Every finding on record at Pendleton Rehabilitation and Nursing Center

Based on review of the clinical record, facility documentation, facility policy, and interviews, for 1 of 5 residents (Resident #5) reviewed for Preadmission Screening and Resident Review (PASARR), the facility failed to submit a request for a Level II screen subsequent to Resident #5 's new psychiatric diagnoses. The findings include: Resident #5 diagnoses included stroke, chronic obstructive pulmonary disease, cognitive communication deficit, and Parkinson's disease. A PASARR Level I screen dated 10/30/25 identified Resident #5 did not have any suspected or confirmed PASARR conditions. The outcome from the assessment indicated a Level II evaluation was not required because the Level I screen did not identify a serious a serious mental illness or an intellectual/developmental disability. The outcome identified no additional screening was required unless Resident #5 was suspected of having a serious mental illness or an intellectual or developmental disability and exhibited a significant change in treatment needs. A Psychiatric Evaluation and Consultation Nurse Practitioner note dated 11/28/25 identified Resident #5 had a psychiatric history of depression, anxiety, cognitive decline, and possible post-traumatic stress disorder (PTSD). The note recommended adding depression, anxiety, and an unspecified mental disorder due to a known physiological condition to Resident #5's diagnoses. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 was moderately cognitively impaired, required substantial assistance with toileting hygiene, and required moderate assistance for ambulation. Following admission on [DATE], Resident #5's medical record was updated to reflect newly identified diagnoses, including depression, post traumatic stress disorder (PTSD), insomnia, anxiety, and unspecified symptoms and signs involving cognitive functions following a stroke. A psychiatrist's note dated 2/26/26 at 3:30 PM identified Resident #5 was exhibiting agitation, attempted to physically assault another resident, and was making delusional statements and reporting visual hallucinations. The note further identified Resident #5 required psychiatric crisis stabilization in the emergency department and ordered 1:1 supervision until the resident could be safely transferred. A nurse's note dated 3/3/26 identified Resident #5 returned from the emergency department and was placed on 15 minute checks for supervision. Review of the clinical record failed to identify the PASARR contracted agency was notified of the new psychiatric diagnoses of depression, post traumatic stress disorder (PTSD), insomnia, anxiety, unspecified symptoms and signs involving cognitive functions following a stroke from 11/28/25 through 8/10/26 in order to conduct an additional Level 1 and Level 2 screen. Interview with Social Worker (SW #2) on 8/10/26 at 8:36 AM identified she was responsible for updating the PASARR contracted agency when a resident was diagnosed with new psychiatric diagnosis, mental health disorder, or intellectual disabilities. SW #2 further identified she is responsible for submitting new screenings to the state designated PASARR agency. SW #2 indicated she is typically informed of new mental health diagnoses through morning reports or communication with nurse managers. SW #2 identified she was unsure which mental health diagnoses were included in Resident #5's original PASARR Level I screening and she was unable to access the document at the time of the interview. SW#2 stated that newly identified diagnoses such as depression, anxiety, and PTSD would qualify as mental health disorders requiring an updated PASARR Level I screening to be submitted to the state PASARR authority. SW #2 identified she was aware of Resident #5's new mental health diagnoses that occurred after admission to the facility but, due to an oversight, she did not update the PASARR contracted agency. Interview with Person #2 (representative of the state designated PASARR agency) on 8/10/26 at 10:08 AM identified the PASARR screening outcome dated 10/30/26 did not identify Resident #5 as having diagnoses of anxiety, depression, PTSD, or dementia. Person #2 further stated that there were no additional PASARR screenings on record for Resident #5. Subsequent to surveyor inquiry, a PASARR submission request dated 8/10/26 was completed by SW #2 and submitted to the state designated PASARR authority to report Resident #5 had new diagnoses of PTSD, anxiety, and depression. Review of facility's undated Resident Assessment and Coordination with PASRR Program policy, directed in part, the facility coordinates assessments with the PASRR program to ensure individuals with a mental disorder, intellectual disability, or related condition receive care and services in the most integrated setting appropriate to their needs. The policy states that all applicants to the facility will be screened for serious mental disorders, intellectual disabilities, and related conditions, and a negative Level I screening permits admission and concludes the PASRR process unless a serious mental health disorder or intellectual disability arises later. The policy further identifies Social Services Director, or designee is responsible for monitoring each resident's PASRR screening status and referring updates to the appropriate authority.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #44) reviewed for Preadmission Screening and Resident Review (PASARR), the facility failed to ensure that a redetermination was submitted to the appropriate state agency when a short-term approval expired. The findings include:Resident #44 diagnoses included schizophrenia, anxiety, depression, and post traumatic stress disorder (PTSD).A Notice of PASSR Level I Screen Outcome dated [DATE], issued by the state contracted agency noted Resident #44 had a PASSAR condition and was approved to remain in the facility for up to 30 days from the date of admission without requiring a PASRR Level II screen. The notice identified if Resident #44 required a stay beyond the 30-day period a rescreening must occur by or before [DATE] if the resident remains beyond the authorized timeframe.The admission Evaluation dated [DATE] at 11:00 AM identified Resident #44 was admitted for respite care.The admission MDS dated [DATE] identified Resident #44 had severely impaired cognition and was independent with personal hygiene, dressing, and toileting.The Resident Care Plan dated [DATE] identified Resident #44's discharge planning was uncertain.Social Service note dated [DATE] at 1:27 PM indicated Resident #44 was approved by the payor to stay past the initial respite time.Social Service note dated [DATE] at 3:56 PM identified Resident #44 decided to stay in facility and the POA was notified.Social Service note dated [DATE] at 3:33 PM identified Resident #44 and his/her POA agree that he/she will remain at the facility.Interview with Social Worker (SW #2) on [DATE] at 8:53 AM identified Resident #44 was approved for a 30-day stay in the facility through [DATE]. SW #2 stated she was responsible for submitting a redetermination when Resident #44's 30-day approval expired in [DATE]. SW #2 identified she had not submitted a redetermination when Resident #44's 30-day approval expired.Interview with Person #2 (representative of the state designated PASARR agency) on [DATE] at 9:52 AM identified Resident #44 had received 30-day approval on [DATE]. Person #2 identified there were no additional updates submitted to the state-designated PASARR authority indicating Resident #44 remained in the facility after the 30-day approval expired on [DATE]. Person #2 indicated SW #2 was in the process of submitting a late Level I update.Follow up interview with SW #2 on [DATE] at 11:30 AM identified she contacted the PASARR authority and confirmed the last update for Resident #44 occurred on [DATE], with a required resubmission due by [DATE]. SW #2 indicated the resubmission update had not been completed due to an oversight on her part.Review of facility's undated Resident Assessment and Coordination with PASRR Program policy directed in part, the facility to coordinate assessments with the PASRR program to ensure residents with mental disorders or intellectual disabilities receive services in the most appropriate setting. The policy identifies the Social Services Director or designee is responsible for tracking PASRR status and ensuring timely submission to the appropriate authority.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #123) reviewed for respiratory care, the facility failed to ensure medications were not left at the bedside. The findings include:Resident #123 was admitted to the facility in July 2026 with diagnoses that included emphysema and chronic respiratory failure with hypoxia. Physician order dated 7/20/26 directed to administer Fluticasone Salmeterol Aerosol (dry powder respiratory inhaler used for asthma and shortness of breath) 250 50 mcg/act (micrograms per actuation — one puff) inhaled orally every 12 hours related to emphysema. The admission Evaluation dated 7/20/26 at 2:11 PM identified Resident #123 did not wish to self administer medications. The Resident Care Plan (RCP) dated 7/20/26 identified Resident #123 had impaired vision with interventions including arranging for consultation with an eye care practitioner. The admission Minimum Data Set (MDS) dated [DATE] identified Resident #123 had intact cognition, required moderate assistance with toileting, and set- up and clean -up assistance with personal hygiene. Observation on 8/4/26 at 10:30 AM identified Resident #123 had a Fluticasone-Salmeterol Aerosol inhaler, an opened bottle of saline nasal spray, and a bottle of eye lubricant tear drops on the overbed table. Interview and observation with Registered Nurse (RN) #1 on 8/4/26 at 10:32 AM identified that the inhaler at the bedside had doses remaining. RN #1 indicated the bottle of nasal spray and bottle of eye lubricant tear drops were not from the facility and were likely brought in by the resident's representative. Interview with Licensed Practical Nurse (LPN #1) on 8/4/26 at 10:35 AM identified she had not yet administered Resident #123's morning medication. LPN #1 identified the Fluticasone-Salmeterol Aerosol inhaler on Resident #123's bedside was missing from the medication cart and must have been left in the resident's room by the evening shift nurse. LPN #1 indicated the eye drops and nasal spray were not facility stock and were likely brought by a visitor. Interview and clinical record review with RN #1 on 8/4/26 at 10:40 AM identified Resident #123 did not have an order to self-administer the inhaler. A review of the physician's orders with RN #1 noted the Fluticasone-Salmeterol Aerosol inhaler was to be administered every 12 hours at 8:00 AM and 8:00 PM. RN #1 stated he believed the inhaler must have been left there from the previous evening shift by LPN #2. RN #1 identified that the inhaler should not be left at the bedside and it was the responsibility of nursing to ensure medications were not left at the bedside. Interview with the Director of Nursing Services (DNS) on 8/4/26 at 11:00 AM identified medications must remain locked in the medication cart unless a resident has a completed self administration assessment and physician's order. The DNS further identified Resident #123 did not have a self administration assessment or a physician order and therefore should not have medications at the bedside. Subsequent to surveyor inquiry, a facility accident and incident report dated 8/4/26 identified three medications were found at Resident #123's bedside, including two over the counter medications brought in by the resident representative. The documentation indicated that the Director of Nursing Services (DNS) and Unit Manager contacted LPN #2, who last signed for the inhaler, and provided education regarding medication administration practices. Although attempted, an interview with LPN #2 was not obtained. Review of facility Resident Self Administration of Medication Policy dated 2026 directed, in part, residents may self administer medications only after an interdisciplinary assessment determines the resident can do so safely. The policy requires evaluation of physical ability, cognition, ability to follow instructions, and ability to safely store medications and results must be documented in the medical record.