Every finding on record at North Ridge Health and Rehab

Based on observation, interview and document review, the facility failed to provide a dignified dining experience for 7 of 7 residents (R28, R124, R128, R197, R233, R244, R257) when meals were served on hard plastic trays in the dining room. Further, the facility failed to ensure resident's right to privacy and dignity for 1 of 1 residents (R2) when staff failed to knock and wait for permission before entering the resident's room. Findings include: R28's quarterly Minimum Data Set assessment (MDS), dated [DATE], indicated R28 had intact cognition, and an admission date of 10/24/25. R124's quarterly MDS, dated [DATE], indicated R124 had severely impaired cognition, no hallucinations or delusions, and an admission date of 11/21/18. R128's annual MDS, dated [DATE], indicated R128 had short-term and long-term memory issues, severely impaired daily decision making, and an admission date of 11/13/20. R197's quarterly MDS, dated [DATE], indicated R128 had intact cognition, and an admission date of 11/25/25. R233's quarterly MDS, dated [DATE], indicated R233 had moderately impaired cognition and an admission date of 10/18/24. R244's quarterly MDS, dated [DATE], indicated R244 had short term and long-term memory issues, severely impaired daily decision making, and an admission date of 4/5/19. R257's annual MDS, dated [DATE], indicated R257 had moderately impaired cognition, no hallucinations or delusions, and an admission date of 8/26/22. During an observation of lunch service on 6/23/26 at 12:59 p.m., five residents (R124, R128, R233, R244, R257) were observed eating in the small dining room on the 2W unit, with two staff observed assisting residents at the tables. Positioned on the table in front of each resident was a meal on a hard plastic serving tray. Each hard plastic tray had a food plate, silverware, and beverage containers on it. The warming lids from the plates were tipped upside down on the table in front of the residents. During an observation of lunch service on 6/24/26 at 11:46 a.m., the lunch meal service was observed on the 2nd floor west main dining room. The dining room had a steam serving table with food items. The staff placed the food items, beverages, and silverware onto a hard plastic serving tray. The meals were then delivered to each resident at their table. However, the hard plastic servicing trays were then left on the table with plated food, beverages and silverware on top of them. Staff did not ask or offer to remove the items from the serving trays and place them onto the table. R28 and R197 were observed eating from the hard plastic meal tray. R197 stated he did not like the hard plastic serving trays and would not eat from one at home. During an observation on 6/25/26 at 8:03 a.m., breakfast meal service was observed on 2nd floor west main dining room. The residents ate in the dining room and their breakfast meal was served on the hard plastic serving tray. The serving trays remained under each resident's dishes during the meal service. The staff that served the meals in the dining room did not ask residents if they wanted the serving tray removed while the residents ate. During an interview on 6/25/26 at 7:49 a.m., nursing assistant (NA)-A stated the nursing assistants helped serve residents in the dining room. NA-A stated the process was to bring the residents the serving tray of food, set the tray in front of the resident, and take the covers off the plates and beverages. NA-A stated staff had not been directed to take the food items off the hard plastic tray. NA-A stated there was no reason why the food was left on the hard plastic tray when served to residents. During an interview on 6/25/26 at 8:59 a.m., registered nurse unit manager (RN)-D stated nursing staff brought the trays to the residents in the dining room during mealtimes. RN-D acknowledged the meals were served to residents in the dining room on the hard plastic tray. RN-D stated he was not sure why the food was left on the hard plastic trays. During an interview on 6/25/26 at 10:37 a.m., director of nursing (DON) stated meals should have been served without the hard plastic trays. DON stated the food should have been taken off the trays when served to residents to create a more homelike environment. R2's quarterly MDS, dated [DATE], indicated R2 was cognitively intact. During an observation and interview on 06/22/2026 at 11:27 a.m., staff entered R2's room without ensuring privacy was maintained. An unidentified nursing assistant (NA) knocked once on R2's door, and entered the room without waiting for a response, to inform R2 it was time for lunch. R2 stated staff just walk right in, expressed fear of changing clothes due to lack of privacy, and reported he did not feel he had adequate privacy in his room. During an interview on 06/24/2026 at 10:33 a.m., NA-E stated that before staff entered a resident's room, staff were expected to knock and wait for a response. During an interview on 06/25/2026 at approximately 9:11 a.m., the nurse manager/ licensed practical nurse (LPN)-C, stated staff were expected to knock and wait for a response prior to entering the room to ensure resident privacy and dignity. During an interview on 06/25/2026 at 11:20 a.m., director of nursing (DON) stated staff were required to knock and wait for a response before entering resident rooms. DON stated this was the facility's expectation to maintain resident privacy. The facility's Dining Environment policy, dated 10/25, indicated the facility would create an appropriate dining environment. The facility's Resident Rights policy, dated 11/2025, indicated federal and state law guarantee residents' basic rights, including the right to privacy.

Based on interview and document review, the facility failed to provide written information on the duration of the bed-hold and reserve bed payment at the time of transfer for 4 of 4 residents (R21, R147, R203, R260) reviewed for hospitalizations.Findings include: R21's annual Minimum Data Set (MDS), dated [DATE], identified R21 with intact cognition, and diagnoses included diabetes, heart disease, kidney disease, and partial amputation of left foot. R21's Clinical Assessment screen identified transferred to the hospital on 6/8/26. R21's electronic medical record (EMR) lacked evidence bed holds were offered, signed, and followed up on. During an interview on 6/22/26 at 11:46 a.m., R21 stated he had never been offered or signed a bed hold form when he transferred to the hospital, and stated, No one from here reached out to me. R147's quarterly Minimum Data Set (MDS), dated [DATE], identified R147 had intact cognition and diagnoses included chronic respiratory failure, quadriplegia, and R147 required suctioning and tracheostomy care. R147's EMR identified R147 was transferred to the hospital on 3/15/26, and 4/3/26. However, review of R147's EMR lacked evidence the facility provided R147 and/or R147's resident representative with written information regarding the facility's bed hold policy at the time of the hospital transfers. During an interview on 6/25/26 at 7:50 a.m., the social services designee (SSD) stated social services completed bed holds when available, and nursing staff completed the process if social services were unavailable. The SSD stated when a bed hold was not obtained by nursing staff at the time of transfer, social services followed up with the resident's representative. The SSD stated the director of nursing (DON) confirmed completion of bed holds. During an interview on 6/25/26 at 10:53 a.m., registered nurse (RN)-A stated staff determined if the resident was their own responsible party or if the resident's representative needed to be contacted regarding the bed hold. RN-A stated completion of the bed hold process was documented in the resident's progress notes. During an interview on 6/25/26 at 11:07 a.m., the registered nurse case manager (RNCM) stated when a resident was transferred to the hospital, nursing staff notified the resident's representative, discussed the bed hold, and documented the information in the progress notes. The RNCM stated social services were updated and a bed hold form was sent with the resident. The RNCM confirmed R147's EMR lacked evidence bed hold information was provided to R147 and/or R147's resident representative for the hospital transfers on 3/15/26 and 4/3/26. During an interview on 6/25/26 at 1:35 p.m., director of nursing (DON) stated for emergency transfers, social services followed up with the resident and/or resident representative regarding whether they wanted a bed hold and documented the information in the progress notes. The DON stated the process was important to determine if the resident or resident representative wanted to hold the resident's bed, identify the length of time the bed would be held, and ensured clear communication. R203's quarterly MDS, dated [DATE], identified R203 with moderate cognitive impairment, and diagnoses included hypertension, peripheral vascular disease, kidney disease, receiving hemodialysis, left below the knee amputation, and diabetes. R203's EMR identified transfers to the hospital on 4/27/26, 5/8/26, and 6/3/26. However, R203's EMR lacked evidence bed holds were offered, signed, and followed up on. During an interview on 6/23/26 at 5:21 p.m., RN-K stated nurses were expected to print out a face sheet, orders, and medication list to send with resident to hospital. In addition, the nurse was expected to start a Transfer Form in the EMR. RN-K stated a signed bed hold form was to accompany the resident to the hospital, and a progress note written after the resident transferred to identify status of the bed hold, such as who was notified. During an interview on 6/23/26 at 5:21 p.m., RN-L stated expectation of nursing staff to print out a face sheet, orders, and medication list to accompany resident to hospital once orders to transfer were obtained. In addition, the nurse was expected to start a Transfer Form in the EMR. RN-L stated the bed hold form was a separate piece of paper that needs to be signed [by the resident] and followed up if they cannot at the time. RN-L stated expectation of a progress note following the transfer to indicate whether bed hold was signed or offered, and to be followed up by social services if it is not signed. During an interview on 6/24/26 at 11:10 a.m., RN-M stated expectation of nursing staff to print out a face sheet, orders, and medication list to accompany resident to hospital once orders are obtained, and the nurse was expected to start a Transfer Form in the EMR. RN-M stated the bed hold form was expected to be offered to and signed by the resident or guardian and accompany the resident to the hospital. RN-M stated expectation of the nurse to document in a progress note whether the bed hold was offered or signed, and if it was not then social services were to follow up. RN-M acknowledged the process was not followed for R21 and R203. During an interview on 6/24/26 at 11:44 a.m., SS-D reviewed EMR for R21 and R203 and stated he was unable to locate any signed bed hold forms. SS-D stated, The process should be to have the patient or guardian sign the bed hold and [facility] scan it in the EMR. We should be following up if it was done or not in a progress note. SS-D stated the facility failed to document if a written notice was offered and provided to R21 and R203, or their guardians on transfer, including notifying the Office of the State Long Term Care Ombudsman. During an interview on 6/25/26 at 8:41 a.m., R203 stated he had never been offered or signed a bed hold form when he was hospitalized . During an interview on 6/25/26 at 10:51 a.m., DON stated expectation of a signed bed hold to accompany resident at time of transfer. It should be scanned in the EMR but [process] is not reliable. DON verified the facility failed to document if a written notice was offered and provided to R21 or R203, or their guardians on transfer, including notifying the Office of the State Long Term Care Ombudsman. R260's admission MDS, dated [DATE], identified R260 was cognitively intact, was able to express needs and wishes, and was able to understand others, and diagnoses included surgical amputation, peripheral vascular disease (a disease with narrowing of the blood vessels which impacts blood circulation throughout the body), and malnutrition. R260's care plan, initiated 3/4/26, identified R260 was at risk for falls and was dependent on staff for cares. R260's progress note, dated 3/25/26 at 5:23 a.m., identified R260 was found on the floor at 5:00 a.m., and denied striking head. At that time, the provider and family were advised. The documentation indicated the provider would follow up with patient to assess. R260's progress note, dated 3/25/26 at 5:14 p.m., identified R260 was noted to have swelling to the left side of face and was confused, and waw not able to recognize family member/power of attorney (POA). Notification was sent to the provider triage nurse and resident was transferred to the hospital for evaluation. The progress note indicated the bed hold was signed by the POA. However, R260's EMR lacked evidence of the signed bed hold from 3/25/26. During interview on 6/25/26 at 11:52 a.m., registered nurse/unit manager (RN/UM)-A stated upon transfer to the hospital, a bed hold wase obtained from the responsible party. This is completed either in person, or via the telephone for verbal consent. Once signed, RN/UM-A stated the document was placed in the medical record. During interview on 6/25/2026, at 2:30 p.m., DON provided a handwritten note which identified 3/25/26 at 5:43 p.m. Bed hold per POA of resident. DON acknowledged this documentation lacked indication as to information provided to the POA, including potential fees and right to appeal. The facility's Bed Hold policy, revised 04/2025, indicated community staff shall inform residents upon admission and prior to a transfer for hospitalization (unless for an emergency) or therapeutic leave of the bed-hold policy, and a copy of the resident's bed-hold or release record will be filed in the resident's medical record.

Based on observation, interview, and document review, the facility failed to ensure controlled substance reconciliation was completed in accordance with established policies and procedures to reduce the risk of diversion and/or theft on 2 of 8 medication carts reviewed. This had the potential to affect 8 residents identified to have controlled substances in the reviewed carts.Findings include: During an observation and interview on 6/23/26 at 1:54 p.m., the 2W far south medication cart was reviewed with registered nurse (RN)-A. The mobile cart was locked with a physical key, along with a separately attached metal narcotic box, which was also locked. The narcotic box was opened and contained numerous controlled substances. RN-A explained that the narcotics and controlled substances were counted at each shift exchange, and these reconciliations were recorded on a Narcotic Shift to Shift Signature form. RN-A provided the flow sheets used to track the documented count(s). However, approximately half of the signature spaces were blank. RN-A confirmed the form had approximately half of the spaces filled and stated all the signature spots should have been completed. RN-A stated she did not know why spaces were blank. The facility's 2 [NAME] FS (far south) Narcotic Shift to Shift Signature Sheet, for June 2026, indicated there were 132 possible signature spaces, with 106 documented signatures for 6/1/26 through 6/26/26. During an observation and interview on 6/23/26 at 2:03 p.m., with RN-B and RN-C, the 2W near south mobile medication cart was observed locked with a physical key, along with a separately attached metal narcotic box, which was also locked. The narcotic box was opened and contained numerous controlled substances. RN-C explained the narcotics and controlled substances were counted at each shift exchange, and these reconciliations were recorded on a form to indicate the count had occurred. RN-C provided the flow sheets used to track the documented count(s). However, approximately half of the signature spaces were blank. The facility's 2 [NAME] NS (near south) Narcotic Shift to Shift Signature Sheet, June 2026, indicated there were 132 possible signature spaces for 6/1/26 to 6/22/26. However, there were 41 signatures total on the sheet for 6/1/26 through 6/22/26. During an interview on 6/23/26 at 2:09 p.m., the nurse manager/ licensed practical nurse (LPN)-A stated staff were expected to sign the controlled medication reconciliation form to indicate that controlled medication reconciliation had occurred. LPN-A confirmed approximately half the signatures were missing on the 2W NS form. LPN-A stated that based on documentation, he was unable to confirm that medication reconciliation had occurred. During an interview on 6/24/26 at 10:17 a.m., the director of nursing (DON) stated nursing staff were expected to complete controlled medication reconciliation at each shift change, and the reconciliation should have been documented on the narcotic shift change forms. The facility's Controlled Substances policy, dated 10/2026, indicated the controlled substance records would be reconciled by a physical count of the remaining controlled substance supply at the change of each shift by the oncoming and outgoing licensed nurse/designee.

Based on observation, and interview, the facility failed to ensure food was served in a timely manner to preserve desired temperatures of food for 5 of 5 residents (R3, R28, R156, R197, R294) reviewed who expressed concerns for food temperatures and palatability. Findings include: R3's quarterly Minimum Data Set (MDS) assessment, dated 3/16/26, identified R3 had intact cognition with an admission date of 11/13/24. During an interview on 6/24/26 at 10:23 a.m., R3 stated she ate in the main dining room on 2W, and she had brought up the concern of cold food to staff previously. R28's quarterly MDS assessment, dated 5/31/26, identified R28 had intact cognition with an admission date of 10/24/25. During an interview on 6/24/26 at 10:23 a.m., R28 stated the food was always cold. It didn't make a difference if you ate in your room or in the dining room. R28 stated he ate in both places and had brought up the concern of cold food to staff previously. R156's quarterly MDS assessment, dated 5/25/26, identified R156 had intact cognition with an admission date of 2/18/26. During an interview on 6/24/26 at 10:23 a.m., R156 stated the food was served cold when it should be hot most of the time. R156 stated he ate in the dining room most of the time and had brought up the concern of cold food to staff previously. R197's quarterly MDS assessment, dated 6/4/26, identified R128 had intact cognition with an admission date of 11/25/25. During an interview on 6/24/26 at 10:23 a.m., R197 stated the French fries were always cold. R197 stated he ate in the main dining room on 2W most of the time and had brought up the concern of cold food to staff previously. R294's quarterly MDS assessment, dated 4/1/26, identified R294 had intact cognition with an admission date of 1/17/26. During an interview on 6/22/26 at 1:02 p.m., R294 stated the food was served cold when it should have been hot. Furthermore, R294 stated the flavor wasn't always great. During an observation and interview on 6/24/26 at 12:56 p.m., dining staff, including the dietary manager (DM), were observed serving food from the 3 west dining room. After all resident meals were plated, DM temped the food that remained in the food warmer. The following temperatures were obtained: turkey 164 degrees Fahrenheit (F), green beans 173.8 F and sweet potato 149.5 F. After the temperatures were obtained, the food remained on the warming table. The DM then followed the meal cart into the memory care unit, waited until the last tray was ready to be served, and obtained the following food temperatures from the last tray: turkey 103.5 F, green beans 96.5 F, and sweet potato 102.4 F. DM stated all the food should have been above 140 degrees at the time it was served, regardless of if it was in the dining room or served in the resident room. DM stated food temperatures that were below 140 degrees were in the danger zone and increased the potential for food-born illnesses.

Based on interview and document review, the facility failed to obtain consent for use of psychotropic medications for 1 of 5 residents (R9) reviewed for unnecessary medicationsFindings include: R9's admission Minimum Data Set (MDS), dated [DATE], indicated R9 had severe cognitive impairment, required assistance with activities of daily living (ADLs), and diagnoses included edema, dementia, hypertension, insomnia and encephalopathy (broad term for any disease, damage, or malfunction that affects the brain). R9's Order Summary Report, printed 6/25/26, indicated R9 had an order dated 4/13/26 for trazodone 25 milligrams (mg) by mouth at bedtime for insomnia. However, review of R9's medical record lacked evidence consent for trazadone was obtained prior to use. During an interview on 6/25/26 at 10:56 a.m., registered nurse (RN)-I stated nurses were expected to complete a form for consent when a psychotropic medication was ordered. RN-I stated a nurse could initially get verbal consent but then needed to have the form signed the next time the person that gave consent was in the facility. During an interview on 6/25/26 at 11:21 a.m., RN-H stated the expectation was for consent for a medication that required it was obtained when a resident admitted on the medication or a new medication was added. RN-H confirmed R9's medical record lacked evidence or consent for trazodone. During an interview on 6/25/26 at 11:46 a.m., director of nursing (DON) stated the consent for psychotropic medications was expected to be obtained when a new psychotropic medication was ordered or when a resident was admitted with a psychotropic medication. The facility's Physician Medication Orders policy did not address obtaining consent for psychotropic medication use.

Based on observation, interview, and document review, the facility failed to assess resident for safety and the ability to self-administer medications for 1 of 1 resident (R21) reviewed for self-administration of medications (SAM). Findings include: R21's annual Minimum Data Set (MDS), dated [DATE], identified R21 was cognitively intact, and diagnoses included diabetes, heart disease, and kidney disease. R21's physician progress note, dated [DATE], identified R21 medication order for nystatin ointment 100000 unit/gram to groin and intergluteal cleft (the deep vertical groove between the buttocks) topically two times a day for fungal rash/dry skin, and with every brief change. R21's electronic medical record (EMR) identified physician orders for nystatin ointment was discontinued on [DATE]. During an observation and interview on [DATE] at 3:37 p.m., R21 had a nearly empty tube of prescription nystatin ointment, with label attached listing R21's name, and instructions for use as indicated on the [DATE] medication order, and the label indicated dates of [DATE], to [DATE]. R21 stated nystatin remained on his rolling bedside table or top of nightstand since January of 2026. R21 stated he applied the ointment when he felt he needed it. R21 stated staff were aware he had it in his room. R21 stated facility staff had never talked to him about an assessment to determine safety and competence to keep the prescription ointment in his room. During an observation on [DATE] at 1:11 p.m., R21's rolling bedside table had a nearly empty tube of the prescription Nystatin ointment. During an interview on [DATE] at 11:21 a.m., registered nurse (RN)-M stated nurses were to document an assessment in the resident EMR if a resident wished to keep prescription and over the counter (OTC) medications at bedside. When a resident was assessed as safe to self-administer their medications, a provider order for self-administration was obtained and the care plan was updated. RN-M stated complete and accurate medication orders were important due to potential risk of contraindications. During an interview on [DATE] at 11:28 a.m., RN-L stated nursing staff were expected to document an assessment in the resident EMR if a resident wished to keep prescription and/or over-the-counter medications at bedside. RN-L stated residents should not have prescription or OTC medications in their rooms unless an assessment was completed and documented in the EMR. RN-L stated, we don't want [residents] medicating themselves and potentially harm[ing] them. During observation and interview on [DATE] at 1:12 p.m., RN-D confirmed the prescription nystatin ointment was in R21's room and verified it was prescribed to R21. RN-D stated the nystatin ointment should not be here because we need to know all meds. RN-D verified a self-administration of medications assessment had not been completed for R21. RN-D stated the discontinued nystatin order meant the nystatin should have been removed from R21's room when it was discontinued.During an interview on [DATE] at 10:56 a.m., director of nursing (DON) stated nurses were expected to document a self-administration assessment for all prescribed and OTC medications left in a resident room. DON stated when a resident was assessed to be safe to self-administer a medication, a provider order for SAM was obtained by staff and documented in the EMR, and the care plan was updated. DON verified R21 was never assessed for safe self-administration of medication, and the order and care plan were never updated. The facility's Self-Administration of Drugs policy, dated 11/2016, indicated residents in our facility who wish to self-administer their medications may do so, if it is determined that they are capable of doing so and clinically appropriate. For self-administering residents, the nursing staff will determine who will be responsible (the resident or the nursing staff) for documenting that medications were taken. The nursing staff will rotate bedside stock and will remove expired, discontinued, or recalled medications.

Based on observation, interview, and document review, the facility failed to accommodate resident needs by ensuring a call light was accessible for 2 of 2 residents (R221, R283) reviewed for call lights.Findings include: R221's admission Minimum Data Set (MDS), dated [DATE], identified R221 was cognitively intact, and diagnoses included diagnoses of neurogenic bladder, diabetes, and schizophrenia. Additionally, R221 had impairment on one side of upper and lower extremities, required a walker and wheelchair for mobility, and required substantial assistance for dressing and hygiene. During an observation and interview on 6/25/26 at 8:37 a.m., R221 was seated in a wheelchair in her room, facing her bed with the bedside table between her and her bed. R221's call light was wrapped around the upper bedrail of the bed and out of reach. R221 was unable to access her call light, and stated, it is too far away. R221 attempted to move her wheelchair around the bed stand but was unable to move. Licensed practical nurse (LPN)-B and nursing assistant (NA)-D entered R221's room and verified the call light was not within R221's reach. LPN-B stated the call light should be in reach. NA-D stated the call light should be [in reach]. R283's admission MDS, dated [DATE], identified R283 with impaired cognition, required assistance with hygiene, and diagnoses of cardiomyopathy, heart disease, kidney disease, diabetes, and depression. During an observation and interview on 6/22/26 at 11:02 a.m., R283 was observed in bed as he watched television (TV). However, R283's call light was wrapped around the wall call light unit and was out of R283's sight and reach. R283 stated if he needed assistance, he would call out and it takes all day to get attention. During an interview on 6/22/26 at 11:06 a.m., nursing assistant (NA)-B verified R283's call light was wrapped around the wall unit and was out of R283's sight and reach. NA-B stated the call light should have been within R283's reach so R283 could call for help if needs it. During an observation and interview on 6/23/26 at 5:08 p.m., R283 watched TV from his bed. R283's call light was wrapped around the wall and was out of R283's sight and reach. R283 stated, I don't use it because I can't reach it. During an interview on 6/24/26 at 10:39 a.m., NA-C stated staff were expected to ensure call lights were within reach of every resident when in their rooms. NA-C stated residents could not request help unless the call light was within reach, and it was important for resident safety. During an interview on 6/24/26 at 11:23 a.m., registered nurse (RN)-L stated expectation of call lights to always be in reach of every resident when in their rooms. During an interview on 6/24/26 at 11:19 a.m., RN-M stated call lights should be ideally within reach. RN-M stated call lights wrapped around the wall unit, and not in reach was not acceptable. RN-M stated the call lights were a lifeline for residents to use if they needed assistance. During an interview on 6/25/26 at 10:59 a.m., DON stated expectation of call lights to be in reach of every resident to have for help if needed. The facility's Answering the Call Light policy, effective 10/2025, indicated when the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident.

Based on observation, interview, and document review, the facility failed to ensure ongoing assessment and evaluation of physical restraints were completed to determine continued need, risks, benefits, and least restrictive interventions for a wheelchair lap tray and set belt for 1 of 1 resident (R147) reviewed for physical restraints. Findings include:R147's quarterly Minimum Data Set (MDS), dated [DATE], identified R147 had intact cognition and required assistance with activities of daily living (ADLs). R147's diagnoses included quadriplegia (paralysis affecting all four extremities), muscle weakness, lack of coordination (difficulty controlling body movements), and abnormalities of gait and mobility (difficulty with movement and positioning). The MDS further identified R147 did not use restraints.During an observation on 6/22/26 at 5:16 p.m., R147 was seated in his wheelchair with a seat belt secured and a lap tray attached to the wheelchair.During an observation on 6/25/26 at 11:05 a.m., R147 propelled throughout the main area in his power wheelchair. R147's wheelchair seat belt was buckled and a lap tray was positioned across the wheelchair.R147's care plan, dated 5/11/26, identified R147 had a seat belt on his wheelchair and R147 was able to lock and release the seat belt independently. The care plan interventions identified R147 was educated on risks versus benefits, and signed consent to use of the seat belt. R147's care plan further indicated R147 understood the seat belt could be removed at any time, the seat belt would be used when R147 was in the wheelchair as desired, and the seat belt did not impede R147's mobility or ability to reposition in the chair.R147's Physical Restraint Quarterly Assessment history, identified the most recent assessment was completed on 2/17/26. R147's electronic medical record (EMR) lacked evidence additional quarterly restraint assessments were completed after 2/17/26, The assessments were used to evaluate continued use of the lap tray and seat belt, verify R147 continued ability to independently remove the devices, determine if the devices continued to meet R147's assessed needs, or identify if less restrictive interventions or restraint elimination were appropriate.During an interview on 6/25/26 at 10:53 a.m., registered nurse (RN)-A stated R147 used a seat belt and lap tray on his wheelchair. RN-A stated the nurse manager was responsible for reassessing the continued need for the devices and R147's ability to use them.During an interview on 6/25/26 at 11:07 a.m., the registered nurse case manager (RNCM) reviewed R147's medical record and confirmed the last Physical Restraint Quarterly Assessment was completed on 2/17/26. The RNCM stated restraint assessments should have been completed quarterly, and confirmed an assessment should have been completed after 2/17/26. The RNCM stated the assessment had not been completed because it had not triggered in the EMR system. The RNCM stated reassessments were important to ensure continued appropriate use, and to verify the resident's needs remained current.During an interview on 6/25/26 at 1:35 p.m., the director of nursing (DON) stated physical restraint assessments were expected to be completed quarterly. The DON stated when residents were transferred to the hospital, assessments were discontinued in the electronic system and could fall off if they were not reviewed upon return to the facility. The DON confirmed R147 should have had another assessment completed after 2/17/26. The DON stated assessments were important to ensure residents remained able to remove the device independently and, if unable to remove the device, alternative interventions would need to be identified to maintain safety and update the care plan.The facility's Use of Physical Restraints policy, dated 6/2025, identified physical restraints were defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual could not remove easily and restricted freedom of movement or normal access to the body. The policy identified the definition of a restraint was based on the functional status of the resident and not the device. The policy further identified restrained individuals would be reviewed regularly, at least quarterly, to determine whether they were candidates for restraint reduction, less restrictive methods of restraint, or restraint elimination. The policy identified care plans for residents with restraints would include interventions addressing the resident's needs and measures to reduce or eliminate restraint use.

Based on interview and document review, the facility failed to ensure psychotropic medications were used in accordance with professional standards by failing to ensure PRN (as needed) psychotropic medication orders were limited to 14 days or contained documented clinical rationale and/or practitioner evaluation to support continued use beyond 14 days. The facility also failed to ensure monitoring was implemented to identify potential adverse effects related to antipsychotic medication use, including orthostatic blood pressure monitoring, for 1 of 5 resident (R152) reviewed for unnecessary medications.Findings include:R152's Medicare 5-day Minimum Data Set (MDS) assessment, dated 5/28/26, identified R152 had intact cognition, and diagnoses included respiratory failure, chronic obstructive pulmonary disease (COPD), and tracheostomy status. The MDS further identified R152 received antipsychotic and antianxiety medications.R152's physician orders, dated 6/22/26, included lorazepam (an antianxiety medication) 0.5 milligrams (mg) by mouth every six hours as needed (PRN) for anxiety, with a maximum of three doses per day. The order had a start date of 6/9/26, and an end date of 7/9/26, which allowed the PRN psychotropic medication to remain active for 30 days. However, R152's medical record lacked documented clinical rationale from the practitioner to support the continued use of the PRN psychotropic medication beyond 14 days.R152's physician orders, dated 6/22/26, included quetiapine (an antipsychotic medication) 37.5 mg by mouth twice daily PRN for generalized anxiety. The order had a start date of 6/16/26, and an end date of 7/16/26, which allowed the PRN antipsychotic medication to remain active for 30 days. However, R152's medical record lacked documentation the practitioner evaluated R152 and determined the continued use of the PRN antipsychotic medication beyond 14 days was appropriate.R152's physician orders, dated 6/22/26, treatment administration records (TARs), and clinical documentation revealed R152 received an antipsychotic medication. However, orthostatic blood pressure monitoring was not ordered or completed to monitor for potential adverse effects associated with antipsychotic medication use.During an interview on 6/25/26 at 11:07 a.m., the registered nurse case manager (RNCM) confirmed PRN psychotropic medications should have been limited to 14 days. The RNCM stated if continued use was needed beyond 14 days, the provider should have been contacted for a new order. The RNCM confirmed R152's lorazepam order had an end date of 7/9/26, and the quetiapine order had an end date of 7/16/26. The RNCM stated the quetiapine order indicated the medication was to continue for seven days, but the stop date indicated in the electronic medical record (EMR) did not match the provider's order. The RNCM stated the previous provider order indicated to continue PRN quetiapine for seven additional days and lorazepam three times daily for two weeks. RNCM stated the extended stop dates were likely a transcription error. The RNCM further stated orthostatic blood pressure monitoring should have been implemented due to antipsychotic (quetiapine) use because of potential adverse effects that could lead to safety concerns. The RNCM confirmed R152 did not have orthostatic blood pressure monitoring in place.During an interview on 6/25/26 at 1:40 p.m., the director of nursing (DON) stated antipsychotic medications and PRN psychotropic medications required 14-day stop dates. The DON stated when a resident routinely required PRN psychotropic medication, the facility reviewed the continued need with the provider to determine if changes were needed, and to prevent unnecessary medication use. The DON further stated residents with ordered antipsychotic medications needed to have orthostatic blood pressures completed because the medication could affect blood pressure, resulting in safety concerns and an increased risk for falls.The facility's Psychotropic Medication Use policy, dated 9/15/24, indicated psychotropic medications were to be used safely and appropriately while minimizing risks and adverse effects in accordance with current practice guidelines and regulatory requirements. The policy indicated PRN psychotropic medication orders should be limited to no more than 14 days. The policy further indicated if the physician/prescriber determined a PRN psychotropic medication, excluding antipsychotics, should continue beyond 14 days, the rationale and duration of use should be documented in the resident's medical record. The policy indicated PRN antipsychotic medication orders were limited to 14 days and could not be renewed unless the physician/prescriber evaluated the resident for the appropriateness of continued medication use. The policy further indicated all medications used to treat behaviors should be monitored for efficacy, risks, benefits, and harm or adverse consequences.

