Every finding on record at Our Lady Of Hope Health Center

Based on resident interview, staff interviews, facility document review and clinical record review, the facility staff failed to acquire medications for administration for one of nine residents in the survey sample, Resident #103The findings include: For R103 the facility staff failed to administer the physician ordered medication Fish Oil Oral Capsule (supplement) on 6/2/26 and 6/7/26. A review of R103's clinical record revealed a physician's order dated 4/8/26 for Fish Oil Oral Capsule 1000 MG (milligrams) one time a day for supplement. A review of R103's June 2026 MAR (medication administration record) revealed the same physician's order for Fish Oil Oral capsule. On 6/2/26 and 6/7/26, the MAR documented the code, 9=Other/See Progress Notes. Nurses' notes dated 6/2/26 and 6/7/23 documented, Medication not available. A review of the facility backup medication supply list revealed it was not stocked in supply. An interview was conducted on 6/8/26 at 11:30 AM with R103 who stated, there is a problem with me receiving my medications here, I just don't understand it. The most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/13/26, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions.An interview was conducted on 6/9/26 at 2:20 PM with LPN (Licensed Practical Nurse) #1. LPN #1 stated medications should be re-ordered from the pharmacy when seven pills are remaining. LPN #1 stated that when a medication is ordered and not available for administration, staff should check the emergency supply, call the pharmacy, notify the physician and the RP(responsible party). A review of the facility policy, Medication Shortage/Unavailable Medications, revealed, in part: upon discovery that facility has inadequate medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy. On 6/9/26 at 4:18 p.m., the administrator and Director of Nursing were made aware of the above findings.

Based on observation and staff interview, the facility staff failed to maintain one of one facility dumpster area in a sanitary manner.The findings include:On 4/14/2026 at approximately 11:30 a.m., an observation of the facility's dumpster area located behind the facility was conducted with the dietary manager. The observation revealed debris that had collected behind the dumpsters, which included a plastic garbage bag with trash inside, multiple loose medical gloves and a nail clipper on the ground. On 4/14/2026 at 11:45 a.m., an observation of the facility's dumpster area and interview was conducted with the maintenance director. Regarding maintaining the facility's dumpsters, the maintenance director stated the janitors maintained the area, but it is also a team effort with kitchen and dietary that should be done daily with a deep clean at least once a week. He agreed that the dumpster area needed cleaning.A review of the facility's Food Services Infection Control policy, revised 7/14/25, revealed regarding handling and disposing of trash and waste: placing all garbage into containers as soon as possible; and using appropriate control measures to eliminate insects and rodents.On 4/16/2026 at 4:30 p.m., Administrator, DON (director of nursing) and Infection Preventionist were made aware of the above findings.No further information was provided prior to exit.

Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to maintain one of one kitchens in a sanitary manner. The findings include: On 4/14/26 at 9:40 a.m., an observation was conducted in the kitchen with the following findings: in dry storage, two 32oz cartons of thick & easy thickened dairy beverage with use by date of 8/14/25. In a 12-quart plastic bin dated 3/6/26, with less than 1 quart marking of lentils there was a portion of the product's bag label on top of the lentils. Observation of the kitchen area, there was debris that could be either scraped or wiped away from the surface inside the mixing bowl, around the base of the stand mixer, and the base of the deli slicer. The dietary manager was present, when observation of twelve cleaned steam tray pans stacked ready for use were made with the third pan found wet on the outside. The dietary manager stated it was wet nesting (droplets of water observed on the inside and outside of the pan). There was a large utility fan on the kitchen floor with visible dust present on the front and back of the fan cageAn interview was conducted with the dietary manager at the end of the kitchen observation, and the dietary manager was taken to the dry storage room and showed the two 32oz cartons of thick & easy thickened dairy beverage with the use by date of 8/14/25. He stated the cartons had expired and should not have been in the dry storage available to use. He was then shown the label inside the plastic bin with the lentils. He stated it was a way to identify the product by placing its label inside the plastic storage bin. When asked about contamination, he responded they can take it out. The dietary manager was then shown the debris inside the food processor bowl, around the stand mixer base and deli slicer base. He stated the appliances needed to be cleaned. He observed the visible dust on the cage of the fan and stated that the utility fan needed to be cleaned. A review of the facility's Food Services Infection Control policy, revised 7/14/25, revealed, All food supplies and equipment used in the food service area meet accepted standards of safety and sanitation; regarding procedure and food storage, the policy revealed, checking all food items on a periodic basis for expiration dates; cleaning and sanitization of equipment, dishes, utensils, etc., thoroughly washing and drying all utensils, food contact surfaces, and equipment between preparation of food items; and insuring proper installation and maintenance of all equipment.On 4/16/2026 at 4:30 p.m., Administrator, DON (director of nursing) and Infection Preventionist were made aware of the above findings.No further information was provided prior to exit.

Based on observations, resident interview, staff interview and facility document review, the facility staff failed to follow professional standards of practice for one of eight residents in the medication administration observation and for one of 37 residents in the survey sample, Residents #65 and #78. The findings include:1. For Resident #65 (R65), the LPN (licensed practical nurse) #2 opened an extended-release (1) capsule of Tolterodine Tartrate (2) before administering the medication. R65 was admitted to the facility with diagnosis that included but not limited to an overactive bladder. On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/10/2026, R65 scored 6 (six) out of 15 on the BIMS (brief interview for mental status), indicating R65 was severely impaired of cognition for making daily decisions. On 04/15/2026 at approximately 8:38 a.m. an observation during the facility's medication administration observation, revealed LPN #2 preparing R65's medications. LPN #2 removed R65's medications of Zinc, Ascorbic Acid, Tolterodine Tartrate and Pro-Stat from the medication cart. She then dispensed one Zinc capsule, one Ascorbic Acid tablet, one Tolterodine Tartrate capsule into a medication cup and dispensed 30 milliliters of Pro-Stat into a separate medication cup. LPN #2 entered R65's room and informed R65 of the medications she was going to receive. After looking at the tablet and capsules in the medication cup, LPN #2 asked R65 if she wanted to take the medication whole. R65 stated that the medications were too large. LPN #2 asked R65 if she would like the medications crushed for easier consumption and R65 stated yes. LPN # 2 was observed crushing the Ascorbic Acid tablet, opening the Zinc and Tolterodine Tartrate capsules, emptying them into the medication cup with the crushed Ascorbic Acid tablet. She re-entered R65's room and administered all three medications to R65. Continued observations revealed that R65 consumed the Zinc, Ascorbic Acid and Tolterodine Tartrate. The physician order for R65 documented in part, Tolterodine Tartrate ER (extended release) Oral Capsule Extended Release 24 Hour 4 MG (milligrams) (Tolterodine Tartrate). Give 1 capsule by mouth one time a day related to overactive bladder. Order Date: 11/12/2025. On 04/16/2026 at approximately 11:09 a.m. an interview was conducted with LPN #2 regarding the administration of Tolterodine Tartrate to R65. When asked how she determines which medications can be crushed or opened before administering them to a resident she stated that she refers to a guide located on the medication cart. She also stated that she refers to the guide when she is not sure if a medication could be crushed or opened and it is sometimes on the physician's order. LPN #2 stated that extended-release medications should not be crushed or opened. Regarding R65's Tolterodine Tartrate, she stated that she should not have opened the capsule. On 04/15/2026 at approximately 12:10 p.m. a request was made to the DON (director of nursing) regarding the drug book used by the facility's nurses. The DON provided the Nursing 2025-2026 Drug Handbook by Wolters Kluwer. Review of the Nursing 2025-2026 Drug Handbook by Wolters Kluwer revealed the drug Tolterodine Tartrate. Under the heading Administration PO (by mouth) it documented in part, Have patient swallow extended-release capsule whole, don't crush or open capsules. On 04/16/2026 at 12:28 p.m. the DON was asked what professional standard the facility's nurses follow. She stated that the nurse's follow the professional standards by [NAME]. Oral Drug Administration: If the patient can't swallow a whole tablet or capsule, ask the pharmacist if the drug is available in liquid form or if it can be administered by another route. If not, ask him if you can crush the tablet or open the capsule and mix it with food. Keep in mind that many enteric-coated or time-release medications and gelatin capsules shouldn't be crushed. Remember to contact the doctor for an order to change the route of administration when necessary. Nursing procedures; Wolters Kluwer, [NAME], [NAME] & [NAME] P529-530. On 04/16/2026 at approximately 4:30 p.m. the Administrator and DON were made aware of the above findings. No further information was provided prior to exit. References: (1) Designed to slowly release a drug in the body over an extended period of time especially to reduce dosing frequency. This information was obtained from the website: https:// www.merriam-webster.com/medical/extended-release. (2) Used to treat overactive bladder (a bladder condition that causes sudden urges to urinate that may be hard to control). This information was obtained from the website: https:// medlineplus.gov/druginfo/meds/a699026.html. 2.a. The facility staff failed to meet professional standards by not administering pain medication for Resident #78. Resident #78 (R78) was admitted to the facility on [DATE] with diagnosis that included but were not limited to chronic pain, spondylosis, bipolar disorder, anxiety disorder and diabetes mellitus. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 4/13/26, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring moderate assist for bed mobility, transfer, hygiene and supervision for eating. A review of the comprehensive care plan dated 4/7/26 revealed, FOCUS: Resident has Chronic Pain issues related to spondylosis, verbalized lower back pain. Uses opioid medication for treatment of pain. INTERVENTIONS: Educate Resident / Representative on prescribed analgesics and / or anti-inflammatory medications. Administer pain medications per order, if non-medication interventions are ineffective. A review of the physician orders dated 4/8/26 revealed, Tramadol (opioid analgesic to relieve moderate to severe pain) (1) 50 mg (milligram), Give 1 tablet by mouth four times a day related to OTHER CHRONIC PAIN. A review of the progress note dated 4/7/26 at 9:03 PM revealed, Tramadol HCl Oral Tablet 50 MG,Give 1 tablet by mouth four times a day related to OTHER CHRONIC PAIN. New admit med not available, provider aware. A review of the progress note dated 4/8/26 at 9:00 AM revealed, Tramadol HCl Oral Tablet 50 MG, give 1 tablet by mouth four times a day related to OTHER CHRONIC PAIN, duplicate order. A review of the MAR (medication administration record) revealed Tramadol 50 mg not administered on 4/7/26 at 9:00 PM and 4/8/26 at 9:00 AM. A review of the facility's Omnicell Drug inventory list, identified Tramadol HCL 50 MG as available in their Omnicell. On 4/14/26 at 12:15 PM an interview was conducted with R78. Asked about pain management, R78 stated, my pain medication is frequently delayed. An interview was conducted on 4/15/26 at 3:45 PM with LPN (licensed practical nurse) #2. Asked to describe R78's pain medication regimen, LPN #2 stated, the first day she was assigned to me (4/8/26 day shift), the Tramadol had not been delivered yet, but the order was with the pharmacy. When that happens, the pharmacy will not give you a code to enter into Omnicell to give her Tramadol from our stock. An interview was conducted on 4/16/26 at 6:45 AM with LPN #3. Asked to describe R78's pain medication regimen, LPN #3 stated, she was admitted on my shift, the orders are sent to the pharmacy the Tramadol script was sent. When the pharmacy receives prescriptions, they will not give us a code for narcotics to pull from our Omnicell. Non-pharmacological interventions and non-narcotic medications are implemented. 2.b. For Resident #78, the facility staff failed to administer pain medication in the prescribed time frame. A request was made for the medication administration time audit report and copy of R78's narcotic sign out sheet for Tramadol 50 mg. A review of R78's Tramadol narcotic sign out sheet, evidenced Tramadol was pulled at the correct administration times of 10:00 AM, 1:00 PM, 6:00 PM and 10:00 PM. A review of R78's MAR revealed delayed administration time for Tramadol on 4/9/26 6:00 PM dose- 2.5 hours late, 4/10/26 6:00 PM dose-1.5 hours late, 4/11/26 1:00 PM dose-2.75 hours late and 4/15/26 6:00 PM dose-1.75 hours late. An interview was conducted on 4/15/26 at 1:00 PM with LPN #1, when asked medication administration process, LPN #1 stated, the medication, dose, time, route, resident name and form are verified. Asked the time frame for medication administration for scheduled doses, LPN #1 stated, an hour before and an hour after the scheduled time. An interview was conducted on 4/16/26 at 1:40 PM with the assistant director of nursing, who stated, according to the nurse's statements, they signed off in the narcotic books, but did not sign them off till later in the MAR. Asked if this followed professional standards of practice, the assistant director or nursing stated, no, the medications, especially narcotics, are to be signed off immediately. A review of the facility's Medication Administration policy revealed, Medications shall be removed from the pharmacy packaging and administered immediately (pre-pouring is not permitted); by the same authorized person; AND within 1 hour before or one hour after scheduled time. Professional practice standards should be utilized for all medication administration. Documentation in the MAR or eMAR shall occur immediately after administration and shall not be delayed or completed in advance. On 4/16/26 at 4:45 PM, the administrator and the director of nursing were made aware of the findings. No further information was provided prior to exit. References: 1. Tramadol (opioid analgesic to relieve moderate to severe pain). [NAME] Pocket Drug Guide for Nurses 2019.