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 1 resident (Resident #116) reviewed for tracheostomy care, the facility failed to maintain proper infection prevention and control practices during tracheostomy care and failed to perform hand hygiene between glove changes and during the care. The findings include:Resident #116 diagnoses included chronic obstructive pulmonary disease (COPD), asthma, chronic respiratory failure, tracheostomy, and intellectual disabilities. The quarterly MDS dated [DATE] identified Resident #116 had moderately impaired cognition and required staff assistance for dressing and toileting. The MDS further identified Resident #116 required oxygen therapy, suctioning, and tracheostomy care.The Resident Care Plan (RCP) dated 6/30/26 identified Resident #116 had a tracheostomy related to chronic respiratory failure, with interventions that directed maintaining secure trach ties, enhanced barrier precautions, and providing tracheostomy care as ordered.The physician's order dated 7/1/26 directed tracheostomy care daily and every 12 hours as needed; change the inner cannula every day during the 7:00 AM-3:00 PM shift; verify placement of the speaking valve every shift; suctioning as needed for mucus, plugging, or increased secretions; change the outer cannula with a cuffless Shiley #60 XLTUD every two months; and enhanced barrier precautions for the tracheostomy tube. Observation of Resident #116's tracheostomy care on 8/10/26 at 10:25 AM with RN #2 identified Registered Nurse (RN) #2 entered Resident #116's room and touched Resident #116's tracheostomy supplies on the 3-tiered metal shelf on the left side of the resident's bed without performing hand hygiene or donning gloves. RN #2 exited the room without performing hand hygiene. RN #2 returned to Resident #116's room with a tracheostomy kit and normal saline. RN #2 donned a yellow gown, gloves, and a surgical mask without the benefit of performing hand hygiene. RN #2 moved Resident #116's garbage can, which had two urinals sitting on top of it, from the side of the bed to the foot of the bed. RN #2 went to the other side of the bed, brought the overbed table to the left side of the bed, and removed two water pitchers from the table. While still wearing the same pair of gloves, RN #2 touched the soiled gauze pad under Resident #116's tracheostomy without removing it. RN #2 opened the sterile kit, placed a paper barrier on the overbed table, placed the tracheostomy supplies on top of the paper barrier, and poured normal saline into the disposable cup without the benefit of changing gloves or performing hand hygiene. RN #2 removed his soiled gloves and placed them on the overbed table, and donned sterile gloves without performing hand hygiene between glove changes. RN #2 removed the soiled gauze pad under the tracheostomy and placed it on the overbed table, then cleaned around the tracheostomy with saline dipped cotton tipped applicators and discarded the used applicators on the overbed table. RN #2 removed the inner disposable cannula and discarded it onto the overbed table near the soiled gloves and gauze. RN #2 inserted a new sterile cannula into Resident #116's tracheostomy without changing gloves or performing hand hygiene. RN #2 transferred the speaking valve from the contaminated cannula to the new cannula without changing gloves or performing hand hygiene. RN #2 placed a new gauze pad under the tracheostomy ties and discarded all items into the trash can. RN #2 entered the resident's bathroom, removed his gown and gloves, and washed his hands in the resident's bathroom sink. RN #2 exited the bathroom and returned the water pitchers to the overbed table without disinfecting the surface after he had placed soiled items on it. Interview with RN #2 on 8/10/26 at 10:35 AM identified he is the Infection Control Nurse. RN #2 indicated he does not routinely perform tracheostomy care because floor nurses usually complete this procedure. RN #2 identified he did not perform hand hygiene when entering Resident #116's room to check for supplies or when exiting the room after touching the supplies because he forgot. RN #2 stated he should have performed hand hygiene when entering and exiting the room, prior to donning clean gloves and Personal Protective Equipment (PPE), and between glove changes. RN #2 stated after removing the used inner cannula, he did not remove his gloves, perform hand hygiene, and apply clean gloves as required. RN #2 identified he performed Resident #116's tracheostomy care out of sequence and without required hand hygiene between glove changes. RN #2 identified after completing Resident #116's tracheostomy care and discarding the used supplies, he returned Resident #116's overbed table and placed the drinks on the table without disinfecting the surface after contaminated items had been placed on it. RN #2 stated he should have sanitized the overbed table before placing supplies onto it and again before returning the water pitchers to the table. Interview with the Director of Nursing Services (DNS) on 8/10/26 at 10:50 AM identified her expectation was nurses provide tracheostomy care according to the physician's orders, facility policy, and proper infection control practices. The DNS stated nurses are expected to perform hand hygiene prior to donning and doffing PPE, between glove changes, and after removing gloves. The DNS identified RN #2 should have maintained proper infection control while providing tracheostomy care to Resident #116 and should have disinfected the resident's overbed table before returning it to the resident.Review of facility Tracheostomy Care Policy dated 2026, directed in part, the facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided with such care consistent with professional standards of practice. Tracheostomy care will be provided according to physician's orders at least daily and as needed. Procedure with use of a disposable cannula explain the procedure to the resident and pull the screen for privacy. Perform hand hygiene and put on clean gloves and other PPE, as indicated due to enhanced barrier precautions. Suction tracheostomy per facility policy as needed. Remove old dressing and discard in appropriate receptacle. Perform hand hygiene. Open and set up the sterile tracheostomy care kit. Perform hand hygiene and put on the clean gloves. Slowly remove inner canula from the tracheostomy tube by squeezing tabs on connector until both snaps clear the ridged lock on the outer cannula. Dispose of the removed inner cannula. Remove gloves and perform hand hygiene and put on the sterile gloves. Pick up the new inner cannula touching only the outer locking portion. Insert and lock the inner cannula into position. Clean the stoma, tube flanges, and surrounding skin with sterile gauze or sterile cotton tipped applicators moistened with sterile normal saline or sterile water. Dry area thoroughly with additional sterile gauze pads. Change trach toes when soiled or wet. Replace dressing using the manufacturer split dressing with flaps pointing upward. Discard gloves and perform hand hygiene.Review of facility Hand Hygiene Policy dated 2026, directed in part, all staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Hand hygiene technique when using alcohol-based hand rub apply to palm of hand and rub together all surfaces for 20 seconds. Hand hygiene with soap and water rub hands vigorously for 20 seconds covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to putting gloves on and immediately after removing gloves.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #47) reviewed for immunizations, the facility failed to ensure the COVID-19 vaccine was offered to the resident upon admission. The findings include:Resident #47's diagnoses included chronic diastolic heart failure, malignant neoplasm of the bladder, and acute kidney failure.The 5 day MDS dated [DATE] identified Resident #47 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition, and was not up to date with COVID 19 vaccination.Review of Resident #47's Immunization Report and clinical record review failed to identify a COVID-19 vaccine had been offered, administered while a resident at the facility, or historically.Interview and clinical record review with Registered Nurse (RN #2) on 8/05/2026 at 11:30 AM identified he was responsible for offering COVID 19 vaccinations to residents upon admission. RN #2 stated Resident #47 had no documented history of receiving a COVID 19 vaccine and had not been offered or educated about the COVID 19 vaccine upon admission or after admission. RN #2 was unable to provide documentation that Resident #47 was offered a COVID 19 vaccine, declined the vaccine, or had any prior documented evidence of receiving the vaccination. Interview with the Director of Nursing Services (DNS) on 08/06/2026 at 8:23 AM identified RN #2, the Infection Prevention Nurse, was responsible for offering the COVID 19 vaccine to eligible residents on admission and for reviewing and offering COVID 19 vaccines twice per year thereafter. Review of the facility's undated COVID 19 Vaccine policy directed, in part, the facility will educate and offer the COVID 19 vaccine to residents, resident representatives, and staff, and maintain documentation of such. The resident's medical record will include documentation of the following: education to the resident or resident representative regarding the risks, benefits, and potential side effects of the COVID 19 vaccine; each dose of the vaccine administered to the resident; or if the resident did not receive the COVID 19 vaccine due to medical contraindications or refusal.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 of 5 residents (Resident #47, Resident #79, and Resident #116) reviewed for immunizations, the facility failed to ensure the clinical record was accurate to include documentation of Resident Care Conferences (RCC). The findings include:1.Resident #47 diagnoses included chronic diastolic heart failure, malignant neoplasm of the bladder, and acute kidney failure.The Resident Care Plan (RCP) dated 3/25/2026 identified Resident #47 needed to utilize his/her independent leisure activity time constructively while at the facility. Interventions included staff provision of a calendar of events, supportive visits, and opportunity for self-expression.The admission MDS dated [DATE] identified Resident #47 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition, required supervision with bed mobility and transfers.Review of the clinical record identified RCC sign in sheets dated 3/26/2026 and 4/13/2026 were signed by those in attendance. The clinical record did not contain documentation to reflect a summary of the conferences on those dates, including Resident #47's goals, preferences, or concerns, any modifications to care plan interventions, whether any care plan revisions were made, whether the interdisciplinary team provided input, and whether the resident or representative meaningfully participated in the conferences. Interview on 8/06/2026 at 10:33 AM with Social Worker (SW #1) identified there were no resident care conference (RCC) meeting notes within Resident #47's medical record to demonstrate Resident #47's or his/her representative's preferences, choices, goals, plan of care, requests, or concerns had been evaluated. SW #1 stated it was the responsibility of SW #2 to document the RCC meeting notes in Resident #47's medical record because SW #2 was responsible for residents receiving long term care services. Interview on 8/06/2026 at 10:53 AM with SW #2 identified Resident #47's resident care conference (RCC) was due on 6/21/2026. SW #2 indicated she did not hold a quarterly RCC meeting in June or July because she was unable to schedule a meeting date when she contacted Resident #47's family member on 6/11/2026. SW #2 stated she was not responsible for documenting RCC notes in the medical record because Resident #47 had not yet transitioned to long term care at the time the RCCs were held. 2. Resident #79 diagnoses included Parkinson's disease, malignant neoplasm of the colon, and hypertension.The Resident Care Plan (RCP) dated 12/06/2024 identified Resident #79 had a communication problem related to dementia and his/her needs would be attended to related to being rarely or never understood.The admission MDS dated [DATE] identified Resident #79 had severely impaired cognition, was dependent with bed mobility, transfers, and required maximal assistance with personal hygiene.Review of the clinical record identified RCC sign in sheets dated 5/29/2025, 6/03/2025, 1/08/2026, 2/27/2026, and 5/28/2026 were signed by those in attendance. The clinical record did not contain documentation to reflect a summary of the conferences on those dates, including Resident #79's goals, preferences, or concerns, any modifications to care plan interventions, whether care plan revisions were made, whether the interdisciplinary team provided input, and whether the resident or representative meaningfully participated in the conferences. Interview on 8/06/2026 at 10:53 AM with SW #2 identified there were no resident care conference (RCC) meeting notes in Resident #79's medical record documenting the resident's or resident representative's preferences, choices, goals, plan of care, requests, or concerns. SW #2 stated it was the facility's expectation that she document RCC meeting notes in the medical record. SW #2 identified the absence of documentation for Resident #79's resident care conferences was due to her poor documentation practices. 3. Resident #116 diagnoses included chronic obstructive pulmonary disease, schizoaffective disorder, and cognitive communication deficit.The Resident Care Plan (RCP) dated 3/03/2025 identified Resident #116 needed to utilize his/her independent leisure activity time constructively while at the facility. Interventions included staff provision of a calendar of events, supportive visits, and opportunity for self-expression.The quarterly MDS dated [DATE] identified Resident #116 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition, and required maximal assistance with personal hygiene and bed mobility. Review of the clinical record identified RCC sign in sheets dated 3/11/2025, 6/16/2025, 9/16/2025, 12/10/2025, 1/22/2026, and 6/30/2026 were signed by those in attendance. The clinical record did not contain documentation to reflect a summary of the conferences on those dates, including Resident #116's goals, preferences, or concerns, any modifications to care plan interventions, whether care plan revisions were made, whether the interdisciplinary team provided input, and whether the resident or representative meaningfully participated in the conferences. Interview on 8/06/2026 at 10:53 AM with SW #2 identified there were no resident care conference (RCC) meeting notes in Resident #116's medical record documenting the resident's or resident representative's preferences, choices, goals, plan of care, requests, or concerns. SW #2 stated it was the facility's expectation that she document RCC meeting notes in the medical record. SW #2 identified the absence of documentation for Resident #116's resident care conferences was due to her poor documentation practices. Interview on 08/10/2026 at 9:04 AM with the Director of Nursing (DON) identified she was not aware SW #2 was not documenting resident care conference (RCC) notes in the medical records for Resident #47, Resident #79, or Resident #116. The DON stated it is the facility's expectation that the social worker document RCC meeting notes in the resident's medical record. Review of the facility's undated Documentation in the Medical Record policy directed, in part, that licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy.