Based on interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded, with the potential for inaccurate federal reimbursement and resident care planning for 3 of 3 residents (R12, R15, R123) reviewed for MDS accuracy.Findings include: R12's readmission Minimum Data Set (MDS) assessment, dated 3/20/26 indicated R12 had not had any falls in the month prior to admission/re-admission, and indicated R12 had not had any fractures related to a fall in the 6 months prior to admission/re-admission. R12's quarterly MDS assessment, dated 6/22/26, indicated R12 had no falls in the previous 90 days. R12's care plan indicated R12 was at risk for falls related to cognition, unsteady gait and weakness. The care plan further indicated a fall with fractured hip on 3/9/26. During an interview on 6/25/26 at 11:17 a.m., licensed practical nurse manager (LPN)-A stated R12's readmission MDS assessment dated [DATE], and quarterly MDS assessments were inaccurate due to R12's fall with hip fracture on 3/9/26. During an interview on 6/25/26 at 1:52 p.m., Director of Nursing (DON) confirmed R12 had a fall with fracture on 3/9/26, the MDS assessments dated 3/20/26 and 6/22/26 were inaccurately coded. DON stated it was important for the MDS assessments to be accurate so residents received the care they needed and to prevent potential negative outcomes to residents. R15's significant change MDS, dated [DATE], indicated R15 took an anticoagulant and not an antiplatelet. R15's Medication Administration Record (MAR), dated 4/1/26 to 4/30/26, indicated R15 had not received an anticoagulant during the look back period (LBP), but had received 81 milligrams (mg) of aspirin (an antiplatelet medication) daily during the LBP. During an interview on 6/25/26 at 8:44 a.m., MDS coordinator (MDSC)-A, a registered nurse (RN), reviewed R15's medical record and stated R15 had taken an antiplatelet medication, aspirin, and had not received an anticoagulant medication during the LBP. R123's annual MDS, dated [DATE], indicated R123 was taking an anticoagulant and not an antiplatelet. R123's May 2026 MAR, dated 5/1/26 to 5/31/26, indicated R123 had not received an anticoagulant during the look back period (LBP) but did receive 81 milligrams (mg) of aspirin (an antiplatelet medication) daily during the LBP. During an interview on 6/25/26 at 7:57 a.m., RN-G reviewed R123's medical record and stated R123 had not been taking an anticoagulant but did take aspirin. During an interview on 6/25/26 at 8:27 a.m., RN-D, a nurse manager, reviewed R123's medical record. RN-D verified R123 had not taken an anticoagulant since 2021 when it was discontinued. RN-D stated R123 was and had been taking aspirin and verified aspirin was not an anticoagulant. During an interview on 6/25/26 at 8:51 a.m., MDSC-A, reviewed R123's medical record and stated R123 had taken an antiplatelet medication (aspirin), and not an anticoagulant medication during the LBP. MDSC-A verified the MDS was coded incorrectly. During an interview on 6/25/26 at 10:35 a.m., DON stated it was important the MDS was accurate as it affected reimbursement and MDS assessment information directed the care plan and interventions. The facility's MDS Assessment Coordinator policy, dated 3/2027, indicated that each individual who completed a portion of the MDS must certify the accuracy of the assessment.

Based on observation, interview and document review, the facility failed to ensure routine personal hygiene and grooming (i.e., shaving) was provided to 1 of 1 residents (R12) reviewed for Activities of Daily Living (ADLs) who were dependent on staff for their care.Findings include:R12's admission Minimum Data Set (MDS) assessment, dated 3/6/26, indicated R12 was cognitively intact, required partial to moderate assistance with personal hygiene, and had not refused or rejected cares.R12's care plan, reviewed 6/24/26, indicated R12 required the assistance of one staff for personal hygiene.During an observation and interview on 6/22/26 at 2:04 p.m., R12 had scruffy facial hair, approximately 3/4 of an inch long, covering his face and neck. R12 stated he preferred to be clean shaven. An electric razor was plugged into the wall on the floor next to R12's bed.During an observation on 6/23/26 at 10:27 a.m., R12 continued to have scruffy facial hair covering his face and neck.During an observation on 6/23/26 at 3:15 p.m., R12 had scruffy facial and neck hair present, and the electric shaver was noted on floor.During an observation and interview on 6/24/26 at 10:19 a.m., R12 continued to have scruffy facial and neck hair. R12 asked for assistance and stated he did not 'like this scruff on my face'. The electric razors were still plugged into wall and lying on the floor.During an interview on 6/24/26 at 10:46 a.m., nursing assistant (NA-D) stated she was familiar with R12's care and identified personal hygiene as shaving, assisting with denture care, cleaning face and hair brushing. NA-D stated facility staff assisted R12 with personal hygiene and specifically assisted with shaving on his bath days. NA-D stated she was unaware of R12 refusing cares.During an interview on 6/25/26 at 11:09 a.m., licensed practical nurse manager (LPN-A) stated the NA staff was responsible for the completion of personal hygiene for residents, and that a resident who was listed as requiring substantial maximal assistance, the NA staff completed the task (shaving) for the R12. LPN-A stated personal hygiene/grooming would normally be completed on bath day, however, if the resident did not receive a full bath, personal hygiene, like shaving, would be completed.During an interview on 6/25/26 at 1:52 p.m., director of nursing (DON) stated personal hygiene/cares included hair care, oral care, nail care and shaving. DON stated floor staff were responsible for completing these tasks on bath days for residents. DON stated residents' personal preferences should be honored and if a resident desired to be clean-shaven, staff were expected to make every effort to do so. DON stated she expected resident preferences to be met whenever possible. DON stated it was important to provide personal care in a manner of resident preference because residents have the right to feel good about the way they look.

Based on observation, interview and document review, the facility failed to ensure fall interventions were implemented to prevent further falls and potential injury for 1 of 3 residents (R6) reviewed for falls. Additionally, the facility failed to comprehensively assess to prevent potential injury for 1 of 1 residents (R44) reviewed for smoking. Findings include: R6's annual Minimum Data Set (MDS), dated [DATE], indicated R6 was cognitively intact, had not rejected cares, was independent with activities of daily living (ADLs), and diagnoses included arthritis and depression. R6's progress note, dated 5/14/26 at 5:13 a.m., indicated that R6 slid from bed and was found on the floor with no injuries observed. R6's fall risk management, dated 5/14/26, indicated R6 had fallen out of bed and was found on her bedside floor by staff. The report indicated R6 stated she was rolling in her bed when she had fallen. The report indicated R6 thought the bed was too small, causing her to fall off her bed, and R6 was given a new and bigger bed to reduce the risk of falling. R6's care plan, dated 5/18/26, indicated R6 was at risk for falls related to gait and balance problems and had fallen on 7/8/25, 1/25/26, 2/10/26, and 5/14/26. The care plan indicated that related to a fall on 5/14/26, R6 was given a bigger bed. R6's progress note, dated 6/22/26 at 5:22 a.m., indicated R6 was found lying on the floor beside her bed, and R6 had stated she was lying on her side in bed and attempted to roll toward the side of the bed and rolled out of bed. The progress note indicated that R6 did not have any injuries at the time of the assessment. During multiple observations on 6/23/26, other beds on the unit were observed and compared to R6's bed. R6's bed appeared to be the standard bed size. During an interview on 6/22/26 at 1:38 p.m., R6 stated she had fallen out of bed a couple of times when trying to reposition herself in bed, and felt her bed was too small. R6 stated she thought she was going to get a bigger bed but never did. During an observation and interview on 6/23/26 at 12:53 p.m., registered nurse (RN)-B stated R6 had a history of falls and R6 was supposed to have given a bigger bed. RN-B stated it appeared R6 had not received a larger bed because the one R6 had was a normal-sized bed. During an interview on 6/23/26 at 1:02 p.m., licensed practical nurse (LPN)-A, the nurse manager for the unit, stated as the fall intervention for R6's fall on 5/14/26, LPN-A ordered a larger bed and thought R6 had received it. LPN-A stated it appeared R6 had not received a larger bed and LPN-A needed to talk to the director of maintenance (DM) to determine what happened. During an interview on 6/23/26 at 1:07 p.m., the DM stated R6's bed was the standard-sized bed, and R6 had not been provided with a larger one. During a follow-up interview on 6/24/26 at 1:37 p.m., the DM stated there had been a miscommunication between maintenance and nursing. The DM stated nursing had indicated that a larger mattress was needed, but R6 already had the largest mattress size for her bed frame. The DM stated the ticket had then been closed out and a larger bed was not ordered. R44's admission Minimum Data Set (MDS), dated [DATE], indicated resident was cognitively intact and received supervision to moderate assistance with all activities of daily living (ADLs). R44's Face Sheet, printed 6/25/26, indicated R44 diagnoses included malignant neoplasm of unspecified kidney, dependence on renal dialysis, anxiety, and traumatic subdural hemorrhage without loss of consciousness. During an observation and interview on 6/22/26 at 3:07 p.m., R44 was in his room with his significant other, and two packs of cigarettes were observed on a corner table. R44 stated he smoked several times each day. No burn holes in R44's clothing were observed. During an observation on 6/24/26, at 11:46 a.m., R44 self-propelled in his wheelchair from his room to the designated outside smoking area, at the rear of the facility. R44 independently lit his cigarette, held it safely, extinguished his cigarette safely, and placed the cigarette butt in the smoking pole (a tall container where residents placed their cigarette butts). During an observation on 6/24/2026 at 12:04 p.m., R44 was seated in his room as he ate his noon meal. Two packs of cigarettes were on the corner table beside R44. During an observation on 6/24/26, at 3:58 p.m., R44 again wheeled himself in his wheelchair from his room to the designated outside smoking area. R44 managed the entire smoking process correctly and safely. R44's Smoking Evaluation, dated 5/14/26, indicated R44 did not wish to smoke during his stay, and R44 did not utilize oxygen. The remainder of the assessment was blank. R44's Smoking Evaluation, dated 5/24/26, indicated R44 did not wish to smoke during his stay, and the remainder of the assessment was blank. R44's Comprehensive Care Plan lacked information related to smoking. During an interview on 6/25/26 at 7:30 a.m., registered nurse (RN)-E stated R44 smoked independently at least four times a day. RN-E stated when R44 first admitted , he was not smoking and went outside to get some fresh air. When staff noted R44 was smoking, staff approached R44 and he told staff, I don't have that much more time to live, so I'm going to smoke. During an interview on 6/25/26 at 8:19 a.m., clinical manager (RN)-F stated he was not the clinical manager for R44's wing when R44 was admitted . and was not aware R44 lacked a comprehensive assessment of his smoking abilities. RN-F stated the facility's expectation was that any resident who smoked, whether known at the time of admission or observed afterwards, was assessed by the facility staff for resident safety. During an interview on 6/25/26 at 8:30 a.m., the director of nursing (DON) stated nursing staff were expected to assess and keep eyes on residents who wished to smoke to determine the resident's ability to smoke safely. If a resident was assessed as safe to smoke independently, they would not need supervision, unless there was a change in their status and needed to be reassessed. The facility's Managing Falls and Fall Risk policy, dated 6/2026, indicated that facility staff would attempt to identify appropriate interventions to reduce the risk of falls. The policy indicated that if a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions. The facility's Accident Prevention - Smoking Policy, revised 10/2022, indicated the facility shall establish and maintain safe resident smoking practices. Residents whom wish to smoke will be evaluated for safe smoking per community protocol. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues, per community protocol.

Based on observation, interview and document review, the facility failed to ensure appropriate provider orders were obtained to maintain an indwelling urinary catheter for 1 of 1 residents (R246) reviewed for catheter care.Findings include: R246's admission Minimum Data Set (MDS), dated [DATE] indicated R246 had moderate cognitive impairment, required assistance with activities of daily living (ADLs), and diagnoses included diabetes, atrial fibrillation, hypertension, dementia, and myelodysplastic syndrome (type of cancer in which the bone marrow does not make enough healthy blood cells). R246's Order Summary identified an order dated 6/4/26, for an indwelling (foley) caterer for comfort. However, the order failed to indicate the catheter size and balloon size needed for catheter replacement. R246's treatment administration record (TAR), dated 6/1/26 to 6/30/26 indicated an order for an indwelling (foley) catheter for comfort. However, the orders failed to include catheter size and balloon size needed for catheter replacement. R246's care plan, initiated 6/22/26, indicated R246 had an indwelling foley catheter. However, the care plan lacked the size of catheter and balloon size needed for catheter replacement. During interview on 0/25/26 at 10:56 a.m., registered nurse (RN)-I stated all orders for catheters were expected to include the size of the catheter and amount of normal saline needed to inflate the balloon. RN-I verified R246's orders did not indicate the catheter size and balloon size. During interview on 6/25/26 at 11:21 a.m., RN-H stated all catheter orders should have contained the diagnosis, catheter size and how much to fill the balloon. RN-H verified R246's orders lacked specifics regarding the size of the catheter and balloon size. During interview on 6/25/26 at 11:46 a.m., director of nursing (DON) stated indwelling urinary catheter orders were expected to include the diagnosis, size of the catheter and how much normal saline was to be used to fill the balloon. DON stated R246's orders looked as though no one had updated the order with the required information. DON stated it was important the correct catheter size and balloon volume were used to decrease discomfort. A facility policy was requested for catheter orders, but was not received.

Based on interview and document review, the facility failed to ensure timely and effective interventions were implemented for significant, unplanned weight loss and failed to ensure consistency between physician orders and care plan directives related to weight monitoring for 1 of 1 residents (R256) reviewed for weight loss. Findings include:R256's annual Minimum Data Set (MDS) assessment, dated 5/25/26, indicated R256 had severe cognitive impairment, was dependent on staff for all activities of daily living (ADLs), including feeding, and had a diagnosis of weight loss. R256 received a mechanically altered diet and was not on a prescribed weight-loss regimen.R256's physician order, dated 5/1/23, indicated an order for monthly weights. Additional orders included a house supplement shake 4 oz twice daily, initiated 1/9/24, for nutritional supplementation and ProStat Advanced Wound Care Liquid daily, initiated, 6/27/25 for wound healing.R256's weight records indicated R256 weighed 153.2 pounds (lbs) on 4/3/26 and 127 lbs on 6/3/26. These weights indicated a weight loss of 26.2 lbs (17.1%) over 2 months.R256's care plan, revised 3/1/23, identified R256 was at risk for altered nutritional/hydration status related to dysphagia, with altered textures, aphasia, hemiplegia, impaired mobility, and cardiac disease. Interventions included feeding assistance and weekly weights. However, R256's care plan directed weekly weights while R256's physician orders directed monthly weights.R256's nutrition progress note, dated 5/22/26, indicated R256's current weight was 127 lbs and identified a recent weight change within the last 30 days. The note indicated no notable change in oral intake over the 30-day lookback period and recommended continuation of the current plan of care. Despite ongoing weight loss trends, no new interventions or escalation of nutritional interventions were implemented at that time.During an interview on 6/24/26 at approximately 2:00 p.m., the registered dietitian (RD) stated residents were generally weighed monthly, but high-risk residents with weight loss were weighed weekly. The RD acknowledged the R256's weight loss trend and stated current interventions were not effective. The RD stated R256 could have received up to three nutritional shakes per day, and weekly weight monitoring should have been initiated to better evaluate trends.During an interview on 6/25/26 at 9:11 a.m., the Licensed Practical Nurse (LPN)-Unit Manager stated weights were typically obtained monthly per physician order. The LPN stated when discrepancies occurred between care plans and orders, staff followed physician orders, and care plans were expected to be updated accordingly. The LPN further stated the R256's weight loss had not been escalated as a concern requiring intervention change.During an interview on 6/25/26 at 11:20 a.m., the director of nursing (DON) stated the resident was monitored as a high-risk resident with weight loss. DON acknowledged R256 continued ongoing nutritional decline and needed for further evaluation of interventions.The facility's Weight Assessment and Intervention policy, dated 10/2025, indicated significant unplanned weight loss was greater than 7.5% weight loss in 3 months and care planning should include individualized identification of the cause of the weight loss, goals and benchmarks and interventions should consider resident choices, preferences, and abilities.

Based on observation, interview, and document review, the facility failed to ensure respiratory care and services were provided according to professional standards of practice and physician orders when the facility failed to ensure tracheostomy orders, included the specific type and size of tracheostomy tube, for 2 of 2 residents (R147 and R152) reviewed for tracheostomy care. In addition, the facility failed to obtain physician orders for oxygen therapy, including prescribed flow rate and administration parameters, for 1 of 3 residents (R152) reviewed for oxygen therapy, and the facility failed to ensure oxygen was administered according to physician orders for 1 of 3 residents (R14) reviewed for oxygen therapy.Findings included:R14R14's quarterly Minimum Data Set (MDS), dated [DATE], identified R14 had intact cognition and required staff assistance with activities of daily living (ADLs). R14's diagnoses included respiratory failure, tracheostomy status (a surgically created opening in the neck to assist with breathing), and acute respiratory failure with hypoxia (low oxygen levels).R14's care plan, dated 5/6/26, identified R14 had a tracheostomy related to impaired breathing mechanics and used a Volera/Metaneb device for secretion management. The care plan directed staff to provide humidified oxygen as prescribed with a goal oxygen saturation greater than or equal to 92%, monitor respiratory status, suction as necessary, and maintain emergency tracheostomy equipment at bedside.R14's physician orders, dated 6/22/26, included an order, initiated 2/24/26, for oxygen at 5 liters per minute (LPM) per tracheostomy collar continuously for hypoxia.During observations on 6/22/26 through 6/25/26, R14's oxygen was set as follows, instead of 5 LPN as per physician orders: On 6/22/26 at 2:04 p.m., R14's oxygen was set at 3 LPM. Additionally, the oxygen tubing contained condensation and was not labeled or dated to identify when it was last changed.On 6/22/26 at 2:04 p.m., R14's oxygen was set at 3 LPM.On 6/23/26 at 1:16 p.m., R14's oxygen was set at 3 LPM.On 6/24/26 at 8:20 a.m., R14's oxygen was set at 3 LPM.On 6/25/26 at 10:53 a.m., R14's oxygen remained set at 3 LPM.R147R147's quarterly MDS, dated [DATE], identified R147 had intact cognition and required staff assistance with ADLs. R147's diagnoses included chronic respiratory failure, respiratory failure, and tracheostomy status. The MDS identified R147 required suctioning and tracheostomy care.R147's care plan, dated 5/11/26, identified R147 had altered respiratory status and difficulty breathing related to tracheostomy status. The care plan directed staff to maintain a clear airway, suction as ordered or required, monitor for signs and symptoms of respiratory distress, and provide oxygen as ordered and needed.Review of R147's physician orders, dated 6/22/26, identified an order initiated 6/12/26, Name of Trach ______ Size of Trach ______ every shift for Tracheostomy care. However, the type or size of tracheostomy tube used by R147 was not identified.R152R152's Medicare 5-day MDS, dated [DATE], identified R152 had intact cognition and required staff assistance with ADLs. R152's diagnoses included acute respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), respiratory failure, and tracheostomy status. The MDS identified R152 received oxygen therapy and required suctioning and tracheostomy care.R152's care plan, dated 5/25/26, identified R152 had a tracheostomy related to impaired breathing mechanics and had a history of adjusting oxygen flow settings despite redirection. The care plan directed staff to check the oxygen flow rate when entering the resident's room, administer humidified oxygen as prescribed, monitor respiratory status, suction as necessary, and maintain emergency tracheostomy equipment at bedside.R152's physician orders, dated 6/22/26, identified an order initiated 6/12/26, Name of Trach ______ Size of Trach ______ every shift for Tracheostomy care, However, the type or size of tracheostomy tube used by R152 was not identified. Additionally, R152's electronic medical record (EMR) had not included a current physician order for oxygen therapy, prescribed liter flow, delivery method, frequency, or parameters. During observations from 6/22/26 through 6/25/26, R152 received oxygen without a physician order:On 6/22/26 at 3:14 p.m., oxygen was set at 5 LPM.On 6/23/26 at 1:19 p.m., oxygen was set at 4.5 LPM.On 6/24/26 at 8:27 a.m., oxygen was set at 4 LPM.On 6/25/26 at 7:39 a.m., oxygen was set at 6 LPM.During an interview on 6/25/26 at 10:53 a.m., registered nurse (RN)-A stated staff checked physician orders to verify oxygen liter flow and tracheostomy information. RN-A reviewed R14's orders and confirmed R14's oxygen was set at 3 LPM instead of the ordered 5 LPM. RN-A reviewed R152's record and confirmed there was no oxygen order and no order identified the specific type and size of tracheostomy tube.During an interview on 6/25/26 at 11:07 a.m., the registered nurse case manager (RNCM) confirmed R152 did not have an oxygen order or an order identifying the tracheostomy type and size. The RNCM stated oxygen orders should have identified the prescribed liter flow, and tracheostomy orders should have included the type and size. RNCM stated the information was important in vsdr T253'd tracheostomy required replacement during an emergency.During an interview on 6/25/26 at 1:35 p.m., the Director of Nursing (DON) stated she expected the tracheostomy type and size to be included in physician orders. The DON stated she expected oxygen orders to include oxygen use, liter flow, tubing changes, and oxygen saturation monitoring. The DON stated complete respiratory orders were important so staff knew how to appropriately care for residents.The facility's Oxygen Administration policy, dated 3/2026, directed staff to verify there was a physician order for oxygen administration and review the physician orders and care plan before providing oxygen. The policy directed staff to ensure the proper oxygen flow rate was administered and documentation included oxygen flow rate, route, frequency, duration of treatment, and resident response.The facility's Tracheostomy Care policy, dated 3/2026, directed staff to check physician orders prior to providing tracheostomy care. The policy directed staff to ensure emergency tracheostomy equipment was available at bedside and identified a replacement tracheostomy tube must be available at the bedside at all times.

Based on observation, interview, and document review, the facility failed to ensure non-pharmacological pain interventions were offered, implemented, and documented when administering as-needed pain medication for 1 of 1 resident (R142) reviewed for pain management.Findings include: R142's diagnoses list, dated 6/12/26, included malignant neoplasm of the prostate with secondary malignant neoplasms of the bone, lung, and lymph nodes, and neoplasm-related pain. R142's Pain Assessment Instrument (PAINAD), dated 6/14/26, documented R142 had no pain. R142's pain assessment, dated 6/16/26, indicated R142 was cognitively intact and had experienced frequent pain during the previous five days. R142's physician orders, dated 6/12/26, included the following as needed (PRN) medications for pain: hydromorphone 8 milligrams (mg) every 2 hours PRN for pain, ibuprofen 600mg every 8 hours PRN for pain, methocarbamol [PHONE NUMBER]mg every 6 hours PRN for muscle spasms, and baclofen 2.5mg two times daily PRN for muscle pain. R142's June 2026 Medication Administration Record (MAR), revealed R142 received PRN hydromorphone up to four times daily 6/12/26 through 6/24/26. Additionally, R142 received PRN ibuprofen one time, and methocarbamol 1000mg one time, between 6/12/26 and 6/24/26. R142's EMR revealed the facility failed to provide and document non-pharmacological pain interventions before or after administration of as-needed pain medication. R142's hospice care plan, initiated 6/15/26, addressed the resident's terminal prognosis related to metastatic prostate cancer. However, individualized, non-pharmacological pain interventions were not identified. During an observation on 6/24/26 at 8:10 a.m., R142's call light was activated. Nurse Manager/Licensed Practical Nurse (LPN)-C responded to the call light. During the encounter, R142 requested pain medication. However, LPN-C did not offer or implement non-pharmacological pain intervention while R142's request was addressed. During an observation on 6/24/26 at 8:15 a.m., LPN-D administered scheduled pain medication, and subsequently administered PRN hydromorphone after R142 requested additional pain medication. However, LPN-D failed to offer or implement any non-pharmacological pain interventions before the PRN narcotic was administered. During an observation and interview on 6/24/26 at 8:32 a.m., nursing assistant (NA)-F assisted R142 with morning cares. NA-F stated R142 frequently experienced significant pain. R142 stated, I don't think just pills will get this pain away. R142 further stated massage had helped in the past but had not been offered since R142 admitted to the facility. During an interview on 6/24/26 at 10:47 a.m., R142 stated his pain remained poorly controlled despite the receipt of pain medication. R142 stated ongoing pain was discussed with the hospice nurse, but no changes had been made. During an observation and interview on 6/24/26 at 1:42 p.m., R142 was in bed and appeared lethargic. R142 stated he felt out of it and did not feel well. During an interview on 6/24/26 at 1:28 p.m., registered nurse (RN)-O stated non-pharmacological interventions were documented under behavior management, and staff were expected to document interventions attempted and their effectiveness in a progress note. During an interview on 6/25/26 at 9:11 a.m., LPN-C stated staff were expected to implement non-pharmacological pain interventions, document interventions attempted in progress notes, and document whether those interventions were effective. LPN-C stated staff were expected to communicate with the provider or hospice when scheduled pain medications had not adequately controlled a resident's pain. During an interview on 6/24/26 at 2:53 p.m., the hospice RN case manager stated facility staff had not communicated concerns that R142 continued to experience uncontrolled pain. During an interview on 6/25/26 at 11:20 a.m., the director of nursing (DON), stated the R142's care plan should have identified individualized non-pharmacological pain interventions were to be attempted. The DON stated nursing staff were expected to document in a nurse's note or progress note the non-pharmacological interventions offered and whether the interventions were effective in managing the resident's pain. The facility's Pain Assessment and Management policy, dated 5/2026, directed staff to monitor the frequency of as-needed (PRN) pain medication use and to notify the practitioner when PRN pain medications were being administered around the clock so routine scheduled pain medication could be considered. The policy further indicated pharmacological interventions alone do not typically address the cause of pain and may result in adverse effects. The policy indicated non-pharmacological interventions may be appropriate, either independently or in conjunction with pain medications, as part of pain management.

Based on observation, interview and document review, the facility failed to ensure licensed nursing staff demonstrated competency by administering the incorrect dose of a controlled medication and inaccurately documenting controlled substance administration for 1 of 3 residents (R142) reviewed for medication administration. Findings include:R142's diagnoses list, dated 6/12/26, included malignant neoplasm of the prostate with secondary malignant neoplasms of the bone, lung, and lymph nodes, and neoplasm-related pain.R142's physician orders, dated 6/12/26, included an order for Methadone HCl 10 milligram (mg) tablets - 50 milligrams (mg) every morning, 20 mg daily (midday), and 40 mg at bedtime for pain. During observation on 6/24/26 at 8:15 a.m., Licensed Practical Nurse (LPN)-D entered R142's room to administer scheduled medications. During the medication pass, R142 requested as-needed pain medication and LPN-D why there were only two pain pills in his medication cup as he should have five pills. LPN-D told R142 that the medication cup contained his morning dose.Review of R142's methadone medication card revealed all three varying doses of methadone were packaged in the same medication card, with each bubble containing either two, four or five 10mg-tablets. LPN-D stated she removed methadone tablets from the medication card in the order they were packaged, rather than verifying the prescribed dose before administration. LPN-D acknowledged she had administered 20 mg (two 10mg-tablets) instead of the ordered 50 milligrams (five 10mg-tablets) for the scheduled 6/24/26 morning dose. Following R142's medication administration on 6/24/26 at 8:15 a.m., LPN-D documented the controlled substance incorrectly in the narcotic accountability record when she recorded an incorrect remaining tablet count. After LPN-D acknowledged she had administered Methadone 20mg instead of 50mg as ordered for R142's morning medication administration, LPN-D corrected the documentation after the error was acknowledged During observation and interview on 6/24/26 at approximately 8:45 a.m., LPN-D returned to R142's room with three additional methadone 10mg-tablets, stated hospice had been contacted, and hospice instructed LPN-D to administer the remaining tablets to complete the prescribed morning dose.During an interview on 6/25/26 at 9:11 a.m., Nurse Manager LPN-C stated licensed nurses were expected to follow the five rights of medication administration, verify medication directions prior to administration, review medication parameters, and maintain accurate narcotic accountability records by documenting the correct quantities administered and remaining. LPN-C stated the nurse should have recognized that multiple methadone doses were packaged within the same medication card. During an interview on 6/25/26 at 11:20 a.m., the Director of Nursing (DON), stated licensed nurses were expected to follow the five rights of medication administration by ensuring the right resident, right medication, right dose, right route, and right time before medications were administered. The DON stated nurses were expected to accurately document controlled substance administration and follow up with nurse management if concerns with medication packaging were noted.The facility's Medication Administration policy, dated 10/2025, directed staff to administer medications safely, timely, and as prescribed. The policy required licensed staff to administer medications in accordance with physician orders, verify the right resident, right medication, right dose, right time, and right route before administration by checking the medication label three times, and accurately document medication administration following administration. The policy further directed staff to contact the resident's physician if a prescribed dosage was believed to be inappropriate or excessive and indicated newly authorized staff were not permitted to administer medications until they had been oriented to the facility's medication administration system.