Based on clinical record review, staff interview, and facility document review, it was determined the facility staff failed to implement a complete immunization program for two of five record reviews for immunizations, Resident #1 and Resident #12.The findings include: 1. For Resident #1 (R1), the facility staff failed to administer the COVID-19 vaccine (1). Review of R1's clinical record documented under Immunizations the following information, COVID-19 Moderna Booster, Pending Immunization, Consent confirmed 10/1/2025, education provided 11/13/2025 .A Vaccination Summary for R1 dated 9/16/2025 documented in part, . COVID-19, Past Due .A Nursing Facility Influenza/Pneumonia Vaccines document for R1 dated 10/1/25 documented consent for the COVID-19 Monovalent Vaccine. The clinical record failed to evidence administration of the COVID-19 vaccine after the consent was given on 10/1/25.On 4/16/2026 at 9:18 AM, an interview was conducted with the infection preventionist who stated that R1 had consented to the Moderna COVID-19 vaccine back in the fall, but she thought that they did not have any in stock at that time. She stated that the former infection preventionist had resigned and it had fallen through the cracks and not been administered. The facility policy, Influenza, Pneumococcal, and Covid Immunizations revised July 2025 documented in part, . Each resident will be offered annual immunization against Influenza and Covid, unless medically contraindicated. The Influenza and Covid vaccines will be offered annually by the community during the Influenza season, October through March, unless otherwise recommended by the Centers for Disease Control and Prevention .On 4/16/2026 at 4:38 PM, the administrator, director of nursing and infection preventionist were made aware of the findings.No further information was provided prior to exit.Reference: (1) CDC recommends the 2025-2026 COVID-19 vaccine for people ages 6 months and older based on individual-based decision making. This includes people who have received a COVID-19 vaccine, people who have had COVID-19, and people with long COVID . This information was obtained from the website: Staying Up to Date with COVID-19 Vaccines | Covid | CDC2. For Resident #12 (R12), the facility staff failed to administer the COVID-19 vaccine. Review of R12's clinical record documented under Immunizations the following information, COVID-19 Moderna Booster, Pending Immunization, Consent confirmed 9/17/2025, education provided 9/19/2025 .A Vaccination Summary for R12 dated 9/16/2025 documented in part, . COVID-19, Past Due .A Nursing Facility Influenza/Pneumonia Vaccines document for R1 dated 9/17/25 documented consent for the COVID-19 Monovalent Vaccine 25-26 Moderna. The clinical record failed to evidence administration of the COVID-19 vaccine after the consent was given on 9/17/25.On 4/16/2026 at 9:18 AM, an interview was conducted with the infection preventionist who stated that R12 had consented to the Moderna COVID-19 vaccine back in the fall, but she thought that they did not have any in stock at that time. She stated that the former infection preventionist had resigned and it had fallen through the cracks and not been administered. On 4/16/2026 at 4:38 PM, the administrator, director of nursing and infection preventionist were made aware of the findings.No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide complete and accurate documentation for two of 37 residents, Resident #78 and #75. The findings include: The facility failed to document Tramadol administered according to scheduled doses and differing from documented narcotic pull times for Resident #78.Resident #78 (R78) was admitted to the facility on [DATE] with diagnosis that included but were not limited to chronic pain, spondylosis, bipolar disorder, anxiety disorder and diabetes mellitus. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 4/13/26, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring moderate assist for bed mobility, transfer, hygiene and supervision for eating. A review of the comprehensive care plan dated 4/7/26 revealed, FOCUS: Resident has Chronic Pain issues related to spondylosis, verbalized lower back pain. Uses opioid medication for treatment of pain. INTERVENTIONS: Educate Resident / Representative on prescribed analgesics and / or anti-inflammatory medications. Administer pain medications per order, if non-medication interventions are ineffective.A review of the physician orders dated 4/8/26 revealed, Tramadol (opioid analgesic to relieve moderate to severe pain) 50 mg (milligram), Give 1 tablet by mouth four times a day related to OTHER CHRONIC PAIN.A review of the progress note dated 4/7/26 at 9:03 PM revealed, Tramadol HCl Oral Tablet 50 MG,Give 1 tablet by mouth four times a day related to OTHER CHRONIC PAIN. New admit med not available, provider aware.A review of the progress note dated 4/8/26 at 9:00 AM revealed, Tramadol HCl Oral Tablet 50 MG, give 1 tablet by mouth four times a day related to OTHER CHRONIC PAIN, duplicate order.A review of the MAR (medication administration record) revealed Tramadol 50 mg not administered on 4/7/26 at 9:00 PM and 4/8/26 at 9:00 AM.On 4/14/26 at 12:15 PM an interview was conducted with R78. Asked about pain management, R78 stated, his pain medication is frequently delayed. An interview was conducted on 4/15/26 at 3:45 PM with LPN (licensed practical nurse) #2. Asked to describe R78's pain medication regimen, LPN #2 stated, the first day she was assigned to me (4/8/26 day shift), the Tramadol had not been delivered yet, but the order was with the pharmacy. When that happens, the pharmacy will not give you a code to enter into Omnicell to give her Tramadol from our stock.An interview was conducted on 4/16/26 at 6:45 AM with LPN #3. Asked to describe R78's pain medication regimen, LPN #3 stated, she was admitted on my shift, the orders are sent to the pharmacy the Tramadol script was sent. When the pharmacy receives prescriptions, they will not give us a code for narcotics to pull from our Omnicell. Non-pharmacological interventions and non-narcotic medications are implemented. A request was made for the medication administration time audit report and copy of R78's narcotic sign out sheet for Tramadol 50 mg.A review of R78's Tramadol narcotic sign out sheet, evidenced Tramadol was pulled at the correct administration times of 10:00 AM, 1:00 PM, 6:00 PM and 10:00 PM.A review of R78's MAR revealed delayed administration time for Tramadol on 4/9/26 6:00 PM dose- 2.5 hours late, 4/10/26 6:00 PM dose-1.5 hours late, 4/11/26 1:00 PM dose-2.75 hours late and 4/15/26 6:00 PM dose-1.75 hours late.An interview was conducted on 4/15/26 at 1:00 PM with LPN #1, when asked medication administration process, LPN #1 stated, the medication, dose, time, route, resident name and form are verified. Asked the time frame for medication administration for scheduled doses, LPN #1 stated, an hour before and an hour after the scheduled time.An interview was conducted on 4/16/26 at 1:40 PM with the assistant director of nursing, who stated, according to the nurse's statements, they signed off in the narcotic books, but did not sign them off till later in the MAR. Asked if this followed professional standards of practice, the assistant director or nursing stated, no, the medications, especially narcotics, are to be signed off immediately. When asked if this differing documentation is evidence of a complete and accurate medical record, the assistant director of nursing, stated, no, it is not.On 4/16/26 at 4:45 PM, the administrator and the director of nursing were made aware of the findings. A review of the facility's Electronic Medical Record policy revealed, PURPOSE: To ensure complete, accurate and timely medical records.No further information was provided prior to exit. 2. The facility staff failed to evidence required clinical documentation after a resident is transferred to the hospital for Resident #75 (R75). R75 was transferred to the hospital on 3/8/26. R75's medical record was reviewed as part of the closed medical record task.R75 was admitted to the facility on [DATE] with diagnosis that included but were not limited to Pneumonia (PNA), Sepsis, Acute respiratory failure and CHF (congestive heart failure).The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 2/23/26, coded the resident as scoring a 06 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers/bathing/dressing and hygiene. A review of the baseline care plan dated 2/19/26 revealed, FOCUS: Ineffective Airway Clearance Upper Respiratory Infection, PNA, shortness of breath, respiratory failure. INTERVENTIONS: Evaluate respiratory rate / effort, cough and shortness of breath.A review of the progress note dated 3/8/26 at 3:30 PM revealed, Functional decline (worsening function and/or mobility) Shortness of breath. Respiratory Status Evaluation: Shortness of breath Cough. Primary Care Provider responded with the following feedback: Recommendations: STAT chest x-ray, Mucinex 600mg twice a day x 7 days, Tylenol 325mg 2 tablets every 6 hours as needed for pain.No evidence of a progress note or eINTERACT (electronic Interventions To Reduce Acute Care Transfers) form documenting hospital transfer.On 4/16/26 at 12:50 PM, an interview was conducted with the director of nursing. The director of nursing stated, there is no evidence of clinical documentation sent with the resident to the hospital.On 4/16/26 at 4:50 PM, the administrator and director of nursing were made aware of the findings.No further information was provided prior to exit.

Based on clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to act in a timely manner on the pharmacy medication regimen review for one of 37 residents in the survey sample, Residents #8. The findings include:For Resident #8 (R8), the facility staff failed to implement pharmacy recommendations that were approved by the attending physician on 3/19/2026 until 4/9/2026. On the most recent minimum data set (MDS), an admission assessment with an assessment reference date (ARD) of 3/17/2026, R8 was assessed as being moderately impaired for making daily decisions and receiving antipsychotic, antidepressant, anticoagulant and antibiotic medications while at the facility. The pharmacy consultation report for R8 dated 3/16/2026 documented in part, .Recommendation: Please attempt a gradual dose reduction of Quetiapine (1) to 12.5mg (milligram) every other night at bedtime for 7 days then discontinue . The report documented under the Physician's Response, I accept the recommendation(s) above, please implement the monitoring plan outlined below. Monitoring Plan: [left blank] . The physician and Director of Nursing signature was dated 3/19/2026. The physician orders for R8 documented a current order for Quetiapine Fumarate Oral Tablet 25 MG (Quetiapine Fumarate) Give 12.5 mg by mouth at bedtime for depression related to Dementia in other diseases classified elsewhere, moderate, with other behavioral disturbance. Order Date: 04/10/2026. Review of the electronic medication administration record (eMAR) for R8 dated 3/1/2026-3/31/2026 documented the Quetiapine 12.5mg administered daily at bedtime through 3/31/2026. Review of the eMAR for R8 dated 4/1/2026-4/30/2026 documented the Quetiapine 12.5mg administered daily at bedtime through 4/8/2026. The eMAR further documented the Quetiapine order changed on 4/9/2026 to 12.5mg every other day for 7 days. The order was noted to be discontinued on 4/10/2026 with a new order that changed the Quetiapine back to the original 12.5mg daily at bedtime starting on 4/10/2026. The progress notes for R8 documented in part,- 03/16/2026 10:41 (AM) Pharmacy note. Note Text : Medication Review: This resident's medical record including electronic documentation was reviewed on this date. [x] See report for any noted irregularities and/or recommendations .- 03/19/2026 15:39 (3:39 PM) Note Text: Per pharm recommendation and MD approval, Oxycodone discontinued as well as GDR (gradual dose reduction) of Quetiapine 12.5mg every other night at HS (bedtime) for 7 days. RP (responsible party) made aware.- 04/09/2026 17:10 (5:10 PM) LATE ENTRY. Note Text: RP aware of medications risk and benefits. Also, aware of GDR attempt. Will like to further speak with physician about medication. MD aware.- 04/10/2026 17:56 (5:56 PM) Note Text: RP would like resident to stay on current dose with current frequency. Aware of risk and benefits of GDR attempts. MD aware and medication changed to previous dose.- 04/13/2025 11:45 (AM) . Today provider returned call to his son and provided update on his overall progress . Son does not want to GDR current low-dose quetiapine as pt is responding well, and provider agrees . On 4/16/2026 at 9:18 AM, an interview was conducted with the assistant director of nursing who stated that they had received the pharmacy recommendations for R8, and the physician had agreed to the GDR of the Quetiapine. She stated that the physician had stated that they were going to put the orders in for the medication change but did not and she became aware when the pharmacy had emailed her last week to check the status of the GDR. She stated that at that time she had called the physician who told them to proceed with the GDR, so they contacted the responsible party who initially had agreed but then changed his mind. She stated that R8's responsible party had requested the resident be placed back on the daily dosage because it had been prescribed in the hospital for sleeping and he did not want the medication to be changed. She stated that she had changed the order back to the original at that time. The facility policy Medication Regimen Review revised 6/1/24, documented in part, .The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it . On 4/16/2026 at approximately 4:38 PM, the Administrator, the Director of Nursing and the Assistant Director of Nursing/infection preventionist were made aware of the findings. No further information was provided prior to exit. References: (1) Quetiapine is used to treat schizophrenia (a mental illness that affects how a person thinks, feels and behaves), bipolar disorder (a disease that causes depression, mania, and other abnormal moods) and major depressive disorder. Quetiapine is in a class of medications called atypical antipsychotics. It works by changing the activity of certain natural substances in the brain . This information was obtained from the website: Quetiapine: MedlinePlus Drug Information

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence of required clinical documentation after a resident is transferred to the hospital for one of 37 residents in the survey sample, Resident #75.The findings include: The facility staff failed to evidence required clinical documentation after a resident is transferred to the hospital for Resident #75 (R75). R75 was transferred to the hospital on 3/8/26. R75's medical record was reviewed as part of the closed medical record task.R75 was admitted to the facility on [DATE] with diagnosis that included but were not limited to Pneumonia (PNA), Sepsis, Acute respiratory failure and CHF (congestive heart failure).The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 2/23/26, coded the resident as scoring a 06 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers/bathing/dressing and hygiene. A review of the baseline care plan dated 2/19/26 revealed, FOCUS: Ineffective Airway Clearance Upper Respiratory Infection, PNA, shortness of breath, respiratory failure. INTERVENTIONS: Evaluate respiratory rate / effort, cough and shortness of breath.A review of the progress note dated 3/8/26 at 3:30 PM revealed, Functional decline (worsening function and/or mobility) Shortness of breath. Respiratory Status Evaluation: Shortness of breath Cough. Primary Care Provider responded with the following feedback: Recommendations: STAT chest x-ray, Mucinex 600mg twice a day x 7 days, Tylenol 325mg 2 tablets every 6 hours as needed for pain.There was no evidence of a progress note or eINTERACT (electronic Interventions To Reduce Acute Care Transfers) form documenting hospital transfer.On 4/16/26 at 12:50 PM, an interview was conducted with the director of nursing. The director of nursing stated, there is no evidence of clinical documentation sent with the resident to the hospital.On 4/16/26 at 4:50 PM, the administrator and director of nursing were made aware of the findings.A review of the facility's Transfer-Discharge Process policy revealed, Information will be provided to the receiving provider to include a minimum of the following: Contact information of the practitioner responsible for the care of the resident. Resident Representative information including contact information. Advance Directive information. All special instructions or precautions for ongoing care, as appropriate. Comprehensive care plan goals. All other necessary information, including a copy of the resident's discharge summary, and any other documentation, as applicable, to ensure a safe and effective transition of care.No further information was provided prior to exit.

Based on resident interview, staff interviews, facility document review and clinical record review, the facility staff failed to acquire medications for administration for one of nine residents in the survey sample, Resident #103 The findings include: For R103 the facility staff failed to administer the physician ordered medication Fish Oil Oral Capsule (supplement) on 6/2/26 and 6/7/26. A review of R103's clinical record revealed a physician's order dated 4/8/26 for Fish Oil Oral Capsule 1000 MG (milligrams) one time a day for supplement. A review of R103's June 2026 MAR (medication administration record) revealed the same physician's order for Fish Oil Oral capsule. On 6/2/26 and 6/7/26, the MAR documented the code, 9=Other/See Progress Notes. Nurses' notes dated 6/2/26 and 6/7/23 documented, Medication not available. A review of the facility backup medication supply list revealed it was not stocked in supply. An interview was conducted on 6/8/26 at 11:30 AM with R103 who stated, there is a problem with me receiving my medications here, I just don't understand it. The most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/13/26, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions.An interview was conducted on 6/9/26 at 2:20 PM with LPN (Licensed Practical Nurse) #1. LPN #1 stated medications should be re-ordered from the pharmacy when seven pills are remaining. LPN #1 stated that when a medication is ordered and not available for administration, staff should check the emergency supply, call the pharmacy, notify the physician and the RP (responsible party). A review of the facility policy, Medication Shortage/Unavailable Medications, revealed, in part: upon discovery that facility has inadequate medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy. On 6/9/26 at 4:18 p.m., the Administrator and Director of Nursing were made aware of the above findings.

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to post daily staffing for one of four days reviewed.The findings include: During the Sufficient and Competent Staffing facility task review started on 4/14/26 and ended on 4/17/26, a review of the daily staffing evidenced the following:On 4/14/26 at 8:00 AM the facility was entered for the survey. There was no evidence of staff posting in the main lobby, the lobby outside of the nursing care center or on the nursing station desk in the nursing care center. 11:00 and 3:30 PM checks of these areas did not reveal any staff posting.The daily staffing was posted correctly the remainder of the survey, 4/15/26, 4/16/26 and 4/17/26.On 4/14/26 at 3:45 PM, an interview was conducted with the Director of Nursing (DON). Asked where the staff posting is located, the DON stated, it is right here in this book. It is not posted, as a plastic frame was needed for it. The DON was referred to the regulations.On 4/15/26 at 8:15 AM, the Director of Nursing stated, the regulations were reviewed and the staff posting should be visible, it is in a frame now.On 4/16/26 at 4:45 PM, the Administrator and the Director of Nursing were made aware of the findings.According to the facility's Posting of Direct Care Staff policy which revealed, It is the policy of the Community to post daily, at the beginning of the shift, the number of licensed and unlicensed direct care staff directly responsible for resident care in the facility, facility name, current date, and resident census.No further information was provided prior to exit.