Based on clinical record reviews, facility documentation, facility policy and interviews for two (2) of three (3) sampled residents (Residents #1 and #2) who were reviewed for an allegation of abuse, the facility failed to ensure a nursing assessment was completed and documented in the clinical record at the time the allegation and assessment was reported. The findings include:1.Resident #1's diagnoses included altered mental status, adjustment disorder with depressed mood and cerebral edema (swelling in the brain caused by an accumulation of excess fluid in the brain tissues). The annual Minimum Data Set assessment dated [DATE] identified Resident #1 had a staff assessment for mental status completed identifying both short and long-term memory problems, required supervision assistance with toileting and was independent with bed mobility, transfers and ambulation. The Resident Care Plan dated 10/9/25 identified Resident #1 could be non-compliant with medication administration, Activities of Daily Living (ADL) care due to cognitive impairment and knowledge deficit. Interventions included offering as many alternatives as possible to choose from, discussing the resident's objections, reasons, fears and ideas, notifying the provider if resident refuses medications and/or treatments and psychiatric/psychological consultations as needed. The Facility Reported Incident form dated 11/2/25 identified that at 3:50 PM, Resident #1's family member reported to the Nursing Supervisor, Resident #1 had reported to the family member he/she had sustained both right and left upper forearm bruising due to a nurse aide who pulled Resident #1 out of bed by the arms and threw Resident #1 into the shower at night time on 10/30/25. The report identified a nursing assessment was completed noting a 1.5 centimeter (cm) circular bruise to the left upper forearm and a 2 cm circular bruise to the right upper forearm. The report indicated the provider and the police were notified of the allegation, the nurse aide was suspended, and an investigation was initiated per protocol. Review of the clinical record dated 11/2/25 failed to identify a nurse's note regarding the allegation or that a nursing assessment was completed following the allegation of physical abuse. A late entry Situation, Background, Assessment and Recommendation (SBAR) dated 11/3/25 at 6:53 PM was noted to be created by the Director of Nursing (DON) on 11/16/25 at 3:04 PM (14-days after the allegation). Interview with the Nursing Supervisor, Registered Nurse (RN) #1, on 11/18/25 at 12:28 PM identified that although she assessed Resident #1 following the allegation of abuse on 11/2/25, she was unable to explain why she did document the allegation or her assessment, stating she must have forgotten but she should have prior to leaving for her shift that evening. 2. Resident #2's diagnoses included generalized anxiety disorder, major depressive disorder and Attention-Deficit Hyperactivity Disorder (ADHD). The admission Evaluation dated 9/6/25 identified Resident #2 was oriented to person, place, time and situation and required assistance for mobility. The Resident Care Plan dated 9/7/25 identified Resident #2 had major depressive disorder and utilized an antidepressant medication. Interventions included monitoring/documenting/reporting to the provider any ongoing signs and symptoms of depression, administering antidepressant medications per physician's orders and monitoring/documenting the side effects and effectiveness and psychiatry and/or psychology consultations as needed. The Facility Reported Incident form dated 9/12/25 identified at 2:40 PM an allegation was made by Resident #2 to the social worker. Resident #2 reported during the 3-11PM shift on 9/11/25, a nurse aide barged into his/her room, ripped the dentures out of his/her mouth, abruptly got Resident #2 off the toilet and called him/her a cunt. The report identified Resident #2 had no injuries, the family, the provider and the police were notified of the allegation, the nurse aide was suspended, and an investigation was initiated. Review of the clinical record from 9/12/25 through 11/18/25 failed to identify a nurse's note was written regarding the allegation or that a nursing assessment was completed following the allegation of both physical and verbal abuse. Interview with the Director of Nursing (DON) on 11/18/25 at 2:40 PM identified for Resident #2, she realized when finalizing the 11/2/25 investigation on 11/16/25 a note nor an assessment were documented on the allegation in the clinical record by RN #1, so she opened the SBAR on 11/16/25 and backdated it 11/3/25 mistakenly instead of 11/2/25. The DON identified RN #1 should have documented her encounter and her assessment of Resident #1 on 11/2/25 following the abuse allegation before the end of her shift. The DON identified for Resident #2 she was present in the facility at the time of the allegation on 9/12/25, and although she personally assessed Resident #2 and completed all the paperwork, she never documented the allegation or her assessment of the resident in the clinical record. Review of the Documentation in the Medical Record policy (undated) directed, in part, that each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate and timely documentation. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation or care service occurred. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. Documentation shall be timely and in chronological order.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1), reviewed for accidents, the facility failed to revise to complete neurological checks as per facility standard. The findings include: Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1), reviewed for accidents, the facility failed to ensure neurological checks were completed after an unwitnessed fall, in accordance with facility policy. The findings include: Resident #1 was admitted with diagnoses that included non-traumatic subdural hematoma, atrial fibrillation (irregular heartbeat) right leg below the knee amputation. The Resident Care Plan (RCP) dated 5/13/2025 identified Resident #1 was at risk for falls due to confusion, disorientation and was on anticoagulation (blood thinner). Interventions directed Resident #1 was independent with transfers, and to remind resident to ask for help. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 11 (had moderate cognitive impairment) and was independent for bed mobility, personal care and required supervision with transfer. A facility incident report dated 7/5/2025 at 1:00 PM identified Resident #1 was found sitting on the floor next to the bed and stated he/she had slid off the bed. The report indicated Resident #1 was alert and pleasant, and an RN assessment was completed with no injuries identified. The physician was notified and vital signs monitored. A nursing note dated 7/5/2025 at 6:15 PM by RN #1/supervisor, identified MD #1 was notified of the fall and instructed to continue neurological vital sign protocol as per policy. A facility incident report dated 7/5/2025 at 4:10 PM identified Resident #1 was found on the floor next to the bed, denied hitting his/her head, denied pain, and was alert and oriented. Two (2) abrasions that measured three (3) and five (5) centimeters (cm) were noted on the left lower extremity. MD #1 was contacted with actions taken that included neurological vitals (neuro checks), RN assessment and labs (blood work). A facility reportable event form dated 7/5/2025 at 6:15 PM identified Resident #1 had an unwitnessed fall; Resident #1 was found on his/her buttocks at the bedside with his/her head against the dresser and denied hitting his/her head. Resident #1 was alert and oriented, had no apparent injury, but a decline in mental status was noted on assessment; decreased interaction and ability to articulate words, neurological vital signs were initiated. The physician was notified and ordered transfer to the hospital for evaluation. The report indicated a CT scan with results acute on chronic subdural (brain) hematoma (localized collection of blood outside of blood vessels due to injury or trauma) with mass effect and midline shift, and Resident #1 was admitted to the hospital. Facility documentation review identified Resident #1's medical record included a neurological check sheet dated 7/5/2025 that directed to evaluate blood pressure, pulse, temperature, level of consciousness, pupil reaction and eye-motor-verbal response every 1/2 hour times four (4), then every hour times 4 hours times twenty-four (24) hours, then every 8 hours for the remaining 72 hours or as ordered by physician. Record review identified neurological assessments were initiated on 7/5/2025 after the fall at 1:00 PM; they were completed at 1:10, 1:40, 2:10, 2:40 PM, and 3:40 PM (completed 4 half hour checks and 1 hourly check). Further review identified although a second unwitnessed fall occurred at 4:10 PM, the next neurological assessment was completed at 4:40 (half an hour after the fall, and one (1) hour after the prior assessment was performed at 4:10 PM). The next assessment was completed one (1) hour later, at 5:45 PM. Resident #1 then had a third fall at 6:15 PM. Review identified that the neurological assessments were not completed every half hour after an unwitnessed fall occurred per the facility policy. Interview with LPN #2 on 8/6/2025 at 10:45 AM identified Resident #1 was his resident on 7/5/2025 during the 3:00 to 11:00 PM shift. LPN #2 stated neurological checks are to be completed as directed by the neurological record form: evaluate blood pressure, pulse, temperature, level of consciousness, pupil reaction and eye-motor-verbal response every 1/2 hour times four (4), then every hour times 4 hours times twenty-four (24) hours, then every 8 hours for the remaining 72 hours or as ordered by physician after an unwitnessed fall. LPN #2 stated he completed the neurological checks as directed on the form, but stated he did not recall if he initiated new neurological checks after the unwitnessed 4:10 PM fall. LPN #2 stated he completed the