Based on interview and document review, the facility failed to ensure recommendations from the consulting pharmacist were acted upon timely to reduce the risk of adverse effects for 1 of 5 residents (R9) reviewed for unnecessary medication use.Findings include: R9's admission Minimum Data Set (MDS), dated [DATE], indicated R9 had severe cognitive impairment, required assistance with activities of daily living (ADLs), and diagnoses included edema, dementia, hypertension, insomnia and encephalopathy (broad term for any disease, damage, or malfunction that affects the brain). R9's Pharmacy Consultation Report, dated 5/19/26, indicated the facility needed to obtain a psychotropic consent for a new order of trazadone (a psychotropic medication) for insomnia. Additionally, the report indicated the facility needed to monitor R9's sleep while R9 received trazadone. However, R9's medical record lacked evidence that the facility obtained psychotropic consent for R9's trazodone. Additionally, R9's medical record lacked evidence sleep monitoring was completed as recommended. During an interview on 6/25/26 at 11:21 a.m., registered nurse (RN)-H stated nurses obtained consent for a psychotropic medication when a resident was admitted to the facility, or when a new psychotropic medication was ordered. RN-H stated she processed the pharmacy recommendations for the nursing department. RN-H verified R9's medical record lacked evidence of psychotropic consent for trazodone. Additionally, RN-H acknowledged sleep monitoring had not been initiated for R9. RN-H stated the sleep monitoring was important to monitor if R9 was sleeping too much or not sleeping enough. During an interview on 6/25/26 at 11:46 a.m., director of nursing (DON) stated the nurse managers were responsible for completing nursing department pharmacy recommendations. DON stated the nurse managers were expected to complete nursing pharmacy recommendations within a week. A policy for follow up and review of consulting pharmacist recommendations was requested, however, not received.

Based on interview and document review, the facility failed to ensure adequate monitoring was completed for 1 of 5 residents (R255) reviewed for unnecessary medications.Findings include: R255's admission Minimum Data Set (MDS), dated [DATE], indicated R255 had severe cognitive impairment, required substantial assistance with activities of daily living (ADLs), and diagnoses included hypertension, chronic kidney disease, dementia, diabetes, and anxiety. R255's order summary report, printed 6/25/26, included an order dated 5/12/26 for metoprolol succinate extended release 50 milligrams (mg) by mouth one time daily, hold for systolic blood pressure (SBP) less than 100 or heart rate (HR) less than 60. R255's medication administration records (MAR) for May 2026 and June 2026, indicated R255's blood pressure was monitored. However, R255's MARs failed to indicate R255's heart rate was monitored and recorded as per provider order. During an interview on 6/25/26 at 10:56 a.m., registered nurse (RN)-I stated staff were expected to check a resident's blood pressure and/or heart rate if the orders had parameters to hold a medication. RN-I verified R255's orders indicated metoprolol was to be held if the SBP was less than 100 or HR less than 60. RN-I stated R255's MAR indicated staff needed to obtain R255's blood pressure prior to the administration of R255's metoprolol. RN-I acknowledged R255's MAR failed to prompt staff to obtain R255's heart rate prior. During an interview on 6/25/26 at 11:05 a.m., RN-J stated when a medication required a heart rate and blood pressure to be taken, the order should have triggered staff to check and record the reading. RN-J stated R255's order did not indicate the HR was to be recorded. During an interview on 6/25/26 at 11:46 a.m., director of nursing (DON) stated when an order was entered into the system supplementary documentation was expected to be added to the order to require both the heart rate and blood pressure to be recorded. DON reviewed R255's orders, stated the supplementary pulse (heart rate) was not selected to require the HR to be recorded, so the metoprolol could have been administered if R255's HR was less than 60. The facility's Physician Medication Orders policy, reviewed 10/2025, did not address medication parameters.

Based on observation, interview, and document review, the facility failed to coordinate blood draws as ordered by the provider for 1 of 2 residents (R25) reviewed for dialysis.Findings include:R25's admission Minimum Data Set (MDS) assessment, completed on 5/12/26, indicated R25 was cognitively intact, was able to communicate wishes to others, understood others, and diagnoses included renal insufficiency with dependence on dialysis and anemia.R25's progress note on 6/8/26, at 1:56 p.m., indicated a call was received from the lab to alert facility R25 had a critical lab value of hemoglobin (hgb-the oxygen carrying cells in the blood) was low at 6.9 (normal hemoglobin level is 12 - 16). The note indicated that the provider was updated. The progress notes lacked indication of subsequent blood draws following the last blood draw on 6/15/26.During interview on 6/22/26 at 1:19 p.m., R25 stated he felt good and denied any symptoms of nausea or vomiting, although stated he was tired after dialysis. R25 stated he had his Hgb checked while at dialysis and his most recent lab value was at 8.2. R25 was unable to recall when that was completed. R25 stated the lab tech did come to draw blood on Monday, 6/22/26, however, R25 stated he had requested lab draws be done on his dialysis days as they were already accessing his site for dialysis. However, R25's narrative notes lacked any indication that the lab work had been attempted and declined by resident. Additionally, the documentation lacked indication that there had been follow up with dialysis facility to request labs while at dialysis, or subsequent follow up with the provider to inform them this had not been completed.R25's June 2026 Medication Administration Record (MAR)/Treatment Administration Record (TAR), identified the nurse on Sunday evening, 6/21/26, prepared a lab slip for weekly CBC (complete blood count-a test which reviews hemoglobin, white count and other measurements to assess status) to be drawn Monday, 6/22/26. However, R25's records, lacked evidence labs had been drawn. During observation and interview on 6/24/26 at 10:05 a.m., health unit coordinator (HUC)-B reviewed the lab book to see if blood had been drawn on 6/22/26 as ordered. HUC-B identified the lab draw had not been documented as having been done, nor was there documentation it had been declined, or of any subsequent follow up with the provider. HUC-B stated documentation was completed by the nurses. HUC-B stated a CBC had been drawn on 6/15/26 as ordered, however, there had been no subsequent follow up. HUC-B stated she was unaware if labs were able to be drawn during routine dialysis run.During interview on 6/24/26 at 1:57 p.m., the dialysis registered nurse (DRN)-A stated it was possible to draw lab work while at the dialysis facility, however, the request needed to be completed by nursing or lab, to allow coordination. DRN-A verified via email on 6/24/26 at 5:51 p.m., R25's hgb was last drawn at the dialysis facility on 6/18/26 and was at 8.2. During interview on 6/25/26 at 8:01 a.m., registered nurse/unit manager (RN/UM)-A stated R25 was admitted to the unit with orders for routine blood work. RN/UM-A stated she was unsure why the labs were not drawn on 6/22/26, and identified the documentation lacked rationale for missed draw or request for change in blood draw process at dialysis.During interview on 6/25/26 at 2:26 p.m., the director of nursing (DON) stated it was her expectation that if labs were not drawn as ordered, the nursing staff would investigate as to why it had not been completed as ordered and follow up with provider. DON stated refusal of lab draws, and subsequent follow up were to be documented to reflect this in the medical record. DON stated if it were the request to have labs done during the dialysis session, this was to be coordinated with the dialysis facility.The facility's Lab and Diagnostic Test Results-Clinical Guidelines policy, last reviewed 6/25, identified labs were ordered by the physician, and staff were to process test requisitions and arrange for tests per community and contracted lab protocol. The policy defined that a nurse was to review all results and alert the provider accordingly.The facility's Guidelines for Charting and Documentation policy, last reviewed 6/25, identified the purpose of charting was to document a complete account of the resident's care, treatment, and response to the care. The policy outlined refusal of treatments were to be documented and the information recorded was to include the date and time the treatment, the treatment refused, resident's response and reason for refusal, the date/time the provider was notified, and the provider response.

Based on interview and document review, the facility failed to ensure a resident's advance directives were accurately and consistently documented in the resident's paper chart, electronic medical record (EMR) banner, Provider Order for Life-Sustaining Treatment (POLST), and physician orders to ensure the resident's wishes would be followed in the event of a respiratory or cardiac arrest. This resulted in immediate jeopardy for 1 of 49 residents (R43) whose code status was not accurately documented and was reviewed for advanced directives. In addition the facility failed to ensure the power of attorney (POA) was identified and would be contacted for care decisions for 1 or 49 residents (R223) who was reviewed for resident rights regarding decisions about care. The immediate jeopardy began on [DATE], when R43 signed an updated POLST indicating wishes were cardiopulmonary resuscitation (CPR) in the event of a cardiac arrest. In contrast, the physician's order and banner in R43's chart indicated R43 was DNR status. Upon interview several staff indicated they would look at the banner, therefore would not provide R43 CPR in the event R43 required resuscitation. The immediate jeopardy was identified on [DATE]. The director of nursing (DON) and administrator were notified of the immediate jeopardy on [DATE], at 12:54 p.m. The immediate jeopardy was removed on [DATE], however, non-compliance remained at a lower scope and severity, level 2, isolated scope, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R43's comprehensive Minimum Data Set (MDS) dated [DATE], indicated R43 was cognitively intact. R43's diagnoses included: end stage renal disease with dialysis, Parkinson's disease, diabetes, and congestive heart failure. R43's face sheet, undated, indicated R4 did not have a power of attorney or designated decision maker other than themselves. On [DATE], the banner in R43's EMR read POLST: Do not attempt resuscitation/DNR. The Provider order in the EMR dated [DATE], read POLST: Do not attempt resuscitation/DNR. The POLST in R43's paper chart and the POLST scanned into the EMR on [DATE], both directed CPR. R43's EMR included a document named, Retired POLST [DATE], which was signed by the provider on [DATE], and directed DNR with selective treatment. A provider note entered by advanced practice nurse (APRN-A) in the EMR dated [DATE] at 8:20 a.m., indicated APRN-A had discussed code status with R43 who expressed they desired to change their status to FULL CODE. The note included Forms discussed/updated: See patient chart. A document named POLST.pdf with a scanned date of [DATE], was scanned into R43's EMR. The POLST directed CPR, and selective treatment. R43 signed the POLST, however the provider (APRN-A) listed as completing the POLST had not signed section D Provider Signature. The POLST was also not dated. A progress note entered in PCC by the DON on [DATE] at 8:55 p.m., indicated APRN-A had not returned to the facility to address R43's undated unsigned POLST so the medical director (MD) was contacted, and the MD gave a verbal order to change R43's code status to full code to align with R43's wishes. The order was processed and R43's code status was changed to CPR. During an interview on [DATE] at 2:34 p.m., R43 verified they were asked about code status and stated their wishes were to receive CPR. During an interview on [DATE] at 1:50 p.m., RN-F stated they would check code status in the EMR first if the computer was closest to them and they would go with the most recent order in the EMR (R43's banner indicated DNR at the time of the interview). RN-F explained every time there was a new POLST it got updated in the EMR, so it was current. During an interview on [DATE] at 1:53 p.m., registered nurse (RN) -D stated they would first look in the EMR banner for the code status (R43's banner indicated DNR at the time of the interview). During an interview on [DATE] at 1:57 p.m., RN-B stated they usually took the code status from the EMR banner and put it on a worksheet they use for the day so they would know what to do right away if a resident coded (R43's EMR banner indicated DNR at the time of the interview). During an interview on [DATE] at 2:04 p.m., RN-C stated if the EMR banner was different from the POLST before they started CPR, they would page the provider and call the resident's family to determine resident/family wishes for code status. It would be the family's choice for code status. RN-C reviewed R43's chart and confirmed R43's POSLT identified R43 wanted CPR. RN-C verified there was no date on the POLST which was in the front of R43's hard chart and scanned into R43's PCC record. RN-C reviewed R43's EMR and confirmed R43's EMR banner identified do not resuscitate (DNR). RN-C reviewed the orders and confirmed there was a current order for DNR. RN-C indicated a delay in CPR while determining R43's code status could have long term negative health consequences for R43. During an interview on [DATE] at 2:26 p.m., RN-I stated they would look at the EMR first. RN-I explained once there was a new POLST, the POLST would go to the HUC after the RN entered the order into PCC, and then the HUC scanned the new POLST into the electronic record and placed it into the paper chart. The old POLST would be sent to medical records. During an interview on [DATE] at 2:38 p.m., health unit coordinator (HUC)-B stated the process was for the POLST be given to the nurse, the social worker, or the HUC and then the HUC would scan the POSLT into the chart. HUC-B stated they would make sure they were signed, filled out completely, and stamped as scanned into the EMR. Normally they would have scanned the POLST in and entered a new order and that order would have updated point click care, but they missed entering R43's order. HUC-B stated they hadn't noticed that R43's POLST hadn't been signed or dated, but they would look for that from now on. During an interview on [DATE] at 6:11 p.m., the director of nursing (DON) stated they would not use R43's POLST scanned into PCC on [DATE], because it was not signed by the provider. At the time of the interview, the DON stated the facility would go off of the [DATE], POLST because it was dated and signed by a provider. Per facility policy, the ,d+[DATE] POLST was not current because it was not signed or dated, so R43's EMR banner and DNR order was/is correct. The unsigned and undated POLST scanned in on [DATE], was done so in error. It should not have been scanned in and placed in the paper chart. The ,d+[DATE] POLST should have been left as current in both the paper chart and PCC. If R43 coded today their status would be DNR. Clearly R43's wish was to be a full code based on the provider note, however facility policy was that a code status change did not go into effect until the provider signed the order. Until the provider signed the POLST to change R43's status to CPR, the current order of DNR status would be honored. Per policy residents would also remain DNR until they submitted a request in writing to have their code status changed from DNR to CPR. If a resident with a DNR code status wanted their status changed to CPR they would need to submit that request in writing and then have a provider order. The code status would not change until there was a new order and the provider completed and signed a new POLST. The provider should have signed and dated R43's POLST, discontinued the old DNR order, and entered a new order so R43's banner reflected the new CPR status. It was communicated to the DON that APRN-A had been notified of the errors in R43's POLST and APRN-A would be coming in to correct R43's POLST. The DON explained in an emergency staff would have to go off of what staff had available to them; they would check the status and respond. Staff would not know there was a code discussion documented in the chart. In an emergency they would not be reviewing notes, staff would be finding the code status and responding. The DON indicated if a resident coded and they were working on their laptop they would check the laptop in front of them and the EMR would show them R43 was/is a DNR, and they would act off of that. There was not a need to double check the paper chart or open the POLST in PCC, because the banner should be right. If the hard chart was closer, the DON stated they would look at the chart and follow the POLST in the front of the chart. The DON indicated if R43 had coded and they had checked the chart and followed the POLST in the chart, R43 would have received CPR, even though his current order, banner and signed POLST were for DNR. The DON confirmed there was not a need to check two sources for code status, the paper chart POLST, PCC order, banner status and scanned POLST should be correct and match in all places. The DON stated even though R43 had indicated they wanted to be a full code, if R43 coded now they should be treated as a DNR. During an interview on [DATE] at 10:24 a.m., APRN-A stated they completed the POLST on their second day working at the facility. Initially, they did not sign the POLST because before they signed, they needed to completely discuss status with the resident and make sure there was not a power of attorney they also needed to contact. Once it was confirmed they did not have to talk to anyone but the patient, the APRN-A indicated they must have forgot to sign the POLST before they put the chart with the new POLST into the order rack. APRN-A stated they did have a concern that if something happened to R43, R43 would have been treated as a DNR. APRN-A stated they did not know who had uploaded the POLST into PCC and confirmed they had not been contacted to sign or date the POLST until yesterday evening. This was concerning because not performing CPR in the event R43 coded would have gone against R43's wishes. If there was delayed CPR, R43 could have experienced worse outcomes like residual deficits or death. The more CPR is delayed the more residual disabilities and issues can/will occur. APRN-A stated they did understand the magnitude of not signing R43's POLST and stated since they had entered a note and documented their credentials on the most current POLST they wanted to believe the facility would follow and honor R43's wishes even though they (as the provider) had forgotten to sign the new POLST. In addition, the POLST was signed by R43 so APRN-A hoped the POLST would be followed based on R43's wishes. During an interview on [DATE] at 1:54 p.m., the medical director (MD) and the DON were present. The MD indicated they had been contacted about R43's POLST last evening and they had provided a verbal order for CPR last evening and then they had completed the POLST today ([DATE]). The DON indicated APRN-A was not available the previous evening, but had come in today ([DATE]) after the MD had corrected R43's POLST. The MD stated it was a very serious issue for a resident's code status to not be updated as soon as a resident expressed a desired change. Delays in starting CPR can result in permanent damage or death. A provider should discuss and then document in the medical record a resident's desire for a code change. Following discussion the POLST should be completed and signed immediately, and an order should be entered so that the residents new code status is in place right away. In R43's situation when the APRN did not sign and date R43's POLST, it put R43 at risk for not receiving CPR when that was what R43 wanted. The immediate jeopardy that began on [DATE], was removed on [DATE] when the facility developed and implemented a systematic removal plan. The removal plan was verified through interview and document review as the facility had corrected R43's code status on the EMR banner/provider order to CPR, completed a facility-wide audit to ensure there were no other code status discrepancies, reviewed related policies and procedures, and provided education for all staff involved in ensuring advance directives were honored, and education on CPR and POLST policies/procedures and their respective roles in the process. Facility Policy F 678 Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS)North Ridge Health & Rehab, dated ,d+[DATE], indicated Change of code status by the resident or representative should be witnessed by two staff members or per state directives to become effective immediately, The provider shall be notified of the changes via telephone or electronic communication, the provider will review the changes on subsequent visit. 49034 R223's quarterly Minimum Data Set (MDS) dated [DATE], indicated R223 had severely impaired cognition. R223's care plan dated [DATE], indicated R223 had impaired cognition related to dementia and a stroke. The care plan indicated the resident had advanced directives in place with a goal of honoring and respecting those wishes. R223's Health Care Directive dated [DATE], indicated R223's POA was family member (FM-B). R223's electronic health record (HER) contact list, indicated FM-C was listed as Emergency Contact # 1 and not FM-B. During an interview and observation on [DATE] at 12:15 p.m., RN-L confirmed he was R223's nurse. When asked who would be called if decisions needed to be made regarding R223's care, RN-L was observed to check the EHR contact list and state he would FM-C as she was listed as R223's emergency contact. During an interview on [DATE] at 12:15 p.m., FM-B stated she was R223's POA as FM-A doesn't know what's up and she would have a problem with the facility contacting FM-C instead of her if decisions needed to be made regarding R223's care. During an interview on [DATE] at 12:27 p.m., RN-Q confirmed she was R223's nurse and stated she would call FM-C if decisions needed to be made regarding R223's care as she was the emergency contact. During an interview on [DATE] at 2:06 p.m., social service designee (SS)-A stated she had received the POA paperwork for R223 sometime last month and was supposed to update the emergency contacts list when she received it so staff knew who to contact but it did not happen. During an interview on [DATE] at 12:53 p.m., RN-J, the nurse manager, stated R223 was no longer able to make his own decisions so staff were expected to ask his POA when they had questions about his care. RN-J confirmed SS-A was supposed to update the emergency contact list so staff would contact the right person if decisions needed to be made. A policy regarding emergency contacts and POAs was requested and not received.

Based on observation, interview and document review, the facility failed monitor, assess, and identify interventions to reduce the risk of catheter related complications for 1 of 3 residents (R1) reviewed for catheter care when R1's penis eroded from the indwelling catheter. R1's catheter was placed on 9/30/22, R1 complained of penile pain associated with the indwelling catheter 11/2/22 and 11/23/22, then was not evaluated by the facility until 11/29/22 identifying erosion of the penile shaft. Findings include: R1's admission Minimum Data Sheet (MDS) dated [DATE], identified intact cognition. R1 required extensive assistance by two nursing staff to move in bed, transfer, dress, and toilet. R1 had a staged two pressure ulcer (a partial-thickness wound involving the outer and middle layers of the skin) located on his buttocks (the fleshy part of the body which a person sits on.) R1's medical provider order dated 9/30/22, at 2:08 p.m. identified an indwelling Foley catheter was placed for urinary retention. Instructions included staff would only change the catheter as needed for any signs or symptoms of an infection, and to ensure the catheter remained secured. R1's treatment medical record (TAR) dated 11/1/22, identified an order for nursing staff to ensure routine catheter cares were completed every shift; days, evenings, and nights. In addition, the Foley catheter would be changed as needed if staff observed any signs or symptoms of an infection, catheter obstruction, or when the closed system becomes compromised. R1's TAR did not include any documentation associated with any assessment data obtained when giving catheter care. R1's physical therapist (PT)-A assistant note dated 11/2/22, at 4:51 p.m. identified R1 told her he was experiencing pain from his Foley catheter. PT-A documented she told R1's nurse about his complaint of pain. R1's weekly skin evaluation dated 11/8/22, at 14:03 p.m. identified R1 had an area of redness on his upper buttocks and no open wounds were found. R1's weekly skin evaluation dated 11/15/22, at 9:24 a.m. identified R1's upper buttock skin was pink and blanchable, the skin was free from any form of breakdown. R1's documentation of catheter cares performed - using soap and water look back period 30 days from 11/17/22 through 12/15/22, indicated there were five days no catheter care was performed and there was no time that catheter care was routinely completed every shift; days, evenings, and nights as identified on the TAR, nor was there any documentation associated any assessment data obtained when giving catheter care. 11/17 at 9:04 a.m. and 2:07 p.m. 11/18 at 10:22 a.m. and 2:22 p.m. 11/20 at 9:45 p.m. 11/21 at 10:41 a.m. and 9:03 p.m. 11/22 at 1:59 p.m. 11/25 at 8:10 a.m. and 4:03 p.m. 11/26 at 9:46 a.m. 11/28 at 10:14 a.m. and 3:08 p.m. 11/29 at 11:01 a.m. and 3:47 p.m. 11/30 at 1:59 p.m. and 9:29 p.m. 12/1 at 1:59 p.m. 12/2 at 10:52 a.m. and 2:30 p.m. 12/3 at 9:46 p.m. 12/4 at 1:59 p.m. and 2:26 p.m. 12/6 at 1:05 p.m. and 2:55 p.m. 12/7 at 1:59 p.m. and 3:40 p.m. 12/8 at 11:23 a.m. and 9:18 p.m. 12/9 at 1:30 p.m. 12/10 at 1:59 p.m. 12/11 at 10:18 a.m. and 9:59 p.m. 12/12 at 1:59 a.m. and 9:59 p.m. 12/13 at 12:24 p.m. and 2:55 p.m. 12/14 at 8:47 p.m. 12/15 at 1:30 p.m. and 5:56 p.m. R1's weekly skin evaluation dated 11/22/22, at 9:24 a.m. identified R1 had an area of redness on his upper buttocks and no open wounds were found. R1's PT-A note dated 11/23/22, at 4:28 p.m. documented when R1 moved his right hip and right knee, it caused him penile pain. PT-A also documented she informed the nurse R1 was experiencing penile pain during the PT session. R1's nursing progress note dated 11/29/22, at 11:58 a.m. a registered nurse (RN)-A documented she notified the medical provider R1 had penile pain, and she observed an erosion developed on the tip of his penis. RN-A received an order from the medical provider to apply a lubricant to R1's penis daily and to make sure the Foley tubing had adequate slack and strapped in place. R1's nursing progress note dated 11/29/22, at 12:01 p.m. identified the medical provider was updated about R1's penis tenderness and he developed a penile erosion related to his Foley catheter. R1's weekly skin evaluation dated 11/29/22. at 1:00 p.m. identified R1 had an area of redness on his upper buttocks and no open wounds were found. R1's TAR indicated an order started on 11/29/22, instructing nursing staff to ensure adequate Foley tubing slack and to secure the tubing with a strap to prevent penile erosion. R1's urologist (MD)-A (a medical provider who specialized in urinary conditions) new order on 11/30/22, identified nursing staff needed to clean R1's Foley catheter and apply bacitracin to the penile wound two times a day. In addition, MD-A notified nursing staff R1's Foley catheter was replaced during the visit, and to continue monthly catheter changes. R1's TAR dated 12/1/22, did not include MD-A's order to change his Foley catheter every month. R1's wound evaluation dated 12/1/22 at 3:52 p.m. identified R1's penile wound size length 1.97 cm by width 1.26 cm. The picture shows an open wound from the tip of the penis extending downward into the penile shaft. R1's MDS dated [DATE], identified R1's skin was free from any form of skin breakdown R1's care plan initiated at admission on 9/11/22 did not identify care planned interventions for R1's indwelling catheter and skin impairment until 12/2/22. The care plan first identified on 12/2/22 R1 had an indwelling Foley catheter related to urinary retention with a goal that R1 would show no signs or symptoms of urinary infection. The interventions for the indwelling catheter included the bag and tubing to be below the level of the bladder, the catheter not be changed at fixed intervals per CDC but upon indications of infection, obstruction, or when the closed system is compromised, check tubing for kinks, monitor and document intake and output, monitor for signs and symptoms of discomfort on urination and frequency, monitor and document for pain/discomfort due to catheter, monitor for urinary tract infections, discuss the risk and benefits of the use of the catheter with the resident. The care plan first identified on 12/2/22 R1 was at risk for skin impairment (erosion to the penis, buttock, and back) with a goal to have no skin complications. The interventions included avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short, educate family and caregivers reasons and measures to prevent skin injury, encourage nutrition and hydration, identify and document causative factors and eliminate/resolve where possible, keep skin clean and dry, monitor/document location size and treatment of skin injury, report abnormalities, failure to heal, signs and symptoms of infection, maceration, and other conditions to the medical doctor. The care plan did not identify interventions to reduce the risk skin complications from the use of the indwelling catheter. R1's nursing progress note dated 12/2/22, at 1:03 p.m. identified his medical provider was updated by RN-B regarding his foley catheter pain, and penile erosion. At 4:12 p.m. the director of nursing (DON) examined R1's penile wound. R1's medical provider order dated 12/2/22, at 2:00 p.m. identified nursing staff to continue monitoring R1's penile wound and ensure the catheter tubing had adequate slack and secured by a thigh catheter strap. In addition, the medical provider requested a picture of R1's penile wound to be sent to their urgent fax for review. R1's medical provider order from physician assistant (PA)-A dated 12/5/22, at 12:46 p.m. identified R1 had an ulceration (open sore)/eroded penis through the glans tissue leading to extreme pain. Nursing staff were directed to apply bacitracin to the penile wound after the penis and catheter was cleaned two times a day until the urologist saw him. R1's medical provider order dated 12/5/22, at 1:30 p.m. identified nursing staff to clean R1's penile wound every day and as needed. R1's weekly skin assessment dated [DATE] at 11:35 a.m. identified R1 had an area of redness on his upper buttocks and no other wounds were found. R1's wound evaluation dated 12/7/22 at 11:31 a.m. identified R1's penile wound size increased to 3.74 cm by 1.57 cm. The picture shows the open wound is through the entire glans extending halfway down the penile shaft. R1's weekly skin assessment dated [DATE] at 11:20 a.m. identified R1's had a penile erosion (tearing of tissue) related to his Foley catheter. R1's medical provider order dated 12/14/22, at 7:00 a.m. identified new wound care orders to clean the wound and Foley Catheter every day and as needed. In addition, staff to apply bacitracin to the wound two times a day and cover the wound with a nonstick gauze dressing. R1's skin and wound evaluation dated 12/14/22, at 9:24 a.m. identified R1 had a severe ventral (underside of the penis) erosion exposing the Foley catheter and the inside of the urethra (a tube from the bladder to the tip of the penis used for urination). The damage to the penile tissue extended from the glans penis (the rounded head of the penis) into the shaft (the penile tissue extending from the glans to the abdomen). The documented identified the wound developed on 12/1/22 and measured 2.3 centimeters (cm) by 1.9 cm. In addition, R1's penile wound increased in size from the previous assessment. R1's Wound evaluation dated 12/14/22 at 12:05 p.m. identified a picture of R1's penile wound and described the wound as stalled. During an interview on 12/14/22, at 11:36 a.m. R1's friend (F)-A stated she met R1 at his 11/30/22, Urology appointment. She was called into the examination room with R1. F-A stated MD-A yelled at her stating this is unacceptable and neglect regarding the penile wound he found during the examination. MD-A stated the Foley catheter had not been changed every month. F-A stated after the appointment she attempted to call R1's nursing staff to discuss the penile wound and MD-A's new orders. F-A spoke with RN-B who stated she would look at the wound right away. F-A stated on 12/1/22, she found RN-B at the nursing home. RN-B told her she did not look at R1's penile wound, and at one point would get to it. F-A stated she took a picture of R1's penis and stated the tissue was split down about two and half inches from the tip of the penis. RN-B told F-A the facility policy for changing Foley catheters identified they would only change the catheter if it was infected, blocked, or became contaminated. F-A stated now R1 had a huge wound that's infected. F-A stated she received a call back on 12/1/22, at 3:45 p.m. from RN-B and the director of nursing (DON) and they told F-A they assessed R1's penile wound, but they refused to give her any more information. F-A visited R1 on 12/4/22 and took a picture of the penile wound. She stated the penile wound was larger than when she looked at it on 12/1/22. F-A stated R1 had extreme pain from the penile wound and according to MD-A the wound was preventable. During an interview and observation on 12/14/22, at 3:34 p.m. R1 stated his Foley catheter caused the surrounding tissue to erode. R1 stated he was unable to see the ventral side of his penis, but remembered the pain started about one month ago. R1 stated he told the staff many times about the pain, but no one looked at it. R1 stated the pain comes and goes and he rated the pain a seven (indicated the level of pain on a scale of zero to 10, 10 being the most pain). R1 stated during the past month the pain level has increased from when he first noticed it. R1 stated prior to the urology appointment on 11/30/22, he never had a strap on his thigh to secure the foley in place. R1 stated today he received a leg strap to prevent the foley catheter from moving. R1 stated in the past when he had a Foley catheter he never had any trouble like this before but then he used a strap to secure the catheter to his thigh. Observed R1's penile wound. The wound started at the tip of the penis and extended halfway down the penile shaft. The wound exposed the urethral tissue and the foley catheter. R1 stated the only provider who examined the penile wound was during the 11/30/22, appointment with the MD-A. During an interview on 12/15/22, at 1:25 p.m. PT-A stated R1 complained to her about penile pain on 11/2/22 and PT-A updated RN-A about the pain. PT-A stated on 11/23/22, R1 was unable to sit at the edge of the bed because the Foley catheter was causing him pain. PT-A stated he told RN-A about the pain and heard her call R1's medical provider. During an interview on 12/15/22, at 1:59 p.m. RN-A stated she called R1's medical provider on 11/29/22 and obtained an order to apply a lubricant to R1's penile wound and to ensure the Foley catheter is secured with a strap. RN-A stated she checked R1's penile wound every time she worked and applied bacitracin to the wound. RN-A stated she did not document R1's penile wound in the electronic medical record (EMR) but instead she informed RN-B. RN-B stated she called the medical provider again on 12/5/22, and the medical provider instructed to apply bacitracin instead of lubricant. RN-A stated R1's penile wound is a typical injury to male residents with Foley catheters. During an interview on 12/15/22, at 2:17 p.m. RN-B stated she thought R1's penile wound was identified on 11/29/22, and the next day R1 saw MD-A. RN-B stated she could not recall the day she first assessed R1's wound. RN-B stated the NA's are responsible to clean the Foley catheter every day, and to report any issues to the nursing staff. RN-B stated Foley catheters come with risks and benefits. After reviewing R1's picture of his penile wound RN-B stated the wound extended from the tip of the penis to the top of the penile shaft and she could not identify how the wound developed. During an interview on 12/15/22, at 2:47 p.m. the DON stated developing a penile erosion from a Foley catheter was a common risk factor. The DON stated after reviewing R1's penile wound she did not think the wound was caused by tension from his foley catheter. The DON stated the nursing staff are trained to ensure the Foley catheter tubing had adequate slack before they secured it in place with a thigh strap. The DON stated once a wound developed, the next step would be for the wound nurse to take a picture of the wound and document detailed description and measurements of the wound. On the following Saturday, the DON would review the wound note and track R1's wound progression. The DON stated R1's did not have a medical condition that would have exacerbated the development of a wound. The DON reviewed R1's penile wound picture taken on 12/14/22. DON stated the wound progression had stalled from the previous 12/7/22, assessment. The DON stated R1's penile wound could have developed quickly instead of over time. The DON stated on 12/1/22, the penile wound measured 1.97 cm by 1.26 cm. On 12/7/22, the wound measured 3.74 cm by 1.57 cm, and on 12/14/22 it measured 2.3 cm by 1.91 cm. During an interview on 12/16/22, at 9:25 a.m. F-A stated after she spoke with RN-B on 11/30/22, she was disappointed to find out RN-B did not examine R1's penile wound until the next day. F-A stated she received a phone call from RN-B on 12/2/22. RN-B told F-A she had examined R1's wound and notified R1's medical provider for an updated treatment plan. F-A stated R1 did not receive a Foley catheter thigh strap until the middle of November. F-A stated since 9/30/22, when the Foley catheter was inserted, it just hanged from his penis. During an interview on 12/16/22, at 12:34 p.m. MD-A stated R1's penile erosion was caused by an infected foley catheter because the foley catheter was in place since September 2022 without being replaced. MD-A stated he changed R1's Foley catheter during the office visit on 11/30/22. MD-A stated once R1 can walk to the toilet the Foley catheter could be removed, and he would only be able to urinate sitting down on the toilet. MD-A stated the penile erosion could be closed with reconstructive surgery, but because of his comorbidities (multiple medical conditions) would make him a poor surgical candidate. R1 required his penis to be kept clean and moist to prevent further irritation and skin damage. MD-A stated he was surprised the facility did not find the penile wound sooner and it meant no one looked at it since it was inserted in September. During an interview on 12/16/22, at 12:47 p.m. with R1, F-A stated when she spoke with him this morning R1 told her his thigh strap became soiled from loose stool, and the staff did not replace it. During the interview RN-B entered the room and stated R1 had a Foley catheter thigh strap on during her morning rounds. RN-C entered the room and stated today was the first time he observed R1's penile wound. RN-C stated he took care of R1 for the past three days, but only learned about the penile wound today when the NA told him R1's thigh strap needed to be replaced. R1 stated he first developed penile pain at the beginning of November. R1 stated the nursing staff only clean his penis and catheter when he was incontinent (loss of bowel control.) R1 stated he experienced loose stool at least two to three times a day. R1 stated he was unable to see the penile wound when he first experienced penile pain. In addition, R1 stated he is no longer able to fully participate in physical therapy because of the penile pain. R1 stated every time he stood up, he felt worsening pain from the Foley catheter rubbing up against the wound. During an interview on 12/16/22, at 3:20 p.m. the DON stated the facility's policy based on the Center for Disease Control's (CDC) recommendations was only replace a Foley catheter when it became infected, obstructed, or compromised. The DON stated signs and symptoms of a catheter infection would include fever, stiffness, low blood pressure, and pain. The DON stated she consulted with the facility medical director who stated the penile erosion could have developed in an acute (rapid) time frame. The DON stated during an acute penile wound development she would not expect any bleeding. The DON added after reviewing R1's documentation she determined RN-A interventions were appropriate, and R1 had the capability to tell staff he was having penile pain, but he did not. During an interview on 12/16/22, at 3:35 p.m. physician assistant (PA)-A stated she saw R1 on 11/8/22, 11/30/22, 12/5/22, and on 12/13/22. PA-A stated all the visits except the one on 12/13/22, were focused assessments, and she did not examine R1's penis. On 12/13/22, PA-A completed full head to toe assessment and examined the penile wound for the first time. PA stated it looked like the indwelling catheter eroded through the ventral side of the penis, and these things can just happen. She did not think the erosion was caused by an infection, instead she felt there were various factors such as his frail condition, and other medical diagnoses to slow R1's healing process. PA-A stated she first learned about R1's penile erosion on 11/30/22. Facility policy Indwelling Urinary Catheters F690 dated, 6/22 did not identify skin or wound complications as a result of an indwelling catheter. The policy identified infection control measures included routine hygiene (e.g., cleansing of the meatal surface during daily bathing or showering) is appropriate. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. And, to ensure the catheter remains secured with a leg strap to reduce friction and movement at the insertion site (catheter tubing should be strapped to the resident's inner thigh). Routine catheter care included the following procedures: Assess the urethral meatus for a male: use a washcloth with warm water and soap to cleanse around the meatus. Cleanse the glans using circular strokes from the meatus outward. Change the position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using the above technique. Return foreskin to normal position. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. Secure catheter utilizing a leg band. Document the date and time that catheter care was given, the name and title of individual giving the catheter care, any assessment data obtained when giving catheter care such as, color clarity and presence of odor in urine, any problems noted with catheter care at the catheter-urethral junction, any complaints from the resident, and if necessary how the resident tolerated the procedure. Report to the supervisor if the resident refuses the procedure and other information in accordance with facility policy and professional standards.