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to report and follow post fall procedures for one of eight residents in the survey sample, Resident #8. The findings include: For Resident #8 (R8), the facility staff failed to report a fall that occurred on evening shift 8/28/24. There was no documentation completed until 9/2/24 after the resident was discovered to have a fractured femur (1) and an investigation for the injury was started. R8 was admitted to the facility with diagnoses that included but were not limited to multiple fractures of pelvis, repeated falls, disorders of bone density and structure, and protein-calorie malnutrition (2). On the most recent MDS (minimum data set), a 5-day assessment with an ARD (assessment reference date) of 9/19/24, the resident was assessed as having one fall with fracture in the past month. The nursing progress notes documented in part, - 08/28/2024 08:23 pm (Recorded as Late Entry on 09/02/2024 08:33 pm). Resident was noted on the bathroom floor at the last round of the shift. Writer was noted called in by the aide and assessed and was noted with no visible injuries and no skin tears or bruises. Resident was placed in her w/c (wheelchair) and assisted back to bed. No pain on transfer to w/c or in bed. Fall event to follow. - 08/29/2024 07:22 am Resident continues skilled services r/t (related to) multiple left pelvic fractures, muscle weakness. Resident is alert and oriented to self only. Denies any pain or discomfort .No s/s (signs or symptoms) of distress . - 08/29/2024 03:22 pm .No s/s of discomfort/distress noted. Will continue to monitor. - 08/30/2024 03:55 am .Denies any pain or discomfort .Bed kept in lowest position for safety. Resting in bed @ this time. No s/s of distress . - 08/30/2024 03:56 pm .ambulates by wheelchair .resident is watching television in day room, no c/o (complaints of) pain/discomfort noted at this time, will continue to monitor per my shift. - 08/30/2024 08:26 pm N.O.S (new orders) received from MD for x-ray of pelvis r/t f/u (follow up) pelvis fx (fracture) and check urinalysis w/ reflex to cx (culture). RP (responsible party) [Name of RP] notified. - 08/31/2024 03:19 am Resident medicated @ the end of previous shift w/ prn (as needed) Oxycodone/acetaminophen r/t c/o (complaints of) back/pelvic pain, has been effective .No s/s of distress . - 08/31/2024 01:49 pm .No s/s of discomfort/distress noted. Will continue to monitor. N/O for pelvic x-ray submitted, but not completed, so far. - 09/01/2024 02:41 am (Recorded as late entry on 09/24/2024 11:42 am) .No s/s of discomfort/distress noted. Will continue to monitor. - 09/01/2024 11:26 am F/U with [Name of imaging] about x-ray and was informed that they're supposed to be here sometime today. - 09/02/2024 09:53 am Resident being sent to [Name of hospital], per MD, for a R femur fx, per x-ray. She will be picked up by non-emergency transportation about 11:30. RP aware, Resident was given a PRN Oxycodone/Acetaminophen for pain before being picked up. - 09/06/2024 04:00 pm Resident is a re-admit from [Name of hospital] via stretcher .admitted for skilled services r/t surgical aftercare for rt femur hemiarthroplasty, multiple pelvic fractures, muscle weakness . The physician progress note dated 8/30/24 documented in part, .A [Age and sex of R8] who was admitted to the hospital from 8/10 until 8/15 with multiple fractures .As per physical therapist she has been having increased weakness and has been complaining of more pain and not participating much with therapy. Not much meaningful history available form the patient at this time .Physical Exam: .Moving all 4 extremities . Assessment and Plan: Generalized weakness, multiple falls. Continue with PT/OT (physical and occupational therapy). Family is planning to put her and [sic] memory care here after her skilled stay. At this time, she has increased pain, weakness, planning on repeat x-rays and a UA. Multiple fractures of the pelvis, found to have acute left superior and inferior pubic rami and left sacral fractures with diffuse osteopenia (3). Non-operative management per orthopedics, weightbearing as tolerated. Continue on Percocet 5/325 Q4 (every four hours) for pain, Pain worse for the last couple of days, we will repeat x-ray of the pelvis. Altered mental status, now improved, likely delirium. Osteopenia, seen on CT scan. I suspect she has osteoporosis (4) since she has a fragility fracture. Now on calcium and Vitamin D, discussed about starting bisphosphonates with her daughter, and at this time we have decided against it . The physician progress note dated 9/2/2024 documented in part, .Assessment and Plans: Right femoral neck fracture, she was complaining of increased pain while being transferred. She was also had [sic] some altered mental status, we repeated the x-ray of her pelvis, and it showed a deformed right femoral fracture which was age indeterminate. Reviewing her hospital records her right femoral x-ray was normal in the hospital, so this is likely a new fracture. We will send her to the ER for further evaluation and an ortho consult for possible surgery . The radiology report for R8 with an exam date of 09/01/2024 documented an impression of 1. Prominently deformed subcapital fracture of undetermined age right femur. 2. Moderate osteopenia. 3. Otherwise, negative pelvis exam. The comprehensive care plan for R8 documented in part, Problem Start Date: 08/22/2024. Category: Falls. I am at risk for falls due to impaired mobility, weakness and unsteady gait, opioid med use. Edited: 09/12/2024. The fall risk assessment for R8 dated 8/16/24 documented the resident being at risk for falls. On 12/6/24 at approximately 9:55 a.m., ASM (administrative staff member) #1, the administrator stated that the nurse who documented the late entry for the fall on 8/28/24, the nurse who sent R8 out to the hospital on 9/2/24 and the physician who examined R8 on 8/30/24 and 9/2/24 no longer worked at the facility and could not be interviewed. On 12/5/24 at 10:45 a.m., an interview was conducted with CNA (certified nursing assistant) #1. CNA #1 stated that they were able to see in the computer when a resident was a high fall risk, and the nurse told them in report also. CNA #1 stated that if a resident fell , they called the nurse to come assess the resident for injuries before getting them up and back in the chair or bed. On 12/6/24 at 9:26 a.m., an interview was conducted with LPN (licensed practical nurse) #2 who stated that when a resident had a fall, they assessed the resident for injuries, sent them to the hospital if needed, notified the physician and responsible party and documented the fall in the computer. LPN #2 stated if the fall was unwitnessed that neurochecks should be done in case the resident hit their head to assess for change in condition. On 2/6/24 at 10:32 a.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that R8's fall was discovered during her investigation of the fracture. She stated that R8 was admitted to the facility with existing pelvic fractures and a history of falls and was a fall risk. She stated that when the x-ray came back showing the femur fracture, she started an investigation because it was a potential injury of unknown origin but when interviewing the nursing staff who worked with R8, one of the nurses told her that R8 had the fall in the bathroom. She stated that the CNA had confirmed the fall, and the nurse had entered the progress note as a late entry. She stated that they had not completed a fall investigation because they were not aware of the fall until R8 was sent to the ER. She stated that R8 had not complained of any pain until 8/30/24 when the physical therapist reported it, and she was seen by the physician who ordered the x-rays. She stated that R8 was unable to tell them what happened, and she had educated staff on notifying the physician if the x-ray was not done in a timely manner. She stated that the x-ray was not ordered stat and was done within 24 hours which was the expectation, but the staff should have called the physician to see if they wanted the resident sent out for the x-ray prior. She stated that she had suspended the nurse for not reporting the fall and they were terminated the next day. She stated that she had educated most of the nursing staff but not all of them and had not done a formal plan of correction. She stated that the process the nurse should have followed was to immediately check vital signs, neurological checks, check for any injuries, call 911 if needed, notify the physician and RP, document the event in the medical record and update the care plan. She stated that this was not done for R8 and if it had been done it would have triggered the post fall observations and other assessments. She stated that R8 was still getting out of bed and participating with physical therapy. She stated that R8's pain was assessed and addressed by the physician when they first complained of it. The facility policy, Post Fall Evaluation and Intervention revised 6/11/21 documented in part, The nursing staff will evaluate falls by assessing causation and potential contributing factors and implementing appropriate interventions to prevent reoccurrence as part of quality assurance of the facility . A post fall assessment in the electronic record is to be completed after each fall in its entirety . On 12/6/24 at approximately 12:18 p.m., ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, the assistant administrator were made aware of the above concern. No further information was provided prior to exit. Reference: (1) femur fracture You had a fracture (break) in the femur in your leg. It is also called the thigh bone. You may have needed surgery to repair the bone. You may have had surgery called an open reduction internal fixation. In this surgery, your surgeon will make a cut to open your fracture. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000166.htm. (2) malnutrition Food provides the energy and nutrients you need to be healthy. If you don't get enough nutrients -- including proteins, carbohydrates, fats, vitamins, and minerals - you may suffer from malnutrition. This information was obtained from the website: https://medlineplus.gov/malnutrition.html (3) osteopenia is a condition that begins as you lose bone mass and your bones get weaker. This happens when the inside of your bones become brittle from a loss of calcium. It ' s very common as you age. This information was obtained from the website: https://familydoctor.org/condition/osteopenia/?adfree=true (4) osteoporosis is a disease in which your bones become weak and are likely to fracture (break). The disease can develop when your bone mineral density and bone mass decrease. It can also happen if the structure and strength of your bones change. Osteoporosis is called a silent disease because it doesn't usually cause symptoms. You may not even know you have the disease until you break a bone. This could happen with any bone, but it's most common in the bones of your hip, vertebrae in the spine, and wrist. This information was obtained from the website: https://medlineplus.gov/osteoporosis.html

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide care and services to promote healing of a pressure injury for one of eight residents in the survey sample, Resident #6. The findings include: For Resident #6 (R6), the facility staff failed to evidence a treatment for a facility acquired deep tissue injury (1) first observed on 10/28/24 until 11/4/24. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 10/28/24, the resident was assessed as having one unstageable deep tissue injury that was not present on admission. The progress notes for R6 documented in part, - 10/28/2024 02:00 pm (Recorded as late entry on 11/01/2024 02:01 pm) DTI observed by therapy and was overheard speaking to son about floating resident's heal [sic] and possibly ordering bilateral heal [sic] protector boots. This writer was told and assessed the resident. It was noted that resident had DTI on right heal [sic] measuring 3.5x5.5cm (centimeter). Nurse made aware, and consult put in place for resident to be seen wound MD. Nursing care continues. - 10/29/2024 11:32 am Resident dx (diagnosed ) with generalized weakness and declining last few weeks/months with AMS (altered mental status) possibly d/t (due to) UTI (urinary tract infection) on antibiotics .10/29 noted with right heel DTI . - 11/4/2024 12:54 am Resident continues skilled services r/t UTI, muscle weakness. Alert and oriented to self only, able to verbalize needs. No c/o (complaints of) pain or discomfort. Requires total assist x 1 w/ ADLs (activities of daily living). Air mattress in place and functioning. DTI to right heel remains, skin prep applied as ordered, heels floating . - 11/4/2024 2:07 pm .PA (physician's assistant) assessed resident at bedside, note new wound care orders to right heel & RUE (right upper extremity) . The wound physician evaluation dated 11/11/24 documented in part, .Unstageable DTI with intact skin .Wound size (LxWxD): 3.5x3.8xnot measurable cm) .Wound progress: Improved evidenced by decreased surface area . The physician order's for R6 documented in part, Skin prep to right heel. Every shift Days, Evenings, Nights. Start Date: 11/07/2024. Review of the eTAR (electronic treatment administration record) for R6 dated 10/1-10/31/24 documented the heels floated when in bed beginning on 10/28/24 however it failed to evidence any treatment to the right heel DTI that was first observed on 10/28/24. Review of the eTAR for R6 dated 11/1-11/30/24 documented the heels floated when in bed each shift. It further documented a treatment of Betadine to the right heel every shift beginning on 11/4/24 through 11/7/24. The eTAR further documented the skin prep treatment beginning every shift on 11/7/24. The comprehensive care plan for R6 documented in part, Problem Start Date: 10/29/2024. I am at risk for pressure ulcers (2)/impaired skin integrity due to: open lesion to the finger from ruptured gout nodule, incontinence, impaired mobility, skin tear to LLE (left lower extremity), edema, fragile skin due to fluid accumulation, right heel DTI (deep tissue injury). Edited: 10/31/2024. On 12/6/24 at 9:26 a.m., an interview was conducted with LPN (licensed practical nurse) #2 who stated that skin assessments were completed weekly on each resident. She stated that if a new pressure injury was observed they were not allowed to stage the wound, so they called the RN (registered nurse) to come assess the wound and stage it. She stated that if there was no RN in the building, they wrote a detailed note regarding the wound and described it without staging it until the RN could assess it. She stated that no matter if it were an LPN or RN the nurse contacted the physician and obtained a treatment order and documented the wound. On 2/6/24 at 10:32 a.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that there was an order placed for skin prep for R6's right heel on 11/1/24 but the order did not show on the eTAR. She stated that the staff that entered the order placed it under the general flow sheet so it did not trigger to show on the eTAR, and staff would not have known that the treatment needed to be completed. ASM #2 stated that when the DTI was first observed on 10/28/24 the nurse should have contacted the physician and entered the order for the treatment if not already entered. The facility policy Pressure Ulcer and Skin Care revised 4/24/24 documented in part, .Intervention: i. Initiate and document nursing interventions (examples: pressure reduction mattress, supportive devices, turning schedule, catheter to prevent further breakdown, etc.) ii. Obtain a treatment order and/or other specific physician orders On 12/6/24 at approximately 12:15 p.m., ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, the assistant administrator were made aware of the findings. No further information was provided prior to exit. Reference: (1) DTI- deep tissue injury Pressure sores that develop in the tissue deep below the skin. This is called a deep tissue injury. The area may be dark purple or maroon. There may be a blood-filled blister under the skin. This type of skin injury can quickly become a stage III or IV pressure sore. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000740.htm (2) Pressure injury A pressure sore is an area of the skin that breaks down when something keeps rubbing or pressing against the skin. Pressure sores are grouped by the severity of symptoms. Stage I is the mildest stage. Stage IV is the worst.tage I: A reddened, painful area on the skin that does not turn white when pressed. This is a sign that a pressure ulcer is forming. The skin may be warm or cool, firm or soft. Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated. Stage III: The skin now develops an open, sunken hole called a crater. The tissue below the skin is damaged. You may be able to see body fat in the crater. Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000740.htm.