neurological checks as directed on the form, but stated he did not recall if he initiated new neurological checks after the unwitnessed 4:10 PM fall. Interview with LPN #1 on 8/6/2025 at 11:30 AM identified she was Resident #1's nurse on 7/5/2025 from 7:00 AM to 3:00 PM. LPN #1 stated she initiated the neurological record to document the required checks after Resident #1's unwitnessed fall at 1:00 PM. LPN #1 further stated she was going off duty when Resident #1 fell at 4:10 PM, but she responded to the fall. LPN #1 stated that the charge nurse on the next shift was LPN #2 and he should have re-started the neurological checks process, with every half hour checks, after the 4:10 PM unwitnessed fall. She identified that neuro checks are done as directed by the form and are initially rechecked every 1/2 hour for four (4) times after a fall. Interview with RN #1 on 8/6/2025 at 1:34 PM identified she was orienting with RN #2 as supervisor on 7/5/2025 from 7:00 AM to 7:00 PM. RN #1 stated she and RN #2 had assessed Resident #1 after each fall on 7/5/2025 (at 1:00 PM, 4:15 PM and at 6:15 PM), and stated she expected staff to initiate neurological checks as per facility policy after each fall. She was not aware that they had not initiated neuro checks after the 4:10 PM fall and that neuro checks should have been done as directed by the form that included every 1/2 hour for four (4) after an unwitnessed fall. Interview with RN #2, on 8/6/2025 at 1:40 PM identified she was orienting RN #1 on 7/5/2025, and RN #1 and RN #2 assessed Resident #1 after each fall. RN #2 stated she expected staff to initiate neuro checks as directed on the form after each fall as each were unwitnessed, and she was not aware the staff had not completed the checks every 1/2 hour times four (4) after the 4:10 PM fall. RN #2 continued that after the 6:10 PM fall, Resident #1 was still alert and oriented, mentation was the same as it was after the 4:10 PM fall but after three (3) falls, it was determined that Resident #1 should be evaluated at the hospital. Interview and documentation review with the DON on 8/6/2025 at 2:30 PM identified that staff should initiate and follow the directions outlined on the facility form entitled Neurological Record, that directed to evaluate blood pressure, pulse, temperature, level of consciousness, pupil reaction and eye-motor-verbal response every 1/2 hour times four (4), then every hour times 4 hours times twenty-four (24) hours, then every 8 hours for the remaining 72 hours or as ordered by physician after an unwitnessed fall. The DON stated there was no physician order entered in the medical record to direct the neurological sign assessments but the neurological assessment form delineated the facility policy and her expectation was that staff would follow the frequency of neurological check monitoring after each fall; a new set of assessments should have been initiated after the 6:15 PM fall. Resident #1's medical record lacked neurological checks at 1/2 hour intervals times four (4) after the fall on 7/5/2025 at 4:10 PM. Review failed it identify the initial neurological checks after the 4:10 PM fall, check was completed at 4:40 PM, and review failed to identify the 1/2 hour later neurological check was completed at 5:10 PM.

Based on observations, review of the clinical record, review of facility policy/procedures and interviews for one sampled resident (Resident #88) who experienced a change in condition, the facility failed to ensure that the physician was notified when the resident experienced symptoms of pain and swelling of the left hand. The findings include: Resident #88 was admitted to the facility in October 2024 with diagnoses that included type 2 diabetes mellitus, gout, and atrial fibrillation. The admission MDS assessment dated [DATE] identified Resident #88 was cognitively intact, required maximum assistance with lower body dressing, bathing, and toileting. Physician's progress notes dated 11/19/24 identified the resident was seen for hand pain to the right hand and noted the resident had superficial thrombophlebitis to the Left hand while at the hospital and recommended that Coumadin be switched to Lovenox(anticoagulant) to minimize the pricks to the fingers required for blood testing as a result of being on Coumadin. The note identified that Resident #88 refused. The Care Plan dated 12/9/24 identified Resident #88 was being treated for a leg wound with interventions for wound care and pressure relieving interventions. Additionally, the care plan indicated that the resident was at risk for skin breakdown Psychotherapy progress notes dated 1/13/25 identified Resident #88 expressed frustration with making physical progress and then suffering a physical ailment making it difficult to participate in therapies. Review of the nursing notes from 12/20/24 to 1/12/25 identified the resident had improved in ADL performance and had no complaints of pain. Nursing progress notes dated 1/13/25 at 1:45 PM identified Resident #88's left fingers were swollen and painful. An occupational therapy note dated 1/14/25 identified Resident #88 had left hand edema, redness and impaired range of motion of the fingers. Further, the note identified that nursing was notified. The physical therapy note dated 1/14/25 identified Resident #88 had edema and pain to the left hand that impacted the resident's ability to complete transfers and noted Resident #88 had asked nursing to utilize the mechanical lift for transfers out of bed to the wheelchair due to the edema and pain to the left hand. Observation on 1/16/25 at 1:31 PM identified Resident # 88 had swelling, redness, pain, and the inability to move the fingers on the left hand. Interview with the DNS on 1/21/25 at 12:45 PM identified that when the nurse identifies that a resident has experienced a change in condition or needs someone to assess the resident, the nursing supervisor should be notified. Interview with RN #5 on 1/22/25 at 10:34 AM identified that there was no documentation that the physician was notified of the swelling, redness, and pain. RN#5 further noted that if the symptoms were important enough to mention in a nursing note, then the doctor should have been notified of the changes to the left hand. Interview with MD#1 on 1/22/25 at 11:54 AM identified that if the condition noted is persistent, then the doctor should be notified and given the resident was experiencing swelling, it should have been reported. Any return or change should be reported so the provider has the opportunity to reevaluate interventions and treatments. Interview with PT #2 and OTA#1 on 1/23/25 at 11:14 AM identified that on January 14th the left hand became swollen, and Resident #88 had a decline in the ability to grasp the walker. Interview with the DNS on 1/23/25 at 1:03 PM identified that if a resident presents with a change, a new presentation, or an exacerbation of a resolved issue the expectation is that the staff communicates that to the doctor via the telephone or the communication binder. Interview with the DNS on 1/23/25 at 1:41 PM identified that chronic conditions that needed interventions intermittently should be included in the care plan and should be reported to the MD. The facility policy for notification of changes identified that the purpose of the policy is to ensure the facility promptly consults the resident's physician when there is a change requiring notification. Additionally, the policy identified that circumstances requiring notification included circumstances that require a need to alter treatment and indicated that those circumstances may include a new treatment or discontinuation of current treatment due to adverse consequences, acute condition, or exacerbation of a chronic condition.

Based on review of the clinical record, review of facility policy/procedures and interviews for one of five sampled residents (Resident #88) reviewed for unnecessary medications and was receiving anticoagulant medication, the facility failed to ensure the care plan addressed the monitoring of possible side effects of anticoagulant medication and actions to take in the event of the need for emergent care. The findings included: Resident #88 was admitted to the facility in October 2024 with diagnoses that included type 2 diabetes mellitus, gout, and atrial fibrillation. The admission MDS assessment dated [DATE] identified Resident #88 was cognitively intact, required maximum assistance with lower body dressing, bathing, and toileting. It further identified the resident received anticoagulant medication. Review of Resident #88's care plan dated 10/31/24 failed to identify the resident was receiving anticoagulant medication and failed to have interventions in place to address monitoring for possible side effects and treatment in the event of an emergent occurrence. The physician's orders dated 12/28/24 directed to administer Coumadin (anticoagulant) in alternating doses of 3.5 mg and/or 4 mg by mouth one time a day. Review of the medication administration records (MAR) for November 2024, December 2024 and January 2025 (through 1/18/25) identified Resident #88 was administered Coumadin on a daily basis. Interview with the DNS on 1/21/25 at 8:02 AM identified that when a resident is receiving anticoagulant medication, the care plan should acknowledge the residents use of use of anticoagulant medication and interventions to address possible side effects of the medication as well as precautions that should be taken. The facility policy for high-risk medications- anticoagulants identified that the resident's plan of care shall alert staff to monitor for adverse consequences and indicated risks associated with anticoagulants to include bleeding and hemorrhage, fall in hematocrit or blood pressure, and thromboembolism. The policy further identified the plan of care should also include interventions to minimize the risk of adverse consequences. The facility policy for Comprehensive care plans identified it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical and nursing needs identified in the resident's comprehensive assessment.