Based on interview and document review, the facility failed to ensure residents were free from abuse for 2 of 3 (R6 and R1) residents reviewed for abuse. This deficient practice resulted in an immediate jeopardy (IJ) when R5 was reportedly masturbating in front of a female resident (R7), then was reported to masturbate in front of another resident (R6), and then was found leaving R1's room whom had her pants down, and a [MEDICATION(S)] like substance on her body. The facility failed to recognize sexual abuse and implement interventions to protect other residents from potential abuse. The IJ began on 2/26/21, when R5 was reportedly masturbating in front of a female resident and the facility did not implement interventions. The administrator and director of nursing (DON) were notified of the IJ on 3/4/21, at 4:52 p.m. The IJ was removed on 3/5/21, but noncompliance remained at the lower scope and severity of a D - isolated scope and severity, which indicated no actual harm with the potential for more than minimal harm, that is not immediate jeopardy. Findings include: R1's significant change Minimum Data Set (MDS) dated [DATE], identified R1 had severely impaired cognition and needed extensive assist from staff for locomotion. R1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R1's care plan dated 12/21/20, directed R1 was not to be left in her room independently while she was awake. The care plan further directed staff were to provide one-on-one interaction when R1 appeared to be, looking for someone. R6's quarterly MDS dated [DATE], identified R6 had severely impaired cognition and was independent with ambulation. R6's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's quarterly MDS dated [DATE], identified cognitively intact with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's quarterly MDS dated [DATE], indicated R5 had severely impaired cognition and ambulated independently. R5's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's care plan dated 1/14/21, indicated he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan further indicated R5 had an, inability to process appropriate ways to manage physical arousal. The interventions included, intervene as necessary to protect the rights and safety and dignity of R5 and others, remove from situation and take him to an alternative location, as needed. The care plan was updated on 3/1/21, and identified one on one staff observation. R5's Psychological Diagnostic assessment dated [DATE], indicated R5 had, exposed himself to female residents twice at the care center. R5's progress notes dated 1/9/21, at 10:14 p.m. indicated R7 reported she entered R5's room to use a telephone. The progress notes further indicated R7 reported R5 exposed his genitals, flashed her, and requested oral sex. The incident was reported to the house supervisor and R5 was placed on, close observation. R5's progress notes dated 1/10/21, at 3:16 p.m. indicated R1 grabbed the front of R5's pants when he stood near her. The progress notes further indicated R5 was instructed not to stand near R1. R5 backed away, however, returned to R1, with his front genital area towards R1 within 20 minutes. Nursing was to, closely monitor R5 for, potential inappropriate behavior with other residents and the information was passed on at nursing report. R5's Behavior Monitoring logs for January 2021 and March 2021 only identified the need to monitor for signs and symptoms of [CONDITION(S)], related to history of alcohol abuse, but did not identify any sexual behaviors even though R5 exhibited sexual behaviors. R5's Psychiatric Evaluation dated 2/3/21, indicated R5 was, verbally and physically aggressive, with other residents. The Psychiatric Evaluation further indicated R5 was noted to be sexually inappropriate, exposed himself on several occasions, and was becoming, too intrusive with other females. The evaluation recommended medication changes, but did not direct staff on how to manage these types of behaviors. R5's progress notes dated 2/26/21, at 4:53 p.m. indicated R6 informed a nursing manager R5 was masturbating in the TV room and looking at her. R5's nursing assistant was requested to, watch him closely. R5's medical record lacked additional information regarding this occurrence. R5's care plan was not updated after this occurrence. There was no indication R5's behavior was assessed and an appropriate intervention implemented in an effort to maintain the safety of all residents. R6's medial record lacked any indication of the 2/26/21 incident she had reported of R5 masturbating in the TV room. A facility incident report dated 3/1/21, indicated at approximately 12:35 p.m. nursing assistant (NA)-A observed R5 exit R1's room. The incident report further indicated, NA-A observed R1 sitting at the edge of her bed. R1's pants were partially down. R1's incontinence product was noted to be slightly pulled down, however, the tabs were intact. The incident report identified there was, no indication of sexual contact or assault. R5's psychology progress notes dated 3/1/21, identified R5 was informed of the appropriate places to masturbate and he was not to enter female residents' rooms. R5 identified he knew these things and denied having engaged in these behaviors. During an interview on 3/3/21, at 9:01 a.m. registered nurse (RN)-C stated R5 was currently on one-to-one supervision to ensure R5 was, appropriate with all the residents. RN-C stated he did not witness the occurrence on 3/1/21, and added he had, heard an incident happened, but did not have firsthand information. RN-C stated staff needed to monitor for appropriateness and intervene as necessary. During an interview on 3/3/21, at 9:18 a.m. RN-A stated R5 had, some adverse behaviors such as, sexual behavior with himself in a public area. She thought R5 was on one-to-one supervision after this incident occurred. RN-A stated R5 had no boundaries due to a TBI. RN-A was uncertain when R5's previous one-to-one supervision was removed, however, stated administration may be aware. RN-A stated, on 3/1/21, R5 was observed exiting R1's room and R1 was found with her incontinence product down to her knees and a wet substance was on R1's shirt and thigh. RN-A stated NA-A, who found R1, told licensed practical nurse (LPN)-A. RN-A stated she was informed of the incident by LPN-A. RN-A stated she did not know what the substance was on R1's shirt and thigh. RN-A stated she escalated the information to the director of nursing (DON) and hospice was updated. RN-A stated, R1 was initially asked about the occurrence and was unable to provide any details. RN-A stated R1 did not appear to be distressed or scared and denied pain. RN-A stated it was reported R1 lacked evidence of trauma and had no bruising or redness. RN-A stated R5's behavioral interventions included, going to the [facility] store and checking his bank account balance, but the main behavior interventions for R5 were, medication and one-to-one [supervision]. During an interview on 3/3/21, at 9:47 a.m. LPN-A stated NA-A informed her she observed R5 exit R1's room. LPN-A stated she observed R1 sitting on the edge of her bed and R1's brief and pants were pulled down to her mid-thighs. LPN-A stated R1 seemed to be, flustered, and some liquid was observed on R1's shirt. LPN-A stated, something, was also on R1's thighs. LPN-A stated the liquid appeared to be, some kind of [MEDICATION(S)] or body fluid. LPN-A stated, there was one drop on each of R1's thighs and several drops on R1's shirt. LPN-A stated she was unsure what the fluid, was or what it wasn't. LPN-A stated, R1 had no bruising or redness noted. LPN-A stated she questioned R1 along with NA-A. LPN-A stated she was unable to recall all the words R1 said, however, verbalized R1 informed her, There was a man, and said, well you know. LPN-A stated R1 did not always complete sentences and there was not much more R1 said that made sense. LPN-A stated the general response from R1 was that there was a man in her room and she did not want him in there. LPN-A stated R5 was on one-to-one supervision previously because he had exposed himself to two residents. LPN-A stated she was not sure when R5's one-to-one supervision was discontinued. LPN-A stated R5 was placed on one-to-one supervision after the incident with R1. LPN-A was not aware of any other behavioral interventions in place for R5. During an interview on 3/3/21, at 10:22 a.m. a hospice nurse, registered nurse (HRN)-B stated she was informed there was an incident between R1 and a, younger male resident. HRN-B stated she was informed the facility found what appeared to be semen on R1. HRN-B stated she asked what the facility was doing to keep R1 safe and was told R5 was on one-to-one supervision. HRN-B stated R5 had previously been on one-to-one supervision as he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . HRN-B stated, R5 had contact with other residents and had also masturbated in the dining room on 2/26/21. HRN-B stated she spent a significant amount of time with R1 on 3/1/21, and R1 was, very weepy and crying, and did not want HRN-B to leave. HRN-B stated this was different from R1's baseline and she, had not seen her like that before. HRN-B stated R1 kept calling herself, dumb. RN-B stated R1 had moods and anxiety, but she just didn't seem right. HRN-B stated she did not ask R1 about the incident with R5 and, just let her talk. During an interview on 3/3/21, at 11:28 a.m. the DON stated she was aware of the incident between R5 and R6 on 2/26/21. The DON stated a resident reported R6) that R5 was masturbating in the dining room. The DON stated staff followed R5's care plan and, told him he needed to masturbate in his room. The DON stated no one was near R5. The DON stated she was made aware of the incident between R1 and R5 by RN-A on 3/1/21, as RN-A was, concerned about what happened. The DON stated she went to R1's room to ask initial questions, introduced herself, and asked how R1 was. The DON stated, R1 responded by saying, Good. The DON stated R1 had a meal tray in front of her and R1 complained of a runny nose. The DON stated R1 wanted to eat and denied pain. The DON stated she asked R1 if she had a visitor and R1 responded, Only me. The DON stated she asked R1 if anyone came into her room and scared her and R1 responded, No. The DON stated she asked R1 if anyone tried to have sex with her and R1 responded, Sex, smiled and added, Now that's an interesting question. The DON stated R1's cognition was, poor and R1, did not want to elaborate. The DON stated R1 had no recall of the event and was not in distress. The DON stated R1 did not have pain or fear and chose not to press the issue any further based on R1's cognition. The DON stated she spoke to LPN-A and RN-A and was informed R1 denied being in pain or afraid. The DON stated RN-A asked R1 if she had sex and was informed R1 said, No. The DON stated she spoke with NA-A and was informed NA-A was passing lunch trays when she saw R5 leave R1's room. The DON stated NA-A informed her R1 was found with her sweatpants down to her knees and was fumbling with her incontinence product. The DON stated she was informed R1's incontinence product was down in R1's sweatpants, but the tabs were intact. The DON stated NA-A observed what she believed to be a wet spot on R1's shirt and a, drip on the top of her thigh. The DON stated the majority of the wet spot was on R1's shirt. The DON stated there also appeared to be a drip between were R1's legs came together. The DON stated NA-A described the fluid as, clear and, gelatinous. The DON stated NA-A described the fluid as, stringy when R1's legs were moved apart. The DON stated NA-A asked R1 if R5 had hurt her and R1 replied, I want to eat. I don't want to screw. The DON stated NA-A asked R1 if R5 had hurt her and R1 replied, He didn't get it in me. I already have seven children. The DON stated R1 was unable to answer if anyone got into bed with her. The DON stated R1's medical provider was updated and didn't feel a sexual assault examination was necessary and would be, more traumatic. The DON stated she did not believe R5 got into R1's bed or penetrated R1 in any way. The DON stated they did not know where the wet spot on R1's shirt came from. R1 was already cleaned up and was sitting on the edge of her bed when the DON arrived in R1's room. During an interview on 3/3/21, at 12:49 p.m. nurse practitioner (NP)-A stated she was at the facility on 3/1/21, and had spoken to the DON regarding the situation between R1 and R5. NP-A stated she had followed R1 since she was admitted to the facility. NP-A stated the DON informed her there was an incident in which NA-A observed another resident leaving R1's room. NP-A stated NA-A evaluated the situation and had found R1 in her wheelchair, or on the bed, with her incontinence product pulled down. NP-A stated some type of body fluid was found on R1's gown, or on R1's thighs. NP-A stated R1 had advanced cognitive impairment, moved on quickly from whatever occurred, and R1 did not appear to be in any distress. NP-A was not aware of a physical assessment being performed on R1 after the incident. NP-A stated NA-A looked at R1's perineal area and R1 had no signs of redness or fluid. NP-A stated she instructed the DON to update R1's family to decide what they wanted done next. NP-A stated she told the DON her understanding was there was no genital-to-genital contact, or penetration, and there was no risk for a sexually transmitted infection. NP-A stated she would provide an order to have R1 evaluated if family desired. NP-A stated R5 had exhibited sexual behavior in the past and had exposed himself prior to this incident. NP-A stated R5 was on one-to-one supervision for a month, however, it has been discontinued prior to this event. NP-A stated the facility was working on developing a care plan to keep everyone safe. NP-A stated, My thought was that he [R5] ejaculated on her. To me that was what happened given the circumstances. This is where my mind went, given the information she had received. NP-A stated it made sense, however, was speculation. During an interview on 3/3/21, at 1:34 p.m. family (F)-A stated the facility called on 3/1/21, at 3:20 p.m. and stated there was an incident in which staff opened R1's door and a man was in R1's room. F-A stated R1 had some liquid on her shirt and R1's pants were down, but the incontinence product was intact. F-A stated the facility asked if R1 was okay and R1 responded, I don't want to screw. I want to go to eat lunch. F-A stated, That is mom lately. F-A stated medication was used in an attempt to, tone down R1's sexual innuendo. F-A stated R1 was fixated on two older gentlemen whom R1 thought were her husband. Both of these gentlemen she viewed as physically incapable of harming anyone. F-A stated the facility did not answer her when she asked if it was one of those men who entered R1's room. F-A stated the facility did not correct her, nor notify her it was a younger man. Therefore, she assumed it was not possible R1 had been sexually assaulted. She also assumed by the staff telling her the incontinent product was, intact, that meant it was up, not down with her pants. F-A stated a hospice nurse informed her it was not one of the two men whom R1 was, chasing after who entered R1's room. F-A stated both men who R1 was fixated on were, sweet old men, however, she would be concerned if a younger gentleman were in R1's room. F-A stated nurses asked her if she wanted R1 to be sent in for a sexual assault exam, but felt it would be more traumatic. F-A confirmed the facility did not notify her it was a younger man who entered R1's room and expressed concern the individual may [NAME] on people. F-A stated the facility had since informed her the young gentleman would be watched 24/7, but questioned how the facility could guarantee this. F-A stated she was concerned the younger man could go in R1's room at any time. During an interview on 3/3/21, at 1:46 p.m. NA-A stated she was delivering meal trays on 3/1/21, and noticed R5 exit R1's room. NA-A stated she found that odd as R5 didn't wander into other residents' rooms. NA-A stated she approached R5, who had a grin on his face, and inquired as to what he was doing. R5 only replied, Yeah. NA-A stated she immediately checked on R1 and she was found sitting on her bed with her brief and pants down. NA-A stated this was, weird, however, R1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . NA-A stated she went to assist R1 and noticed R1 had, goop on her shirt, her legs, and one drop of fluid between her thighs. NA-A stated she asked R1 if she was alright, however, did not get a, straight answer. NA-A stated the, dots started to connect for me and she ran out of R1's room and found LPN-A. NA-A stated she returned to R1's room, with LPN-A, and she showed LPN-A a drop of viscous fluid which was connected to R1's thighs. NA-A stated R1 was questioned and replied, I just want to eat. I didn't want to screw. NA-A stated R1's memory was already fading. NA-A stated R1 was asked if R5 tried anything and R1 replied, He didn't try. I already have seven children. I don't want to have any more. R1 added, Do I seem like the kind of lady that would do that? NA-A stated additional questioning was conducted then LPN-A instructed her to clean R1. NA-A stated she checked R1 and there was no redness or bruising. NA-A stated there was no fluid between R1's thighs or coming out of her. NA-A stated she changed R1's shirt because it had goop on it. NA-A stated R1's hands were clean. NA-A stated she then set R1 up with her meal tray because R1 said she was hungry. NA-A stated R1 seemed a little disconcerted, but it passed quickly. NA-A stated the, goop on R1's shirt was, three spots about a quarter size each, maybe a little bigger. NA-A stated R1 had two drops on her right thigh and one drop between her thighs. NA-A described the fluid as, clear and a little bit cloudy. NA-A confirmed she did not observe a licensed nurse complete a body assessment of R1. During an interview on 3/3/21, at 2:44 p.m. R5 denied knowing R1. R5 stated, I try to stay away from the women. They are nothing but trouble. R5 denied having a relationship with anyone at the facility. R5 stated most residents had, missing limbs and I'm not a predator. R5 denied exposing himself to anyone at the facility. During an interview on 3/3/21, at 3:23 p.m. R5's legal guardian, F-B stated, I was aware [R5] exposed himself to somebody a few weeks ago. F-B stated SW-A called and informed R5 was found masturbating in the dining area and had taken, mutual affection with this lady and he went into her room, but they didn't think anything happened. F-B stated they were not provided any additional details regarding either event. During an interview on 3/4/21, at 8:51 a.m. the DON stated it was an interdisciplinary decision to remove R5 from one-to-one supervision on 2/19/21. The DON stated it was discussed during a morning meeting and the social worker, nurse manager, and administrator were at the meeting. R5 had been removed from one-to-one supervision before the 2/26/21 sexual behavior occurrence, and not placed back on the one on one supervision until the episode with R1 occurred on 3/1/21, even though it was reported that R5 was masturbating on 2/26/21. During an interview on 3/4/21, at 9:50 a.m. social worker (SW)-A stated, initially R5 did not have any behaviors. SW-A stated R5 then started making some sexual remarks or showing himself to people. SW-A stated R5 was previously on one-to-one supervision. SW-A stated, We thought that another male resident that was part of the situation had left and that it would get better. SW-A stated she was unaware of when the previous one-to-one supervision intervention was removed. SW-A stated the only time she heard of actual actions was during the most recent incident involving R1. SW-A stated R5's medications were reviewed and discharge planning to an all-male facility was in-process. R5 was currently back on one-to-one supervision after the 3/1/21 incident with R1. During an interview on 3/4/21, at 10:02 a.m. the DON stated there was no incident report related to R5 masturbating in the dining room on 2/26/21. The DON stated another resident saw R5 masturbating and reported the occurrence to the nurse. The DON stated it was reported R5, was tucked in a corner away from everyone. The DON added the nurse intervened as directed by R5's care plan. During an interview on 3/4/21, at 12:31 p.m. R1 was unable to provide information regarding the occurrence on 3/1/21. During an interview on 3/4/21, at 12:31 p.m. RN-D stated he recalled R6 complained about witnessing R5 masturbating. RN-D stated R6 complained to the manager and the manager, told me about it. RN-D stated he would report the incident to the state, but did not know if it was reported. During an interview on 3/4/21, at 12:58 p.m. RN-A stated she recalled the incident between R6 and R5. RN-A stated the occurrence happened in the commons area. RN-A stated by the time she arrived at the commons area, There was nothing going on. RN-A stated staff informed her R5 was masturbating. RN-A was unable to recall who informed her of R6's concern. RN-A stated it was not considered abuse if a resident is not, aware of it, or doesn't look uncomfortable. RN-A stated the situation could be considered abuse if another resident was uncomfortable. RN-A stated she notified the nursing supervisor of the incident immediately. RN-A stated if a resident was not cognitively aware of an incident, I don't perceive it as abuse. During an interview on 3/4/21, at 4:13 p.m. NA-B stated sometimes R5 gave residents a hug. NA-B stated they observed R5 in the hallway with his pants down once before. NA-B stated R5 gets himself naked in front of other residents and tried to show his private parts. NA-B stated R6 complained about this. NA-B stated residents did not like it. NA-B stated R5 showed his private parts to R6, according to R6. NA-B stated R5's behavior could be considered sexual abuse, however, was not abuse if a resident is not cognitively intact. During an interview on 3/4/21, at 4:20 p.m. LPN-B stated a resident who exposed themselves to another resident would be considered abuse. LPN-B stated if it was not consensual it was abuse. During an interview on 3/4/21, at 4:52 p.m. both administrator and DON stated the incident on 2/26/21, when R6 observed R5 masturbating in the TV room did not take place. The DON stated no incident report was completed for this occurrence adding, Why would you do an incident report for something that didn't happen? This contradicted the statement the DON made when interviewed earlier that same day, at 10:02 a.m. when she acknowledged being aware a resident had reported observing R5 masturbating staff had redirected R5 to his bedroom as outlined in his care plan. The DON had also acknowledged this incident was documented in R5's medical record. The DON now clarified the facility had, completed an extensive look into the alleged incident documented in [R5]'s medical record and had determined R5 had not been observed masturbated as reported by R6. The DON stated R6 had reported the event to a NA or nurse, however, R6 never actually saw the alleged masturbation. The DON stated R5 had exposed himself to R6 in January when he had wandered into R6's room. The DON stated R6 may have been thinking of that incident when she reported this recent event. An incident report or follow-up documentation was requested regarding R6's report on 2/26/21. The DON and administrator stated they did not have any documentation but would, type something up. R5's medical record contained no clarification to the initial documentation of this event. Although the facility was aware of R5's sexual behaviors there was no indication they implemented appropriate interventions to prevent other residents from being sexually abused/assaulted, after R5 was reportedly masturbating in front of a female resident on 2/26/21. R5's sexual behavior progressed when R5 was observed on 3/1/21 leaving R1's room and R1 was found with her pants down and a [MEDICATION(S)] substance on her body. The facility then implemented one-to-one intervention after the 3/1/21 incident. There was no indication the facility recognized sexual abuse and took appropriate actions to investigate the incident and protect other female residents from further abuse. Facility policy Abuse Prevention Program dated 1/2020, directed, Residents have the right to be free from abuse, neglect, misappropriate of resident property, corporal punishment, exploitation and involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical condition. The policy also directed, The facility administration and employees are committed to protecting residents from abuse by anyone including, but not necessarily limited to: facility staff other residents, consultants, volunteers, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individuals. In addition, Upon receiving reports of physical or sexual abuse, a licensed nurse or physician shall immediately examine the resident. Findings of the examination must be recorded in the resident's medial record. (Note: If sexual abuse is suspected, DO NOT bathe the resident or wash the residents clothing or linen. Do not take items from the area in which the incident occurred. Call the police immediately). The IJ which began on 2/26/21, was removed on 3/5/21, when the facility completed an incident report, filed a report with the state agency, and began an investigation for the incident reported by R6 on 2/26/21. R5's care plan was updated to reflect current behavior interventions. R5, R6, and R1 would receive an emergent visit for psychological services. A head-to-toe physical assessment was completed and entered into R1's medical record. R1 and R5 were evaluated for the capacity to consent to sexual activity. The facility reviewed all current residents and identified one additional resident with similar sexually inappropriate behaviors. This resident's care plan was updated as necessary. Staff were re-educated regarding abuse and abuse reporting including action to take when abuse is reported by a resident. These actions were verified by observation, interview, and document review by surveyors of 3/5/21.

