes document R1 received [MEDICATION NAME] 10/325 mg two tabs for pain on 9-17-13 at 2:00 p.m., 9-18-13 at 4:30 a.m., 9-20-13 at 5:00 a.m., 9-21-13 at 8:30 a.m., and 9-23-13 at 9:20 a.m., but do not include a follow up result/response to the medication. R1's MAR documents a daily pain score is to be done, but every day is blank. R1's Progress Notes on 9-17-13 at 4:15 p.m., document a skin assessment for R1 could not be completed because R1 was having increased pain. Facility concern form dated 9-17-13 and signed by E2 (DON), documents a medication order was not faxed until after the cut off time for R1 and the prescription for pain medication was not received until the next day. Facility concern form dated 9-17-13 and signed by E2, documents Z1 (R1's daughter) was concerned R1 did not receive pain medication the entire first night of R1's stay at the facility. The facility's Pain Practice Guide dated 11/2011 documents patients are to be evaluated daily for evidence of pain and responses are to be documented on the MAR as well as a pain evaluation to be completed before and after PRN pain medication is administered. Patients with a pain score of 4 to 7 twice in a 7 day period or who had one score of 8,9,or 10 are to be reported to the Physician for possible treatment adjustment.