Based on observations, review of clinical records, review of facility policy/procedures and interviews for two of three sampled residents (Resident #22 and Resident #101) observed with medications at the bedside, the facility failed to ensure that medications were administered according to acceptable standards of practice. The findings include: 1. Resident #22's diagnoses included respiratory failure, chronic obstructive pulmonary disease (COPD), unspecified asthma, and dependence on supplemental oxygen. The quarterly MDS assessment dated [DATE] identified Resident #22 was cognitively intact, required moderate assistance for dressing, personal hygiene, and transfers, was independent with toileting hygiene, bed mobility and utilized a wheelchair for mobility. The care plan dated 10/1/24 identified Resident #22 had oxygen therapy related to COPD with interventions that included give medications as ordered by physician and monitor for signs and symptoms of respiratory distress and report to provider as needed. The monthly physician's order for January 2025 directed Advair Diskus Inhalation (Fluticasone-Salmeterol) Aerosol Powder Breath Activated 500-50 micrograms (mcg) to inhale 1 puff orally twice daily and rinse after use for COPD and Fluticasone Propionate suspension 50 mcg one spray in both nostrils one time a day for allergies. Observation on 1/16/25 at 12:05 PM identified Resident #22 lying upright awake in bed wearing a nasal cannula and on the right side of the bed was a nightstand. The nightstand contained a plastic bag with a biohazard label containing: Fluticasone Propionate and Salmeterol 500/50 mcg (Advair Diskus) that was dispensed from the pharmacy used by the facility with the resident's name and a dispensed date of 10/1/2024, which indicated that there were 25 dosages left; Symbicort 160/4.5 mcg connected to a spacer which had no dosage remained; and Fluticasone Propionate 50mcg spray bottle with a label that identified the medication was dispensed from the hospital in which the resident was previously admitted from that was approximately half filled. Observation on 1/16/25 at 12:16 PM with the Unit Manager (RN #4) identified Resident #22 lying upright awake in bed wearing a nasal cannula and on the right side of the bed was a nightstand. The nightstand contained a plastic bag with a biohazard label containing: Fluticasone Propionate and Salmeterol 500/50 mcg (Advair Diskus) that was dispensed from the pharmacy used by the facility with the resident's name and a dispensed date of 10/1/2024, which indicated that there were 25 dosages remained; Symbicort 160/4.5 mcg connected to a spacer which had no dosage remained; and Fluticasone Propionate 50mcg spray bottle with a label that identified the medication was dispensed from the hospital where the resident was previously admitted from that was approximately half filled. RN #4 then took the bag containing the medications out of the resident's room. Resident #22 identified that the last time he/she used those medications were about a month ago and it was the nurses who left the medication there for convenience. Two of the medications within the bag (Fluticasone Propionate and Salmeterol 500/50 mcg (Advair Diskus) and Fluticasone Propionate suspension 50 mcg) was identified as Resident #22's prescribed medications. Review of Resident 22's clinical records failed to identify a physician's order directing self-administration of medication or a completed self-administration assessment. Review of the electronic Medication Administration Record (MAR) with the Charge Nurse LPN #3 on 1/16/25 at 12:25 PM identified Fluticasone Propionate suspension 50 mcg and Advair Diskus are scheduled for 9:00 AM were signed off as administered by LPN #3. Interview with LPN #3 on 1/16/25 at 12:25 PM identified that she had signed the MAR this morning after asking the resident if he/she had taken the inhaler and the nasal spray, as the resident is alert and could answer. LPN #3 further identified that she only administers Resident #22's oral (PO) medications, and the resident would administer the inhaler and the nasal spray (respiratory medications). LPN #3 identified she was aware that the medications were at the bedside as the resident prefers to administer his/her own inhaler and nasal spray. LPN #3 indicated she assumed the resident had an order for self-administration as the medications are left at the bedside for as long as the resident been on the unit since at least October of 2024. Interview with the Nursing Unit Manager (RN #4) on 1/16/25 at 12:16 PM identified medications should not be left at the resident's bedside without a physician's order and a self-administration assessment. RN #4 identified she was not aware of the resident having medications at the bedside as Resident #22 had never had a self-administration order since admission. Interview with the DNS on 1/17/25 at 1:35 PM identified on admission residents are screened for self-medication administration, in which Resident #22 had responded no to self-medication administration. The DNS added that if the resident wanted to self-administer medication an assessment is completed to assess what the resident can self-administer and whether the medication could be left at the bedside. The DNS added that if the medication was to be stored at the bedside, it should be in a locked box with both the resident and nurse having the key to the box. The further identified medications should not be stored at the bedside without having an order and an assessment completed. Interview with the Respiratory Therapist on 1/17/25 at 2:15 PM identified he was not aware that Resident #22 had the inhaler left at his/her bedside for the resident to self-administer and noted he/she requires the supervision of the nurse because the resident is non-complaint. He further identified that if the resident does not take the inhaler as ordered, it can result in bronchial spasm, decrease in saturation and increased shortness of breath. Review of the Resident Self-Administration of Medications policy identified that a resident may only self-administer medications, after the facility interdisciplinary team has determined which medication were safe to self-administer. Each resident is offered the opportunity to self-administer medications during the routine assessment by the facilities. The policy further identified that all nurses and aides are required to report to the charge nurse on duty on duty any medication found at the bedside not authorized for bedside storage. 2. Resident 101's diagnoses included kidney disease, high blood pressure and gout. The quarterly MDS assessment dated [DATE] identified Resident #101 was moderately cognitively impaired, required max assistance with bed mobility, transfers, dressings and personal hygiene. The assessment further identified that the resident required a mechanically altered diet. The care plan dated 11/12/24 identified Resident #101 was at risk for self-care deficit related to need for assistance, with interventions that included providing the resident assistance with dressing, bathing, bed mobility and assist of 2 for transfers. Physician's order(s) dated 9/5/24 directed to administer protein liquid 30 milliliters (ml) one time a day at 9:00 AM. The nurse's quarterly assessment dated [DATE] at 2:12 PM identified Resident #101 did not want to self-administer his/her own medications. Observation on 1/16/25 at 12:04 PM in Resident #65's room, identified a medication cup containing 30 milliliters (ml or 1.014 fluid ounces) of a red colored liquid left in front of the resident on the overbed table. The resident was found sleeping at that time. Also noted, mupirocin ointment 2% in a plastic zip lock bag with Resident #101's name on it left on the dresser. Interview with the DNS on 1/17/25 at 1:37 PM indicated the self-administration assessments were completed when a resident wants to self-administer and upon admission to the facility, and when a resident is assessed and able to self-administer, they are provided with a lock box which is kept at the bedside. The resident and nurse would each have a key to the lock box. Residents should be assessed for self-administration upon admission and if requested and should have a physician's order in place for self-administration. Interview with Resident #101 on 1/17/25 at 1:49 PM identified the only medication left at bedside daily is the red stuff. The resident also indicated the nursing staff stand and watch the resident take the medications, except the red stuff. Resident #101 was unable to recall what the red liquid was. The resident felt that it was o.k., as he/she was able to self-administer the red liquid. Resident #101 did not know what the ointment was in the plastic bag. Interview with the DNS on 1/22/25 at 11:03 AM, indicated the process for evaluating a resident for self-administration of medications, included an evaluation for safety, and education. If the resident is found to be safe/competent to self-administer, then a doctor's order is obtained identifying the resident may self-administer. A lock box is then kept in the resident's room containing the medications. Both the nurse and resident have a key. Review of the Resident Self-Administration of Medications policy directed, in part, that a resident may only self-administer medications, after the interdisciplinary team has determined which medications were safe to self-administer. Each resident was offered the opportunity to self-administer medications during the routine assessment by the facilities interdisciplinary team. 48335

Based on review of clinical records, review of facility documentation, review of facility policy, and interviews for one of three sampled residents (Resident #44) reviewed for activities of daily living (ADL), the facility failed to ensure showers were provided as scheduled. The findings include: Resident #44's diagnoses included muscle weakness, difficulty walking, and abnormalities of gait and mobility. The annual MDS assessment dated [DATE] identified Resident #44 was moderately cognitively impaired, required supervision with bed mobility, supervision with toileting, required partial to moderate assistance with bathing and utilized a walker and wheelchair for mobility. The care plan dated 1/3/25 identified Resident #44 had an ADL self-care performance deficit with interventions that included: provide resident with level of care for bathing and showering, break tasks into sub tasks if needed, and shower and bath on specified day/shift. Interview with Resident #44 on 1/17/24 at 3:00 PM identified that in the last two months he/she has only received two showers. Review of the nurse aide care card indicated Resident #44 was scheduled for a shower every Tuesday and Saturday on the second shift. Review of the Nurse Aide (NA) charting documentation for November 2024, December 2024 and January 2025 identified Resident #44 was showered twice in the last three months when he/she is scheduled to be showered twice weekly. Additionally, the documentation failed to identify the reason why the showers were not conducted. Interview with NA#4 on 1/23/24 at 9:35 AM identified she works both 1st and second shift and that each day the Nurse Aide care tasks prompts them if a shower/bath is scheduled and if it is not given, they mark N/A. If the shower is conducted, they document yes and if the resident refuses the shower, there is an area to document the refusal. She further noted that if for any reason the resident is unavailable for the scheduled shower, there is an area to document that. Additionally, NA #4 noted that she has worked with Resident #44 and noted that the resident does not refuse showers. She further noted if a resident refuses a shower, he/she should be reapproached and that also should be documented. Interview with the DNS on 1/23/25 at 12:54 PM identified that she was unsure what the N/A meant in the nurse aide documentation but if a resident did not get showered on a specific day and time, the expectation would be that it was documented, and the resident reapproached. The nurse on the unit should also be notified. The DNS further identified that each resident is expected to be showered according to their scheduled shower day and time and if that cannot be done or a resident does not like their scheduled time, then they need to make efforts to accommodate the resident's request. The Activities of Daily Living (ADLs) policy identified care, and services will be provided for the following activities of daily living included bathing, dressing, grooming and oral care. The policy further identified that a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 47900