Based on observation, interview and document review, the facility failed to ensure smoking interventions assessed for safety were implemented for 1 of 3 residents (R1) who was observed to smoke with oxygen on. This resulted in an immediate jeopardy (IJ) situation, which resulted in substandard quality of care for R1, who remained at high risk for injury related to smoking with oxygen. The IJ began on 7/11/19, at 2:07 p.m. when it was identified R1 was smoking unsupervised while wearing oxygen, placing R1 at risk . Although, facility staff had knowledge of previous unsafe smoking events and had been assessed to need supervision with smoking, the care plan was not updated to identify this restriction and the facility was not providing consistent supervision for R1 while smoking. On 7/11/19, at 4:24 p.m. the director of nursing (DON) and administrator were notified of the IJ for R1. The IJ was removed on 7/12/19, at 3:34 p.m., however, non-compliance remained at an isolated scope and severity which indicated no actual harm with potential for more than minimal harm (Level D). Findings include: R1's quarterly Minimum Data Set ((MDS) dated [DATE], identified R1 had intact cognition and required supervision with locomotion on and off the unit. R1 had no impairments to her upper extremities. [DIAGNOSES REDACTED]. During observation on 7/11/19, at 2:07 p.m. R1 was seated in her wheelchair alone next to the the front entrance. R1 was smoking a cigarette in her left hand and had a nasal cannula on. R1's portable liquid oxygen tank was on, at 2.5 liters (L). The potable liquid oxygen tank had visable condensation coming from the bottom vents on the tank. At 2:08 p.m. the surveyor alerted unidentified staff inside the building that R1 was smoking outside the front entrance with oxygen on. Nursing assistant (NA)-A walked outside shut off R1's oxygen off and walked back into the facility. NA-A did not remove the oxygen or nasal cannula tubing from R1. R1 continued to smoke the cigarette. NA-A stated she did not know who the resident was or what R1's smoking care plan directed. NA-A stated R2 was smoking and R1's oxygen was on 2.5 L and it was dangerous to smoke with oxygen on. At 2:10 p.m. R1 put out her cigarette and wheeled herself back into the facility. The front desk receptionist (FDR) identified R1 and had alerted the facility staff R1 was outside smoking with her oxygen on. FDR stated she did not see her smoking outside or would have intervened. R1 always wore oxygen and smoked frequently throughout the day. Residents were not allowed to smoke in the front of the building near entrances or with oxygen on. FDR was not instructed by facility staff to monitor for unsafe smoking practices by residents. FDR was not aware where R1 left her oxygen when going out to smoke. At 2:12 p.m. the administrator stated R1 was being re-assessed for safe smoking and would educate R1 on the safety risks to herself and others smoking with oxygen poses. At 2:30 p.m. the DON stated smoking with oxygen was not allowed as oxygen was very flammable. Staff had been storing R1's cigarettes and lighters on the medication cart because she had several previous smoking violation and had been on and off smoking supervision. The DON was not aware how R1 had received the cigarettes and started an investigation. The DON stated R1 would be immediately placed on supervised smoking. R1's physician orders [REDACTED]. R1's care plan initiated 10/27/17, identified R1 had a potential for a smoking related injury. R1 refused to sign the facility smoking policy; however, verbalized understanding of the policy. Interventions included: 10/31/17, educated R1 on not smoking when wearing oxygen; 12/4/17, smoking assessment to be completed quarterly and as needed; 4/9/19, R1 aware of smoking rules and provided contract; 6/11/19, smoking materials would be kept at the nursing station and the resident would bring them back to the nurse after utilizing them. The care plan did not address R1's oxygen use, who was responsible to remove it or where the oxygen would be stored while out smoking. R1's smoking contract dated 10/27/17, identified the following: R1 would smoke in designated areas only; agree to a smoking evaluation on admission, quarterly and as needed, if nursing deemed resident unable to smoke safely then smoking activity would be supervised; if assessed to require supervision with smoking, smoking would be supervised at 7:00 a.m., 9:00 a.m., 11:00 a.m., 1:00 p.m. 3:00 p.m., 7:00 p.m. and 9:00 p.m.; if assessed to require supervision, supervision may be competed by a initiator after training; if assessed to require supervision all smoking material would be secured by staff; if using oxygen resident agrees to remove oxygen and store with staff while smoking; the facility did not allow resident to give any smoking materials to other residents; failure to comply with the smoking contract would result in the removal of smoking privileges. R1 refused to sign the smoking contract. The smoking contract did not identify if R1 was an independent or supervised smoker. R1's smoking violations identified the following: - 7/12/18, R1 was found smoking in her room on 7/11/18 and in the room next door. - 7/14/18, R1 was observed on 7/13/18, smoking with portable oxygen tank on in the designated smoking area. - 9/18/19, R1 violated the facility smoking policy on 9/14/18; however, did not identify what the smoking violation was. - 12/5/18, R1 violated the facility smoking policy on 12/2/18; however, did not identify what the smoking violation was. - 1/5/19, R1 was smoking in resident bedroom. R1's progress notes from 1/4/19, through 7/11/19, identified the following: - 1/4/19, social services and nurse manger attempted to meet with R1 to discuss a 30 day discharge notice due to receiving multiple smoking violations. R1 was sleeping. - 1/5/19, smoke could be smelled from R1's bathroom. R1 had both doors to the bathroom locked and could be heard spraying then opened the door. R1 had her oxygen on R1 denied smoking. Safety risks of smoking in the building with oxygen were explained. Later in the day strong cigarette smoke could be smelled from residents bathroom again. R1 denied having smoking materials and denied smoking in her bathroom. Room and bathroom smelled strongly of cigarette smoke and cigarettes had been extinguished under the bathroom sink. A search was conducted and two boxes of cigarettes and two lighters were found. The supervisor was notified. - 1/8/19, social services and nurse manager spoke with resident and issued her a smoking violation from 1/5/19. R1 refused to sign the violation. Social services explained a 30 day discharge notice was being issued because of the repeated violations of the smoking policy and it was endangering R1 and others in the facility. Assistance with alternative placement would be completed. - 1/10/19, R1 was smoking in her bathroom. - 1/13/19, R1 was found smoking in her room with her oxygen on. When staff tried to redirect R1 she stated I don't care, I just want to die. Updated supervisors. Cigarettes were collected from the room and placed on 1:1 supervision for suicidal ideation. - 1/16/19, social services and nurse manager went over smoking contract with R1 and highlighted the supervised smoking section as R1 was now considered a supervised smoker. It meant R1 could only go smoke during supervised smoking times, and must give her smoking materials to nursing immediately upon returning to the unit. - 4/4/19, R1 awoke at 11:00 p.m. and had been going back and forth fro the smoking area unit 4:00 a.m. The note did not identify R1 was supervised while smoking. - 4/5/19, R1 awoke at 3:30 a.m. and went out to smoke. The note did not identify if staff supervised R1 while she smoked. - 5/30/18, R1 had gone outside to smoke three times. The note did not identify if R1 was supervised while she smoked. - 6/11/19, resident restricted with smoking because she was caught smoking with her oxygen on. R1 should be monitored at all times while smoking with no cigarettes or lighters in her possession. - 6/12/19, R1 had been awake most of the night going out to smoke. The note did not identify if R1 was supervised while she smoked. - 6/22/19 R1 had some mild confusion. Went to the smoking area one time and able to make it back to bed without concerns. The note did not identify if R1 was supervised while she smoked. - 6/23/19, R1 went outside to smoke one time during the shift. The note did not identify if R1 was supervised while she smoked. - 6/27/19, R1 had a fall in the smoking area. The note identified R1 was previously supervised in the smoking area; however, was not compliant with supervision. The note did not address steps to ensure safe smoking. R1's most recent Smoking Evaluation dated 6/12/19, identified R1 wanted to smoke during her stay. R1 did not have any cognitive loss, vision or dexterity issues. R1 smoked mornings, afternoons and nights. R1 could light her own cigarette and required supervision while smoking. R1 was safe to smoke with limitations and community rules had been supplied. The care plan was updated. The smoking assessment did not identify R1's use of oxygen or her history of unsafe smoking practices. During interview on 7/12/19, at 8:55 a.m. the DON stated the facility would be revising their smoking violation policy as residents were receiving smoking violations without consequences. R1 obtained cigarettes from her family, which were not turned into the facility to monitor and that was how R1 ended up outside smoking. The DON was not aware R1 was supposed to be supervised following a smoking assessment dated [DATE], following a smoking violation and her care plan was not updated. The facility Smoking policy dated 11/16, identified any smoking restrictions and concerns would be noted on the care plan and all personnel responsible for the resident would be alerted to the issues. Any resident with restricted smoking privileges, requiring monitoring would have direct supervision of a staff person at all times. The facility Oxygen Administration policy dated 10/10, identified all potentially flammable items including smoking articles would not be in the area oxygen was administered. The IJ that began on 7/11/19, was removed on 7/12/19, at 3:34 p.m. after the facility successfully implemented a removal plan through interviews and document review, which included the following: - The facility updated their smoking assessment to include oxygen use. - R1 was re-assessed and identified to need continuous 1:1 supervision until discharge related to multiple unsafe smoking violations. - Family was educated on not obtaining and proving R1 with smoking materials. - R1's care plan was updated to include smoking safety interventions and staff were updated. - Staff were educated on shutting oxygen off, removing the tubing and tank, if residents were witnessed to smoke with oxygen on and then have the resident extinguish the cigarette immediately and bring the resident to the floor nurse for an immediate assessment. - Books were placed on units identifying smokers and their current care plans. - Other residents identified to smoke and utilize oxygen were re-assessed with [REDACTED]. - The smoking violation policy was reviewed and updated to reflect consequences for smoking violations.

Based on observation, interview and document review, the facility failed to ensure 2 of 5 residents (R81, R31) identified at risk for pressure ulcers received timely repositioning. The failure of the facility to consistently implement a turning and positioning program resulted in actual harm, when R81 acquired three (3) new stage II pressure ulcers (partial-thickness loss of skin with exposed dermis). Findings include: R81 did not receive a position change on 11/7/18, for over three hours and acquired three new, stage II, pressure ulcers. R81's quarterly minimum data set (MDS) assessment dated [DATE], identified [DIAGNOSES REDACTED]. The MDS indicated R31 had severely impaired cognition and required physical assistance of two staff with toileting, bed mobility and transfers. The MDS further indicated R31 was frequently incontinent of cares, and had no refusal of care behaviors. R81's care plan dated 9/12/18, identified a risk for impaired skin integrity related to fragile skin and incontinence. The care plan indicated R81 had a history of [REDACTED]. The care plan further indicated R81 had a stage 2 pressure ulcer to the coccyx and left buttocks. The care plan directed staff to assess and complete treatments to the pressure areas on the coccyx and left buttocks. The care plan directed staff to provide assistance with turning and repositioning at least every 2 hours and more often as needed. On 11/5/18, at 9:58 a.m. when asked if R81 had any pressure ulcers, family member (FM)-B stated yes. FM-B also stated the pressure sores were on the buttocks, that R81 was not changed often enough, and that R81 was left to sit on her buttocks for a long time. During continuous observations on 11/7/18, from 6:25 a.m. to 9:54 a.m., the following observations were made: R81 was observed to lay on the backside in bed sleeping. At 7:50 a.m. nursing assistant (NA)-F went past R81's room but did not offer repositioning. At 9:40 a.m. R81 remained asleep on the backside with no attempts by staff to reposition (3 hours and 15 minutes), at which time the surveyor intervened and alerted licensed practical nurse (LPN)-E. Nursing assistant (NA)-F was interviewed on 11/7/18 at 9:44 a.m. NA-F stated he did not know the last time R81 had been repositioned as he had come in late that morning. At 9:52 a.m., NA-F approached R81 and cued her they were going to check, change and reposition her. At 9:54 a.m. (3 hours and 29 minutes after last repositioning), NA-F and NA-M turned R81 to the left side. R81's incontinent pad was saturated with urine and three open bleeding areas were noted on R81's left lower buttock, with two other areas on the right buttock. In addition, a foam dressing was observed around the coccyx. At 10:02 a.m. on 11/7/18, LPN-E was observed to remove the old dressing revealing an open area to the coccyx. LPN-E measured the three bleeding wounds and stated she was going to let the nurse manager know about them. LPN-E said in the meantime, she was going to apply a foam dressing until the physician could be contacted to obtain a treatment for [REDACTED]. She said if the NAs were not able to complete repositioning in a timely manner, they were supposed to let her know. During a follow up interview with NA-F at 10:30 a.m. on 11/7/18, NA-F stated he did not know he was assigned to R81 until the surveyor had asked about it. On 11/7/18, after concern was brought to the facility attention, a progress note dated 11/7/18, at 8:57 p.m. indicated the following:: Resident noted with three new small stage 2 pressure wounds on the coccyx The areas were measured as: 1.1 cm (centimeter) by 0.5 cm by 0.1 cm; 2.3 cm by 1.4 cm by 0.1 cm; and 1.1 cm by 0.8 cm by 0.1 cm; and one stage 2 wound on the left buttock measuring: 1.2 cm by 0.6 cm by 0.1 cm; and four small stage 2 pressure areas on the right buttock measuring 0.5 cm by 0.5 cm by 0.1 cm; 0.8 cm by 0.5 cm by 0.1 cm; 0.2 cm by 0.2 cm by 0.1 cm; and 0.3 cm by 0.2 cm by 0.1 cm. The note also indicated: Resident also has a reddened blanchable area measuring 16 cm by 14 cm by 0.1 cm . During review of the Nursing Daily Pressure Injury Documentation dated 11/4/18, 11/2/18, 11/1/18, and 10/31/18, it was revealed that on all four dates the coccyx had been identified to have an open area. On 11/1/18, the assessment had indicated there was an open area on the left buttock. The documentation lacked staging, size, drainage color, odor and approximate amount, pain if present, nor did it include assessment of the wound bed to include the color and type of tissue/character and a description of wound edges and surrounding tissue. On 11/7/18, at 10:24 a.m. when asked about the wound documentation, registered nurse (RN)-K stated for the past few weeks the floor nurses had been doing the wound rounds for her. RN-K stated they were supposed to complete the documentation. RN-K verified the medical record lacked documentation related to staging, size, drainage color, odor and approximate amount, pain if present, wound bed including the color and type of tissue/character and a description of wound edges and surrounding tissue. On 11/7/18, at 1:56 p.m. RN-I stated he was not familiar with R81 however, after reviewing the care plan he stated the minimum expectation was R81 would be repositioned every two hours as she was at risk for pressure ulcers and already had a current pressure ulcer. On 11/7/18, at 2:02 p.m. RN-I reviewed the actual working schedule and verified R81 had been assigned to NA-F's team from the beginning of the shift. RN-I stated there was no reason NA-F should have been confused about being assigned to assist R81. On 11/8/18, at 2:02 p.m. the director of nursing (DON) stated she had been at the facility for less than two months and was in the process of working on various care concerns. The DON stated wound assessments were something the clinical coordinators were working on as well as having the whole interdisciplinary team round. The DON further stated residents who were at risk for pressure ulcers were supposed to be repositioned at least every two hours or as directed by the care plan. The facility's Skin Integrity, Pressure Injuries, Nursing Protocol policy revised (MONTH) (YEAR), indicated: The resident will receive care, consistent with professional standards of practice to prevent pressure injuries and will not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable; and the resident with pressure injuries will receive necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing . R31's quarterly MDS dated [DATE] indicated the resident had [DIAGNOSES REDACTED]. The MDS indicated R31 had severely impaired cognition, had both short and long term memory problems and required total physical assistance of two staff with toileting, bed mobility and transfers. The MDS further identified R31 had not walked during the assessment period and was at risk for pressure ulcer development. R31's care plan dated 11/2/18, identified a risk for skin breakdown due to bladder and bowel incontinence, cognitive loss and decreased mobility. The care plan directed staff to offer repositioning every two hours and as needed. On 11/7/18, R31 was continuously observed from 6:25 a.m. unit 11:34 a.m. (5 hours and 9 minutes). At 7:50 a.m. nursing assistant (NA)-F approached R31, tilted the wheelchair back and left R31 in the television lounge. At 8:41 a.m. the registered dietician (RD) wheeled R31 to the dining room table. R41 ate and was assisted directly to the main dining room for an activity where he remained until 11:20 a.m. when the surveyor intervened. At 11:20 a.m., NA-F stated when he came to the unit at 7:50 a.m. he had noticed R31 in the television lounge and had tilted the wheelchair back and at the same time had uncrossed R31's legs. When asked if that was an appropriate form of repositioning, NA-F stated it was and indicated it helped a resident change positions. NA-F stated he did not know when R31 had been repositioned last as the night shift had gotten him up. At 11:40 a.m., NA-F and NA-I were observed to use a mechanical lift to get R31 onto the bed. R31's brief was observed to be wet from urine. On 11/7/18, at 2:02 p.m. registered nurse (RN)-I stated a resident had to have tissue relief of at least two minutes for it to be considered repositioning, which meant a resident had to be off- loaded from the surface. RN-I verified R31 was on an every two hour repositioning schedule and staff were supposed to follow the care plan. On 11/7/18, at 2:26 p.m. the DON stated residents who were at risk for pressure ulcers were supposed to be repositioned at least every two hours or as directed by the care plan. When asked what she considered to be appropriate repositioning, the DON stated a resident needed to be off- loaded from the surface.

Based on interview and document review the facility failed to ensure one of four residents reviewed for medications (R1) was free of a significant medication error when R1 received insulin (a diabetic medication that lowers blood sugar) instead of [MEDICATION NAME] (a blood thinner). R1 was harmed when his blood glucose dropped, R1 became unresponsive, and was hospitalized . Findings include: R1's medical record was reviewed. R1 admitted to the facility on (MONTH) 20, (YEAR) for rehabilitation after a left [MEDICAL CONDITION]. R1's [DIAGNOSES REDACTED]. R1's brief interview of mental status dated (MONTH) 2, (YEAR) indicated R1 had no cognitive impairment. R1 received [MEDICATION NAME] injections every 8 hours for the prevention of blood clots. R1's medication order dated (MONTH) 21, (YEAR) directed to inject R1 subcutaneously (just below the skin) 0.5 milliliters (ml) of [MEDICATION NAME] every eight hours (4:00 a.m., 12:00 p.m., and 8:00 p.m.) for [MEDICAL CONDITION] (blood clot prevention.) R1's (MONTH) (YEAR) blood sugar record indicated R1's blood sugars were within normal range (70-100) prior to the incident. (On (MONTH) 21, (YEAR) at 12:10 p.m. blood sugar = 81, (MONTH) 21, (YEAR) at 5:37 p.m. blood sugar =78, (MONTH) 22, (YEAR) at 8:08 a.m. blood sugar =89, (MONTH) 22, (YEAR) at 8:59 p.m. blood sugar =119, (MONTH) 23 at 11:40 a.m. blood sugar =117, (MONTH) 24 at 12:32 p.m. blood sugar =72, and (MONTH) 24, (YEAR) at 4:05 p.m. blood sugar =96) R1's nursing progress note dated (MONTH) 24, (YEAR) at 1:56 p.m. indicated R1 returned from [MEDICAL TREATMENT] at noon, blood sugar was 72, and ate well for noon meal. R1's Medication Administration Record [REDACTED]. R1's nursing progress note dated (MONTH) 24, (YEAR) at 10:27 p.m. indicated R1 coping well with no concerns and vital signs taken within normal limits. R1's nursing progress note dated (MONTH) 25, (YEAR) at 7:25 a.m. indicated R1 noted to have signs and symptoms of low blood sugar between 5:30 a.m. and 6:00 a.m. and registered nurse (RN)-E administered orange juice. RN-E checked R1's blood sugar and administered glucose gel. RN-E checked R1's blood sugar and administered a glucose injection as R1 became unresponsive. 911 called. R1's hospital record dated (MONTH) 25, (YEAR) indicated R1 admitted to the emergency room due to low blood sugar in the 30's (normal range 70-100). emergency room medical doctor (ERMD)-G's progress note indicated R's low blood sugar was due to receiving an insulin injection. Facility in-service documentation dated (MONTH) 31, (YEAR) indicated the facility provided RN-E and twelve additional nurses education on medication administration review. The facility investigation dated (MONTH) 1, (YEAR) indicated the facility received 30 bottles of [MEDICATION NAME] from the pharmacy for R1 and 17 doses of [MEDICATION NAME] remained after the incident, but did not provide evidence of the doses of [MEDICATION NAME] remaining after the incident. The facility did provide photo evidence of R1's pharmacy packages of [MEDICATION NAME] vials dated (MONTH) 20, and 22, (YEAR), which indicated 30 doses sent to facility prior to the incident. The investigation indicated the resident refused dinner the previous evening and had a blood sugar of 96. The investigation concluded: the investigation did not support the resident receiving a [MEDICATION NAME] injection, and found no evidence of purposeful harm or abuse/neglect. The facility indicated it would educate the nurses on the six rights of medication administration (right drug, right resident , right time, right dose, right route, and right documentation) in order to prevent this from happening again. During an interview on (MONTH) 23, (YEAR) at 11:18 a.m. registered nurse care coordinator (RNCC)-A stated a nursing assistant called her to R1's room on the morning of the incident. RNCC-A stated R1's eyes rolled back in his head and he did not respond to verbal direction. RNCC-A stated RN-E had responded to R1's call light and treated R1 for low blood sugar with orange juice and glucose gel. R1 remained unresponsive so RNCC-A gave R1 an injection of glucose to raise his blood sugar. RNCC-A stated R1 did not have an order for [REDACTED].>During an interview on (MONTH) 23, (YEAR) at 11:25 a.m. family member (FM)-B stated R1 had not been on insulin for months and R1's blood sugars had been stable. FM-B stated R1 knew the symptoms of low blood sugar as R1 experienced it in the past. During an interview on (MONTH) 23, (YEAR) at 12:15 p.m., R1 stated he recalled RN-E gave him a shot in the belly on the morning of the incident. R1 stated that about half an hour to an hour later he started to feel his blood sugar get low. R1 stated he had been through low blood sugar before and had the same symptoms. R1 saw stars, ears rang, was sweating, and had shaky hands. R1 stated he put on his call light and RN-E entered his room and asked if it was his blood sugar. R1 stated it was odd, since he had not yet told RN-E what was wrong. R1 stated he then passed out and did not remember anything until he woke up later that day in the hospital. R1 stated he stayed overnight at the hospital, and when he returned to the facility moved to a hall where RN-E did not work, per his request. During an interview on (MONTH) 23, (YEAR) at 2:40 p.m. RN-E stated on the night of the incident she learned in report that R1 had gone to [MEDICAL TREATMENT] that day and was fine. RN-E stated she gave R1 an injection in his belly at 4:00 a.m. RN-E stated later R1 was sweaty and had slurred speech. RN-E left R1's room and returned when R1 put on his call light. RN-E checked R1's blood sugar and RN-E stated the blood sugar was 55, so she gave R1 orange juice. RN-E checked R1's blood sugar fifteen minutes later and it was 43 and then 48. RN-E stated she gave R1 glucose gel, and a glucose injection. RN-E called for additional help and someone called 911. RN-E initially stated during the interview that she did not know if she gave R1 insulin or [MEDICATION NAME]. RN-E stated both [MEDICATION NAME] and insulin were in a glass container and drawn up into a needle. RN-E stated another resident on the same hall had scheduled insulin during the night that was drawn up into a needle. During an interview on (MONTH) 24, (YEAR) at 9:37 a.m. nursing assistant (NA)-F stated she entered R1's room because R1 had put on his call light. NA-F stated when she entered the room, registered nurse (RN)-E was in the room and NA-F heard R1 ask for orange juice. During an interview on (MONTH) 28, (YEAR) at 4:40 p.m. emergency room medical doctor (ERMD)-G stated he treated R1 when he came in to the emergency room with injections and intravenous glucose until R1 became alert, and blood sugar returned to normal. ERMD-G stated after a complete work-up with labs and a CT scan (an x-ray that showed a cross section of the brain) he consulted with a doctor in endocrinology who agreed an insulin injection was the only plausible cause of R1's low blood sugar. During a follow-up interview on (MONTH) 5, (YEAR) at 3:00 p.m., RN-E stated R1 already had slurred speech when she gave him the shot at 4:00 a.m. but she left the room because R1 was not in a crisis. RN-E stated she was sure she did not give R1 insulin. RN-E stated she did not recall who entered R1's room when his light went off. RN-E stated it was a busy night because she had a resident in another room who kept trying to get out of bed. Registered Nurse job description (undated) indicated the registered nurse was responsible to administer medication as ordered by the physician. The insulin administration policy dated (MONTH) 2010 indicated a licensed staff must verify the type of insulin, dosage, strength, and method of administration with the physician's orders [REDACTED]. The medication administration policy dated (MONTH) (YEAR) indicated the nurse must check the medication label three times to verify the right medication, dosage, time, and method of administration before giving a medication.

Based on record review and interview, the facility failed to ensure catheter hygiene was performed and the catheter was monitored for infection for one of one resident (R1) reviewed for catheter cares when R1 was hospitalized with a urinary tract infection [MEDICAL CONDITIONS], and pneumonia. R1's medical record was reviewed. R1 had chronic [MEDICAL CONDITION], heart failure, diabetes and neuromuscular dysfunction of the bladder. R1's care plan dated 10/31/14 and revised 2/12/18 indicated R1 had an indwelling 16 French catheter with 30 cc balloon for a [MEDICAL CONDITION] bladder. R1's care plan interventions included: staff to perform catheter cares, catheter to be changed for dysfunction, monitor/document for pain/discomfort due to catheter, monitor/record/report to MD for signs and symptoms UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. R1's Basic Interview of Mental Status (BIMS) dated 3/30/18 with a score of 11 indicated R1 was mildly cognitively impaired but could make her needs known. R1's care plan, dated 4/10/18 indicated R1 required an extensive assist of 2 staff for toilet use and incontinence cares. A progress note dated 5/7/18 at 23:30 indicated R1's condition had changed and an Situation, Background, Assessment and Recommendation (SBAR) was completed for the physician. The nurse assessed R1's oxygen saturation was 87% at 2 liters of oxygen, with labored breathing and unusual behavior. An Episode Note dated 5/8/18 at 5:38 a.m. indicated the nurse contacted the telemedicine physician on call and R1 was remotely assessed for lethargy, oxygen sats at 87% declining condition, shortness of breath, difficulty breathing, not eating, not hydrating, a drastic decline. The physician indicated in the assessment she couldn't see R1 very well on the screen. R1 was described as ashen with cold skin and lethargic. The physician wrote an order for [REDACTED]. A progress note dated 5/8/18 indicated the nurse contacted R1's nurse practitioner and left a message that R1 had been sent to the hospital. A hospital admission history and physical (HP) dated 5/8/18 at 5:57 a.m. indicated R1 had a chronic indwelling Foley catheter which appeared to have been in a long time and was clearly infected. R1 was admitted to the hospital and started on antibiotics for a UTI,[MEDICAL CONDITION] and pneumonia. An emergency department note dated 5/8/18 at 6:10 p.m. indicated R1's Foley catheter was adhered to her labia and vaginal vulva and the catheter was filled with dark sediment. The ED physician indicated the catheter had not been maintained or changed in a very long time and contributed to indwelling catheter induced urosepsis. The physician was concerned about R1 as a neglected vulnerable adult. Hospital photographs dated 5/13/18 at 9:49 a.m. and 9:50 a.m. show R1's old Foley catheter after removal. The catheter tubing shows black and green sediment in cloudy yellow urine and brown crusty material covering the catheter tip. A hospital discharge summary dated 5/15/18 indicated R1 had a complicated UTI due to urinary indwelling Foley catheter,[MEDICAL CONDITION] due to UTI and moderate malnutrition. R1 needed to follow up with her primary physician and her Foley catheter needed to be replaced monthly. During an interview on 6/14/18 at 1:45 pm, licensed practical nurse (LPN-A) said residents with a Foley catheter are prone for infection. During an interview on 6/14/18 at 2:09 p.m. registered nurse (RN)-B said the Foley catheter bag should be changed as needed. (RN)-B said he never saw R1's catheter or catheter bag. During an interview on 6/14/18 at 2:46 p.m. director of nursing (DON)-C said it is not uncommon for a catheter to discolor. DON-C said R1 went to the hospital for respiratory issues not for a UTI. DON-C said the facility changes a catheter as needed per Center for Disease Control (CDC) guidelines. During an interview on 7/3/18 at 3:46 p.m. nurse practitioner (NP)-E said she is at the facility 4 days a week and is updated by the nurses with any concerns. NP-E said the staff at this facility does not do typical document a daily progress notes, which is concerning. During an interview on 7/5/18 at 10:24 a.m. family member (FAM)-F said R1 smelled so bad for so long. She smelled dirty, a not female clean and urine smell. FAM-F said once the catheter was changed at the hospital the smell was gone. During an interview on 7/17/18 at 1:09 p.m. Social Worker (SW)-G said the condition and smell of R1's catheter was indescribable when it was removed at the hospital. SW-G said R1's catheter had a thick cheese-like discharge on the catheter tip and tubing and parts of the catheter were black with sediment. A facility policy titled Quality of Life-Activities of Daily Living, dated (MONTH) (YEAR) indicated residents are provided with appropriate care and services including: hygiene and elimination. A facility policy titled Catheter Care, Urinary, General Guidelines, dated 2001 and revised (MONTH) 2010 indicated maintain clean technique when handling or manipulating the the catheter, tubing or drainage bag. Routine hygiene (cleansing of the meatal surface during daily bathing or showering) is appropriate. A facility policy titled Catheter Care, Urinary, Documentation, dated 2001 and revised (MONTH) 2010 indicated the following information should be recorded in the resident's medical record: the date and time catheter care was given; name and title of individual(s) giving the catheter care, all assessment data obtained when giving catheter care, character of urine such as color, clarity and odor; any problems noted at the catheter-urethral juncture during perineal cares such as drainage, redness, bleeding, irritation, crusting or pain; any problems or complaints made by the resident related to the procedure; how the resident tolerated the procedure; if the resident refused the procedures and why and intervention(s) taken. A facility policy titled Urinary Tract Infections/Bacteriuria - Clinical Protocol, dated 2005 and revised (MONTH) (YEAR), indicated nurses should observe, document and report signs and symptoms (for example, fever or hematuria) in detail and avoid premature diagnostic conclusions.