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to implement the comprehensive care plan for one of eight residents in the survey sample, Resident #6. The findings include: For Resident #6 (R6), the facility staff failed to implement the comprehensive care plan to provide treatment to a pressure injury (1). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 10/28/24, the resident was assessed as having one unstageable deep tissue injury (2) that was not present on admission. The comprehensive care plan for R6 documented in part, Problem Start Date: 10/29/2024. I am at risk for pressure ulcers/impaired skin integrity due to: open lesion to the finger from ruptured gout nodule, incontinence, impaired mobility, skin tear to LLE (left lower extremity), edema, fragile skin due to fluid accumulation, right heel DTI (deep tissue injury). Edited: 10/31/2024. Under Approach it documented in part, .Treatment as ordered. Created: 10/29/2024 . The progress notes for R6 documented in part, - 10/28/2024 02:00 pm (Recorded as late entry on 11/01/2024 02:01 pm) DTI observed by therapy and was overheard speaking to son about floating resident's heal [sic] and possibly ordering bilateral heal [sic] protector boots. This writer was told and assessed the resident. It was noted that resident had DTI on right heal [sic] measuring 3.5x5.5cm (centimeter). Nurse made aware, and consult put in place for resident to be seen wound MD. Nursing care continues. - 10/29/2024 11:32 am Resident dx (diagnosed ) with generalized weakness and declining last few weeks/months with AMS (altered mental status) possibly d/t (due to) UTI (urinary tract infection) on antibiotics .10/29 noted with right heel DTI . - 11/4/2024 12:54 am Resident continues skilled services r/t UTI, muscle weakness. Alert and oriented to self only, able to verbalize needs. No c/o (complaints of) pain or discomfort. Requires total assist x 1 w/ ADLs (activities of daily living). Air mattress in place and functioning. DTI to right heel remains, skin prep applied as ordered, heels floating . - 11/4/2024 2:07 pm .PA (physician's assistant) assessed resident at bedside, note new wound care orders to right heel & RUE (right upper extremity) . The wound physician evaluation dated 11/11/24 documented in part, .Unstageable DTI with intact skin .Wound size (LxWxD): 3.5x3.8xnot measurable cm) .Wound progress: Improved evidenced by decreased surface area . The physician order's for R6 documented in part, Skin prep to right heel. Every shift Days, Evenings, Nights. Start Date: 11/07/2024. Review of the eTAR (electronic treatment administration record) for R6 dated 10/1-10/31/24 documented the heels floated when in bed beginning on 10/28/24 however it failed to evidence any treatment to the right heel DTI that was first observed on 10/28/24. Review of the eTAR for R6 dated 11/1-11/30/24 documented the heels floated when in bed each shift. It further documented a treatment of Betadine to the right heel every shift beginning on 11/4/24 through 11/7/24. The eTAR further documented the skin prep treatment beginning every shift on 11/7/24. On 12/6/24 at 9:26 a.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that the purpose of the care plan was to promote interventions for caring for the resident. She stated that the care plan should be implemented for safety reasons and to promote care of the resident to get them back to their baseline functioning. On 2/6/24 at 10:32 a.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that there was an order placed for skin prep for R6's right heel on 11/1/24 but the order did not show on the eTAR. She stated that the staff that entered the order placed it under the general flow sheet so it did not trigger to show on the eTAR and staff would not have known that the treatment needed to be completed. ASM #2 stated that when the DTI was first observed on 10/28/24 the nurse should have contacted the physician and entered the order for the treatment if not already entered. She stated that the purpose of the care plan was to plan the residents care and ensure that it was centered to the residents needs at the facility. She stated that the care plan should be implemented, because it was the way to know how to care for the resident based on their needs. The facility policy Comprehensive Person-Centered Care Planning revised May 7, 2024, documented in part, .The facility will develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychological needs as identified throughout the comprehensive Resident Assessment Instrument (RAI) process . On 12/6/24 at approximately 12:15 p.m., ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, the assistant administrator were made aware of the findings. No further information was provided prior to exit. Reference: (1) Pressure injury A pressure sore is an area of the skin that breaks down when something keeps rubbing or pressing against the skin. Pressure sores are grouped by the severity of symptoms. Stage I is the mildest stage. Stage IV is the worst.tage I: A reddened, painful area on the skin that does not turn white when pressed. This is a sign that a pressure ulcer is forming. The skin may be warm or cool, firm or soft. Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated. Stage III: The skin now develops an open, sunken hole called a crater. The tissue below the skin is damaged. You may be able to see body fat in the crater. Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000740.htm. (2) DTI- deep tissue injury Pressure sores that develop in the tissue deep below the skin. This is called a deep tissue injury. The area may be dark purple or maroon. There may be a blood-filled blister under the skin. This type of skin injury can quickly become a stage III or IV pressure sore. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000740.htm

Based on clinical record review, staff interview and facility document review, it was determined the facility staff failed to review and revise the care plan for one of eight residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to review and revise the comprehensive care plan to evidence resident-centered preferences for care. On the most recent MDS (minimum data set) assessment, an admission assessment with an ARD (assessment reference date) of 8/25/2023, the resident scored 12 of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. Section G documented R1 requiring extensive assistance of one person for dressing, bathing and personal hygiene and extensive assistance of two persons for toileting. The comprehensive care plan for R1 documented in part, Problem Start Date: 08/28/2023. Category: ADLs (activities of daily living) Functional Status/Rehabilitation Potential. I have alteration in ADL function due to weakness associated with multiple compression fx's (fractures). Risk factors include: impaired mobility, anxiety. Created: 08/28/2023. The care plan failed to evidence resident-centered choices regarding preference for no male caregivers due to religious choices. The dietary communication orders documented, Muslim diet. 8/21/2023. and No Pork. 9/2/2023. The progress notes for R1 documented in part, 09/06/2023 01:17 pm Care plan meeting was held on Friday, September 1, 2023, with son, (Name of son), (Name of the executive director), (Name of the assistant director of nursing), (Name of occupational therapist), director of rehab services, and this writer [social worker]. Resident did not attend. Concerns and facility routines were discussed with son . Review of the clinical record failed to evidence documentation of the resident's preference for no male caregivers due to religious choices. Review of the as worked schedules for nursing dated 8/21/2023-9/20/2023 documented female CNA (certified nursing assistant) staff assigned to care for R1 each shift. On 9/26/2023 at 3:46 p.m., an interview was conducted with CNA (certified nursing assistant) #2, scheduling coordinator. CNA #2 stated that R1 and their son had requested that only women provide care for them due to their religion. She stated that they did not have many male CNA's and that they communicated the request to the nurses verbally so that none were assigned to care for them. On 9/26/2023 at 4:36 p.m., an interview was conducted with RN (registered nurse) #1, MDS coordinator. RN #1 stated that the purpose of the care plan was to identify the resident needs and used to provide individualized care to the residents. She stated that the comprehensive care plan was completed by MDS and included the care areas that were triggered by the MDS assessment and the interdisciplinary team updated the care plan as needed. She stated that she would expect that R1's preference to have female caregivers be addressed on the care plan and would expect the care plan to address cultural perspectives. On 9/27/2023 at 11:18 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that they worked with R1 often. LPN #3 stated that they did not have any male CNA's working their shift so R1 only had female CNA's taking care of them. She stated that there was one shift when R1 was assigned a male nurse and the nursing supervisor had handled the situation accordingly. On 9/27/2023 at 11:25 a.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that the care plan was developed by the MDS staff and nursing could add to it as needed. She stated that R1 and R1's son had requested to only have female caregivers and they had accommodated the request by assigning only females. She stated that they would expect to see the preference to have only female caregivers addressed on the care plan. The facility policy, Comprehensive Person-Centered Care Planning revised 11/15/2017 documented in part, .All reasonable efforts will be made to incorporate the resident's personal and cultural preferences in developing goals of care . On 9/27/2023 at 1:20 p.m., ASM #1, the executive director, was made aware of the findings. No further information was obtained prior to exit.

Based on staff interview and clinical record review, it was determined that the physician failed to write, sign and date a progress note during a visit for one of eight residents in the survey sample; Resident #2. The findings include: Resident #2 was most recently admitted on [DATE] and discharged to home on 8/3/23. The resident had diagnoses of, but not limited to, high blood pressure and atrial fibrillation (a-fib). The resident was coded on the most recent MDS (Minimum Data Set), an admission assessment dated [DATE] coded the resident as being cognitively intact in ability to make daily life decisions, scoring a 13 out of a possible 15 on the BIMS (Brief Interview for Mental Status). A review of the clinical record revealed the resident was admitted on [DATE]. The hospital discharge orders included Metoprolol Tartrate 100 mg (milligrams) twice daily (1). Admission orders to the facility dated 6/30/23 included Metoprolol Tartrate 100 mg, twice daily. A review of the clinical record revealed blood pressure readings were obtained from admission on 6/30/23 through 7/14/23. The lowest reading was on 6/30/2023 at 02:58 PM and was documented as 97/52. The highest reading was on 7/03/2023 at 01:31 AM and was documented as 133/70. On 7/14/23 the dose was changed and an order was written for Metoprolol Tartrate 25 mg once daily. A review of the clinical record failed to reveal any documentation by the physician regarding her assessment and rationale for lowering the dose of this medication. On 9/26/23 at 1:50 PM, an interview was conducted with ASM #3 (Administrative Staff Member), the physician. She stated that she reviewed the blood pressures and noted that they were trending low, so she talked to the resident, who was awake, alert and oriented, regarding the blood pressure trending low, and wanted to reduced the dose of Metoprolol. She stated that the resident was in agreement. She stated that even after lowering the dose, the resident's blood pressure remained under control and was still low at times but she did not want to lower the dose any further because the resident needed the medication for a-fib. She stated that she probably should have wrote a note about her assessment of the resident's blood pressures and clinical decision to lower the dose. On 9/27/23 at 11:37 AM, ASM #1 the Administrator was made aware of the findings. He stated that there was not a policy regarding physician requirements for documentation. No further information was provided by the end of the survey. Reference: (1) Metoprolol is used to treat high blood pressure, angina, and heart failure.) Information obtained from https://medlineplus.gov/druginfo/meds/a682864.html

Based on staff interview, facility document review and clinical record review, it was determined that the facility failed to report an allegation of abuse to the State Agency for one of eight residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to report an allegation of abuse to the State Agency that had been reported to the executive director via email on 9/22/2023. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 8/25/2023, the resident scored 12 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. R1 no longer resided at the facility and could not be observed during the survey dates. The record was reviewed as a closed record. Review of the facility synopsis of events from 4/1/2023 through the present failed to evidence any events for R1. Review of R1's clinical record failed to evidence documentation of allegations of abuse by R1 or R1's family. On 9/27/2023 at 11:40 a.m., an interview was conducted with ASM (administrative staff member) #1, the executive director. ASM #1 stated that they had several meetings with R1's son to discuss their care and concerns when they were at the facility. He stated that R1's son had discussed concerns regarding obtaining medical records, having to pay a fee for the records, call bell response, R1's medications, the resident's room not being clean, the attitudes of some of the CNA's (certified nursing assistants) and the end of skilled services at the facility. When asked if he received any email correspondence from R1's son regarding concerns, he stated that he had not received any directly from the son but had received an email from (Name of Senator's) office on 9/22/2023 which had concerns that R1 was being discharged for retaliation purposes. He stated that he did not go through the email completely because the parts that he saw were saying that they were deceptive and covering up the truth. When asked about the allegation of being shaken after pushing the call bell on 9/15/2023, ASM #1 stated that he was not aware of any allegations of R1 being shaken by anyone and he did not believe that it took place in any way, shape or form but he would have reported the allegation if it were brought to his attention. On 9/27/2023 at 12:45 p.m., ASM #1 provided a printed copy of the email sent to them dated 9/22/2023 1:01 p.m. which documented in part, . Attached is correspondence from (Name of R1's son) regarding his mother, (Name of R1), who was a resident at (Name of facility). We are forwarding this correspondence as a courtesy to the family . The attached documented in part, Statement of Problem. Patient/Resident: (Name of R1). I am writing to once again formally communicate my horror and concerns of multiple incidents of elder abuse, flagrant violations of Resident's rights (per the Code of Federal Regulation), and medical malpractice that my helpless (age and name of R1), has experienced while in the care of you and your staff at (Name of facility) . b. When staff did respond to her (in the absence of advocates), they spoke to her in a threatening and aggressive manner saying disrespectful things to her like: What to you want now? or What is it now?. This was obviously done to intimidate her and make her feel scared to push the call button . e. My mom told me of one incident on 9/15/23 where she said: A lady grabbed me and shook me one evening after I pushed the call. That is clear criminal assault . 6. Physical assault from caregivers. She told me that a lady grabbed me and shook me after I pushed the call button for help. Unexplained cuts, bruises, and injuries . The facility policy Right to Dignity Freedom from Abuse Neglect and Exploitation revised 2/13/2023 documented in part, . The Administrator or designee will immediately make an oral or written report of the allegation or of the first suspicion of abuse to the local social services department, to the adult protective services unit and to other agencies in accordance with established procedures. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, and misappropriation of resident's property, are reported immediately, but not later than 2 hours after allegation is made if the events that cause the allegation involve abuse or results in serious bodily injury; or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. The Administrator will report the results of the investigation within five (5) working days of the first report of the incident . On 9/27/2023 at 1:20 p.m., ASM #1, the executive director was made aware of the findings. ASM #1 stated that they did not send a report because the resident was already discharged from the facility when they received the email and they did not read it completely. He stated that they had met with the son and the long term care ombudsman on the day of discharge and no one had reported any allegations of abuse to them at that time and they would have reported it if they had. No further information was provided prior to exit. As of 10/2/2023, the State Agency had not received notification from the facility staff of the allegation of abuse.

Based on staff interview, facility document review and clinical record review, it was determined that the facility failed to implement their abuse policy for investigating and reporting an allegation of abuse when reported to the facility staff for one of eight residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to implement their abuse policy to investigate and report an allegation of abuse that was reported to the executive director via email on 9/22/2023. The facility policy Right to Dignity Freedom from Abuse Neglect and Exploitation revised 2/13/2023 documented in part, . The Administrator or designee will immediately make an oral or written report of the allegation or of the first suspicion of abuse to the local social services department, to the adult protective services unit and to other agencies in accordance with established procedures. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, and misappropriation of resident's property, are reported immediately, but not later than 2 hours after allegation is made if the events that cause the allegation involve abuse or results in serious bodily injury; or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. The Administrator will report the results of the investigation within five (5) working days of the first report of the incident . The Administrator or Assistant Administrator is responsible for the coordination of a timely and thorough internal investigation. The investigation will include, but is not limited to, a physical assessment of the resident; resident, staff and witness interviews, reportable incident form and chart reviews as necessary, and/or psychosocial assessment if warranted. Adult Protective Services, the local Ombudsman, and/or police department will be contacted to assist in the investigation as appropriate. The Administrator or designee will complete an investigative report summarizing the internal investigation. The investigative report will include the individuals involved; a description of the occurrence including date, location and description of the incident; injury to the resident, immediate corrective action taken, mechanisms in place to prevent recurrence and documentation of report to appropriate agencies. If needed, the Administrator or designee will submit this investigative report to the Office of License and Certification within 5 working days of the initial report . R1 no longer resided at the facility and could not be observed or interviewed during the survey dates. The record was reviewed as a closed record. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 8/25/2023, the resident scored 12 out of 15 on the BIMS (brief interview for mental status) assessment, which indicated the resident was moderately impaired for making daily decisions. Review of the facility synopsis of events from 4/1/2023 through the present failed to evidence any events for R1. Review of R1's clinical record failed to evidence documentation of allegations of abuse by R1 or R1's family. On 9/27/2023 at 11:40 a.m., an interview was conducted with ASM (administrative staff member) #1, the executive director. ASM #1 stated that they had several meetings with R1's son to discuss their care and concerns when they were at the facility. He stated that R1's son had discussed concerns regarding obtaining medical records, having to pay a fee for the records, call bell response, R1's medications, the resident's room not being clean, the attitudes of some of the CNA's (certified nursing assistants) and the end of skilled services at the facility. When asked if he received any email correspondence from R1's son regarding concerns, he stated that he had not received any directly from the son but had received an email from (Name of Senator's) office on 9/22/2023 which had concerns that R1 was being discharged for retaliation purposes. He stated that he did not go through the email completely because the parts that he saw were saying that they were deceptive and covering up the truth. When asked about the allegation of being shaken after pushing the call bell on 9/15/2023, ASM #1 stated that he was not aware of any allegations of R1 being shaken by anyone and he did not believe that it took place in any way, shape or form but he would have reported the allegation if it were brought to his attention. On 9/27/2023 at 12:45 p.m., ASM #1 provided a printed copy of the email addressed to them dated 9/22/2023 1:01 p.m. which documented in part, . Attached is correspondence from (Name of R1's son) regarding his mother, (Name of R1), who was a resident at (Name of facility). We are forwarding this correspondence as a courtesy to the family . The attached documented in part, Statement of Problem. Patient/Resident: (Name of R1). I am writing to once again formally communicate my horror and concerns of multiple incidents of elder abuse, flagrant violations of Resident's rights (per the Code of Federal Regulation), and medical malpractice that my helpless (age and name of R1), has experienced while in the care of you and your staff at (Name of facility) . b. When staff did respond to her (in the absence of advocates), they spoke to her in a threatening and aggressive manner saying disrespectful things to her like: What to you want now? or What is it now?. This was obviously done to intimidate her and make her feel scared to push the call button . e. My mom told me of one incident on 9/15/23 where she said: A lady grabbed me and shook me one evening after I pushed the call. That is clear criminal assault . 6. Physical assault from caregivers. She told me that a lady grabbed me and shook me after I pushed the call button for help. Unexplained cuts, bruises, and injuries . On 9/27/2023 at 1:20 p.m., ASM #1, the executive director was made aware of the findings. ASM #1 stated that they did not send a report because the resident was already discharged from the facility when they received the email and they did not read it completely. He stated that they had met with the son and the long term care ombudsman on the day of discharge and no one had reported any allegations of abuse to them at that time and they would have reported it if they had. No further information was provided prior to exit. As of 10/2/2023, the State Agency had not received notification from the facility staff of the allegation of abuse.