Based on observation, review of the clinical records, review of facility policy, review of facility documentation, and interviews for one of four sampled residents (Resident #22) reviewed for accidents, the facility failed to ensure that medications were administered as prescribed by the physician. The findings include: Resident #22's diagnoses included respiratory failure, chronic obstructive pulmonary disease (COPD), asthma, and dependence on supplemental oxygen. The quarterly MDS assessment dated [DATE] identified Resident #22 was cognitively intact, required moderate assistance for dressing, personal hygiene, transfers, and independent with toileting hygiene and bed mobility. The assessment further identified the resident utilized a wheelchair independently for mobility. The care plan dated 10/1/24 identified Resident #22 had oxygen therapy related to COPD with interventions that included give medications as ordered by physician and monitor for signs and symptoms of respiratory distress and report to provider as needed. Review of the physician's orders from October/2024 through January 17, 2025, directed to administer Advair Diskus Inhalation (Fluticasone-Salmeterol) Aerosol Powder Breath Activated 500-50 micrograms (mcg) to inhale 1 puff orally twice daily and rinse after use for COPD and Fluticasone Propionate suspension 50 mcg one spray in both nostrils one time a day for allergies. Observation on 1/16/25 at 12:16 PM with the Unit Manager (RN #4) identified Resident #22 lying upright awake in bed wearing a nasal cannula and on the right side of the bed was a nightstand. The nightstand contained a plastic bag with a biohazard label containing: Fluticasone Propionate and Salmeterol 500/50 mcg (Advair Diskus) that was dispensed from the pharmacy used by the facility with the resident's name and a dispensed date of 10/1/2024, which indicated that there were 25 dosages remained; Symbicort 160/4.5 mcg connected to a spacer which had no dosage remaining; and Fluticasone Propionate 50mcg spray bottle with a label that identified the medication was dispensed from the hospital where the resident was previously admitted from that was approximately half filled. RN #4 then took the bag containing the medications out of the resident's room. Resident #22 identified that the last time he/she used those medications were about a month ago and it was the nurses who left the medication there for convenience. Observation and review of the medication cart on the B wing unit with the Nursing Unit Manager (RN #4) on 1/16/25 at 12:17 PM identified Advair Diskus Inhalation (Fluticasone-Salmeterol) Aerosol Powder Breath Activated 500-50 mcg dispensed from the pharmacy on 12/1/24 with 59 dosages remaining but failed to identify Fluticasone Propionate suspension 50 mcg suspension spray. RN #4 and the Charge Nurse (LPN #3) reviewed the medication storage room which contained overstock supplies, also failed to identify any Fluticasone Propionate suspension 50 mcg spray and Advair Diskus Inhalation (Fluticasone-Salmeterol) Aerosol Powder Breath Activated 500-50 mcg belonging to Resident #22. Interview and review of the MAR with the Charge Nurse (LPN #3) on 1/16/25 at 12:25 PM identified that she had signed the MAR that morning after asking the resident if he/she had taken the inhaler and the nasal spray, as the resident is alert and could answer. LPN #3 further identified she only administered oral medication to the resident and that the resident does his/her respiratory medication such as the inhaler and the nasal spray. LPN #3 identified that when supplies are running low, the resident would let the nurse know to reorder the medication. Interview with the Pharmacy Technician on 1/21/25 at 10:21 AM identified Fluticasone Propionate 50mcg nasal spray was last dispensed to the facility on [DATE] for a physician order dated 7/10/24, however the order was discontinued on 7/22/24. She further identified that Fluticasone Propionate 50mcg spray was then reordered and dispensed on 1/17/25 and contains a total of 120 sprays, which would last a total of 2 months. The Pharmacy Technician further identified Advair Diskus Inhalation (Fluticasone-Salmeterol) Aerosol Powder Breath Activated 500-50 microgram was dispensed to the facility on [DATE] containing 60 quantity (dosage) and on 12/1/24 containing 60 dosages. She added each of the Fluticasone-Salmeterol medication dispensed contained a 30-day supply as the resident was ordered to receive the medication twice daily and medication is due to be reorder but the pharmacy has not received a refill order from the facility since the last dispense date of 12/1/24. The Pharmacy Technician further identified that medication is not automatically dispensed to the facility, and the facility must reorder medications via fax, telephone call or electronically. Review of Resident #22's Medication Administration Record (MAR) for Advair Diskus Inhalation (Fluticasone-Salmeterol) Aerosol Powder Breath Activated 500-50 microgram (mcg) is schedule to be administered at 9:00 AM and 9:00 PM identified the resident received the medication: From October 2, 2024, through October 31, 2024, a total of 50 times From November 1, 2024, through November 30, 2024, a total of 56 times From December 1, 2024, through December 31, 2024, a total of 60 times. From January 1, 2025, through January 16, 2025, a total of 31 times. Based on the MAR from October 2, 2024, to January 16, 2025, the resident received Advair Diskus Inhalation (Fluticasone-Salmeterol) Aerosol Powder Breath Activated 500-50 mcg a total of 196 dosages when the pharmacy dispensed only a total of 120 dosages to the facility from October 1, 2024, to January 16, 2025. Review of Resident #22's Medication Administration Record (MAR) for Fluticasone Propionate suspension 50 mcg identified it was scheduled to be administered at 9:00 AM identified the following: From October 2, 2024, through October 31, 2024, a total of 26 times. From November 1, 2024, through November 30, 2024, a total of 28 times From December 2, 2024, through December 31, 2024, a total of 30 times. From January 1, 2025, through January 16, 2025, a total of 16 times. Based on the MAR from October 2, 2024, to January 16, 2025, the resident received Fluticasone Propionate suspension 50 mcg a total of 100 dosages when the pharmacy last dispensed the medication on 7/10/24 a bottle containing a total of 120 spray to the facility. Interview with the Pharmacist on 1/21/25 at 10:38 AM identified that an adverse effect of the resident not taking his/her Advair Diskus Inhalation (Fluticasone-Salmeterol) Aerosol Powder Breath Activated 500-50 mcg as ordered can result in the worsening of the resident's COPD diagnosis. He further identified that if the resident is not taking the Fluticasone Propionate nasal spray as order that the resident allergies would not be resolved, his/her symptoms will continue. Interview with the DNS on 1/22/25 at 9:58 AM identified that the MAR should be signed at the time when the medication is administered to the resident. The DNS further identified that medications are ordered by the nurses on the unit. She indicated that Resident #22 would have other pharmacies delivery medication to the facility in the past and the resident was educated but is unable to identify if the resident had received any outside medications recently. The DNS added that the pharmacy was unable to provide a written dispensary report of the medications but when she called the pharmacy, they provided the same information that the nasal spray was not ordered until 1/17/25 and the inhaler was ordered on 10/1/24 and 12/1/24. Interview with the Charge Nurse (LPN #5) on 1/21/25 at 11:38 AM identified that when asked if she had administered Resident #22's inhaler and nasal spray as ordered, would the medications supply be completed and did she recall having to reorder any of the medications given that the pharmacy last sent the inhaler on 12/1/24, which she responded the supply on hand would have been completed and that she could not recall reordering any of those medications for the resident. She indicated that she was with the resident whenever she had administered his/her inhaler and nasal spray medication, and medications are ordered when the resident has only 3 days' supply left. Review of the Medication Administration policy identified medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state as ordered by the physician and in accordance with professional standards of practice. The policy further identifies to observe resident consumption of medication and sign MAR after administration.

Based on review of clinical records, review of facility policy, review of facility documentation, and interviews for one of five sampled residents (Resident #18), reviewed for immunizations, the facility failed to ensure that the pneumococcal vaccine was administered as requested by the resident upon admission. The findings include: Resident #18 was admitted to the facility in June of 2024 and had diagnoses that included cervical disc disorder with myelopathy, unspecified dementia, and chronic obstructive pulmonary disease (COPD) with exacerbation. The quarterly MDS assessment dated [DATE] identified Resident #18 was cognitively intact, and the assessment further identified Resident #18 pneumococcal vaccination was not up to date. Review of the Immunization Report identified Resident #18 received pneumococcal conjugate (PCV 13) historically (prior to admission to the facility) on 12/7/2015 and pneumococcal polysaccharide (PPV23) historical on 12/4/2017. Review of the Pneumococcal Immunization Informed Consent form for pneumococcal vaccination identified that Resident #18 legal representative gave the facility permission to administer the pneumococcal vaccine PCV 20 on 6/29/24. Review of Resident #18 clinical records failed to identify that he/she had received the vaccination at the facility or had change his/her decision. Interview with the Infection Preventionist Nurse (RN #2) and the Regional Clinical Manager (LPN #2) on 1/21/25 at 12:01 PM identified RN #2 was responsible for reviewing the immunization consent forms after they were signed by the resident or responsible party, obtain the physician's order for the appropriate vaccine and herself or the nurse on the resident unit would then administer the vaccine. Both RN #2 and LPN #2 identified that Resident #18 had not received the vaccine nor was the resident's pneumococcal vaccine history and request for the PCV 20 vaccine discussed with the physician. RN #2 identified that based on Resident #18's pneumococcal vaccination history he/she would be eligible for the PCV 20 vaccine, however she would need to consent with the physician given that the resident had received two of the pneumococcal series. RN #2 further identified she could not recall discussing Resident #18's pneumococcal vaccination with the resident's primary physician. Interview with MD #1 (Resident #18's primary physician) on 1/22/24 at 11:00 AM identified he had no recollection of anyone calling him regarding Resident #18's had requested to receive the PCV 20, as if he did, he would have approved the resident to receive the vaccine. MD #1 further added he would not go ahead an order a pneumococcal vaccine for a resident who had received two of the pneumococcal vaccine series but if the resident requested and consented, he would have approved the order for the resident to receive the vaccine as he is aware that the guidance have changed. Review of the Pneumococcal Vaccine (series) policy identified each resident will be offered a pneumococcal immunization unless it is medically contraindicated, or the resident has already been immunized. Also, following assessment for any medical contraindications the immunization may be administered in accordance with physician-approved standing orders. The policy further identified they can get PCV20 or PCV21 if they have received both PCV13 (but not PCV 15, PCV20, or PCV21) at any age and PPSV23 at or after the age [AGE] years old.