Based on interview, observation, and record review, the facility failed to ensure the facility resident weights accurately reflected the nutritional status for one of four residents (R1) reviewed for significant unplanned weight change. The resident's weight was recorded as 95 pounds in the facility but only 67 pounds when admitted to the hospital for a urinary tract infection [MEDICAL CONDITIONS], and pneumonia. R1's hospital discharge indicated moderate malnutrition. Findings include: R1's medical record was reviewed. R1 had chronic [MEDICAL CONDITION], heart failure, diabetes, neuromuscular dysfunction of bladder and dysphagia. A physician's orders [REDACTED]. A nutrition note dated 3/27/18 at 11:12 indicated R1's nutrition assessment was complete and the registered dietitian (RD) was to follow up per routine schedule (low risk) or sooner as needed. R1's Basic Interview of Mental Status (BIMS) dated 3/30/18 with a score of 11 indicated R1 was mildly cognitively impaired but could make her needs known. R1's Minimum Data Set (MDS) quarterly review assessment dated [DATE] indicated the resident was 62 inches tall, 96 pounds and had no or no known weight loss. R1's care plan dated 4/10/18 , indicated R1 would call out for help in her room and the dining room. Interventions included anticipate all resident's needs, escort resident back to room after meals. R1 was at risk for malnutrition due to mechanical soft ground diet. Interventions included provide adequate assistance for food intake, offer alternatives, supplements, encourage adequate food and fluid intake, and routine weights. R1's facility weight was documented as 96.2 pounds on 4/1/18, 95.2 pounds on 4/3/18, 95.0 pounds on 4/10/18, 95.1 pounds on 4/17/18, and 95.4 pounds on 5/1/18. The weight document indicated R1 was weighed on the wheelchair scale. An Episode Note dated 5/8/18 at 5:38 a.m. indicated the nurse contacted the telemedicine physician on call and R1 was remotely assessed for lethargy, oxygen sats at 87% declining condition, shortness of breath, difficulty breathing, not eating, not hydrating, a drastic decline. The physician indicated in the assessment she couldn't see R1 very well on the screen. R1 was described as ashen with cold skin and lethargic. The physician wrote an order for [REDACTED]. A progress note dated 5/8/18 indicated the nurse contacted R1's nurse practitioner and left a message that R1 had been sent to the hospital. A hospital admission history and physical (HP) dated 5/8/18 at 5:57 a.m. indicated R1 had a chronic indwelling Foley catheter which appeared to have been in a long time and was clearly infected. R1 was admitted to the hospital and started on antibiotics for a UTI,[MEDICAL CONDITION] and pneumonia. R1's hospital weight was documented as 67 pounds on 5/8/18. The hospital weight was completed while lying flat. A hospital discharge summary dated 5/10/18 indicated R1 had moderate malnutrition, weighed 67 pounds, had a body mass index (BMI) of 11.64, appeared cachectic, and chronically ill. R1's facility weight documented as 70.9 pounds on 5/17/18 on a wheelchair scale. R1's wheel chair weight and scale calibration records were requested from the facility but not received. A facility fax dated 7/20/18 indicated the facility does not keep track of the wheelchair weight. During an observation and interview on 6/14/18 at 1:30 p.m., R1 was in her room watching TV. R1 was in her bed with blankets covering her lower body. R1's upper body was thin and bony. Her lips were dry and cracked. R1 said she'd eaten all of her breakfast and lunch, which she indicated was good. R1 stated she eats in the dining room. Her overbed tray had five glasses of clear and colored fluids and one glass of a milky liquid. The tray was pushed out of R1's reach. Staff entered the room and left without asking R1 if she wanted anything to drink or moving tray to within her reach. During an interview on 6/14/18 at 1:45 p.m., licensed practical nurse (LPN)-A said the nursing assistants do the resident weights. They should weight the wheelchair, then weigh the resident in the wheelchair, subtract the wheelchair weight to get the resident's weight. Weights should be done weekly on bath day. During an interview on 6/14/18 at 2:09 p.m., registered nurse (RN)-B said R1 used to feed herself and was independent but started to decline, lost interest in her food and was not as motivated to eat. During an interview on 6/14/18 at 2:46 p.m. director of nursing (DON)-C said there had been some issues with the scales and resident weights. The DON-C said she met with maintenance about calibrating the scales monthly and going forward there should be no issues with the scales. DON-C said she could not recall the residents with questionable weights. During an interview on 7/3/18 at 10:23 a.m. registered dietician (RD)-D said resident weights are done weekly or more often with a physician's orders [REDACTED]. During an interview on 7/3/18 at 3:46 p.m. nurse practitioner (NP)-E said malnutrition is something unavoidable verses the weight loss. R1 has chronic [MEDICAL CONDITION] and low [MEDICATION NAME], which is reflective of malnutrition. NP stated she was made aware that R1 went to the hospital with over a 20 pound weight loss. NP-E said she was bothered that R1's weights looked okay for so long and now wonders if weights were done properly. NP-E said the weekly weighing of the resident was variable and that was a failure of the nursing staff. During an interview on 7/5/18 at 10:24 a.m., family member (FAM)-F said she noticed R1 had lost weight but the staff did not say anything about R1's weight or their ability to move R1 to a feeding assistance table. FAM-F said the glasses of juice and water in R1's room were often days old. A facility policy titled Weight Assessment and Intervention, revised 9/12 indicated the interdisciplinary team will strive to prevent, monitor and intervene for undesirable weight loss or gain for our residents. The policy indicated each resident is weighed upon admission, the next day and weekly x 2 and unless indicated otherwise, monthly thereafter. Any weight change or 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight change is verified, nursing will notify the RD per facility protocol. A facility policy titled Weighing and Measuring the Resident, revised 10/10, indicated when staff weighed a non-ambulatory resident using the platform scale they need to subtract the weight of the wheelchair and record the resident's weight. Report significant weight loss/weight gain to the nurse supervisor. The threshold for significant, unplanned and undesired weight loss/gain will be based on the following criteria: 1 month - 5% weight loss is significant; greater than 5% is severe; 3 months 7.5% weight loss is significant; greater than 7.5% is severe; 6 months 10% weight loss is significant; greater than 10% is severe.

Based on interviews and record review, the facility failed to ensure a resident was free of significant medication error for one of four residents (R1) reviewed, when the resident was administered a higher than ordered dose of [MEDICATION NAME]. The resident was found dead hours later. Findings include: R1's medical record was reviewed. R1's was admitted to the facility for short term rehabilitation while undergoing [MEDICAL CONDITION] and [MEDICAL CONDITION]. R1's [DIAGNOSES REDACTED]. R1 ambulated independently, was alert, oriented and able to make needs known to staff. R1's nurse practitioner orders dated February 16, 2017 was reviewed and indicated an order of [MEDICATION NAME] 5 milligrams (mg)/5 milliliters (ml) to give 20 mg every four hour as needed for pain rated five to seven and 30 mg for pain rated eight to ten. R1's nurse practitioner orders dated February 21, 2017 was reviewed and indicated the [MEDICATION NAME] concentration was changed to 20 mg/1 ml with same dosage of 20 mg every four hour as needed for pain rated five to seven and 30 mg for pain rated eight to ten. R1's nurse practitioner orders dated [DATE] was reviewed and indicated the [MEDICATION NAME] concentration was changed to 5 mg/5 ml with same dosage of 20 mg every four hour as needed for pain rated five to seven and 30 mg for pain rated eight to ten. R1's nurse practitioner orders dated [DATE] was reviewed and indicated the [MEDICATION NAME] concentration was changed to 10 mg/0.5 ml with same dosage of 20 mg every four hour as needed for pain rated five to seven and 30 mg for pain rated eight to ten. R1's narcotic record dated [DATE] indicated LPN-H administered 30 ml of the prescribed [MEDICATION NAME] 10 mg/0.5 ml labeled 20 mg/1 ml to R1 at 2:00 a.m. Nursing progress note dated [DATE] indicated R1 requested [MEDICATION NAME] and rated the pain at 10 on a zero to ten scale around 2:00 a.m. The note indicated LPN-H administered 30 ml of [MEDICATION NAME] to R1. LPN-H indicated she checked on R1 around 4:00 a.m. and R1 appeared to be sleeping. At the end of her shift, LPN-H asked the supervisor, registered nurse (RN)-F, to re-order R1's [MEDICATION NAME] because the nurse gave the one delivered as a single dose. After RN-F confirmed the dose of the [MEDICATION NAME] delivered from the pharmacy, he instructed LPN-H to check on R1 because the pharmacy has sent a three-day supply and not an one-day supply. Nursing progress note dated [DATE] indicated R1 was found unresponsive on the floor in R1's room around 7:25 a.m. RN-F asked LPN-H to call the emergency medical services. RN-F rolled R1 on the back and started chest cardiopulmonary resuscitation (CPR). RN-F clarified R1's code status as no CPR and CPR was aborted, but R1 continued received oxygen until EMS arrived and took over. LPN-D was interviewed on [DATE] at 2:20 p.m. and stated she was assigned to R1 on the evening shift before the incident. LPN-D stated R1 requested [MEDICATION NAME] for pain at bedtime. LPN-D stated she noted R1 was out of the [MEDICATION NAME] and she called the pharmacy to send R1's supply of [MEDICATION NAME]. LPN-D stated she reported to LPN-D the pharmacy was to deliver R1's [MEDICATION NAME] later that night. RN-F was interviewed on [DATE] at 2:49 p.m. and stated LPN-H asked him to re-order R1's [MEDICATION NAME] because the pharmacy sent a single dose on the prior shift. RN-F stated he called the pharmacy and confirmed the pharmacy had sent three-day-supply of [MEDICATION NAME] instead of one-day supply as reported LPN-H. RN-E stated LPN-H verified the bottle of the [MEDICATION NAME] that she administered to the resident. RN-F asked LPN-H to check on the resident because LPN-H gave a higher than ordered dose of the [MEDICATION NAME] to R1. Both LPN-H and RN-F went to the R1's room, found R1 on the floor, lying on the left side, and facing the entrance. RN-F stated he asked LPN-H to call the emergency medical services (EMS) and have another staff bring the automatic external defibrillator (AED). RN-F started cardiopulmonary resuscitation (CPR). Staff brought and applied AED with no heart rhythm noted. RN-E was notified of the resident's code status as limited, meaning no chest compression but ok for manual breathing. RN-E stopped the CPR, but continued administering oxygen with manual breathing bag until EMS arrived. LPN-H was interviewed on [DATE] at 4:30 p.m. and stated s/he was assigned to R1 on the night shift. LPN-H stated R1 requested [MEDICATION NAME] for pain. LPN-H stated she administered 30 mls of the [MEDICATION NAME] received from the pharmacy. LPN-H stated she did not verify the concentration and dose of the [MEDICATION NAME] administered because she was very busy with multiple patients. LPN-H stated she knew, as a licensed nurse, she was supposed to check the dose and order of the [MEDICATION NAME] prior to administration. LPN-H stated the resident's previous order was for 5 mg/5 ml [MEDICATION NAME], not 10 mg/0.5 ml. LPN-H acknowledged she did not follow the facility's policy on medication administration. When asked if LPN-H reassessed R1 after [MEDICATION NAME] administration, she stated she did not. LPN-H stated she relied on the nurse aide to check on R1 during rounds. The director of nursing was interviewed on [DATE] at 5:29 p.m. and stated the facility is working with its medical director and the pharmacy to change how pharmacy communicates dose/concentration change with staff. The facility's medical director was interviewed on [DATE] at 8:26 a.m. and stated he reviewed and signed medication administration policy at the facility. The medical director stated he was notified that LPN-H administered 30 ml of [MEDICATION NAME] to R1. The medical director confirmed the equivalence of 30 ml of 20 mg/1 ml of [MEDICATION NAME] is 600 mg. The medical director stated, based on his professional experience and opinion, the 30 ml of [MEDICATION NAME] administered instead of the prescribed 1.5 ml (30 mg) was responsible for R1's death. The medical director also stated the change of concentrations of R1's [MEDICATION NAME] played a role in the medication error. R1's nurse practitioner (NP) was interviewed on [DATE] at 12:54 p.m. and stated R1's [MEDICATION NAME] was changed from less concentration to more concentration. The NP confirmed he ordered the [MEDICATION NAME] concentrations: 5mg/5ml on February 16, 2017; 20mg/1ml on February 21, 2017; 5mg/5ml on [DATE]; and 10mg/0.5ml on [DATE]. The NP acknowledged changing concentrations of the same orders increased the risk of medication error. Facility's record review indicated staff were re-educated on [DATE] medication administration policy and the rights of medication administration (right patient, right medication, right dose, right route, right time, right documentation, right reason, and right response) at every opportunity of medication administration. The facility also indicated the medical director and pharmacy were working on a policy and procdure to improve the way of nurses are notified when a medication dosage was changed. The facility indicated the notification process of dosage change would be monitored by audit of medication dosage changes received from the pharmacy. The facility's policy and procedure titled Administering Medications, dated [DATE], indicated medication must administered in accordance with the orders. The policy and procedure also stated the administering staff must check the label three times to verify, among other things, the right medication and right dosage.

Based on observation, interview and document review, the facility failed to provide care including monitoring and assessment, to prevent deterioration of pressure ulcers for 1 of 4 residents (R439) reviewed who had presssure ulcers. The failure to provide adequate care resulted in actual harm for R439 whose pressure ulcers deteriorated. In addition the facility failed to prevent development of pressure ulcers for 2 of 4 residents (R35, R62). Findings include: R439 was interviewed on 3/16/16, at 8:35 a.m. and stated The night shift does not turn me. R439 stated he had reported that to the head nurse, and several aides were no longer allowed to care for him. R439 was admitted to the facility on [DATE], after extensive hospitalization s in acute care hospitals and long term acute care hospitals. R439's admission [DIAGNOSES REDACTED].g., tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers), type II diabetes and [MEDICAL CONDITION], and [MEDICAL CONDITION]. The admission Care Area Assessment (CAA) dated 9/27/15, indicated R439 was admitted with stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling) to the sacrum/coccyx and two stage III pressure areas (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling) to left and right buttocks. The areas had developed during prolonged hospitalization with multiple medical complications. A [MEDICAL CONDITION] (intestinal diversion) and Foley catheter (urine collection system in the bladder) was initiated during the hospitalization as well as wound vac (mechanical wound management) to manage/treat pressure areas. A plastics (plastic surgery) doctor (MD) was following R439 and was considering a flap closure of the pressure ulcer (surgical covering of pressure ulcer to promote healing),and the follow-up scheduled for 10/1/15. A wound MD was following R439 while here and CAA indicated to see the physician progress notes [REDACTED]. A Nutrition CAA had triggered as R439 had lost 150 pounds over the past six months, which was nutritionally significant, increased metabolic needs secondary to pressure areas. The initial care plan dated 9/28/15, indicated R439 had pressure ulcers and potential for pressure ulcer development related to disease process and prolonged immobility. There was no discussion on the care plan of where the pressure ulcers were or any stages listed. The initial goal dated 9/28/15, indicated R439's pressure ulcer would show signs of healing and remain free from infection. The initial interventions dated 9/28/15, indicated staff were to assess/record/monitor wound healing. They were to measure length, width and depth where possible. assess and document status of wound perimeter, wound bed and healing progress. Staff were directed report improvements and declines to the MD. Inform the resident and family/caregivers of any new area of skin breakdown. Pressure relieving/reducing device in bed/chair. Treat pain as per orders prior to treatments/turning etc. to ensure comfort. R439 required supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing. Staff were to educate R439/family/caregivers as to causes of skin breakdown which included transfer/positioning requirements; importance of taking care during ambulating /mobility, good nutrition and frequent repositioning. The physician progress notes [REDACTED]. - On 9/16/15, initial progress note since admission to facility. R439 was admitted for management of Sacrococcygeal Stage IV pressure ulcer with possible osteo[DIAGNOSES REDACTED] (infection in the bone) and [MEDICAL CONDITION] requiring [MEDICAL CONDITION] and lower [MEDICAL CONDITION]. Chronic pain due to sacral pressure ulcer, now on [MEDICATION NAME] (extended release pain control) with [MEDICATION NAME] (oral pain control) for break through pain. A [MEDICAL CONDITION] and Foley catheter were started to promote wound healing .Nursing reports patient has been cooperative with cares since admission. Patient with chronic sacral ulcer stage IV which was developed during extended and complicated hospitalization , being managed by a wound vac and followed by plastic surgery. Air mattress to assist with wound healing. Plan to continue physical therapy (PT) and occupational therapy (OT). - On 9/17/15, VOHRA (a wound company that specializes in wounds) Wound specialist progress note: Consult requested for pressure ulcers. Stage IV wound of sacrum with moderate serous exudate. Stage IV pressure ulcer of the sacrum 7 cm (centimeters) x 11.5 cm x 0.5 cm moderate serous exudate, 100% granulation tissue, dressing negative pressure three times per week (wound vac). Stage III pressure ulcer of the right ischium 4 cm x 4 cm x 1.5 cm with moderate serous exudate, thick adherent devitalized necrotic tissue 90%, granulation tissue 10%. Wound debrided via surgical excision and subcutaneous tissue removed along with necrotic tissue. Post debridement depth 1.6 cm. Dressing Foam once daily, Santyl (helps clean wound) once daily. Stage III pressure ulcer of the left ischium 4 cm x 5.5 cm x 2 cm with moderate serous exudate. Thick adherent devitalized necrotic tissue 90%, granulation tissue 10%. Wounds debrided via surgical excision and subcutaneous tissue removed along with necrotic issue. Post debridement depth 2.1 cm. Dressing, foam once daily, Santyl once daily, Calcium Alginate (provide antimicrobial action to prevent infection, absorb exudates and maintain a moist environment to promote rapid healing) once daily. - On 9/21/15, nursing home (NH) progress note: seen by plastics team on 9/17/15, (transported to appointment) suggested a different wound vac. Patient requested to be up 1-2 hours a day for meals and mental health, stated 'feels like he is in jail.' Requested shower on wound vac change days, charge nurse promised they will work around when more staff would be available to help. Sacrococcygeal wound connected to wound vac, left and right ischial (the lowest of the three major bones that make up each half of the pelvis) wounds covered with dressings, unable to assess. (R439) had a normal mood and affect, and behavior was normal. Bedrest except up 1-2 hours per day for a meal or leisure . - On 9/24/15, Wound specialist progress note: Stage IV pressure ulcer of the sacrum 10 x 11.5 x 1.5 cm moderate serous exudate, 100% granulation tissue, dressing negative pressure three times per week (wound vac) deteriorated to generalized decline of patient. Optimize nutrition. Stage III pressure ulcer of the right ischium 5 cm x 5 cm x 0.5 cm with moderate serous exudate, thick adherent devitalized necrotic tissue 90%, granulation tissue 10%. No change. Stage III pressure ulcer of the left ischium 4 x 6 x 0.6 cm with moderate serous exudate. Thick adherent devitalized necrotic tissue 90%, granulation tissue 10%. Improved, decreased depth . - On 9/30/15, VOHRA Wound specialist progress note read, Stage IV pressure ulcer of the sacrum 8.2 x 14.8 x 1.6 cm moderate serous exudate, 100% granulation tissue, dressing negative pressure three times per week (wound vac). No change. Stage III pressure ulcer of the right ischium 5.0 cm x 4.2 cm x 0.2 cm, improved, decreased depth. Stage III pressure ulcer of the left ischium 4 x 6 x 1.4 cm, improved, increased granulation. - On 10/1/15, Plastic Surgery Clinic, doctor (D)-B: (R439), last seen 1 month ago. Referral to D-A was never made, under the care of wound providers at facility. Sacral wound looked substantially improved with a nice granulating bed with no debris and no [MEDICATION NAME] material, and Unfortunately in the last month, he had a significant progression and worsening of his ischial tuberosity pressure wounds. With a comment of the lack of pressure ulcer care which contributed to worsening pressure wounds. When I saw him last his right side was fairly clean and his left side had a stage I pressure wound. Now both are stage IV easily. They both have necrotic material in them and are worsening in nature. His cares are not being met in an appropriate manner to my opinion. He is under the care of a wound care nurse, but how a wound-care nurse can look at his wounds and feel like the cares are appropriate is not adequate to me. Lastly, (Dr F.) will see him today. - On 10/1/15, Wound Clinic Initial Note of Plastic Surgery Clinic, Dr F: Requested, but page 3 of the 4 page report was missing, which included the impression and plan of care. - On 10/6/15, NH progress note: seen by the wound/burn specialist (transported to appointment) for concern for patient wound, wound dressing directions were given during that visit. Sacral wound dressing continues with wound vac. Nurse reported bilateral ischial wounds were putting out excessive drainage and it has some odor, nurse had already completed dressing change today. Poor wound healing. Sacrococcygeal wound connected to wound vac, left and right ischial (the lowest of the three major bones that make up each half of the pelvis) wounds covered with dressings, unable to assess. (R439) had a normal mood and affect, and behavior was normal. Sacral ulcer stage IV, chronic and nonhealing. Patient also had bilateral ischial stage 2 ulcer (partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater) which is now draining excessive purulent malodorous drainage. Low grade temperature and nausea over the weekend. Obtain wound cultures (to look for infection) prior to next dressing change and blood culture next lab day. - On 10/7/15, VOHRA Wound specialist signed off on R439. The Progress Notes for the nursing home were reviewed from 10/13/15, going forward and the following was noted: - On 10/13/15, NH progress note: Bilateral unstageable ischial wound which was noted to be draining copious, malodorous greenish yellow drainage few days ago. Wound culture collected which came back with moderate growth of [DIAGNOSES REDACTED] pneumoniae (bacteria), moderate growth of [MEDICATION NAME] aerogenes (gram negative bacteria) and heavy growth of streptococcus B Beta [DIAGNOSES REDACTED] (S. Agalactiae) (gram positive bacteria). Poor wound healing. Agrees to see in house psych (psychologist) and increase antidepressants and pain control. Wound culture with mixed growth, sensitive to [MEDICATION NAME] (antibiotic). Continue to change wound dressing daily per wound specialist order. - On 10/15/15, NH progress note indicated that the bilateral unstagable ischial wound were draining copious malodorous greenish yellow drainage. - On 10/21/15, Nursing Weekly skin condition report (pressure and non pressure) noted the Sacrum measured 10.0 cm x 9.0 cm x 1.25 cm stage IV, the left IT (ischial tuberosity) measured 5.0 cm x 5.0 cm x 1.5 cm, and was a stage IV, the third ulcer on the right IT measured 4.0 cm x 4.0 cm x 1.25 cm and was a stage III ulcer. - On 11/19/15, Nursing Weekly skin condition report (pressure and non pressure) noted the Sacrum measured 11.0 cm x 7.0 cm. The depth and the stage was not documented. The right IT measured 5.0 cm x 3.5 cm. The depth and the stage was not documented. The left IT measured 5.8 cm x 6 cm. The depth and the stage was not documented. The medical record was incomplete for the staging and measuring the depth for R439's wounds. In addition, review of the nursing notes for R439 between 9/15/15 and 10/14/15, lacked any documentation of refusals to turn or reposition. The quarterly Minimum Data Set ((MDS) dated [DATE], indicated R439 was fully cognitively intact and had [MEDICAL CONDITION], was on bedrest due to pressure ulcers, required assistance of two with turning and repositioning and did not resist cares. On 2/9/16, the care plan was updated to state the pressure ulcers were all stage IV on admission, which directly conflicted with the physician progress notes [REDACTED]. In addition, the care plan lacked direction for staff should R439 refuse cares, especially based on the significance of his wounds. In addition, there was no risk/benefit assessment completed and shared with R439. The nursing assistant care card print date of 3/16/16, directed staff assist of two to reposition and turn in bed. grab bars on bed, turn and reposition every two hours when in bed and 30 minutes when up in wheelchair. R439 required assist of staff for mobility with stretcher transport to appointments. On 3/16/16, at 8:36 a.m. R439 stated the night shift staff did not turn him, and he had reported that to registered nurse (RN)-N, and a handful of aides were no longer able to care for him. On 3/17/16, continuous observations for two hours and fifteen minutes from 5:45 a.m. until 8:00 a.m. the resident was not repositioned. At 6:24 RN-P knocked and entered room for blood glucose test. At 7:08 RN-P entered the room without knocking, called R439's name, and left the room within 15 seconds of entering. At 8:03 a.m. R439 was interviewed and stated he had not been turned all night. At 8:05 a.m. RN-N was notified the resident had not been turned during the time of continuous observation, and the resident stated he had not been turned all night. RN-N stated He should be turned every two hours. At 10:55 a.m., a pressure ulcer observation was not able to be obtained. At 11:00 a.m. the assistant director of nursing (ADON) stated the wounds have not changed in staging, it's maybe the difference between wound clinics. R439 had D-A and now had D-D and so maybe that accounted for the difference, but RN-N actually did the measurements. RN-N stated they have not changed stages since he started in September 2015. When interviewed at 11:16 a.m., RN-P stated she had entered R439's room to get his blood sugar and the second time to give insulin. At 11:20 a.m. nurse practitioner (NP)-B, stated she first saw R439 in 12/15, since then the wounds have decreased in size from grapefruit to less than a baseball, but bigger than a golf ball, and continue to have deep tunneling. An magnetic resonance imaging (MRI) was done on 3/14/16, to rule out osteomyelisitis (in the ischial tuberosities) and when the results arrived today we sent him to the hospital to receive intravenous antibiotics. NP-B stated the aides need to inform the nurses of what they see, because NP-B relied on the nursing staff to inform her of what's happening. The aides don't take direction from the nurses. At 11:30 a.m. D-C, stated with the change in ownership quality declined, but was coming back, You have to have enough staff, and people who care what they are doing. D-C stated there was a system breakdown in pressure ulcer care in the facility. At 12:00 p.m. RN-N stated the wound had changed a lot since the last time she saw it, as it was oozing a lot more. RN-P charge nurse, stated nursing does wound care daily, and the facility did wound rounds as the doctor measures and RN-P wrote it down. RN-P stated there had been three different wound providers for the facility, they had just started with a new wound doctor during the current week. The MRI exam completed 3/14/16, identified bilateral deep ulcerative changes at the inferomeidal buttock soft tissue with extension anteriorly along the medial aspect of both ischial tuberosities, concerning for osteomyletitis (infection in the bone) and he was admitted to North Memorial Medical Center for IV antibiotics. Review of North Memorial Medical Center (NMMC) emergency department records indicated the resident was sent back to the facility the evening of 3/17/16, on oral antibiotics, and indicated the osteo[DIAGNOSES REDACTED] was chronic and not a new concern as stated by the MRI. On 3/18/16, at 9:00 a.m. R439 stated the last time he was repositioned was at 8:30 p.m., a period of 12.5 hours. At 9:20 a.m. nursing assistant (NA)-Q stated they just transferred to this unit and didn't know R439, but just check the care card on the door. R439's care card said to reposition every two hours, and R439 was repositioned 15-20 minutes ago with NA-R. At 9:30 a.m. RN-N was informed the resident stated he had not been turned last night, and was asked if he had reported the allegation of neglect reported to him yesterday. RN-N stated he had reported it to the DON and consultant nurse (CN). RN-N was asked if he had interviewed the resident after the allegation of neglect was reported. RN-N stated he had talked to R439, but had not asked about being repositioned on the night shift. At 10:24 a.m. the DON stated she spoke to the evening supervisor and R439 frequently refused to be turned at night, according to the night supervisor. At 11:04 a.m. RN-N, stated R439 told me he was not being turned at night. At 2:04 p.m. RN-N stated he put an every two hour turn and reposition sheet up in R439s room, because he took it very seriously when informed this morning, that R439 again stated he had not been turned again last night. RN-N called the nurse at home, who told him R439 had requested not to be disturbed at night. At 2:10 p.m. R439 stated he had never asked to not be disturbed at night. he may have occasionally refused to turn, because his shoulders may have been sore. R439 could not say what shift that occurred on, but clarified it was not very many times. R439 stated I know I have to turn to get better. On 3/21/16, at 5:10 a.m. no staff was observed in R439's unit, until RN-T made a facility wide announcement to welcome the health department to the facility. At 5:11 a.m. LPN-H, stated R439 refused the midnight turn, and accepted the 2:00 a.m. turn and got pain medicine, accepted the 4:00 a.m. turn but requested not to be awakened at 6:00 a.m. LPN-H stated R439 was offered pain meds whenever he's awakened. LPN-H, stated she would turn R439 again now, but stated aide who was working with her was helping in the 800 hallway (one of four hallways on the unit) right now. At 5:30 a.m. LPN-H called two other wings and asked if the aide was there with them, both answered no. At 5:35 a.m. the director of nursing (DON) came to R439's unit and spoke with LPN-H. At 5:42 a.m. LPN-H and LPN-I offered to turn R439, LPN-I stated he just wanted the pillow removed, he didn't want to turn to the other side, and it's whatever makes him comfortable. At 6:53. a.m. LPN-I asked NA-S Hey where were you, we were looking for you. NA-S stated, I was taking my break. At 6:54 a.m. NA-Q was asked how many times R439 was turned last night, and she stated hmm 3 or 4, however, acknowledged she had not been down the hallway to know whether R439 turned the forth opportunity or not. At 6:00 a.m. the DON stated there must be a language barrier, as RN-N was in R439's room right away at 8:00 a.m. At that time the DON was informed RN-N did not discuss the repositioning concern with R439. R35's annual minimum data set ((MDS) dated [DATE], indicated R35 had multiple [DIAGNOSES REDACTED]. The MDS identified R35 had modified Independence with decision making, required occasional assistance of one person in maneuvering in bed and while transferring from bed to chair or walking with walker. R35 required assistance with dressing, toileting and hygiene. R35 was incontinent of bowel and bladder. R35 was identified as at risk for the development of pressure ulcers. R35's Pressure Ulcer Care Area Assessment (CAA) dated 2/12/16, indicated R35 had risk for pressure ulcers related to being incontinent of bladder, below normal weight, and needing assist with bed mobility. The CAA also indicated skin was intact and free of breakdown. CAA indicated R35 had a ROHO cushion (air filled cushion to reduce pressure on bottom while sitting) in the chair and would care plan interventions to minimize risk factors for skin breakdown. The care plan revised 2/15/16, indicated R35 had a Self Care Performance Deficit r/t pain and weakness. The care plan was revised on 3/15/16, one day after survey entrance. It included resident is currently enrolled on North Memorial Hospice. Decline expected. The care plan instructed staff to check and change R35 every two hours and as needed (PRN). R35 could turn and reposition using bilateral grab bars. Two staff were to assist every two hours and PRN, per preference. Family was aware of resident refused to turn and reposition. The risks and benefits was provided to the resident and family. R35 was observed continuously on 3/17/16, from 7:05 a.m. until 9:55 a.m. and the following was observed: At 7:05 a.m. R35 was observed sleeping lying flat on back with mouth open. R35 had oxygen via a nasal cannula in place. The head of the bed was elevated 45 degrees. At 8:51 a.m. nursing assistant (NA)-J entered the room and spoke with R35. NA-J offered to get R35 breakfast and orange juice. R35's nasal cannula was in only one nostril. R35 said I hope I can get up today. This thing behind my ear hurts. NA-J did not ask R35 about turning or repositioning before leaving room to get breakfast tray. R35 was not repositioned. At 9:08 a.m. registered nurse (RN)-G started the nebulizer machine and applied mask. RN-G completed the wound care to R35's left heel and left without repositioning R35. At 9:23 a.m. RN-G entered and finished wound care on the other heel. RN-G left the room without repositioning R35. The heels were left flat on the mattress after the treatment had been completed. The heels were not placed in a position to relieve pressure. At 9:32 a.m. R35 was being fed breakfast and not been offered repositioning. During wound care observation on 3/17/16, at 11:44 a.m. RN-G informed R35 it was time to change the dressing on her bottom. NA-J rolled R35 toward the wall and held her in place during the dressing change. NA-J opened the incontinence brief. There was brown stool on the brief. RN-G removed dressing from coccyx (tailbone). RN-G applied wound cleanser to gauze and cleansed the wound. The coccyx wound was irregularly shaped with two ovals connected by a narrow strip of slough (unhealthy) filled skin. The two ovals were filled with cream colored slough and the right oval was larger than the left oval. RN-G applied a pink dressing to R35's coccyx. NA-J cleaned stool from R35's bottom. NA-J then wiped stool off gloves with an incontinence wipe. A clean incontinence brief was placed under R35. RN-G removed the dressing from left ischial tuberosity (hip) and cleansed wound with wound cleanser. The wound was circular and approximately two centimeters in diameter. RN-G applied a pink dressing to wound. NA-J did not wipe the front of peri-area before applying incontinence product. NA-J removed gloves, washed hands and applied new gloves. RN-G said to NA-J, usually when I do a dressing change, I wear two to three gloves so I just remove one layer at a time because after you remove your gloves you cannot put the others on. The Nursing Weekly Skin Evaluation (NWSE) dated 2/19/16, indicated R35's skin was intact without redness. The NWSCR dated 2/25/16, instructed staff to Measure All Wounds, Stage Pressure Wounds Only . The NWSCR indicated R35 had a Left heel blister measuring 4 centimeter (cm) x 4 cm and the blister was Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling). However, the National Pressure Ulcer Advisory Panel (NPUAP) directs professionals that purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear should be considered a deep tissue injury. The NWSCR indicated the date the blister was first observed was 2/25/16. No individualized interventions such as specialty mattress/bed, were identified. The comment section of report instructed staff to Keep heels dry & off load pressure while blisters intact bilateral. If either blister opens use Allevyn heel dressings topically & change every two days. A second wound was also identified on the report as a right heel blister measuring 3 cm x 4 cm and staged as a stage II pressure ulcer. The date it was first observed was listed on the report as 2/25/16. A specialty bed and wheelchair cushion were indicated as interventions. The comment section of report instructed staff to Keep heels dry & off load pressure while blisters intact bilateral. The NWSCR indicated [REDACTED]. The NWSE dated 2/26/16, indicated R35's skin was intact, dry but had moist and redness on upper buttocks bilateral. [MEDICATION NAME] (cream) applied res (resident) repositioned . On 2/29/16, the treatment sheet noted to keep heels dry and offload heels while blisters were intact. The care plan lacked direction for the staff on how to relieve pressure on the heels while in bed. The physician progress notes [REDACTED]. The Progress Note also indicated R35 had new o/a (open area) bil (bilateral) Buttocks stage 2 dark terminal Kennedy ulcers (pressure ulcers that develop when a person is actively dying) and blisters both heels has heels floated. The NP note indicted declining terminal condition, R35 wanted comfort care and declined hospice on 2/10/16. The NWSCR dated 3/3/16, indicated R35 had a left heel blister that now measured 5 cm x 6.4 cm and was still a stage III pressure ulcer. The wound bed was described as slough -moist yellow or gray necrotic tissue . The report indicated that the blister had deteriorated and to continue same treatment. The right heel blister now measured 4 cm x 4 cm and was described as a stage II pressure ulcer that was unchanged with a dark pink/red wound bed. The report included a third wound that was described as a stage I pressure ulcer (nonblanchable [DIAGNOSES REDACTED] of intact skin, the heralding lesion of skin ulceration) on R35's coccyx measuring 5 cm x 4.8 cm that was first observed on 3/1/16. The wound bed was described as pink, pale tissue with reddened surrounding skin. R35 was noted to have pain from all three wounds. The pressure ulcer care plan dated 3/3/16, identified that R35 has the potential for skin breakdown/bruising r/t (related to) fragility/aging, incontinence, [MEDICATION NAME] (a steroid medication) use- has chronic senile purpura (a rash of purple spots on the skin caused by internal bleeding from small blood vessels) of both limbs and muscle wasting. The resident also had a [DIAGNOSES REDACTED].Resident with skin breakdown on buttock r/t refusal to turn and reposition, end of life . The care plan instructed staff: Creams/ointments/tx (treatments) as ordered, encourage side to side positioning - resident reluctant but encourage, encourage to sit with legs elevated as she allows, (R35) has a ROHO cushion in WC pressure reduction mattress on bed. Check cushion inflation q (every) shift, observe skin daily with cares report concerns to licensed nurse, and skin check weekly on bath day by licensed nurse, treatments per MD/NP orders . While the care plan identified R35 as having skin breakdown on the buttocks, it did not address the heel ulcers or Kennedy Ulcer. The care plan did not address the location or stages of ulcers. The care plan was not revised to include interventions to reduce pressure on the on heels. The NWSE dated 3/4/16, indicated R35's skin was intact with redness and that, Buttocks/coccyx areas excoriated. Resident refused to cooperate with full skin assessment. R35's heels were not addressed on the evaluation. Progress Note dated 3/5/16, at 1:00 p.m. indicated Late Entry: Focus Area - Weights, Falls, Behaviors, Wounds, Restraints, Other: Open area 3/1/2016: Resident's skin around gluteal folds was darkened in color. Open areas measured 3 cm x 0.5 cm and 3.4 cm x 1.2 cm. Resident has been declining and refusing to be turned/ repositioned. Resident's skin on buttocks is currently being treated with topical [MEDICATION NAME] barrier cream. Update /Progress: Resident has a [DIAGNOSES REDACTED]. Resident is decline recently and stay in bed most of time. Resident is recently admitted to North Hospice. She refused turn and reposition and asked staff to leave her alone. NP [DIAGNOSES REDACTED]. Care plan updated. Will monitor for healing Notes: Resident description: 'Oh please don't move me. I'm hurting so much. My legs are hurting bad. Don't make me turn please.' Continue to encourage turning/ repositioning q2 hours as resident allows to reduce pressure on buttocks. Pre-medicate 20-30 minutes before turning. Updated nursing supervisors and NP on resident's new skin condition. Received new order to clean wound and apply Allevyn dressing over o/a, change QD (every day). Continue [MEDICATION NAME] treatment. Updated son about open areas . The medical record lacked any information for relieving pressure on the heels. The NWSCR dated 3/10/16, indicated R35 had a left heel blister that measured 5 cm. x 5.3 cm and was now an unstageable pressure ulcer (full-tissue thickness loss in which the base of the ulcer is covered by slough or an eschar and, therefore, the true depth of the damage cannot be estimated until these are removed). Wound bed was described as pink, pale tissue, Slough-moist yellow or grey necrotic tissue and eschar-thick hard leathery, black. The surrounding skin was described as reddened. The comment section indicated, Resident takes iron pills, left heel is 50% granulation and eschar (dead skin). Unstageable. Resident has an air mattress, positioning device and is on a schedule for repositioning. Continue with current orders at this time . The right heel blister measured 5.3 cm x 4.5 cm and was described as a stage III pressure ulcer. The wound bed was described as both pink, pale tissue and as slough-moist yellow or grey necrotic tissue with the surrounding skin reddened. A nutritional supplement was added as an intervention. The coccyx pressure ulcer was now described as a stage II with measurements of 6.8 cm x 5.5 cm x 0.3 cm. The wound bed was described as both pink, pale tissue and as slough-moist yellow or grey necrotic tissue with the surrounding skin reddened. The comment section indicated, Resident is comfortable, repositioned q (every) 2 hrs (hours) . R35 was noted to have pain with all three wounds. A NWSE dated 3/11/16, indicated R35's skin was intact with no open areas. It went on to describe right heal as healing and to keep repositioning R35. The left heel with healing area noted and to keep repositioning R35, and the coccyx was described as healing. R35 was repositioned but had refused to cooperate with repositioning during the day shift. The Visual Bedside Kardex Report sheet updated 3/17/16, 2 days following survey entrance and investigation, instructed staff to encourage R35 to allow side to side positioning, R35 can turn and reposition using bilateral grab bars. Staff assist of two every 2 hours and PRN, per preference. Family is aware of resident refuse to turn and reposition. The risks and benefits was provided to resident and family . In addition, staff was to check and change R35 every two hours and as needed, Keep heels dry and off load pressure while blisters are intact. However the sheet lacked direction for the staff on how to relieve pressure on the heels while in bed. During interview on 3/17/16, at 9:50 a.m. NA-J stated, I am to turn (R35) after every two hours. I check her for incontinence in the morning