Based on staff interview and clinical record review, it was determined that the facility staff failed to maintain an accurate MDS (minimum data set) assessment for one of 28 residents in the survey sample, Resident #29. The findings include: For Resident #29 (R29), the facility staff failed to code the quarterly MDS assessment with an ARD (assessment reference date) of 2/27/2023 for hospice services received during the assessment period. Review of the clinical record for R29 revealed the most recent MDS assessment to be a quarterly MDS with an ARD of 2/27/2023. Section O of the assessment failed to document R29 receiving hospice services during the assessment period. The physician orders for R29 documented in part, Admit to [Name of hospice] for Alzheimer's disease. Order Date: 11/24/2022. The comprehensive care plan for R29 failed to evidence a care plan related to hospice services. On 5/2/2023 at 1:45 p.m., an interview was conducted with RN (registered nurse) #2, MDS coordinator. RN #2 stated that they used the RAI (resident assessment instrument) manual when completing the MDS assessments. RN #2 reviewed R29's quarterly MDS assessment with the ARD of 2/27/2023 and stated that it looked like it was not coded for hospice services. RN #2 stated that R29 was receiving hospice services during the assessment period and that it should have been marked on the assessment. According to the RAI Manual, Version 1.16, dated October 2018, section O0100 documented in the steps for assessment, 1. Review the resident's medical record to determine whether or not the resident received or performed any of the treatments, procedures, or programs within the last 14 days .O0100K, Hospice Care, Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. The hospice must be licensed by the state as a hospice provider and/or certified under the Medicare program as a hospice provider . On 5/2/2023 at 4:03 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the assistant administrator were made aware of the concern. No further information was provided prior to exit.

Based on staff interview, clinical record review, and facility documentation review, it was determined that the facility failed to promote and facilitate the resident's right to self-determination by promoting resident's choice in desired bedtime for one of 28 residents in the survey sample, Resident #23. The findings included: For Resident #23, the facility staff failed to promote the resident's desired bedtime. Resident #23 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: right lower leg fracture, DM (diabetes mellitus) and depression. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 3/20/23, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring limited assistance for bed mobility, transfer, walking, locomotion, dressing, eating, hygiene and bathing. A review of the comprehensive care plan dated 1/3/22, which revealed, PROBLEM: ADLs (activities of daily living) Functional Status/Rehabilitation Potential. Resident has alteration in ADL function due to weakness associated with right tibia/fibula fracture. Risk factors include impaired mobility, muscle weakness and NWB (non-weight bearing) status. APPROACH: Allow me choices regarding my preference with where I would like to eat, picking out clothing, taking baths/showers and how I would like to accept my medications. Assist with turning and repositioning on rounds and as needed. A review of the ADL form dated 4/30/23 at 7:00 PM, revealed, How did resident transfer? Activity did not occur. No other documentation on the ADL form for evening shift on 4/30/23. An interview was conducted with Resident #23 on 5/1/23 at 11:01 AM. Resident #23 stated, It took almost three hours for me to be able to get in bed on April 30th. I started calling every 15 minutes beginning at 9:00 PM till close to 12:00 AM when the night aide put me to bed. The evening aide would come into the room and shut off the light and tell me she would be back and never returned. Resident #23 was asked to push the call button which revealed it was functioning, and a nurse answered. When asked how the call system functioned, LPN (licensed practical nurse) #1 stated, the call bells go to the call bell phone that the CNAs (certified nursing assistant) carry. An interview was conducted on 5/1/23 at 2:45 PM with ASM (administrative staff member) #2, the director of nursing. When asked if she had been informed of the delay in getting Resident #23 into bed on evening shift 4/30/23, ASM #2 stated, yes, the executive director spoke with the daughter. This was an agency CNA and there will not be any agency CNAs assigned to Resident #23. An interview was conducted on 5/2/23 at 8:50 AM with Resident #23, when asked how their evening went, Resident #23 stated, It was great, they put me to bed when I wanted to go. On 5/2/23 at approximately 4:00 PM, ASM #1, the executive director, ASM #2, the director of nursing and ASM #3, the assistant administrator was made aware of the findings. On 5/3/23 at 9:15 AM, ASM #2, the director of nursing stated, in regard to the CNA with this resident, I have tried to contact her and she has not called me back, I called her agency and she still has not responded. Since she cannot be bothered to return my calls, she will not be back. According to the facility's policy Medical Care Rights in a Nursing Facility dated 12/2016, revealed, The Resident has the right to be fully informed in language that he or she can understand of his/her total health status, including but not limited to, his/her medical condition. The Resident has the right to refuse treatment and to refuse to participate in experimental research, and also the right to request treatment and/or discontinue treatment. Moreover, the Resident has the right to: Choose a personal attending physician; Be fully informed in advance about care and treatment, type of professional delivering care, risks and benefits of treatment and options, and of any changes in that care of treatment that may affect the Resident's well-being, and; insofar as possible, the Facility will assist Residents to use their preferred health care providers and to participate in planning their programs of care and services while in the Facility, and will respect each Resident's decision about accepting or refusing medical care. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to assess one of 28 residents in the survey sample for self-administration of medication, Resident #41. The findings include: For Resident #41 (R41), two bottles of diabetic Tussin (1) liquid medication and two bottles of Systane (2) lubricant eye drops were observed at the bedside in R41's room unsecured. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 4/14/2023, the resident scored 11 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately impaired for making daily decisions. On 5/2/2023 at 10:14 a.m., an observation of R41's room was conducted. Two bottles of diabetic Tussin liquid medication were observed on a corner shelf storage rack, one four ounce bottle was observed to be unopened and one 8 ounce bottle was observed to be approximately three-quarters full. Two bottles of Systane lubricant eye drops were observed on the window sill to the right of R41's bed. Both bottles contained liquid inside. At that time, an interview was conducted with R41. When asked about the Tussin liquid medication, R41 stated that their daughter had brought the medication in and they had not taken any recently. When asked about the Systane lubricant eye drops, R41 stated that one bottle was given to them by the facility staff and they had purchased the other bottle. R41 stated that they put one drop in both eyes daily and it was effective. Additional observations of R41's room at 5/2/2023 at 2:00 p.m. revealed the two bottles of Tussin liquid medication on the corner shelf storage rack and two bottles of Systane lubricant eye drops on the window sill in the room. The physician orders for R41 failed to evidence an order for Systane lubricant eye drops or diabetic Tussin liquid medication or self-administration of medications. Review of R41's clinical record failed to evidence an assessment for self-administration of medications. On 5/2/2023 at approximately 2:00 p.m., a request was made to ASM (administrative staff member) #1, the executive director for evidence of a self-administration of medication assessment for R41 and the facility policy for self-administration of medications. On 5/2/2023 at 2:15 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that when a resident wanted to self-administer medications they notified the physician and completed an assessment to determine whether the resident was able to self-administer their medication. LPN #1 stated that they were required to observe the resident self-administering their medication to make sure they were able to perform the task and then they would put in an order for the medications that could be self-administered and left at the bedside. LPN #1 observed the two bottles of Tussin liquid medication and two bottles of Systane lubricant eye drops in R41's room and stated that they did not know if R41 was able to self-administer the medication or how it was to be stored in the room. LPN #1 stated that they typically do not lock medications up when residents self-administer medications and they thought that it would depend on the medication. LPN #1 stated that they would have to confirm with the director of nursing. On 5/2/2023 at approximately 4:00 p.m., ASM #2, the director of nursing stated that R41 did not have a medication self-administration assessment. ASM #2 stated that R41 should not have any medications in their room and they were not able to self-administer their medications. ASM #2 stated that they had residents who self-administered medications and some stored the medications in drawers and some kept them beside them. ASM #2 stated that the storage depended on the medication. On 5/2/2023 at approximately 4:03 p.m., ASM #1, the executive director stated that they did not have a policy regarding self-administration of medications. On 5/2/2023 at approximately 4:05 p.m., ASM #1, the executive director, ASM #2, the director of nursing and ASM #3, the assistant administrator were made aware of the concern. No further information was presented prior to exit. The facility policy, Medical Care Rights in Nursing Facility dated 12/31/2016 documented in part, .Each Resident has the right to self-administer medications. The interdisciplinary team will determined for each Resident that this practice is clinically appropriate. Such determinations will be documented in the Resident's plan of care . Reference: (1) Tussin Guaifenesin is used to relieve chest congestion. Guaifenesin may help control symptoms but does not treat the cause of symptoms or speed recovery. Guaifenesin is in a class of medications called expectorants. It works by thinning the mucus in the air passages to make it easier to cough up the mucus and clear the airways. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682494.html (2) Systane Systane is used in adults to relieve burning, irritation, and discomfort caused by dry eyes. This information was obtained from the webstie: https://www.drugs.com/mtm/systane.html

Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure a resident was free from significant medication errors for one of 20 residents in the survey sample, Resident #10. The facility staff failed to administer the correct physician ordered medications to Resident #10. LPN (Licensed practical nurse) #4 administered Resident #4's medications ([MEDICATION NAME] (1), [MEDICATION NAME] (2) and [MEDICATION NAME](3)) to Resident #10 on [DATE]. These significant medication errors resulted in a change in condition (including diaphoresis (sweating), nausea, a lowered blood pressure and a lowered pulse) and Resident #10's hospitalization where the resident received [MEDICATION NAME] (4), IV (intravenous) fluids and telemetry (heart) monitoring. The findings include: Resident #4 was admitted to the facility on [DATE]. Resident #4's [DIAGNOSES REDACTED]. Resident #4's most recent MDS (minimum data set), a significant change in status assessment with an ARD (assessment reference date) of [DATE], coded the resident's cognition as moderately impaired. Review of Resident #4's physician's orders [REDACTED].>-[DATE]- [MEDICATION NAME] 0.1 mg (milligrams) twice daily scheduled at 9:00 a.m. and 5:00 p.m. -[DATE]- [MEDICATION NAME] 0.5 mg twice daily scheduled at 6:00 a.m. and 6:00 p.m. -[DATE]- [MEDICATION NAME] every 12 hours scheduled at 6:00 a.m. and 6:00 p.m. Resident #10 was admitted to the facility on [DATE]. Resident #10's [DIAGNOSES REDACTED]. Resident #10's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of [DATE], coded the resident's cognition as moderately impaired. Review of Resident #10's (MONTH) (YEAR) physician's orders [REDACTED]. Review of Resident #10's (MONTH) (YEAR) MAR (medication administration record) revealed the resident's blood pressure was documented as ,[DATE] on [DATE] at 8:30 a.m. and ,[DATE] on [DATE] at 2:30 p.m. Review of Resident #10's vital sign record revealed the resident's pulse was documented as 82 on [DATE] at 8:56 a.m. A FRI (facility reported incident) submitted to the OLC (office of licensure and certification) on [DATE] documented, On [DATE] during the 5 pm medication administration pass, the resident, (name of Resident #10), was administered medications ordered for another resident. The attending MD (medical doctor) was immediately notified of the incident and informed the nurse to monitor the resident and report back to him in an hour. The resident remained alert but did complain of nausea. Her blood pressure and pulse were below her normal range, so the MD ordered her to be sent to the ER (emergency room ) to be evaluated. The responsible party was notified. An investigation is pending. A nurse's note dated [DATE] documented, After medication discrepancy V/S (vital signs) taken ,[DATE] (blood pressure), P (pulse) 72, R (respirations) 18, Spo2 (oxygen saturation) 95% RA (room air), Temp (temperature) 96.4, MD notified, new orders noted to monitor for s/sx (signs and symptoms) of diaphoresis, monitor V/S q (every) hr (hour), call back with V/S in 1 hr. RP (Responsible party) called no answer left message awaiting return call. Approx (Approximately) 645pm V/S obtained B/P (blood pressure) ,[DATE] P 49 resident noted diaphoretic, writer called MD notify, new order send resident to ER for eval (evaluation). Resident states fell s (sic) nauseated, v/s taken B/P noted ,[DATE], resident noted pale increase (sic) sweating noted. Last set of V/S taken prior to EMS (emergency medical services) arriving noted ,[DATE] (blood pressure) P 47, resident noted sitting up in bed, responsive to verbal stimuli, no emesis noted. EMS arrived, resident left building with EMS approx 740PM to (name of hospital) ER. A hospital history and physical dated [DATE] documented, Chief complaint of changes in blood pressure and heart rate after receiving 0.5 mg of [MEDICATION NAME], as well as 15 mg of MS Contin. Patient was given these medications at the (sic) approximately 5:50 p.m. tonight at the nursing home. Her blood pressure went from around 130 systolic to 103 systolic, and her heart rate went from the 70s down to the 50s so the patient was sent to the ER. I spoke to the nurse at the nursing home to obtain this history. She was not sure why the patient was given these medications, but states it may have been in error. No other reports of illness. A medication discrepancy report signed by ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) on [DATE] documented, RESIDENT NAME: (name of Resident #10). Immediate Action taken to counteract medication error: Vital signs immediately obtained, MD and family notified. Order obtained to monitor VS (vital signs) Q (every) 1 hr (hour). Outcome to Resident: felt nauseous and with VS changes. Doctor's Response: MD called with VS changes and order to send to ER for further evaluation. Family Response: Family responsive to orders. Name and Title of Staff Person Administering Medication: (Name and title of LPN #4). Check items that are applicable: (a check beside) The medication dosage was correct but given to the wrong resident . A follow up report submitted to the OLC on [DATE] documented, Dear Sir/Madam, The purpose of this letter is to provide your agency with more information regarding the medication error report sent to your office on July, 16, (YEAR) involving the resident, (name of Resident #10). (Name of Resident #10) received [MEDICATION NAME] Release 15 milligram tablet, [MEDICATION NAME] 0.5 milligram tablet, and [MEDICATION NAME] 0.1 milligram tablet which was prepared for administration for another resident, (name of Resident #4), during the 5 pm medication pass on [DATE]. (Name of LPN #4), LPN, was the nurse who administered the medication to (name of Resident #10). (Name of LPN #4) was hired on [DATE] and has held an LPN license for [AGE] years. She completed her general orientation and (name of computer software program) training after hire at this facility on [DATE]. (Name of LPN #4) was administering medications under the supervision of (name and title of RN (registered nurse) #2), on the ,[DATE] shift on [DATE]. (Name of RN #2) has been employed at the facility since [DATE] serving as the MDS coordinator. (Name of RN #2) was an LPN for 8 years and became an RN [AGE] years ago. (Name of RN #2) was observing (name of LPN #4) pour and pass each medication on one medication cart. That medication cart stores the medications for 20 residents on that hall. (Name of RN #2) is not routinely scheduled to administer medications, but does help pass medications when extra help is needed to adhere to the facility medication pass schedule. (Name of LPN #4) and (name of RN #2) selected (name of Resident #4's) medication profile on the Matrix screen. The medications were prepared following the facility policy. (Name of LPN #4) and (name of RN #2) entered the room together and (name of RN #2) identified (name of Resident #10). Immediately after (name of Resident #10) had swallowed the medications, the nurses realized that the meds (medications) prepared were those ordered for (name of Resident #4). This incident occurred at about 5:50 pm. (Name of Resident #10's) attending physician, (name of physician), was immediately notified of the medication error. (Name of physician) asked that the resident be monitored for diaphoresis and that her vital signs be obtained every hour. (Name of Resident #10's) blood pressure at that time was ,[DATE] and her pulse was 72. At approximately 6:45 pm the resident was noted to be diaphoretic with a blood pressure of ,[DATE] and her pulse rate was 49. The resident, who was responsive to verbal stimuli, voiced a complaint of some nausea. (Name of physician) was notified of the findings of the ongoing physical assessment and ordered (name of Resident #10) be sent to (name of hospital) for evaluation. The resident was transported to (name of hospital) at 7:40 pm. The resident's daughter was notified of the incident and that the resident was being sent to the ER (emergency room ) .INVESTIGATION/CONCLUSION: During their nursing career neither (name of LPN #4) nor (name of RN #2) have experienced a medication error which resulted in a resident being sent to the ER. The (name of pharmacy) 'General Dose Preparation and Medication Administration Policy' has been reviewed with both nurses. Facility nursing administration has observed a medication pass with (name of LPN #4) and will conduct an observed med pass with (name of RN #2) on her next scheduled day to work. (Name of LPN #4) exhibited proficiency with her observed med pass. The other facility licensed nurses will receive a review of the (name of pharmacy) med pass policy. Observed medication passes will continue to be ongoing for facility nurses. (Name of Resident #10) was kept at the hospital for observation and will be returning to this facility today. Facility staff met with the resident's son and daughter, explained the incident, and informed them of the actions being taken to prevent any further resident care issues . The hospital discharge summary dated [DATE] documented, BRIEF HOSPITAL COURSE: A [AGE] year-old with history of hypertension (high blood pressure), ischemic stroke, left-sided [MEDICAL CONDITION] (paralysis), brought to the hospital from nursing home due to lethargy. The patient was given wrong medication [MEDICATION NAME] ([MEDICATION NAME]). Family was notified as per the history and physical and patient was sent to the emergency room from the nursing home with lethargy. She had been evaluated in the emergency room . A CT (computed tomography) head showed old right MCA (middle cerebral artery) infarct. She received [MEDICATION NAME] and was admitted to the telemetry, treated with IV fluids and was monitored on telemetry. Her lethargy improved while she was in the hospital. She is back to her baseline at this point . A note signed by the nurse practitioner on [DATE] documented, CC (Chief complaint): Follow up from hospital. Interval History: Was asked to see patient to evaluate after admission to the hospital. Nursing reports that patient is returning to facility after staying overnight in the hospital. Patient had received another patient's medications and then started with [MEDICAL CONDITION] (low blood pressure), [MEDICAL CONDITION] (low heart rate), diaphoresis and c/o (complaint of) nausea. Patient was monitored in the hospital and received IVF (intravenous fluids) . Resident #10's comprehensive care plan with a problem start date of [DATE] documented, Resident is at risk for adverse side effects of 9+ meds (medications) XXX[DATE] Medication discrepancy . The nurse who administered the wrong medications to Resident #10 was no longer employed at the facility and was not available for interview. On [DATE] at 4:38 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 was asked how she ensures she administers the correct medication to the correct resident. LPN #3 stated the resident's name is on the medication package and she writes the resident's room number on the medication cup. LPN #3 stated she compares the room number to what she writes on the medication cup and the medication package with the resident's name. LPN #3 also confirmed residents' pictures are located on the MAR (medication administration record). On [DATE] at 8:18 a.m., an interview was conducted with LPN #6. LPN #6 was asked how she ensures she administers the correct medication to the correct resident. LPN #6 stated, We have pictures and I also call them by name. On [DATE] at 9:39 a.m., an interview was conducted with RN #2 (the MDS nurse who supervised LPN #4 on [DATE]). RN #2 was asked to describe her experience with medication administration in the facility. RN #2 stated that during (MONTH) (YEAR) she was on the floor a couple of times during that month. RN #2 stated she was not actually administering medications but she was overseeing other staff members administer medications. When asked why, RN #2 stated there were some staffing challenges and the supervisors were trying to get the newly hired nurses comfortable and acclimated to the residents so the nurses did not feel they were by themselves. When asked how nurses ensure the correct medication is administered to the correct resident, RN #2 stated, Checking against the MARs, the medication packet. We have photos in the (name of computer MAR indicated [REDACTED]. RN #2 stated she was in the vicinity, of the medication cart but not actually standing at the cart when LPN #4 was preparing medications. RN #2 stated LPN #4 prepared medications and asked her to show her who Resident #10 was. RN #2 stated she walked LPN #4 over to Resident #10, introduced her to Resident #10 and LPN #4 administered medications to the resident. RN #2 stated LPN #4 went back to the medication cart and pulled the next medication listing minutes after administering medications to Resident #10. RN #2 stated she guessed this is when LPN #4 realized she administered Resident #4's medications to Resident #10 because LPN #4 came to her and said she gave Resident #4's medications to Resident #10. RN #2 stated after this, the nurses immediately obtained Resident #10's vital signs, which were stable so the nurses immediately notified the physician. RN #2 stated the physician responded by telling the nurses to monitor Resident #10's vital signs every hour and monitor the resident for diaphoresis. RN #2 stated she believed sometime afterward, Resident #10's blood pressure became low and the resident complained of not feeling well so LPN #4 notified the physician of the changes in condition and the physician ordered for Resident #10 to be sent to the emergency room . On [DATE] at 10:16 a.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 was asked the facility process for newly hired nurses administering medications. ASM #2 stated depending on the individual nurse's abilities, usually the nurse shadows another nurse on the medication cart during day two and day three then the nurse administers medications on day four. ASM #2 stated another nurse is present in the area if the newly hired nurse has questions or concerns but the other nurse is not with the newly hired nurse at all times. ASM #2 stated on [DATE], another nurse was overseeing LPN #4. ASM #2 was asked how nurses are supposed to ensure they administer the correct medications to the correct resident. ASM #2 stated many residents in the facility are able to state who they are. ASM #2 stated the facility does not use armbands but residents' names are documented outside their room doors and residents' pictures are located on the MARs. ASM #2 was asked to describe the incident regarding Resident #10 that occurred on [DATE]. ASM #2 stated she was not in the building at the time but LPN #4 called her so she asked LPN #4 what happened and made sure LPN #4 called the physician and family. ASM #2 stated she believed the physician told LPN #4 to do vital signs and monitor the resident. ASM #2 stated she guessed LPN #4 did not really know Resident #10 and Resident #10 was at her baseline the whole time. When asked if the resident's pulse of 49 was normal and at the resident's baseline, ASM #2 stated, That wasn't normal. When asked to explain what she meant about Resident #10 being at her baseline the whole time, ASM #2 stated the resident's physical and activity of daily living presentation was at baseline and the resident always presented with a slumping posture and affected speech. When asked how she knew Resident #10 was at her baseline on [DATE] if she was not in the building, ASM #2 stated she knew by the description LPN #4 gave her and there was another nurse (LPN #5) present that stated Resident #10 looked like her typical self. When asked if Resident #10's vital signs were at her typical baseline, ASM #2 confirmed they were not. ASM #2 stated LPN #4 monitored Resident #10 and said the resident's pulse was getting lower so she sent the resident to the ER. ASM #2 stated Resident #10 was gone by the time she got to the building. On [DATE] at 3:05 p.m., an interview was conducted with LPN #5. LPN #5 was asked to describe the incident regarding Resident #10 that occurred on [DATE]. LPN #5 stated, I called her name. She could respond. She wasn't talking but could say year or no and (name of resident) has a really low voice so you have to lean in to actually hear her. She looked a little sleepy. When asked if she looked sleepier than her usual baseline, LPN #5 stated, Yes. When asked if Resident #10's vital signs were at her baseline on [DATE], LPN #5 stated, By the time I had gotten to the room the nurse had taken her vitals and called the doctor and called the ambulance. When asked if Resident #10 was typically diaphoretic, LPN #5 stated, No. When asked if she recalled Resident #10 being diaphoretic, LPN #5 stated, No. When asked if she recalled Resident #10 being nauseous, LPN #5 stated, No. Like I said, the nurse had already assessed and called 911. I was in there for a couple minutes before 911 was there. When asked if Resident #10 was typically nauseous, LPN #5 stated, No. When asked if Resident #10's pulse was typically 47, LPN #5 stated, No. On [DATE] at 4:21 p.m., ASM #1 (the administrator) and ASM #2 were made aware of the above concern and the concern for harm. ASM #1 and ASM #2 were asked to provide any further information. The facility policy titled, Administration of Medications documented, 5. Before administering the medication or dietary supplement, check to see that the following are correct: a. the right medication b. the right dosage and strength c. the right resident (photo identification with MAR indicated [REDACTED] d. the right time e. the right route, and f. the right form (i.e. tablet, liquid, capsule, or other) g. no known allergy h. the medication is not damaged, contaminated, or expired . The facility policy titled, Orientation Outline Nursing documented, l. Administration of Medication- The employee is to follow the facility medication administration policy and procedure . On [DATE] at approximately 12:00 p.m., ASM #1 and ASM #2 provided an in-service meeting sign in sheet dated [DATE]. The topic was General Dose Preparation & Medication Administration. ASM #2 confirmed the in-service was not provided to all nurses. No further information was presented prior to exit. (1) [MEDICATION NAME] used to treat high blood pressure. Side effects are usually mild and include sedation, fatigue, [MEDICAL CONDITION] (slow heartbeat), dry mouth, headaches, dizziness, postural [MEDICAL CONDITION], male impotence and gastrointestinal upset. https://livertox.nih.gov/[MEDICATION NAME].htm (2) [MEDICATION NAME] ([MEDICATION NAME]) is a benzodiazepine used to treat anxiety: Clinically Significant Drug Interactions: The benzodiazepines, including [MEDICATION NAME] ([MEDICATION NAME]), produce increased CNS-depressant effects when administered with other CNS depressants such as alcohol, barbiturates, antipsychotics, sedative/hypnotics, anxiolytics, antidepressants, narcotic [MEDICATION NAME], sedative [MEDICATION NAME], anticonvulsants, and anesthetics. This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=ba6ce50e-c5a,[DATE]ca-9803-a1ed b0e (3) [MEDICATION NAME] an opioid agonist indicated for the management of pain. BOXED WARNING: WARNING in part: LIFE-THREATENING RESPIRATORY DEPRESSION; and RISKS FROM CONCOMITANT USE WITH BENZODIAZEPINES OR OTHER CNS DEPRESSANTS Life-Threatening Respiratory Depression Serious, life-threatening, or fatal respiratory depression may occur with use of MS CONTIN. Monitor for respiratory depression, especially during initiation of [MEDICATION NAME] Risks From Concomitant Use With Benzodiazepines Or Other CNS Depressants Concomitant use of opioids with benzodiazepines or other central nervous system (CNS) depressants, including alcohol, may result in profound sedation, respiratory depression, coma, and death. Clinically Significant Drug Interactions with MS CONTIN: Due to additive pharmacologic effect, the concomitant use of benzodiazepines or other CNS depressants, including alcohol, can increase the risk of [MEDICAL CONDITION], respiratory depression, profound sedation, coma, and death. This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=e0472c,[DATE]f,[DATE]e,[DATE]b,[DATE]b2e9ff65f6#boxedwarning (4) [MEDICATION NAME] is used to treat opioid (including MS Contin) overdose. This information was obtained from the website: https://www.samhsa.gov/medication-assisted-treatment/treatment/[MEDICATION NAME]

Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to follow professional standards of quality practice for two of 20 residents in the survey sample, Residents #10 and #128. 1. The facility staff failed to administer the correct physician ordered medications to Resident #10. LPN (Licensed practical nurse) #4 administered Resident #4's medications ([MEDICATION NAME] and MS Contin) to Resident #10 on [DATE]. This resulted in a change in condition (including diaphoresis, nausea, a lowered blood pressure and a lowered pulse) and Resident #10's hospitalization where the resident received [MEDICATION NAME], IV (intravenous) fluids and telemetry (heart) monitoring. 2. The facility staff failed to administer the correct physician ordered medication (senna s (senna with [MEDICATION NAME])) to Resident #128 on [DATE]. LPN #6 administered Resident #78's senna with no [MEDICATION NAME] to Resident #128. The findings include: 1. The facility staff failed to administer the correct physician ordered medications to Resident #10. LPN (Licensed practical nurse) #4 administered Resident #4's medications ([MEDICATION NAME] (1), [MEDICATION NAME] (2) and [MEDICATION NAME](3)) to Resident #10 on [DATE]. This resulted in a change in condition (including diaphoresis (sweating), nausea, a lowered blood pressure and a lowered pulse) and Resident #10's hospitalization where the resident received [MEDICATION NAME] (4), IV (intravenous) fluids and telemetry (heart) monitoring. Resident #4 was admitted to the facility on [DATE]. Resident #4's [DIAGNOSES REDACTED]. Resident #4's most recent MDS (minimum data set), a significant change in status assessment with an ARD (assessment reference date) of [DATE], coded the resident's cognition as moderately impaired. Review of Resident #4's physician's orders [REDACTED].>-[DATE]- [MEDICATION NAME] 0.1 mg (milligrams) twice daily scheduled at 9:00 a.m. and 5:00 p.m. -[DATE]- [MEDICATION NAME] 0.5 mg twice daily scheduled at 6:00 a.m. and 6:00 p.m. -[DATE]- [MEDICATION NAME] mg every 12 hours scheduled at 6:00 a.m. and 6:00 p.m. Resident #10 was admitted to the facility on [DATE]. Resident #10's [DIAGNOSES REDACTED]. Resident #10's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of [DATE], coded the resident's cognition as moderately impaired. Review of Resident #10's (MONTH) (YEAR) physician's orders [REDACTED]. Review of Resident #10's (MONTH) (YEAR) MAR (medication administration record) revealed the resident's blood pressure was documented as ,[DATE] on [DATE] at 8:30 a.m. and ,[DATE] on [DATE] at 2:30 p.m. Review of Resident #10's vital sign record revealed the resident's pulse was documented as 82 on [DATE] at 8:56 a.m. A FRI (facility reported incident) submitted to the OLC (office of licensure and certification) on [DATE] documented, On [DATE] during the 5 pm medication administration pass, the resident, (name of Resident #10), was administered medications ordered for another resident. The attending MD (medical doctor) was immediately notified of the incident and informed the nurse to monitor the resident and report back to him in an hour. The resident remained alert but did complain of nausea. Her blood pressure and pulse were below her normal range, so the MD ordered her to be sent to the ER (emergency room ) to be evaluated. The responsible party was notified. An investigation is pending. A nurse's note dated [DATE] documented, After medication discrepancy V/S (vital signs) taken ,[DATE] (blood pressure), P (pulse) 72, R (respirations) 18, Spo2 (oxygen saturation) 95% RA (room air), Temp (temperature) 96.4, MD notified, new orders noted to monitor for s/sx (signs and symptoms) of diaphoresis, monitor V/S q (every) hr (hour), call back with V/S in 1 hr. RP (Responsible party) called no answer left message awaiting return call. Approx (Approximately) 645pm V/S obtained B/P (blood pressure) ,[DATE] P 49 resident noted diaphoretic, writer called MD notify, new order send resident to ER for eval (evaluation). Resident states fell s (sic) nauseated, v/s taken B/P noted ,[DATE], resident noted pale increase (sic) sweating noted. Last set of V/S taken prior to EMS (emergency medical services) arriving noted ,[DATE] (blood pressure) P 47, resident noted sitting up in bed, responsive to verbal stimuli, no emesis noted. EMS arrived, resident left building with EMS approx 740PM to (name of hospital) ER. A hospital history and physical dated [DATE] documented, Chief complaint of changes in blood pressure and heart rate after receiving 0.5 mg of [MEDICATION NAME], as well as 15 mg of MS Contin. Patient was given these medications at the (sic) approximately 5:50 p.m. tonight at the nursing home. Her blood pressure went from around 130 systolic to 103 systolic, and her heart rate went from the 70s down to the 50s so the patient was sent to the ER. I spoke to the nurse at the nursing home to obtain this history. She was not sure why the patient was given these medications, but states it may have been in error. No other reports of illness. A medication discrepancy report signed by ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) on [DATE] documented, RESIDENT NAME: (name of Resident #10). Immediate Action taken to counteract medication error: Vital signs immediately obtained, MD and family notified. Order obtained to monitor VS (vital signs) Q (every) 1 hr (hour). Outcome to Resident: felt nauseous and with VS changes. Doctor's Response: MD called with VS changes and order to send to ER for further evaluation. Family Response: Family responsive to orders. Name and Title of Staff Person Administering Medication: (Name and title of LPN #4). Check items that are applicable: (a check beside) The medication dosage was correct but given to the wrong resident . A follow up report submitted to the OLC on [DATE] documented, Dear Sir/Madam, The purpose of this letter is to provide your agency with more information regarding the medication error report sent to your office on July, 16, (YEAR) involving the resident, (name of Resident #10). (Name of Resident #10) received [MEDICATION NAME] Release 15 milligram tablet, [MEDICATION NAME] 0.5 milligram tablet, and [MEDICATION NAME] 0.1 milligram tablet which was prepared for administration for another resident, (name of Resident #4), during the 5 pm medication pass on [DATE]. (Name of LPN #4), LPN, was the nurse who administered the medication to (name of Resident #10). (Name of LPN #4) was hired on [DATE] and has held an LPN license for [AGE] years. She completed her general orientation and (name of computer software program) training after hire at this facility on [DATE]. (Name of LPN #4) was administering medications under the supervision of (name and title of RN (registered nurse) #2), on the ,[DATE] shift on [DATE]. (Name of RN #2) has been employed at the facility since [DATE] serving as the MDS coordinator. (Name of RN #2) was an LPN for 8 years and became an RN [AGE] years ago. (Name of RN #2) was observing (name of LPN #4) pour and pass each medication on one medication cart. That medication cart stores the medications for 20 residents on that hall. (Name of RN #2) is not routinely scheduled to administer medications, but does help pass medications when extra help is needed to adhere to the facility medication pass schedule. (Name of LPN #4) and (name of RN #2) selected (name of Resident #4's) medication profile on the Matrix screen. The medications were prepared following the facility policy. (Name of LPN #4) and (name of RN #2) entered the room together and (name of RN #2) identified (name of Resident #10). Immediately after (name of Resident #10) had swallowed the medications, the nurses realized that the meds (medications) prepared were those ordered for (name of Resident #4). This incident occurred at about 5:50 pm. (Name of Resident #10's) attending physician, (name of physician), was immediately notified of the medication error. (Name of physician) asked that the resident be monitored for diaphoresis and that her vital signs be obtained every hour. (Name of Resident #10's) blood pressure at that time was ,[DATE] and her pulse was 72. At approximately 6:45 pm the resident was noted to be diaphoretic with a blood pressure of ,[DATE] and her pulse rate was 49. The resident, who was responsive to verbal stimuli, voiced a complaint of some nausea. (Name of physician) was notified of the findings of the ongoing physical assessment and ordered (name of Resident #10) be sent to (name of hospital) for evaluation. The resident was transported to (name of hospital) at 7:40 pm. The resident's daughter was notified of the incident and that the resident was being sent to the ER (emergency room ) .INVESTIGATION/CONCLUSION: During their nursing career neither (name of LPN #4) nor (name of RN #2) have experienced a medication error which resulted in a resident being sent to the ER. The (name of pharmacy) 'General Dose Preparation and Medication Administration Policy' has been reviewed with both nurses. Facility nursing administration has observed a medication pass with (name of LPN #4) and will conduct an observed med pass with (name of RN #2) on her next scheduled day to work. (Name of LPN #4) exhibited proficiency with her observed med pass. The other facility licensed nurses will receive a review of the (name of pharmacy) med pass policy. Observed medication passes will continue to be ongoing for facility nurses. (Name of Resident #10) was kept at the hospital for observation and will be returning to this facility today. Facility staff met with the resident's son and daughter, explained the incident, and informed them of the actions being taken to prevent any further resident care issues . The hospital discharge summary dated [DATE] documented, BRIEF HOSPITAL COURSE: A [AGE] year-old with history of hypertension (high blood pressure), ischemic stroke, left-sided [MEDICAL CONDITION] (paralysis), brought to the hospital from nursing home due to lethargy. The patient was given wrong medication [MEDICATION NAME] ([MEDICATION NAME]). Family was notified as per the history and physical and patient was sent to the emergency room from the nursing home with lethargy. She had been evaluated in the emergency room . A CT (computed tomography) head showed old right MCA (middle cerebral artery) infarct. She received [MEDICATION NAME] and was admitted to the telemetry, treated with IV fluids and was monitored on telemetry. Her lethargy improved while she was in the hospital. She is back to her baseline at this point . A note signed by the nurse practitioner on [DATE] documented, CC (Chief complaint): Follow up from hospital. Interval History: Was asked to see patient to evaluate after admission to the hospital. Nursing reports that patient is returning to facility after staying overnight in the hospital. Patient had received another patient's medications and then started with [MEDICAL CONDITION] (low blood pressure), [MEDICAL CONDITION] (low heart rate), diaphoresis and c/o (complaint of) nausea. Patient was monitored in the hospital and received IVF (intravenous fluids) . Resident #10's comprehensive care plan with a problem start date of [DATE] documented, Resident is at risk for adverse side effects of 9+ meds (medications) XXX[DATE] Medication discrepancy . The nurse who administered the wrong medications to Resident #10 was no longer employed at the facility and was not available for interview. On [DATE] at 4:38 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 was asked how she ensures she administers the correct medication to the correct resident. LPN #3 stated the resident's name is on the medication package and she writes the resident's room number on the medication cup. LPN #3 stated she compares the room number to what she writes on the medication cup and the medication package with the resident's name. LPN #3 also confirmed residents' pictures are located on the MAR (medication administration record). On [DATE] at 8:18 a.m., an interview was conducted with LPN #6. LPN #6 was asked how she ensures she administers the correct medication to the correct resident. LPN #6 stated, We have pictures and I also call them by name. On [DATE] at 9:39 a.m., an interview was conducted with RN #2 (the MDS nurse who supervised LPN #4 on [DATE]). RN #2 was asked to describe her experience with medication administration in the facility. RN #2 stated that during (MONTH) (YEAR) she was on the floor a couple of times during that month. RN #2 stated she was not actually administering medications but she was overseeing other staff members administer medications. When asked why, RN #2 stated there were some staffing challenges and the supervisors were trying to get the newly hired nurses comfortable and acclimated to the residents so the nurses did not feel they were by themselves. When asked how nurses ensure the correct medication is administered to the correct resident, RN #2 stated, Checking against the MARs, the medication packet. We have photos in the (name of computer MAR indicated [REDACTED]. RN #2 stated she was in the vicinity, of the medication cart but not actually standing at the cart when LPN #4 was preparing medications. RN #2 stated LPN #4 prepared medications and asked her to show her who Resident #10 was. RN #2 stated she walked LPN #4 over to Resident #10, introduced her to Resident #10 and LPN #4 administered medications to the resident. RN #2 stated LPN #4 went back to the medication cart and pulled the next medication listing minutes after administering medications to Resident #10. RN #2 stated she guessed this is when LPN #4 realized she administered Resident #4's medications to Resident #10 because LPN #4 came to her and said she gave Resident #4's medications to Resident #10. RN #2 stated after this, the nurses immediately obtained Resident #10's vital signs, which were stable so the nurses immediately notified the physician. RN #2 stated the physician responded by telling the nurses to monitor Resident #10's vital signs every hour and monitor the resident for diaphoresis. RN #2 stated she believed sometime afterward, Resident #10's blood pressure became low and the resident complained of not feeling well so LPN #4 notified the physician of the changes in condition and the physician ordered for Resident #10 to be sent to the emergency room . On [DATE] at 10:16 a.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 was asked the facility process for newly hired nurses administering medications. ASM #2 stated depending on the individual nurse's abilities, usually the nurse shadows another nurse on the medication cart during day two and day three then the nurse administers medications on day four. ASM #2 stated another nurse is present in the area if the newly hired nurse has questions or concerns but the other nurse is not with the newly hired nurse at all times. ASM #2 stated on [DATE], another nurse was overseeing LPN #4. ASM #2 was asked about the professional standard staff follows for resident identification during medication administration. ASM #2 stated many residents in the facility are able to state who they are. ASM #2 stated the facility does not use armbands but residents' names are documented outside their room doors and residents' pictures are located on the MARs. ASM #2 was asked to describe the incident regarding Resident #10 that occurred on [DATE]. ASM #2 stated she was not in the building at the time but LPN #4 called her so she asked LPN #4 what happened and made sure LPN #4 called the physician and family. ASM #2 stated she believed the physician told LPN #4 to do vital signs and monitor the resident. ASM #2 stated she guessed LPN #4 did not really know Resident #10 and Resident #10 was at her baseline the whole time. When asked if the resident's pulse of 49 was normal and at the resident's baseline, ASM #2 stated, That wasn't normal. When asked to explain what she meant about Resident #10 being at her baseline the whole time, ASM #2 stated the resident's physical and activity of daily living presentation was at baseline and the resident always presented with a slumping posture and affected speech. When asked how she knew Resident #10 was at her baseline on [DATE] if she was not in the building, ASM #2 stated she knew by the description LPN #4 gave her and there was another nurse (LPN #5) present that stated Resident #10 looked like her typical self. When asked if Resident #10's vital signs were at her typical baseline, ASM #2 confirmed they were not. ASM #2 stated LPN #4 monitored Resident #10 and said the resident's pulse was getting lower so she sent the resident to the ER. ASM #2 stated Resident #10 was gone by the time she got to the building. On [DATE] at 3:05 p.m., an interview was conducted with LPN #5. LPN #5 was asked to describe the incident regarding Resident #10 that occurred on [DATE]. LPN #5 stated, I called her name. She could respond. She wasn't talking but could say yes or no and (name of resident) has a really low voice so you have to lean in to actually hear her. She looked a little sleepy. When asked if she looked sleepier than her usual baseline, LPN #5 stated, Yes. When asked if Resident #10's vital signs were at her baseline on [DATE], LPN #5 stated, By the time I had gotten to the room the nurse had taken her vitals and called the doctor and called the ambulance. When asked if Resident #10 was typically diaphoretic, LPN #5 stated, No. When asked if she recalled Resident #10 being diaphoretic, LPN #5 stated, No. When asked if she recalled Resident #10 being nauseous, LPN #5 stated, No. Like I said, the nurse had already assessed and called 911. I was in there for a couple minutes before 911 was there. When asked if Resident #10 was typically nauseous, LPN #5 stated, No. When asked if Resident #10's pulse was typically 47, LPN #5 stated, No. On [DATE] at 4:21 p.m., ASM #1 (the administrator) and ASM #2 were made aware of the above concern and the concern for harm. ASM #1 and ASM #2 were asked to provide any further information. On [DATE] at 10:15 a.m., ASM #2 confirmed the facility utilizes the policy titled, Administration of Medications as a standard of practice. The policy documented, 5. Before administering the medication or dietary supplement, check to see that the following are correct: a. the right medication b. the right dosage and strength c. the right resident (photo identification with MAR indicated [REDACTED] d. the right time e. the right route, and f. the right form (i.e. tablet, liquid, capsule, or other) g. no known allergy h. the medication is not damaged, contaminated, or expired . The facility policy titled, Orientation Outline Nursing documented, l. Administration of Medication- The employee is to follow the facility medication administration policy and procedure . On [DATE] at approximately 12:00 p.m., ASM #1 and ASM #2 provided an in-service meeting sign in sheet dated [DATE]. The topic was General Dose Preparation & Medication Administration. ASM #2 confirmed the in-service was not provided to all nurses. No further information was presented prior to exit. (1) [MEDICATION NAME] is used to treat high blood pressure. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a 3.html (2) [MEDICATION NAME] is used to relieve anxiety. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a 3.html (3) [MEDICATION NAME] used to relieve moderate to severe pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a 3.html (4) [MEDICATION NAME] is used to treat opioid (including MS Contin) overdose. This information was obtained from the website: https://www.samhsa.gov/medication-assisted-treatment/treatment/[MEDICATION NAME] 2. The facility staff failed to administer the correct physician ordered medication (senna s (senna with [MEDICATION NAME])) (1) to Resident #128 on [DATE]. LPN #6 administered Resident #78's senna (2) with no [MEDICATION NAME] to Resident #128. Resident #78 was admitted to the facility on [DATE]. Resident #78's [DIAGNOSES REDACTED]. Resident #78's admission MDS (minimum data set) assessment was not complete. A nursing admission observation dated [DATE] documented Resident #78 as alert and oriented. Review of Resident #78's physician's orders [REDACTED].>Resident #128 was admitted to the facility on [DATE]. Resident #128's [DIAGNOSES REDACTED]. Resident #128's most recent MDS, a 14 day Medicare assessment with an ARD (assessment reference date) of [DATE], coded the resident as being cognitively intact. Resident #128's comprehensive care plan with a problem start date of [DATE] documented, I am at risk for adverse side effects of 9+ meds (medications) .Administer medications as ordered . Review of Resident #128's clinical record revealed a physician's orders [REDACTED]. Resident #128's (MONTH) (YEAR) MAR (medication administration record) documented the same physician's orders [REDACTED].>On [DATE] at 7:55 a.m., LPN (licensed practical nurse) #6 was observed preparing and administering Resident #128's medications. In addition to other medications, LPN #6 removed two tablets of senna (with no [MEDICATION NAME]) (2) 8.6 mg from a package that was labeled with Resident #78's name. LPN #6 administered the medications (including the senna with no [MEDICATION NAME]) to Resident #128. On [DATE] at 10:43 a.m., an interview was conducted with LPN #6. LPN #6 was asked to show this surveyor Resident #128's senna with [MEDICATION NAME]. LPN #6 entered the medication cart, reviewed packages of senna (with no [MEDICATION NAME]) and stated, I gave her (Resident #78's) senna 8.6 milligrams but that is the same dose that is ordered. I'm sorry. LPN #6 was asked to review Resident #128's physician orders. LPN #6 confirmed Resident #128's physician order [REDACTED].#78's senna with no [MEDICATION NAME]. LPN #6 confirmed she did not administer the correct medication to Resident #128. LPN #6 stated she should have double and tripled checked the medications especially since she prepared the medications on a hall with dark lighting. When asked if she should make sure the package has the correct resident's name on it, LPN #6 stated, Yes. On [DATE] at 4:21 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. (1)Senna S (senna with [MEDICATION NAME]) is a combination medication containing senna (a laxative) and [MEDICATION NAME] (a stool softener) and is used to treat constipation. This information was obtained from the websites: https://medlineplus.gov/druginfo/meds/a 3.html and https://medlineplus.gov/druginfo/meds/a 2.html (2) Senna (sennosides with no [MEDICATION NAME]) is a laxative used to treat constipation. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a 2.html

Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to assess, monitor, and provide interventions to prevent and promote healing of a pressure ulcer for one of 12 residents in the survey sample, Resident #3. The facility staff failed to conduct an initial assessment and ongoing wound measurements/assessments for pressure sores. On 7/15/14 Resident #3 was found with a necrotic wound on the outer bottom side of the left foot. The facility staff failed to ongoing assessment/monitoring and measurements of the wound between 7/15/14 and 9/15/14. In addition the facility staff failed to ensure the resident was wearing a physician ordered multi podus boot used to promote wound healing. A stage II pressure ulcer is described as partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough (non viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture). May also present as an intact or open/ruptured blister. An Unstagable pressure wound is a known wound but not stagable due to coverage of wound bed by slough and/or eschar. Eschar is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound. (1) The findings include: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 7/2/14. Resident #3 was coded as scoring nine out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating the resident's cognition was moderately impaired. In Section M, Skin Conditions, the resident was coded as being at risk for developing pressure ulcers. Resident #3 was coded as having a Stage 1* ulcer at the time of the assessment. "Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area." * A review of the clinical record revealed a Braden scale assessment for predicting pressure sore risk dated 4/2/14 which indicated that Resident #3 was at moderate risk for developing a pressure ulcer. There were no other Braden scale assessments in the clinical record. Review of the clinical record revealed Resident #3 was admitted with a Left heel wound described in the nurses' admission note dated 4/2/14, "Pressure ulcer to (L) (left) heel 5.5 x 3.5 x 0." A physician order dated 9/30/14 documented in part, "D/C (discontinue) tx (treatment) w (with)/optimofoam to left heel - healed." Further review of the clinical record did not reveal any wound staging, measurements or additional assessments of the left heel wound between the 4/2/14 date of admission and the 9/30/14 date when the wound healed and the physician discontinued treatment. A review of the physician notes revealed a note dated 6/27/14 that documented, in part: "(L) foot 2nd toe red and tender." A physician note dated 7/15/14 documented, in part, "(L) foot: 2nd toe, medial aspect with 1 cm (centimeter) ulcer with adherent yellow exudates. Mild surrounding [DIAGNOSES REDACTED] (redness). Tender to palpation." There was no documentation in the clinical record that indicated what stage the ulcer was and there were no further assessments or ongoing measurements, staging and monitoring documented in the clinical record. An observation report dated 7/15/14 at 1:23 p.m. documented, in part, the following: "Type of skin condition: Pressure sore. Location of area: On outer side of bottom left foot has pressure area 2cm x 1cm. Character of tissue: Necrotic Tissue." No further assessments or monitoring of this wound were found in the clinical record. A review of the nursing progress notes revealed, in part, the following entries: ? "7/15/14 1:33 p.m. - Hard area with dark tissue around on outside side of left bottom foot 2 cm (centimeters) x 1 cm. RP (responsible party) aware, MD (medical doctor) aware. ? 7/16/14 1:42 p.m. - Obtain new order for [MEDICATION NAME] to left heal (sic) and [MEDICATION NAME] to left side left bottom feet (sic) and change daily until healed. RP (responsible party) aware." An observation report dated 9/18/14 provided a "monthly summary" of Resident #3's health status. Under pressure ulcers there were no pressure ulcers noted. Under treatments, the following was checked, "Other preventative or protective care." There was no clarification provided regarding this documentation. The care plan dated 4/2/14 was an interim care plan. It documented, "Pressure ulcer 2nd stage (L) heel". The care plan dated 5/29/14 documented an identified problem for skin and pressure ulcer with the intervention, "protect bony prominence." A handwritten unsigned revision dated 7/15/14 documented wound area to left heel improvement. A 9/30/14 handwritten entry documented resident noted to have area on outside of foot and 2nd toe. There was no care plan update for the wound found on 7/15/14 on the bottom of the left side of the foot for Resident #3 and there were no wound tracking sheets documented in the record between 7/15/14 and 9/30/14. The following physician orders were documented in the clinical record: ? "5/14/14 - Pt. (patient) provided with LLE (left lower extremity) multipodus boot to promote wound healing and skin integrity." ? "7/16/14 - Apply [MEDICATION NAME] to (L) (left) side bottom feet - change every day until healed." No other orders were documented until 10/20/14. ? "10/20/14 - (L) lateral foot wound. Cleanse with NS (normal saline), apply [MEDICATION NAME] and cover with foam dressing. Secure with tape QOD (every other day) and PRN (as needed. (L) foot. An order dated 10/24/14 written by hospice documented, D/C (discontinue)." ? "10/20/14 - PB (podis ** boot) to lt (left) foot for persistent wound lt lateral foot." ? "10/24/14 - Cleanse with NS L lateral foot. Apply [MEDICATION NAME] and cover with bupilux and change Q (every) 3 days." A review of the physician progress notes [REDACTED].#3's left lateral foot. On 10/29/14 at 11:20 a.m. LPN (licensed practical nurse) #4 (wound care nurse) was observed performing wound care to Resident #3's left lower foot. LPN #4 was asked when the wound was found. LPN #4 stated, "She didn't have it when she came to the facility, it was acquired in July. I didn't know about it until about a week ago." LPN #4 was asked how nursing notifies her of wounds. LPN #4 responded, "I only do wounds one time per week, sometimes they (nursing) tell me sometimes they don't." When asked what stage Resident #3's wound currently was, LPN #4 responded, "It is a Stage II, nursing has been treating the wound, but I didn't know about it until last week." LPN #4 was asked what the multi podus boot was for, LPN #4 responded, "To prevent this wound, and they (the staff) haven't been putting it on." The wound was observed by this surveyor as a dime sized open wound on the lateral side of the left foot, below the fifth toe. No exudate or redness was noted at the site of the wound. LPN #4 completed the dressing change using the current physician orders. On 10/29/14 an event report was created for "Skin Integrity." The following information was documented, in part, by the wound nurse: "Pressure Ulcer: Location and size 2.0 x 2.0 x 0.1. Stage of pressure sore - Stage II. Status - unchanged. Character of wound bed - [MEDICATION NAME]." No other event reports were documented by the wound nurse prior to this date. On 10/29/14 at 1:00 p.m. ASM (administrative staff member) #2, the corporate director for quality assurance, was notified of the concern regarding the wound and a request was made for all documentation regarding the wound from the acquisition date of 7/15/14 to 10/29/14. On 10/29/14 at approximately 3:00 p.m. an interview was conducted with LPN #6. LPN #6 was asked to describe the wounds on Resident #3's left foot. LPN #6 responded, "She (Resident #3) came to us with a wound on her left heel which healed in September or October. LPN #6 was asked to demonstrate where the information regarding the wounds was documented (see left heel wound and other wound documentation above). This surveyor showed LPN #6 four reports that were completed by LPN #6 on 7/15/14, three reports were titled, "Observation Report" one report was titled "Event Report." LPN #6 was asked to describe the four reports. LPN #6 stated, "An event report is done for any unusual occurrence." LPN #6 stated that the event report dated 7/15/14 indicated that there was a new finding (note this report documented the pressure area on the left foot with necrotic tissue found on 7/15/14)." LPN #6 stated, "A stage II wound was found on (Resident #3's) left foot (as noted above the area found was necrotic which is not consistent with a stage II pressure ulcer). LPN #6 stated, "The areas on the toe have healed." LPN #6 was then asked when the wound nurse was notified of the wound found on 7/15/14. LPN #6 stated, "I did not notify the wound nurse, she needs to check the MARs (medication administration records) to know when there is a new wound." LPN #6 was then asked where the documentation was done regarding the status of the wound between 7/15/14 and 9/25/14. LPN #6 stated, "It should be in the monthly summaries." LPN #6 was asked whether or not they were entered into the computer, LPN #6 stated "Yes, they should be there. This is a new system and I may not have put them in." When LPN #6 was asked how the wound was monitored, she stated, "We do not document after each dressing, only if there is a problem, something that shouldn't be happening." LPN #6 was asked if there was any documentation available to demonstrate that the wound on Resident #3's left foot was assessed, monitored and treated to promote healing from the time the wound was found on 7/15/14 and 9/25/14. LPN #6 stated, "No, I don't see any." On 10/28/14 at 3:20 p.m. Resident #3 was observed lying in bed with both legs hanging over the side of the bed. Resident #3 was sleeping. Above the headboard a sign was observed that provided the following direction; "Multi podus ** boot for L (left) foot. Boot on when in or out of bed. When in bed pull beige kick stand out." A picture of the boot was also posted above the bed. A CNA was observed to enter Resident #3's room and proceed to place Resident #3's legs on to the bed and under the blankets. There was no boot observed on Resident #3's left foot and the CNA did not make any attempt to locate and place the boot on Resident #3's foot. On 10/28/14 at 4:55 p.m. Resident #3 was observed lying in the bed. There was no multi podus boot observed in place on the left foot. On 10/29/14 at 7:40 a.m. Resident #3 was observed to be lying in the bed sleeping. The sign regarding the multi podus boot had been removed from above the bed. On 10/29/14 at 8:45 a.m. CNA (certified nursing assistant) #3 was asked to accompany this surveyor into Resident #3's room. Resident #3 was observed to be lying in the bed with her eyes open. The resident was asked whether it was okay to lift the blankets from her lower extremities. Resident #3 agreed and CNA #3 raised the blankets from the resident's lower legs. Resident # 3 did not have a multi podus boot in place. The sign above the bed had been removed. CNA #3 was asked whether or not the resident was supposed to have a multi podus boot on, CNA #3 stated, "I don't know." CNA #3 was asked what happened to the sign above the resident's bed, CNA #3 stated, "I don't know." On 10/29/14 at 9:15 a.m. LPN (licensed practical nurse) #2 was asked to accompany this surveyor into Resident #3's room. LPN #2 was asked whether or not Resident # 3 was ordered to have a multipodus boot on. LPN #2 stated, "I am not sure, I will have to check the chart." LPN #2 reviewed the chart and stated, "She is supposed to have the boot on; there is an order. The boot was documented as "on" Resident #3 for all shifts on 10/28/14." On 10/29/14 at 9:20 a.m. LPN #4, the wound care nurse, stated, "She (Resident #3) is supposed to have the boot on at all times." LPN #4 went into Resident #3's room to search for the boot; LPN #4 was unable to locate the boot. LPN #4 asked for some time to "Figure this all out." On 10/29/14 at approximately 3:00 p.m. an interview was conducted with LPN #6 regarding the multi podus boot for Resident #3. LPN #6 stated, "She should have the boot on at all times." When asked why the multi podus boot was needed, LPN #6 stated, "That leg is contracted and this helps to relieve pressure." LPN #6 was asked about the sign above Resident #3's bed regarding the multi podus boot, LPN #6 stated, "Yes we put it there because the aides could never remember what to do with the boot." When asked what happened to the sign above Resident #3's bed LPN responded, "I don't know it should still be there. She is still supposed to have the boot on." LPN #6 was asked about a clarification order that was written on 10/29/14 and dated for 10/20/14. LPN #6 stated, "When hospice took over the care of her (Resident #3) their order read "Podis boots", our order in the system read "Multi podus boots", they are the same thing, but I wanted the system to be correct so I d/c'd (discontinued) the original order and put in the new hospice order. It is the same thing. She should have the boot on." On 10/29/14 at 6:55 p.m. the Administrator, DON (director of nursing) and the Corporate Director of Quality Assurance were notified of the above findings. Documentation was requested at this time to demonstrate the wound on Resident #3's left lateral foot had been appropriately assessed, monitored and that treatments had been put in place to promote healing of the wound. A current facility policy was requested at this time for the recognition and treatment of [REDACTED]. On 10/30/14 at approximately 8:00 a.m. ASM (administrative staff member) #2, the Corporate Director of Quality Assurance, provided a time line for Resident #3 since admission. There was no information provided for the time frame between 7/16/14 and 9/25/14 that indicated that the wound had been assessed, measured or monitored on an ongoing basis. In addition no documentation was provided evidencing ongoing assessment and monitoring of any of Resident # 3's wounds. A review of the facility policy "Pressure Ulcer" revised 06/2014 documented, in part, the following: "Policy: The facility will ensure appropriate prevention and treatment of [REDACTED]. If a pressure ulcer is present, a weekly pressure ulcer/status ulcer form will be completed in the EMR (electronic medical record.) b. Prevention: Use pressure reducing/relieving support surface or devices to help prevent pressure ulcers. Treatment Procedure: 1. Residents with Pressure Ulcers should be documented on a weekly basis using the Documentation of Wound Assessment form NF-85. 2. The Director of Nursing Services (DON) is responsible for weekly verifying that the appropriate treatment is administered as ordered and that documentation and evaluation reflect the current status of each pressure ulcer. Assessment: c. The pressure ulcer weekly report tracking report (NF-86) is to be completed by DON weekly. d. The charge nurse must also write a weekly narrative in the nurses' notes in the resident's chart only. Intervention: iv. Assess resident condition and response to treatment (progress/lack of progress/regression) weekly and during routine personal care. vi. If no improvement in the wound is noted after 2 weeks of treatment, the physician must be notified immediately. vii. Notify the wound consultant if no improvement is noted in 2 weeks and for all wounds greater than Stage II. " The documentation reviewed in the clinical record did not reveal that the directions regarding prevention and treatment of [REDACTED]. treatment of [REDACTED]. Department of Health and Human Services, Publication Number 15, documents, in part: " The assessment of an individual with a pressure ulcer is the basis for planning treatment, evaluating treatment effects, and communicating with other caregivers. Initially, the clinician should determine the location, stage, and size of the pressure ulcer. Accurate staging and description of pressure sores is a perquisite to the development and implementation of appropriate, effective treatment protocols and to effective, ongoing monitoring of tissue healing." The Pressure Ulcer Treatment Quick Reference Guide by NPUAP states on page 8 concerning pressure ulcer assessment, "Asses the pressure ulcer initially and re-assess it at least weekly, documenting findings...A 2-week period is recommended for evaluating progress toward healing. However, weekly assessments provide an opportunity for the health care professional to detect early complications and the need for changes in the treatment plan." Page 9 of this reference states, "With each dressing change, observe the pressure ulcer for developments that may indicate the need for a change in treatment (e.g., wound improvement, wound deterioration, more or less exudate, signs of infection, or other complications)...Assess and accurately document physical characteristics such as location, Category/Stage, size, tissue type (s), wound bed and periwound condition, wound edges, sinus tracts, undermining, tunneling, exudate, necrotic tissue, odor, presence/absence of granulation tissue, and [MEDICATION NAME]." Page 10 of this reference states, "Re-evaluate the pressure ulcer, the plan of care, and the individual if the pressure ulcer does not show progress toward healing within 2 weeks (or as expected given the individual's overall condition and ability to heal)...Signs of deterioration should be addressed immediately." (2) No further information was provided prior to the end of the survey process. Potter and Perry's Fundamentals of Nursing, 7th Edition, page 231, documents the following statements: "Assessment is the deliberate and systematic collection of data to determine a client's current and past health status...The purpose of the assessment is to establish a database..." Page 243 documents: "If you do not record an assessment finding or problem interpretation, it is lost and unavailable to anyone else caring for the client...Observation and recording is a legal and professional responsibility." (1) Centers for Medicare & Medicaid Services; Long-Term Care Facility Resident Assessment Instrument User's Manual; Version 3.0 October 2011, pages M-22. (2) National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Pressure Ulcer Prevention and Treatment: Clinical Practice Guideline. Washington, DC: National Pressure Ulcer Advisory Panel, 2009. * Pressure Ulcer Staging Revised by NPUAP. Copyright 2007. National Pressure Ulcer Advisory Panel. 8/3/2009 <http://www.npuap.org.pr2.htm>. **Multi podus * boots are sometimes spelled Mulit podis* boots. These boots are used primarily for decubitus ulcer healing, wound care, contracture management and ankle/foot stabilization. This information was obtained from the website: <http://www.leedergroup.com/cmo/multipodus-boots>