Based on observation, review of the clinical record, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #12) reviewed for respiratory care, the facility failed to ensure nebulizer equipment was stored/labeled properly and discarded when not in use. The findings included: Resident #12's diagnoses included high blood pressure, obesity, and depression. The quarterly MDS assessment dated [DATE] identified Resident #12 was cognitively intact, had no behaviors, required max assistance with bathing, dressing, and transfers. The assessment further identified that the resident did not ambulate and utilized a wheelchair for mobility. The care plan dated 1/13/25 identified Resident #12 had an inability to perform self-care, related to impaired mobility with interventions that included: aiding in any assistance when needed, providing quarter/half-length enablers (side rails) to assist with bed mobility and providing female caregivers. Observation of Resident #12's room on 1/16/25 at 11:50 AM identified a mask/tubing hanging from the light fixture above Resident #12's bed. The mask and tubing were attached to a nebulizer machine located in the resident's bedside table. Interview with Resident #12 indicated he/she had not had a breathing treatment in several months. Resident #12 was unable to recall a date or time frame of last nebulizer treatment received. Review of the Medication Administration Records (MAR) for the time periods of 11/1/24-11/30/24; 12/1/24-12/31/24 and 1/1/25-1/17/25, identified an order for Albuterol Sulfate solution 2.5 milligrams (mg) per 3 milliliters (ml). Give 3 milliliters, inhale orally every 6 hours as needed for shortness of breath had not been administered. Interview on 1/16/25 at 11:55 AM with LPN #1 identified Resident #12 had not been administered a nebulizer treatment since July of 2023. LPN #1 removed the mask/tubing and nebulizer machine from the room. Subsequently to surveyor inquiry, the order for the nebulizer medication-Albuterol sulfate nebulization solution (2.5mg/3ml) 0.083%-3ml, inhale orally via nebulizer every 4h as needed for shortness of breath (ordered on 6/30/23) was discontinued on 1/17/25. Interview on 1/22/25 at 9:55 AM with RN #1-unit manager of unit B2 and LPN #1, indicated no explanation of why the mask, tubing and nebulizer machine had been left in Resident #12's room, when it had not been used in months. Review of the Nebulizer Therapy policy directed, in part, that care of nebulizer equipment, include changing the tubing weekly or per facility policy. When not in use, once cleaned the equipment (mouthpiece/mask) should be stored in a zip lock bag.

Based on review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for one sampled resident (Resident #67) reviewed for dialysis, the facility failed to ensure four Minimum Data Set (MDS) assessments were accurately coded for dialysis. The findings include: Resident #67's diagnoses included end stage kidney disease, heart failure and diabetes. A review of the physician's orders identified Resident #67 has had an order for hemodialysis from February 2024 through January 2025 for every Tuesday, Thursday, and Saturday in the afternoon at the dialysis center. Review of the following MDS assessments identified they did not reflect that the resident was receiving hemodialysis treatments. 1. Admission MDS assessment dated [DATE] 2. Quarterly MDS assessment dated [DATE] 3. Quarterly MDS assessment dated [DATE] 4. Admission MDS assessment dated [DATE] An interview on 1/23/25 at 12:33 PM with the MDS Coordinator (RN #3) indicated dialysis should have been coded on the MDS assessments for Resident #67. RN #3 could not give a reason as to why the assessments did not reflect that the resident received hemodialysis treatments. According to RN #3, the MDS assessment process includes reviewing the nurses' notes, physician orders, any recent paperwork or documentation from the hospital, morning report meetings and the weekly risk management meetings, and all the information garnered is utilized in completing the MDS assessments. Additionally, RN #3 further identified that the resident is interviewed as a part of the process. Review of the MDS 3.0 Completion policy identified that residents are assessed using a comprehensive assessment process, to identify care needs and to develop an interdisciplinary care plan. According to RAI guidance when assessing a resident requiring dialysis, the assessment should thoroughly document the resident's dialysis needs, including the type of dialysis, frequency, access site and any complication and how it impacts the resident's functional ability. This information is typically captured through specific items within the MDS section of the RAI assessment.

Based on clinical record reviews, facility documentation, facility policy, and staff interviews for one of three sampled residents (Resident #1) who was a recent admission, the facility failed to follow the physician's order for proper medication dosing and failed to follow the warning on the Medication Administration Record alerting staff to improper medication dosing. The findings include: Resident #1's diagnoses included congestive heart failure, mitral valve insufficiency, and prostate cancer. The admission Medication Regimen Review note dated 5/13/24 at 7:56 AM identified a dose alert for the medication Relugolix. A physician's order dated 5/15/24 directed to administer Relugolix 120 milligram (mg) tablet, take 360mg once on day one (1), 5/16/24, and then 120mg daily thereafter. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had no memory recall deficits and was oriented to person, place, and time. Review of the May, June, July, and August 2024 Medication Administration Records (MAR) identified the Relugolix was transcribed correctly and signed off by the nurses that had administered the medications. Review of the MARs indicated the Relugolix was administered a total of ninety-three (93) times. The pharmacy had confirmed the delivery of 120 tablets, therefore twenty-seven (27) tablets should have been left on 8/14/24. The medication variance report dated 8/15/24 identified on 8/14/24 the facility discovered the wrong dose of Relugolix had been administered to Resident #1 for an undetermined number of doses. The facility determined on some occasions three (3) tablets of 120mg Relugolix was administered instead of the prescribed one (1) tablet. A physician's order directed to hold the Relugolix from 8/14/24 to 8/16/24. The nurse's note dated 8/16/24 at 10:556 AM identified Resident #1's oncologist directed to obtain an EKG and a testosterone level, the results were forwarded to the oncologist's office and there were no new orders. The nurse's note dated 8/16/24 at 1:43 PM identified Resident #1 was discharged home. Interview with the 7AM-3PM unit manager, Registered Nurse (RN) #2, on 9/18/24 at 11:47 AM identified on 8/14/24 she was notified by the nurse who was administering medication that Resident #1 had run out of the Relugolix. RN #2 stated when she contacted the resident's family member to bring in more Relugolix because this was a medication being supplied through the oncologist's office, the family member indicated he/she had brought in a ninety (90) day supply in June and there should have had enough pills until September. Interview with RN #1 on 9/18/24 at 1:13 PM identified she investigated the missing medication, and one (1) nurse identified she had given three (3) tablets instead of one (1) tablet. RN #1 indicated although the MAR noted to administer one (1) tablet the original order remained in the computer which included to administer three (3) tablets for one (1) dose and then one (1) tablet thereafter and the nurse who had administered the wrong dose reported she misread the order. An interview with the pharmacist on 9/18/24 at 11:47 AM identified Resident #1's family member was sent a shipment of Relugolix 120mg quantity of thirty (30) tablets on 5/13/24 and ninety (90) tablets on 6/10/24 and the family member delivered all the bottles to the facility for use. Interview with the Director of Nursing (DON) on 9/18/24 at 2:50 PM identified the way the multi-step order was entered into the MAR led to confusion for the staff that had administered the medication. The DON explained with a multi-step order an end date would be put in and, in this case, we discovered the order for 360mg still showed up on the MAR for the nurses to see. The facility policy for Medication Administration identified in part that medications are administered by licensed nurses as ordered by the physician and in accordance with professional standards. The policy further identified the facility must ensure the right dosage is administered.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident # 1) reviewed for abuse or neglect, the facility failed to ensure care was provided with dignity and respect. The findings include: Resident #1 was admitted with diagnoses that included dementia with behavioral disturbance, dementia and nocturia. An admission MDS assessment dated [DATE] identified Resident #1 had severe cognitive impairment, can usually understand others, required limited assistance for transfers and bed mobility, and supervision for ambulation with a rolling walker. The RCP dated 6/2/2022 identified Resident #1 had impaired cognitive function and impaired thought processes due to dementia and a communication problem. The RCP directed for staff to ask yes/no questions to determine resident needs, cue/re-orient and supervise as needed, provide consistent caregivers to decrease confusion and to anticipate and meet needs validating resident's message by repeating, speaking clearly out loud. A facility incident report dated 6/22/2022 at 9:40 AM identified an allegation of staff to resident abuse (without injury). A family member alleged he/she observed on a camera monitor in Resident #1's room, that LPN #1 was rough when assisting Resident #1 to bed. Resident #1 was assessed, and identified to have no injury, distress or discomfort. LPN #1 was suspended pending investigation and appropriate notifications were completed. A facility summary report dated 6/29/2022 identified Resident #1 was alert, confused and oriented to name only at baseline. A family member called the facility and requested a meeting on 6/22/2022 to review the contents of the room monitor video. The investigation indicated that Resident #1 was restless throughout the shift and required frequent redirection for episodes of calling out for help and walking without an assistive device. LPN #1 by interview reported that on 6/22/2022 he had responded to Resident #1's call for help and found Resident #1 crouched at the bedside with half his/her body on the bed and grasping the bed rail. LPN #1 attempted to instruct Resident #1 for positioning/lift with transfer, but Resident #1 was unable to follow instructions. LPN #1 used a firm verbal approach with Resident #1 as Resident #1 was physically capable of assisting with repositioning. Interview and review of the facility summary dated 6/29/2022 with the Administrator on 5/14/2024 at 11:03 AM identified that her review of the video showed LPN #1 in Resident #1's room at 2:08 AM on 6/22/2022. The resident was noted to be hanging onto the bed rail and leaning off the side of the bed. LPN #1 could not reposition Resident #1 alone, and LPN #1 lowered the bed to the low position and was talking to the resident, attempting to cue the resident on how to transfer back to bed. The Administrator stated in the video, LPN #1 appeared to be frustrated and his tone was loud and degrading. The Administrator indicated LPN #1 was heard on the video to say to Resident #1, You don't want to listen to me. I can't do anything if you aren't going to listen to me and LPN #1 continued to attempt unsuccessfully to instruct Resident #1 to assist with the transfer. LPN #1 then straightened the resident's torso to a sitting position and proceeded to lift Resident #1 into bed by lifting under his/her legs and rolling him back onto the mattress. LPN #1 then left Resident #1 lying diagonally on the lower end of the bed, in a [NAME] but uncovered by blankets. As he was leaving the room the LPN #1 said in a frustrated and forceful voice If you aren't going to help, I can't do nothing. You stay like that. It was noted that an aide entered Resident #1's room at 2:15 AM and assisted Resident #1 to stand with a walker and then assisted Resident #1 into bed, covered Resident #1 with linens/blankets and left Resident #1 in a safe position. The Administrator stated although the allegation of abuse was not substantiated, LPN #1 had failed to treat Resident #1 with dignity and respect and LPN #1's employment at the facility was terminated in. Interview and review of the facility reportable summary dated 6/29/2022 with the former DON on 5/14/2024 at 1:36 PM identified LPN #1 acknowledged that Resident #1 was left in unsafe position and that his verbal comments were abrupt and forceful. The DON stated LPN #1 failed to treat the resident with dignity and respect and was unable to explain why the incident occurred. Attempts to contact LPN #1 during survey were unsuccessful. Residents' [NAME] of Rights Policy dated July 2021 directed in part, residents have the right to be treated with consideration, respect and full recognition of their dignity and individuality.