Based on observation, interview and document review, the facility failed to ensure 3 of 3 resident's (R4, R481, R57) were free from significant medication errors related to improper transcription. This resulted in actual harm for R4 and R481. R4 who was hospitalized related to [MEDICAL CONDITION] activity and R481 who suffered almost constant pain rated 10/10. Findings include: R4's quarterly Minimum Data Set ((MDS) dated [DATE], indicated she had some cognitive impairment, required extensive to total assistance with all activities of daily living, and had an active [DIAGNOSES REDACTED]. During an observation on 3/16/16, at 2:40 p.m., R4 was sitting up in her wheel chair. She was alert and able to converse briefly with surveyor. During an interview on 3/16/16, at 2:40 p.m., family member (F)-B stated R4 was more down and depressed. F-B stated she brought R4 to an appointment with the physician who admitted R4 to the hospital. She stated during the hospital stay it was discovered that R4 was getting too little [MEDICATION NAME]. F-B stated R4 should have been receiving 200 milligrams (mg) four times daily and an additional 50 mg as needed. A review of facility Medication Administration Record [REDACTED]. At that time the dose was decreased to 50 mg four times daily. A review of a facility Transfer/discharge Report dated 1/5/16, indicated a new order for [MEDICATION NAME] 25 mg tab - take two tablets by gastric (G)-tube as directed. The order did not include the time/times it should be administered. The order was transcribed by the health unit coordinator (HUC) and verified by registered nurse (RN)-L. The order was transcribed as follows: [MEDICATION NAME] 50 mg via [DEVICE] four times a day for cluster [MEDICAL CONDITION]. That was a decrease from 800 mg daily to 200 mg daily. The transfer/discharge report also indicated orders for Hyaluronic acid, Prevnar, and lab draws. A review of a North Ridge Skilled, LLC Progress Note dated 1/8/16 indicated, spoke with R4's physicians office to clarify orders for labs and Hyaluronic acid. There was no indication a clarification was requested for the dosage of [MEDICATION NAME]. A review R4's hospital history and physical (H & P) dated 2/7/16, indicated R4 had been hospitalized [DATE], due to atypical withdrawn behavior, decreased interaction, and new left leg stiffness. The overall etiology of the patient's altered mental status was thought to be multifactoral secondary to probable urinary tract infection, mild [MEDICAL CONDITION] and/or subclinical [MEDICAL CONDITION]. The H&P indicated R4 had undergone an electroencephalogram (EEG). (an EEG is a test that measures and records the electrical activity of the brain and is often used to detect [MEDICAL CONDITION] activity) and was placed on continuous EEG monitoring as she was found to have intermittent [MEDICAL CONDITION]. Her [MEDICATION NAME] dose was increased and two additional anti-epileptic medications were added. During an interview on 3/18/16 at 8:06 a.m. RN-K stated she was aware of a discrepancy with R4's [MEDICATION NAME] error, but stated she was not sure of the details. During an interview on 3/21/16 at 12:38 p.m., the director of nursing (DON) stated, I was aware of the [MEDICAL CONDITION] during (R4's) hospitalization . The DON further stated RN-K should have done a full chart review when R4 returned from the hospital. During a subsequent interview on 3/18/16, at 12:51 p.m., RN-K stated she would have expected RN-L to question the decrease in R4's [MEDICATION NAME] dose and call the physician to get a clarification. R481's admission MDS dated [DATE], indicated R481 was cognitively intact, suffered from moderate/severe depression, and required assistance with all activities of daily living except eating. In addition, R481 was identified as having almost constant pain that limited her day to day activities, with the most severe pain being rated at 10/10 (on a scale where 10 is the most painful). The Physician's admission orders [REDACTED]. R481 was placed at harm as R481 did not receive the physician ordered pain medication and R481 remained in pain. A Care Area Assessment (CAA) for pain dated 2/11/16, was completed in relation to the 2/9/16 MDS. The CAA for pain had been triggered due to R481's responses to interview questions indicating she had pain which limited her activity, was almost constant, and rated 10/10. The CAA indicated R481 had advanced metastatic (mets) adenocarcimoma with mets to lymph and bone, arthritis/ DJD ([MEDICAL CONDITION] joint disease), back pain with chronic pai[DIAGNOSES REDACTED] hx (history) and opioid dependence. The CAA further indicated Allina Hospice was closely involved and along with their consulting pharmacist are working closely to manage pain with a goal of pain < (less than) 5. The care plan initiated 2/11/16, indicated R481 had pain related [MEDICAL CONDITION] of the stomach and lymph system that had spread to the bones, and interventions instructed staff to administer [MEDICATION NAME] (sic) (pain killer medication) as per orders. The post hospital Discharge Orders dated 2/2/16, indicated staff were to give R481 [MEDICATION NAME] (medication to treat nerve pain) 800 mg three times daily for nerve pain, [MEDICATION NAME] (narcotic pain medication) 5 mg three times daily for severe pain, [MEDICATION NAME] (narcotic pain medication) concentrate 20 mg/milliliter (ml) give 0.75 ml every four hours as needed for pain (PRN) or shortness of breath, and [MEDICATION NAME] (a mild [MEDICATION NAME]) 1000 mg three times daily for pain. The Hospice Certification and Plan of Treatment dated 2/2/16, also indicated R481 was to receive [MEDICATION NAME] 800 mg three times a day and care planed for treatment neuropathic pain. A review of R481's MAR indicated [REDACTED]. The Allina Hospice and Palliative Care Facility Visit Record dated 2/3/16, patient complained of pain at 10/10. The Allina Hospice and Palliative Care Facility Visit Record dated 2/4/16, R481 indicated pain improved to 7/10. R481 received seven doses of [MEDICATION NAME] 15 mg. in last 18 hours. New orders written to increase [MEDICATION NAME] to 10 mg three times a day and increase [MEDICATION NAME] to 20 mg every hour PRN. Allina Hospice and Palliative Care Facility Visit Record dated 2/6/16, R481 rated pain at 6/10. Goal set to get pain down to 5/10. Allina Hospice and Palliative Care Facility Visit Record dated 2/11/16, patient rated pain at 7/10. The Physician order [REDACTED]. A copy of R481's Physician order [REDACTED]. A Medication Error Report dated 2/11/16, and revised 3/3/16, indicated: Hospice nurse informed writer that resident has not received [MEDICATION NAME] 800 mg TID (three times a day) since arrival. Two nurses checked and it was not transcribed into PCC (Point Click Care-electronic health record). The report further indicated there had been no injury to the resident, but failed to address the resident's pain level. The root cause analysis section of the Error Report indicated: resident is a new admit on 2/2/16. Resident on hospice. Resident has not received [MEDICATION NAME] 800 mg TID since arrival. Medication was not given d/t (due to) the fact it was not transcribed into PCC. Educate staff update MD (medical doctor) and family. R481 was placed at harm as R481 did not receive the physician pain medication upon admission. RN-K said R481's medication error was discovered by an evening supervisor. The admission orders [REDACTED]. RN-K said, I think it is the consistency of having someone on the desk. My assistant can cover the desk but only to 3:30 p.m. R57's admission MDS dated [DATE], indicated R57 was cognitively intact, required assistance with all activities of daily living except eating, and had [DIAGNOSES REDACTED]. A Geriatric Services of Minnesota (GSM) long term care (LTC) Initial Intake form dated 2/4/16, indicated R57 had undergone a CABG x 4 (coronary artery bypass graft involving four arteries) in December of 2011. The nursing home Admission Record, indicated R57 had been admitted to the facility 2/2/16. After Discharge Orders dated 2/2/16, indicated staff were to administer [MEDICATION NAME] 3.125 mg by mouth three times weekly on Monday, Wednesday, Friday; and [MEDICATION NAME] 6.25 mg by mouth with breakfast four times weekly Sunday, Tuesday, Thursday, and Saturday. The After Discharge Orders also instructed staff to give R57 [MEDICATION NAME] 6.25 mg daily with the evening meal and indicated R57 attended [MEDICAL TREATMENT] Mondays, Wednesdays and Fridays at 12 :00 p.m. The facility's Order Summary Report dated 3/21/16, indicated only [MEDICATION NAME] 6.25 mg every day with evening meal had been entered into the electronic health record from 2/2 through 2/12/15, when [MEDICATION NAME] 3.125 mg by month three times weekly Monday, Wednesday, Friday with breakfast; and [MEDICATION NAME] 6.25 mg by mouth with breakfast four times weekly Sunday, Tuesday, Thursday, and Saturday were added. Review of R57's MAR indicated [REDACTED]. Review of R57's Weights and Vitals Summary dated 3/23/16, indicated R57's blood pressures had been checked daily, and had fluctuated, systolic 154-195, over diastolic 60-96 between 2/2 and 2/11/16. After the [MEDICATION NAME] order had been clarified, R57's blood pressure range was identified as systolic 125-162, over diastolic 64-85 as documented 2/12 to 2/29/16. There were only two days between 2/12 through 2/29/16, where R57's systolic blood pressure was greater than 166 compared to nine days between 2/2 through 2/11/16. A Medication Error Report dated 2/12/16, and revised 3/11/16, indicated, Huc (health unit coordinator) indicated that [MEDICATION NAME] was not on PCC and need clarification. Res. missed [MEDICATION NAME] medicalization (sic) since admit ion (sic). [MEDICATION NAME] order was not clarified. The report further indicated new orders received and no injury. Predisposing factors identified medications with similar names. Root cause analysis indicated, Resident received less than prescribed dose of [MEDICATION NAME]. NP (nurse practitioner) notified. Error occurred with follow up clarification. Resident without injury from med error. Orders clarified with provider same day. IDT (interdisciplinary team) to provide education to individual recognized as responsible for error. During interview on 3/21/16, at 10:19 a.m. registered nurse (RN)-E said, the process when we receive a new order is the health unit coordinator (HUC) inputs the order in to the computer and then the nurse will check it. If the HUC does not input the order, one nurse will input it into the computer and the second nurse will check it. During interview on 3/21/16, at 10:45 a.m. RN-K nurse manager said, the process for orders when a new admit arrives were The HUC would enter the orders into PCC then the charge nurse would clarify any orders needing clarification and then perform a second check on them. We try to do the clarification and second check on the same day as admission. RN-K said R57's medication error occurred because, the HUC wrote the order needed clarification and then we were without a charge nurse for several days. The nurse practitioner found the error and clarified the order. It was communicated to staff that it was not appropriate to write needs clarification. If an order has not been inputted into PCC the nurse checking the orders would enter the order and then have another nurse second check it. RN-K said, We have not had a charge nurse consistently. The floor nurses having to pick that up. During interview on 3/21/16, at 11:09 a.m. the DON said, We changed our process for medication errors in October. Any nurse who finds a medication error should enter it in the computer, notify the doctor and responsible party. The nurse should get new orders and any monitoring needed and any assessments needed. They would notify the supervisor and possible call the DON or Assistant DON. Then the nurse manager can view the medication error, do education, and follow up, looking at precipitating factors, root cause analysis and sometimes discipline. Once the medication errors are signed by nurse manager then the DON reviews the errors. The administrator reviews the errors then the medication errors are taken to quality assessment and assurance meeting and the minimum effective dose committee. The DON said, Our medication error trends are transcription errors. The DON said if there was harm from a medication error, if the resident required medical attention, if the resident required increased in monitoring, or if there was a negative effect from the medication error we would report the error to the state. Administering Medications Policy revised April 2010, indicated, Medications shall be administered in a safe and timely manner, and as prescribed. 3. Medications must be administered in accordance with orders, including a required time frame. 4. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's Attending Physician or the facilities Medical Director to discuss the concerns.

Based on observation, interview and document review the facility failed to thoroughly evaluate the root cause for falls, implement appropriate interventions and follow the individual care plan which resulted in actual harm for 1 of 3 residents (R138) reviewed for accidents and who had sustained fractures from falls. Findings include: R138's incident report dated [DATE], indicated R138 fell while being transferred from the toilet with the assistance of one staff member. A Fall Risk Evaluation dated [DATE], indicated R138 had ,[DATE] falls in the 90 days prior and had no cognitive changes. The Fall Risk Evaluation indicated R138 ambulated with problems, used a device for ambulation, his gait was unsteady and was unable to stabilize without physical assistance of staff. R138's fall risk score was 18, indicating he was at high risk for falls. An incident report dated [DATE], indicated R138 fell while being transferred in the bathroom with assistance of one staff. R138 indicated he lost his balance when the nursing assistant (NA) held him from the left side. The incident report indicated R138 had a [DIAGNOSES REDACTED]. The subsequent nursing note dated [DATE], indicated R138 required the assistance of two staff for transfers and the NA did not follow R138's Care Card (the care plan used by NAs) which resulted in the fall. The note further indicated R138's Care Card was updated to reflect R138's [DIAGNOSES REDACTED]. A nurse practitioner (NP) progress note dated [DATE], indicated R138 had a fall on [DATE]. There were no changes in orders. An incident report dated [DATE], indicated R138 fell while being transferred from the toilet to the wheelchair with the assistance of one staff. The note indicated R138's legs gave out and he sat down quickly in the wheelchair causing the wheelchair to tip backwards and R138 hit his head on the floor. The nursing note on the incident report dated [DATE], indicated R138 required the assistance of two staff for transfers and R138's care plan was not followed by the NA which resulted in the fall. A Fall Risk Evaluation dated [DATE] indicated R138 was at high risk for falls and had ,[DATE] falls in the previous 90 days. The fall risk assessment indicated R138 had no cognitive status changes but was confined to a chair, did not ambulate and was not able to attempt standing without physical help. A nursing progress note dated [DATE], indicated R138 fell during a transfer to the shower chair. The note also indicated R138 fell back on the bed on his left arm. An incident report dated [DATE], indicated R138 reported arm pain and stated he landed on his arm. -A progress note dated [DATE], indicated R138 had gone to an unrelated physician appointment and was sent to the emergency room for x-rays of his left arm due to complaints of pain and report of breaking his arm. -A progress note dated [DATE], indicated the facility was informed R138 had a fractured humerus (upper arm). An incident report with further information was not provided for the fall. A physician's consultation note dated [DATE], indicated R138 had returned to the physician's office for a follow up visit that was unrelated to the fall on [DATE]. R138 reported he had a fall the previous day and experienced pain and snapping in his left upper extremity. He was referred to the emergency room for an x-ray which identified R138 had a fracture of the left humerus. A NP note dated [DATE], indicated R138 had returned from the hospital with a fractured left humerus related to a fall on [DATE]. The NP note indicated R138 was having pain related to the fracture. Orders for pain medication were reviewed. A Fall Risk Evaluation dated [DATE], indicated R138 was at high risk for falls and had ,[DATE] falls in the 90 days prior. The Fall Risk Evaluation indicated R138 had no cognitive changes, ambulated with problems and a device, his gait was unsteady and he required staff physical assistance to stabilize. An incident report dated [DATE], indicated R138 fell during a transfer with one assist from the wheelchair to the toilet when R138 lost his balance and fell against the wall. R138 bumped his left arm and the left side of his head. The director of nursing (DON) and the nursing supervisor were notified. The nursing note on the incident report dated [DATE], indicated R138's care plan was updated to direct two staff assist for transfers and ambulation. The predisposing physiological factors indicated on the report were identified as weakness/fainted. -A progress note dated [DATE], indicated R138 complained of pain in ribs from fall. -A progress note dated [DATE], at 2:41 p.m., indicated R138 complained of pain in his chest on both sides. -A progress note dated [DATE], at 10:30 p.m. indicated R138 complained of left side pain, pointing to the rib area. No bruising or swelling was noted. -A progress note dated [DATE], indicated a chest x-ray identified R138 had three rib fractures. R138 reported the fractures occurred when he fell the previous week in the bathroom. He reported his pain level as 10 on a scale of ,[DATE]. A radiology report dated [DATE], indicated R138 had acute rib fractures of the left third, fourth, and fifth ribs. A NP progress note dated [DATE], indicated R138 had falls with injury and noted R138 had left rib fractures. The incident reports and documentation lacked a thorough post fall assessment and root cause analysis to determine causal factors of each fall nor was a trend in falls identified, interventions initiated and implemented in order to minimize / prevent further falls and injury. R138's undated Face Sheet and [DIAGNOSES REDACTED]. R138's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R138 had a moderate cognitive deficit, displayed no rejection of care and required extensive assistance of two staff for transfers and ambulation. The MDS also indicated R138 had balance problems and was unsteady with position changes. R138's Falls Care Area Assessment (CAA) dated [DATE], indicated R138 was potentially at risk for falls due to balance problems during position changes and receiving an antidepressant medication. The CAA indicated R138 required assistance with transfers and would ambulate short distance in his room with staff assist and the use of a walker, but the wheelchair was his primary mode of transportation. R138's care plan for falls initiated [DATE], and last revised [DATE], indicated R138 was at risk for falls. The care plan directed staff to follow the facility fall protocol, review the information on past falls and attempt to determine cause of falls, record possible root causes of the falls and then to alter or remove any potential causes if possible. Staff were to educate the resident, family and staff regarding the causes. R138's care plan for activities of daily living (ADLs) initiated [DATE], and revised [DATE], indicated R138 required the assistance of two staff for transfers, bed mobility and toilet use. R138's care plan for mobility initiated [DATE], indicated R138 required the assistance of two staff for ambulation with the quad cane (a cane with 4 ends, hemi-cane). R138's Resident Care Card (the care plan used by nursing assistants) printed [DATE], directed two staff for transfer, two staff assist with the quad cane for ambulation and two assist for toilet use. The previous Resident Care Card printed [DATE], indicated R138 required two staff assist with transferring. A note by the registered nurse (RN)-H dated [DATE], indicated the Resident Care Card dated [DATE], directed staff to transfer R138 with two assist, and that the care plan was not followed during incident of [DATE], when resident fell during a transfer with one staff assist. The undated nursing assistant (NA) group sheet provided by RN-H indicated NAs were to refer to the Care Card for transfers and toilet use directives. The group sheet did not indicate how R138 was to ambulate or if he could ambulate. On [DATE], at 2:09 p.m. R138 was observed lying bed and had put on his call light to request assistance to get up. Trained medication assistant (TMA)-C and RN-I were observed to sit then stand R138 up. R138 was observed to be unsteady and require the extensive assist of two staff, a gait belt and the hemi walker while he walked a few steps and turned to sit in the wheelchair. During an interview on [DATE], at 2:17 p.m. R138 stated he did not try to get up by himself. R138 stated he had a fall onto the bed during a transfer and has had broken bones. R138 stated the staff had not always used two staff to transfer him into the bathroom. R138 was noted to have bruising on his arms and on his back. R138 stated they were from his falls and from trying to get his balance and also laying on it. R138 further stated he had pain from his falls and that the pain pills had not helped much. At this time, R138's Care Card with a print date of [DATE], was observed posted in his closet which indicated R138 was to be transferred with two staff assistance. During an observation on [DATE], at 7:25 a.m. NA-Q and NA-R were observed to assist R138 up from bed. R138 had asked to walk to the bathroom. NA-Q told R138 that he could not walk, Remember, you can't walk. NA-Q informed him they were going to use the wheelchair. The NAs were observed to assist R138 to stand, walk a few steps, turn and sit in the wheelchair. R138 was observed unsteady on his feet and required the balancing support of the two staff as R138 was unable to steady himself. Once in the bathroom, R138 was observed to require two staff assistance to transfer onto the toilet. R138 stated sometimes they used two staff to transfer him and sometimes not. Both NA's were observed to stand R138 up, cue him to hold onto the grab bar as they dressed him then transferred R138 back into the wheelchair. Both NAs stated R138 was doing good while standing and holding on to the handrail. Both NAs said R138 could not usually stand that long. During an interview on [DATE], at 2:09 p.m. RN-H verified R138 currently transferred with the assistance of two staff. RN-H verified R138 had previously transferred with the assistance of ,[DATE] staff but had an incident/fall and was changed to the assist of two staff. In addition, RN-H stated the staff had interdisciplinary team (IDT) meetings to discuss resident falls, injuries and to determine the root causes. RN-H stated R138 has had different causes but staff only documented pertinent findings and not everything that had been ruled out. RN-H identified the only root cause for the incident when R138 fell from his wheelchair in the hallway when he caught his foot under the chair. In addition, RN-H stated if R138 fell on [DATE], there should have been an incident report with analysis completed for that fall. RN-H stated the rib fractures were probably from the incident that week when R138 had fallen while being transferred or the incident prior to that one. RN-H stated that after the incident in November, she changed R138's Care Card to indicated R138 was to be transferred with the assist of two staff but someone else was completing R138's care plan and would have gotten the care plan information from the MDS. RN-H stated she changed R138's Care Card with a pen by writing the change on the Care Card and did not change it in the computer. RN-H verified R138 should have been transferred with the assist of two staff ever since the incident in November and was 100% sure the group sheets reflected that. RN-H verified R138's care plan should have indicated R138 was required transfer with the assist of two staff and that she had provided education and communication to staff on [DATE], regarding R138's fall on [DATE], because R138's Care Card was not followed for transfers on [DATE], which resulted in the fall. RN-H further stated when there was a change in care it was to be written in the staff communication book so that the NAs could see and read that there was a change/ update in a residents' care needs. RN-H verified it was her expectation R138's Care Card was followed by staff. RN-H again verified the residents' Care Cards were the care plans the NAs referred to for care directives. During an interview on [DATE], at 2:25 p.m. NA-V stated R138 required two staff assistance for transfers. During an interview on [DATE], at 2:30 p.m. NA-W stated R138 required two staff assist for ambulation and transfers. NA-W stated R138 was sometimes weaker and did not transfer as well when he was agitated. During an interview on [DATE], at 2:40 p.m. NA-X stated R138 transferred with the assist of one before he broke his arm, but now required two staff assist. NA-X stated R138 was weaker on the left side and stronger on the right and needed two staff to assist with transfers due to the weakness. During an interview on [DATE], at 4:35 p.m. the director of nursing (DON) verified the resident Care Cards were the care plan directives for the NAs and stated it was her expectation the staff followed the Care Cards as written. The DON stated staff could always increase the amount of assistance they provided but could not decrease the amount of assistance provided to the residents as directed on the Care Cards. The DON further stated that since [DATE], the nurse who assisted a resident up after a fall was to call the DON, and that was with every fall. The DON stated staff had an IDT meeting to determine the root cause of falls and to also request a therapy screen following the fall. The DON stated R138's rib fractures on [DATE], were related to a fall on [DATE]. During an observation and interview on [DATE], at 10:40 a.m. NA-Q stated R138 had walked to the bathroom and to his bed that morning. R138 stated it was the first day he had recently walked and stated it was good to walk. NA-R and NA-Q came to assist R138 up from his bed to go to lunch. NA-R put the ankle/foot orthotic brace on R138's left leg and was going to put on his regular tennis shoes. R138 reminded him that he needed his black shoes on with the brace. R138 sat up in bed with the extensive assistance of two staff. A gait belt was put on and his hemi-walker was given to him. He stood up from his bed with the extensive assistance of two staff, staff allowed R138 time to get steadied and R138 slowly and deliberately walked out of his room and down the hall with NA-R and NA-Q holding the gait belt on each side of him. During an interview on [DATE], at 9:04 a.m. the certified occupational therapy assistant (COTA)-I stated therapy received the 24 hour facility report and would screen residents who had fallen in addition to any routine quarterly screens. COTA-I stated therapy screened R138 on [DATE], following a fall and had changed R138's transfer status to ,[DATE] staff during toileting because R138 had slipped during toilet transfers with an NA and he had previously been transferred with one assist. When COTA-I was informed R138's Care Card had indicated two staff to assist with transfers since the end of November, she said, Oh, Ok. During an interview on [DATE], at 2:55 p.m. the DON stated she was not aware R138's Care Card had been changed to indicate two staff assist with transfers and thought R138's care plan had been followed. The DON verified the floor interdisciplinary team meetings were to be held to also review falls and root causes and then the daily clinical full team met daily and also reviewed the facility's 24 hour report board which included facility falls. The facility policy and procedure for Falls-Clinical Guidelines revised ,[DATE], indicated a Fall Risk Evaluation would be completed upon admission and quarterly and the interdisciplinary team would attempt to identify individuals with a history of falls and risk factors for subsequent falling. The policy and procedure further indicated if a fall should occur, the staff would complete the Falls Investigative Worksheet as well as an Incident Report. The care plan was to be updated at that time with a review of current interventions and communicated to staff. A request for therapy screen was to be made as appropriate.

Based on observation, document review, and interview, the facility failed to adequately monitor, reassess and implement interventions including timely repositioning, to minimize the risk of pressure ulcer development for 1 of 3 residents (R106) in the sample identified with pressure ulcers. This resulted in harm for R106, who developed a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) on her right buttocks/coccyx. Findings include: R106 was admitted to the facility from an acute care hospital on [DATE], with [DIAGNOSES REDACTED]. The interagency assessment and transfer form from the hospital printed on 5/31/11, indicated R106's coccyx bony prominence was reddened, and was blanchable. The reddened area was noted by hospital staff on 5/29/11, and that information was included on the transfer form sent to the facility by the hospital. At 8:15 a.m. on 5/2/12, R106 was observed lying on her left (L) side in the bed on an air mattress. The wound dressing change was observed at that time. Licensed practical nurse (LPN)-B was assisted by nursing assistant (NA)-B. There was a large pressure ulcer on the resident's coccyx. The ulcer had slightly raised bulging edges, and per LPN-B the wound had undermining (ulceration extending under the skin edges) all the way around. The wound bed was pink and there was a small bulging white area toward the middle of the wound. She stated R106 was up in her wheel chair for one hour intervals, at each meal. The Temporary Skin Care Plan dated 5/31/11, noted the mushy bilateral heels but did not note the reddened areas on the buttocks. The interventions included pressure reduction mattress, pressure reduction wheelchair cushion, repositioning per the Tissue Tolerance assessment, but did not indicate any specific timeframe's for repositioning even though the facility had assessed R106's need of being repositioned every hour in the chair. The Temporary Plan of Care did not indicate R106 refused to be repositioned, refused to lie down or was non-compliant with physician's orders [REDACTED]. The Comprehensive Risk assessment dated [DATE], the day of R106's admission to the facility, indicated R106 was at risk for pressure ulcer development due to decreased activity, immobility, and was at risk for nutritional compromise. The form identified multiple areas of skin concerns, which included: right buttock redness measuring 2 cm (centimeters) x 2.5 cm; coccyx reddened measuring 2 cm x 2.2 cm, blanchable; (R) buttock redness measuring 7 cm x 4.5 cm; and left buttock redness measuring 9 cm x 8 cm. During an interview at 12:45 p.m. on 5/3/12, with the registered nurse (RN)-B who completed the assessment, RN-B stated only one of the four reddened areas was blanchable, and stated the reddened areas on R106's buttocks and coccyx were stage 1 pressure ulcers. On 6/1/11, a Tissue Tolerance Assessment indicated the resident was to be repositioned every two hours in bed and every one hour in the chair. The admission Minimum Data Set ((MDS) dated [DATE], indicated R106 was cognitively intact, was totally dependent on two staff for assistance with bed mobility, transfers, toilet use, and needed one staff for assistance with dressing, personal hygiene and bathing. R106 was also identified as always incontinent of bowel and bladder, unable to walk or stand, and as dependent on the use of a wheel chair for mobility. The MDS also revealed R106 was at risk for developing pressure ulcers and had two stage 1 pressure ulcers. The MDS further noted R106 did not reject care. The Care Area Assessments dated 6/13/11, revealed R106 had bilateral soft heels with no open areas, and that the heels were to be floated off the bed with the use of a pillow. The assessment further noted the resident was turned and repositioned every two hours and as needed. The CAA's also did not address the reddened areas (stage 1) on R106 buttocks that were present at the time of admission and noted in the Clinical Note Report on 5/31/11, 6/2/11, and 6/3/11. The CAA's lacked evidence if R106 was to be repositioned every two hours while in bed, while in the wheelchair or both. The CAA's did not indicate R106 refused to be repositioned, refused to lie down or was non-compliant with physician's orders [REDACTED]. The Clinical Notes Report was reviewed from the time of admission forward. - At 2:21 p.m. on 6/1/11, the note indicated R106 " was up in the wheelchair throughout the day " and "[MEDICATION NAME] (a multipurpose moisture barrier that helps heal skin irritations from moisture or caustic drainage relieves discomfort) was applied to resident ' s reddened buttock area." - At 3:23 p.m. on 6/2/11, " Weekly skin assessment completed this shift, bruise on R and L arm and forearm remains, reddened area on buttocks remains A&D (ointment- soothes red irritated skin; allows skin to heal naturally) apply." - At 2:02 p.m. on 6/3/11, the note indicated [MEDICATION NAME] was applied to resident's reddened buttock area. - At 3:15 p.m. on 6/9/11, the note read, "skin intact" and at 3;19 p.m. the entry indicated, "resident is able to make slight changes in position, but unable to make big and frequent changes in position." The Clinical Notes Report did not indicate R106 refused to be repositioned, refused to lie down or was non-compliant with physician's orders [REDACTED]. The Plan of Care dated 6/13/11, was reviewed and noted R106 had open areas on her buttocks and coccyx. The Care Plan noted R106 was to be turned and repositioned every two hours even though the Tissue Tolerance assessment completed 6/1/11, indicated the resident should be repositioned in the chair every hour. According to the nurses notes dated 8/2/11, R106 acquired a stage 2 pressure ulcer on the (L) buttock, which measured 1.5 cm x 1.5 cm. Although a Braden scale (score 13: moderate risk) and comprehensive risk assessment were completed, the facility did not reassess R106's tissue tolerance (ability of the skin to endure the effects of pressure) to determine an appropriate repositioning schedule. R106 continued to be repositioned every two hours, even though she had acquired a stage 2 pressure ulcer and the Tissue Tolerance Assessment completed on 6/1/11, indicated R106 was to be repositioned every hour. The occupational therapist (OT) reassessed R106 on 8/4/11, and provided a different pressure reduction cushion, a Roho cushion. According to progress notes dated 8/9/11, the (L) buttock wound was healed on 8/8/11. Record review revealed in the nurses notes on 8/8/11, R106 had acquired another pressure ulcer, that time on the (R) buttocks, identified as a discolored area with 100 % granulation, which measured 4 cm x 1.5 cm. There was no evidence in the medical record, that a comprehensive risk assessment, Braden scale, or tissue tolerance were completed when R106 presented with a newly developed stage 2 pressure ulcer on 8/8/11. The facility failed to comprehensively reassess R106 at that time for additional contributing factors for pressure ulcer development to minimize the risk of further deterioration or to determine an appropriate repositioning schedule. The Clinical Notes Report did not indicate R106 refused to be repositioned, refused to lie down or was non-compliant with physician's order [REDACTED]. The Plan of Care was not updated until 8/26/11 (18 days later), to reflect the open area on the (R) buttocks. The interventions included, " Only up in chair during the day for 3 hours." The care plan was updated to include the use of the Roho cushion (a cushion to reduce pressure) in her wheelchair on 8/11/11 (the use of the cushion was instituted on 8/4/11). On 8/28/11, the plan of care was updated to include the information R106 was to be up in the wheelchair for meals only and was turned side to side in bed (even though she had been noted with open areas on her buttocks on 8/2/11 and 8/9/11). The Plan of Care did not indicate R106 refused to be repositioned, refused to lie down or was non-compliant with physician's orders [REDACTED]. A subsequent comprehensive risk assessment was not completed until 9/3/11, (26 days after right buttocks wound onset) with the summary note indicating R106 was at risk for skin breakdown due to incontinence of bowel and bladder. The summary note further stated R106 needed encouragement to lie in bed and reposition due to the wound on her buttock. A quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R106 was totally dependent on two staff for assistance with bed mobility, transfers, toilet use, and needed one staff for assistance with dressing, personal hygiene and bathing. R106 was also identified as always incontinent of bowel and bladder, unable to walk or stand, and as dependent on the use of a wheel chair for mobility. The MDS also noted R106 had one unstageable pressure ulcers with suspected deep tissue injury (DTI-defined as tissue that is firm, mushy, boggy, warmer or cooler as compared to adjacent tissue) that was in evolution, the injury was present on admission and R106 was at risk of developing pressure ulcers. The MDS further noted R106 did not reject care. Further record review revealed a note by the medical director dated 8/26/11, indicated, "R inner buttock has 7 x 5 cm area of open pressure and blistering (deep tissue injury). That appears to be caused by the new cushion placed in (R106's) wheel chair two weeks prior. Recommend OT (occupational therapy) to re-evaluate cushion, and R106 to be up in chair for only one hour TID (three times a day)." Record review revealed R106's condition and wound continued to deteriorate. A progress note by the nurse practitioner (NP)-B dated 9/2/11, noted the (R) buttock inner open area measured 9.5 cm x 5.7 cm x 0.5 cm, with 100 % slough with tan, foul smelling drainage. The note also indicated R106 appeared acutely ill, and there was "worsening DTI on coccyx." The physician's orders [REDACTED]. On 9/23/11, based on wound culture (test to detect infection) results, R106 was started on antibiotic ([MEDICATION NAME] DS twice daily for ten days) for a wound infection. NP-B's progress note dated 10/7/11, indicated the wound culture from 9/23/11, identified three different bacterial infection (Proteus, [DIAGNOSES REDACTED], [MEDICATION NAME]) in the wound. Antibiotic treatment was completed on 10/3/11. The weekly wound documentation dated 10/10/11, indicated the buttocks wound was at stage 4, and the measurements were: 7 cm x 7 cm x 3 cm (depth), had moderate serosanguinous drainage, with tunneling at 12 o'clock was 3 cm, at 6 o'clock was 1 cm, and at 9 o'clock was 3 cm. According to the Skin Documentation sheet on 3/19/12, the buttocks wound measured 14 cm x 6.5 cm, with 50 % granulation (pink-red moist tissue), and 50% slough (light colored necrotic tissue), and undermining from 6 to 8 o'clock was 8 cm, 12 o'clock was 1 cm, 3 o'clock was 3 cm, and at 9 o'clock was 2 cm. The skin documentation sheet dated 4/30/12, indicated the stage 4 pressure ulcer on R106's buttocks/coccyx measured 10 cm x 6 cm (no depth was measured), the wound bed had 75% granulation, 25 % slough, with undermining present 1 cm at 12 o'clock, 3.5 cm at 3 o'clock, 2.5 cm at 6 o'clock, 7 cm at 8 o'clock, and 4 cm at 9 o'clock. A phone interview was conducted with NP-B at 2:07 p.m. on 5/2/12. NP-B stated she was R106's care giver only since the end of August or the beginning of September 2011. NP-B explained she wrote in her notes that the cause of the coccyx/ buttocks wound was DTI, because sometime in November 2011, a NA told her, during wound rounds, that R106's coccyx skin was purple, dark colored upon admission. She stated that in her experience, skin with DTI usually broke down within two-three weeks. When the surveyor reminded her the resident's admitted was 5/31/11, NP-B stated, she did not realize such a long time passed by. She then stated that was only speculation, since she could not find documentation in the medical record regarding DTI. NP-B further explained that sometime in November 2011 there was disagreement between R106's primary physician (PP) and the medical director (MD). The MD stated R106's wound was an end of life (Kennedy type of ulcer), but the PP and NP-B felt R106 wanted to live, was a fighter, loved to socialize with other residents, and was in good spirits. Per NP-B the primary physician did not think that wound would heal. The MD was interviewed on the phone at 3:58 p.m. on 5/2/12. The MD stated he was aware of R106's situation and sacral ulcer. He stated R106 was a frail lady with debilitated condition. The MD explained he got involved into R106's cares in August, when R106's skin broke down, which looked like an ulcer people get right before they die. Per MD R106 started eating for whatever reason and now she was doing well, but the wound was impossible to heal. An interview was conducted with the Director of Therapy Services (DTS) at 12:15 p.m. on 5/3/12. The DTS stated R106 was assessed upon admission, and the private wheel chair with the cushion was appropriate at that time. DTS explained that on 8/4/11 (after the resident developed a stage 2 pressure ulcer), R106 was reassessed, and therapy provided a Roho cushion. The DTS stated in her experience, changing the cushion did not cause R106's skin breakdown. The DTS stated she was not aware of the medical director's progress note dated 8/26/11, where he questioned the use of the cushion. She stated she and the occupational therapist (OT) attended the monthly wound rounds to receive updates and to monitor resident's progression. The DTS also stated R106 was seen often by the OT, since R106 had kyphosis (spinal cord deformation). She confirmed no changes had been made to the resident's seating system after the physician recommended a re-evaluation. An interview was conducted at 12:45 p.m. on 5/3/12, with RN-B, she confirmed R106 was totally dependent on staff with bed mobility and transfers. RN-B also stated the packet (tissue tolerance, Braden, comprehensive risk assessment and wound sheet) had been completed for R106. RN-B also stated the packet was to be completed when new wounds were identified. RN-B verified the Tissue Tolerance Assessment was completed on 6/1/11, and that the information from the assessment should have been care planned. RN-B could not remember if a tissue tolerance assessment had been completed when the left buttock wound was identified on 8/2/11, nor could she remember if any assessment had been completed when R106 developed the ulcer on her (R) buttocks on 8/8/11. She stated the nurses on the floor completed the tissue tolerance assessments, and the nurse manager reviewed them. The nurse manager (NM)-A and RN-C, who completed the MDS's, and wrote care plans were interviewed at 1:15 p.m. on 5/3/12. NM-A explained the facility's policy was to assess residents upon admission using their 'skin packet' which included; tissue tolerance, comprehensive risk assessment, and a Braden scale for predicting pressure ulcers. NM-A stated that nurses on the floor were responsible for the completion of the assessment tools, NM-A was responsible to ensure these were completed, and RN-C was responsible for writing the care plans based on the assessments. NM-A stated the skin packet was completed again if a new skin concern, or wound was identified, or if there was a change in a resident's condition. RN-C acknowledged the discrepancy between the care plan and the Tissue Tolerance assessment, and had no explanation on why R106 was originally scheduled to be repositioned every two hours in the wheel chair, when the tissue tolerance dated 6/1/11, directed that the resident should be repositioned every 1 hour. RN-C verified R106 had been repositioned every two hours in the wheelchair and the bed since 6/1/11, until 8/26/11 (87 days later), even though the facility assessed R106 as needing to be repositioned every hour in the wheelchair. NM-A reviewed the medical record and verified there was no new Tissue Tolerance assessment completed on 8/2/11, when R106 was found to have stage 2 pressure ulcer the left buttocks or on 8/8/11, when R106 was identified with a right buttock pressure ulcer. The nurse manager did not know when the stage 1 pressure ulcers resolved from admission, and verified the lack of weekly wound measurements for the stage 1 pressure ulcers. After NM-A reviewed the care plan date 6/13/11, she stated they did not start repositioning R106 every one hour in the wheelchair until the facility received the physician's orders [REDACTED]. The director of nursing (DON) was interviewed at 2:45 p.m. on 5/2/12. The DON stated as per the facility's policy, staff used the skin packets at the time of the resident's admission to complete the assessments. The DON verified the packets included the Braden scale, Comprehensive Risk Assessment and Tissue Tolerance. The DON explained that the nurse managers on the floors were responsible to make sure the required assessments were completed, and the infection control nurse did monthly record audits on the residents identified with ulcers. The DON stated she would also be notified regarding new skin concerns at daily report meetings, or through their '24 hour' board. NM-A joined the interview at around 2:55 p.m. and verified that process. The DON also reviewed R106's medical record and confirmed the lack of tissue tolerance assessments with the new wounds on 8/2/11, and 8/8/11. When queried, NM-A stated she did not find any additional assessments. The facility policy, Pressure Ulcer and Deformity Prevention dated 3/11/08, indicated; "A comprehensive risk skin evaluation will be completed on: * Admission/Readmission then weekly x 4 * Significant change in condition * Change in skin integrity including pressure, vascular, blisters caused by pressure, mushy heel(s) and suspected deep tissue injury. * Quarterly." The policy also indicated: "3. Repositioning of residents will be done minimally every 2 hours for one minute. Based on a resident's needs, repositioning frequency will be individualized per Tissue Tolerance Test. "4. Tissue Tolerance Test will be completed on residents that require assistance with mobility. (No Tissue Tolerance test is required if the resident is independent.) * Admission/Readmission * Significant Change in condition * Change in Skin Integrity including pressure, vascular, blisters caused by pressure." The facility did not implement the individualized wheelchair repositioning need of R106 and did not re-assess the repositioning need after she developed the new pressure ulcers.

Based on interview and record review the facility failed to ensure that each resident received adequate supervision to prevent resident to resident altercations for 1 of 4 residents, (Resident #2), who was displaying aggressive behavior toward his other residents. Findings include: Resident #2's medical record was reviewed and facility face sheet revealed that Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 resided on the memory unit. A review of Resident #2's nursing notes revealed that Resident #2 began displaying aggressive behavior on 2/23/2011, the next day after admission. Resident #2's preadmission assessment dated [DATE] indicated he resisted care on occasion. Resident #2's PRN antipsychotic medication monitoring sheet dated 2/24/2011 through 3/8/2011 indicated he was medicated for verbally and/or physically aggressive behavior on 2/24, 2/26, 2/27, 2/28, 3/2, 3/5, 3/6, 3/7, and 3/8. The temporary care plan dated 2/23/2011 was reviewed and revealed that Resident #2 displayed combative, negative behaviors. The intervention documented was PRN Haldol. Nursing notes and temporary care plan notes for Resident #2 revealed the following: On 2/23/2011 Resident #2 pulled the fire alarm and attempted to kick staff. The nurse practitioner was contacted and an as needed/(PRN) medication was ordered. The temporary care plan put in place was to monitor and redirect the resident. On 2/24/2011 Resident #2 attempted to hit, kick and yell at staff during cares. A prebath PRN medication was attempted. No temporary care plan was noted. On 2/25/2011 Resident #2 attempted to elope form the building, raised fist to another resident, and needed frequent redirection from other resident rooms. The temporary care plan put in place was to place the resident on 15 minute checks. On 2/26/2011 Resident #2 was wandering in to other patient rooms, hit a peer and picked up a knife, staff intervened. The temporary care plan put in place was 1 to 1 supervision and his medications were changed. His temporary care plan indicated he was to be monitored every shift for 2 weeks. On 2/27/2011 Resident #2 was verbally and physically aggressive with staff. His PRN medication was administered. No revision on the temporary care plan was noted. On 2/28/2011 Resident #2 was verbally aggressive with peers, and was wandering into other resident rooms. Resident #2's 15 minute checks were discontinued. No revision on the temporary care plan was noted. On 3/1/2011 Resident #2 told facility a staff that he was going to "kill her" and "Beat the[***]out of you." Resident #2 was placed back on 15 minute checks. There is no documentation of the 15 minute checks or how long they were in place. On 3/2/2011 Resident #2 threw a chair in the dining room, punched a nurse in the eye and a nursing assistant in the nose and was noted to be "very unpredictable." and will "punch with no warning." Resident #2's nurse practitioner was called and started scheduled doses of medication. The temporary care plan put in place was to monitor every shift for 2 weeks and reassess on 3/16/2011. On 3/5/2011 Resident #2 was medicated for aggressive behavior that was not redirectable, struck staff member in the arm. PRN medication was given. No revision on the temporary care plan was noted. On 3/6/2011 Resident #2 was medicated for aggressive behavior which could not be alleviated by staff intervention. PRN medication was given. On 3/7/2011 Resident #2 hit a staff member and attempted to hit another staff member. PRN medication was given. No revision on the temporary care plan was noted. The document titled CEP (the state common entry point reporting system) report dated 3/10/2011 revealed that on 3/9/2011 Employee (B) heard a posey alarm going off and entered Resident #1's room to find Resident #2 in the room. Resident #1 was lying on the floor next to her bed and Resident #2 stated that he "hit that man that's on the floor." Resident #1 reported that Resident #2 came in the room and started hitting her "all over". Employee (C)/RN was interviewed on 6/23/2011 at 1:35 p.m. and stated that on 3/9/2011 she heard the posey alarm on Resident #1's bed sounding. She stated she went to the room to check on Resident #1. Employee (C) stated that she found Resident #2 in Resident #1's room standing over Resident #1, who was on the floor, and he stated "I hit that man." Employee (C) stated that she removed Resident #2 from the room, and attended to Resident #1's injuries. Employee (C) stated that Resident #2 was fairly new and that his behavior would change quickly. Resident #1's medical record was reviewed and the facility face sheet revealed that Resident #1 was admitted to the facility in August 2010 with [DIAGNOSES REDACTED]. Resident #1 resided on the memory unit. Resident #1's family conference note dated 3/1/2011 revealed that Resident #1 was afraid of the other residents who wandered into her room, as a result the facility put up a do not enter sign on the entrance to her room. Nursing notes dated 3/9/2011 revealed that, as a result of the altercation, Resident #1 experienced 2 bruises on her left arm, an abrasion to her right cheek, an abrasion to her left cheek, abrasions to each side of her nose, swelling and bruising to her left ear, abrasion to her right upper chest, redness to the left side of her head, redness to her chin, redness to her upper lip, and lacerations to her upper and lower lips. Resident #1's physician visit note dated 3/9/2011 was reviewed and indicated that she told her physician that Resident #2 physically attacked her and said she was "going to get it." She stated that she was hit multiple times in the face, she was scared and tried to climb out of bed. She subsequently fell out of bed, landed on her right side and hit her head. She stated she was hit with Resident #2's fist and a slipper. She stated she was fearful that he was going to rape her. Resident #1's psychology visit note dated 3/31/2011 was reviewed and revealed that Resident #1 was still frightened, and had repetitive thoughts about the incident. She stated she still wakes screaming at night and still doesn't feel safe. The policy Titled Behavior interventions for Crisis Behavior: Resident one to one intervention policy dated 5/6/11 was reviewed and revealed that "One to one supervision is utilized for any resident who presents behavior that is considered dangerous to self or others." 4. "The one to one will be maintained for a minimum of 24 hours and if no further crisis behaviors occur, an individual plan for supervision will be implemented..."

Based on observation, record review, family interview, resident interview, staff interview, and policy review, the facility failed to re-assess pain related to a contractures of the right hand, wrist, and arm for 1 of 1 resident (R444) in the sample who had pain with any movement to the right upper extremity which resulted in actual harm. Findings include: R444 was admitted ,[DATE], with [DIAGNOSES REDACTED]. The resident had a loss of range of motion (ROM) to right side, arm, hand, leg, and foot. R444 had a decline in upper extremity ROM. The facility failed to re-assess R444 for pain related to contractures of the right hand and wrist. The decline in ROM caused a change in functional mobility and increased pain which caused actual harm. On 6/8/11, at approximately 5:30 p.m. the resident was observed in the dining room and the resident's family member (FM)-B was assisting the resident with his meal. R444's right arm was firmly against his body resting on a half lap tray with right hand tightly clenched. The resident did not move his right arm throughout the dining room/meal observation. The resident was not able to open his clenched right hand when asked to do so. There was no splint or cloth roll placed in the resident's right hand. R444's FM-B was interviewed on 6/8/11, at 7:15 p.m. about the use of support devices for the resident's right hand and arm for the resident. FM-B confirmed that R444 had not worn any devices on his right hand and arm for a long time. FM-B indicated that the resident used to wear a splint but she had not seen the splint in quite some time. R444 was in attendance during the interview and was able to nod and mumbled that the staff did not put a splint on his right hand/wrist. The resident was non-verbal but could indicate with facial movements a yes or no response. R444 also indicated that he had pain when his hand and arm were moved when questioned. During observations of personal cares for R444 on 6/8/11, from 8:00 p.m. through 9:00 p.m. nursing assistant (NA)-A washed R444's face with a wash cloth and then held onto R444's hand attempting to lift his arm to wash underneath. R444's right hand and upper arm were tight against his body, making it difficult to lift his right arm when washing and dressing the resident. R444 kept his arms tight against his body. R444 displayed facial grimacing, loud inaudible moaning, and mumbled when the right arm, hand and fingers were minimally moved to complete cares. NA-A stated on 6/8/11, at approximately 8:20 p.m. that R444 was very stiff and it had been difficult to remove the resident's clothing. NA-A also acknowledged it was very difficult to lift the resident's right arm and remove the shirt because R444 was extremely stiff and clenched his arms against his body and stated the NA's have to pull his right hand up in order to lift his arm so they can wash. When NA-A was questioned how often he cared for R444, NA-A stated he was assigned to R444 whenever he worked and was a full time employee. NA-A was interviewed on 6/8/11, at 8:25 p.m. if he had heard R444 moaning and observed the resident's facial expression when clothing was removed involving the movement of the right upper extremity and while giving the resident a partial bath. The NA-A confirmed that he had heard the resident and the resident was probably in pain. On 6/8/11, at 9:00 p.m. NA-A acknowledged that he had completed evening cares for R444. After removing soiled linens used for the partial bath NA-A brought the soiled linens to the soiled utility room. After leaving the utility room NA-A went into another resident's room to begin evening cares. NA-A did not report to the nurse that the R444 had pain while the NA-A removed the resident's shirt and during the partial bath. The resident was observed on 6/10/11, at 9:01 a.m. and indicated in the affirmative nod with his head that he does not wear his splint at night and that the right wrist and hand was always painful. He displayed non-verbal signs of pain by pulling back his right hand, mumbled an in-audible sound, and had facial grimacing at time of interview. R444 protected his right hand using his left hand. Clinical notes dated 4/28/11, at 9:55 a.m. indicated that, "Resident assessment reviewed this date. Resident is social when first approached and on a one to one basis. Resident has shown an improvement with communication this quarter. R444 is better able to respond to 'yes' or 'no' questions when kept simple and direct and allowing Res {resident} time to respond." The note further read, " Resident appears oriented to person and place and needs reminders of date and times." The quarterly minimum data set ((MDS) dated [DATE], indicated that R444 had no signs of pain such as non-verbal sounds (crying, whining, gasping, moaning, or groaning), facial expressions (grimaces, winces, wrinkled forehead, furrowed brow, cleaned teeth or jaw), protective body movements or postures (bracing, guarding, rubbing or massaging a body part/area, clutching or holding a body part during movement). Although the MDS revealed R444 was rarely or never understood, and had memory deficits with short and long term memory, the information conflicted with the clinical note dated 4/28/11. R444 care plan updated on 5/6/11, indicated the resident had impaired mobility related to a [MEDICAL CONDITION] (stroke) with right [MEDICAL CONDITION]. He had loss of ROM to right side arm, hand, leg and foot. The care plan indicated that R444 had a potential for pain related to stroke with [MEDICAL CONDITION], and arthritis to right hand which was noted on an X-ray dated 10/13/10. The goal for R444 will be reduce pain to an acceptable level/eliminate as evidenced by resident statement and absence of non-verbal indicators of pain. The nursing staff was to anticipate resident's potential for pain, to administer pain mediation per physician orders [REDACTED]. Tylenol ES as ordered. Monitor characteristics of pain, duration, intensity, location, and precipitating factors. R444's quarterly/change of condition seven day pain monitoring flow sheet dated 4/30/11, indicated that the resident was having no pain. The resident could have Tylenol Extra Strength (ES) 1000 milligrams (mg) three times a day, Tylenol 650 mg every four hours for pain as needed (PRN). The summary indicated that the resident had used no PRN pain medications. The medical record lacked evidence that the pain was re-assessed during cares and ROM. R444 was last evaluated by occupational therapy on 10/14/10. The documented note from the evaluation indicated, "The resident was re-evaluated for bruising on the dorsum of the right wrist. The splint was provided to the resident on 3/10, so the patient had been tolerating that well past 6 months, with no skin issues. Due to the shape of the bruise being round, not a line (strap shaped) it is unlikely that bruise was a result of the splint strap. The wrist strap of splint in area of bruise was labeled to not tighten too much while area heals. Splint remained to fit well and it was this therapist's opinion that hand would tighten if splint was not worn at night. Patient tolerated splint well during the occupational therapy evaluation". The nurse manager of the unit (1SW) was interviewed on 6/9/11, at 8:45 a.m. and was queried about pain complaints from R444. The nurse manager indicated that the resident did not receive any pain medications during the last two months. The nurse manager indicated that she was not aware of any pain issues for R444. The nurse manager confirmed that nursing assistants were to report voiced or observed pain to the nurse. The restorative aide (RA-A) was interviewed on 6/10/11, at 9:15 a.m. and confirmed that R444 received restorative care daily. The resident would moan and complain of pain daily with restorative exercises. The RA-A was not aware of R444 receiving any pain medications prior to restorative exercises. R444 could not open his right hand because it was very contracted. "The resident can get through exercises but the right hand is very sensitive". The director of rehabilitation therapy was interviewed on 6/10/11, at approximately 9:25 a.m. and confirmed that R444 was last evaluated on 10/14/10, and there had not been any requests for a re-evaluation. The director of rehabilitation therapy who also was an occupational therapist (OT) visited with R444 and completed a mini evaluation of R444's right hand, wrist and arm. The OT tried to get R444 to open his tightly clenched right fist one finger at a time. R444 would grimace in pain and indicated with a loud inaudible moan that he had pain with each finger as the OT performed the evaluation ROM. The OT also tried to extend the right arm from the body and the arm was very stiff and there was almost no movement of the right arm away from the side of the body. R444 also moaned and grimaced as the therapist tried to move the arm. The OT confirmed that R444 needed a complete evaluation for ROM of the right arm, hand and wrist. The therapist indicated that she would call the resident's physician and get an order for [REDACTED]. The OT indicated that there had been some changes since the resident was last seen and would need to do a complete evaluation to know the extent of the change/decline in range of motion and pain. The OT confirmed that there had been no changes in the physician's orders [REDACTED]. The lack of ROM and lack of splint use caused a functional change and pain in the right hand and arm of R444. The facility's policy on Pain Evaluation, dated 12/08 indicated the nursing assistants "will immediately report any complaints of resident's pain to their nurse. The nurse will implement interventions and document this information on the PRN Pain Monitoring Flow sheet." Nursing assistant-A and restorative aide did not report indicators of pain to the nurse as described in the facility's Pain Evaluation policy which resulted in actual harm to R444.