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for pressure ulcers, the facility failed to notify the physician of pressure injuries. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included fracture of the left tibia, diabetes type II and morbid obesity. The care plan dated 6/9/23 identified Resident #1 had a fracture of the left tibia shaft with interventions that included to checking circulation, sensation and motion of the affected extremity every shift. A skin check dated 6/9/23 identified no skin alterations and a left lower extremity cast in place for fractured tibia surgery. Physician's orders dated 6/9/23 directed to monitor skin integrity under/around the cast every shift, monitor circulation, mobility, sensation and pulse to Left Lower Extremity (LLE) every shift, and directed diabetic foot checks every evening shift. A physician's order dated 6/10/23 directed to apply Vitamin A & D ointment to the feet and heels every evening shift in accordance with diabetes protocol. The admission MDS dated [DATE] identified Resident #1 had no impairments in cognition, required extensive assistance of two staff for bed mobility and transfers, did not have any unhealed pressure ulcers/injuries, was at risk of developing pressure ulcers/injuries and had a surgical wound. A subsequent care plan dated 6/20/23 identified Resident #1 was at risk of skin breakdown related to diabetes mellitus, impaired mobility and a surgical incision with interventions which included to assess for and provide pressure relieving devices as per PT/OT recommendations, complete skin risk assessments per facility policy and provide protective/preventative skin care. An outpatient orthopedic consultation report dated 6/22/23 identified Resident #1's sutures were removed, the cast was removed and a full cam boot was placed to the LLE, and to remove the boot for hygiene and Range Of Motion (ROM) and to follow up in four weeks. A skin check dated 6/23/23, completed by RN #1, identified no skin issues, Resident #1's cam boot was in place to the LLE and the surgical incision was clean, dry and intact. A nursing progress note written by RN #4 dated 7/1/23 at 2:29 AM identified no new skin issues. A skin check dated 7/2/23 identified Resident #1 refused the skin check. Review of the Treatment Administration Record for July 2023 identified that the facility was removing the cam boot every shift to check the skin integrity and the resident's bilateral heels were elevated while in bed. A skin check dated 7/5/23 identified a new skin impairment was noted, Resident #1 had a left heel abrasion, and left toe abrasion of 2nd and 3rd digit, the supervisor was made aware. A facility wound note dated 7/5/23 identified Resident #1 was seen for newly noted areas of impaired skin integrity. Resident #1 had an abrasion to the left dorsal foot measuring 1.1 centimeters (cm) x 0.9 cm with no drainage or odor. The Left heel measured 0.5 cm x 0.3 cm and Left toes measuring 0.3 cm x 0.2 cm with no drainage or odor noted. The physician ordered skin prep twice a day until the areas were resolved. A nursing progress note dated 7/6/23 identified a message was left for the orthopedic surgeon to notify him of the new skin irritation to Resident #1's left heel/toes/foot. An occupational therapy encounter note dated 7/12/23 identified Resident #1's family member reported skin integrity concerns about Resident #1's left foot, and identified nursing was made aware. A wound note dated 7/12/23 identified Resident #1's dorsal foot, left heel and left toes were resolved. Review of the clinical record for Resident #1 failed to identify any further documentation of wounds and/or pressure ulcers. Review of the out of facility release form for Resident #1 identified on 7/13/23 Resident #1's family member signed Resident #1 out of the facility and returned at 2:00 PM. An outpatient orthopedic consultation report dated 7/13/23 identified Resident #1 was seen in the clinic for follow up to a left leg injury. Resident #1 returned to the clinic earlier than scheduled because he/she reported pressure sores developing secondary to the cam boot. The note further identified a pressure ulcer noted to the dorsal mid-foot as well as a large pressure ulcer noted to the posterior heel which appeared to have eschar. Although review of Resident #1's medical record identified Resident #1 had no skin impairments documented after Resident #1's areas resolved on 7/12/23, Resident #1's orthopedic surgeon identified on 7/13/23 Resident #1 had a pressure ulcer on his/her's dorsal mid-foot and posterior heel. A skin check dated 7/16/23, completed by RN #3 identified Resident #1's skin was intact. Review of the out of facility release form for Resident #1 identified on 7/19/23 Resident #1's family member signed Resident #1 out of the facility and returned at 4:29 PM. Review of the after-visit summary from the outpatient wound clinic, maintained in Resident #1's medical records, dated 7/19/23 identified Resident #1 had a pressure injury of the left anterior foot and the left heel that was to be dressed 3 times a week with santyl and a foam cover. Review of the outpatient wound clinic consultation dated 7/19/23 identified Resident #1 had a pressure injury to the left anterior foot that was red, ecchymotic and measured 1.4 cm x 2 cm x 0.1 cm. Resident #1 also had a pressure injury to the left heel that was staged as a deep tissue pressure injury that was black and measured 4 cm x 4.7 cm x 0.1 cm. The discharge instructions identified for the left anterior foot to apply xeroform and foam three times a week and for the left heel to apply santyl and foam cover three times a week and to offload heels when in bed. Review of Resident #1's medical record failed to identify Resident #1 had a pressure ulcer to the dorsal mid-foot and posterior heel as identified in the consultation report on 7/13 and 7/19/23, failed to identify monitoring and treatment of the pressure ulcers. Review of the physician orders failed to identify the outpatient wound clinic recommendations for treatment of Resident #1's pressure ulcers were followed. Interview with the outpatient wound physician on 11/22/23 at 12:58 PM identified she assessed Resident #1 on 7/19/23. She identified Resident #1 had a thick, black, unstageable deep tissue injury to the left heel. She identified Resident #1's injury had a thick crusted black eschar that would not have developed in a few days and would have been present for a few weeks. She identified when she saw Resident #1 on 7/19/23 his/her pressure injury was deep, and they were just trying to salvage Resident #1's heel at that point. She identified Santyl was ordered as a debridement three times a week to allow for the scab to come off slowly and let the wound heal below. She identified the heel is close to bone and could have gotten worse if not treated properly. She further identified the visit report was sent with Resident #1. Interview with the facility Wound Care RN (WCRN) on 11/29/23 at 11:45 AM identified on 7/5/23 Resident #1 was seen after wound rounds for abrasions to the left dorsal foot, left heel and left toes. Resident #1 was not seen by MD #1, the wound physician. The WCRN further identified that she assessed the areas on the left foot to be resolved on 7/12/23. The WCRN further identified that she was not aware of the wound report from 7/19/23 did not see Resident #1 after his/her skin areas were resolved on 7/12/23 because no new skin issues were reported to her. Interview with MD #1, contracted wound physician, on 11/29/23 at 11:45 AM identified he did not see Resident #1 during Resident #1's stay in the facility. He identified he would made rounds one time a week and the facility nurses would tell him what residents needed consultations. Interview with Resident #1 on 11/29/23 at 12:30 PM identified on 7/12/23 physical therapy identified a black area on his/her heel. Resident #1's family member called the orthopedic surgeon on 7/12/23. Interview with OT #1 on 11/29/23 at 1:10 PM identified she worked with Resident #1 on 7/12/23 and identified the family member reported a new skin integrity concern to Resident #1's left foot, although could not remember if she saw Resident #1's left foot. OT #1 identified she told Resident #1's nurse, however, she could not remember who she told. Interview with RN #3, who completed the skin check dated 7/16/23 and was one of Resident #1's primary nurses during the 7:00 AM to 3:00 PM shift, on 11/29/23 at 2:26 PM identified she could not remember if she looked at Resident #1's heels when completing his/her skin check and diabetic foot checks, and further identified she could not remember if Resident #1 had any skin impairments. RN #3 identified that when doing a diabetic foot check the ideal process was to check the skin on the top of the foot, lift the foot and assess the bottom and in-between the toes. She further identified if a new skin concern was identified, a change in condition would be done and the wound team would be notified. Interview with LPN #3, who was one of Resident #1's primary nurses during the 3:00 PM - 11:00 PM shift, and Resident #1's nurse on 7/12/23 from 7:00 AM - 11:00 PM, on 11/29/23 at 2:30 PM identified she could not remember if Resident #1 had any skin concerns. She identified when completing a foot check she would look for open wounds, cuts, assess the toes. She would then hold the resident's legs up to apply the skin prep. She identified if there were new skin concerns identified, she would tell the supervisor and complete a change in condition form. Interview with the DNS on 11/29/23 at 10:00 AM identified she was not aware of Resident #1's medical appointments and consultations reports from 7/13/23 and 7/19/23. She identified Resident #1's post visit report from 7/19/23 was scanned into the resident's chart on 7/21/23 (a Friday) and Resident #1 was discharged on [DATE] (a Monday). She identified she does not know who Resident #1 and/or his/her family member gave the 7/19/23 wound consultation summary report to. She identified the process for the summary to be placed in the MD bin for review where it is then signed and uploaded into the resident's chart. She identified it was not signed by the physician; therefore it was never placed in the MD bin for review. She further identified a pressure ulcer/injury is different from a skin abrasion and would be a change in condition and although the physician should have been notified, the clinical record lacked the documentation. Review of the notification of changes policy directed the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for pressure ulcers, the facility failed to assess, monitor, and treat the resident's pressure ulcer. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included fracture of the left tibia, venous insuffiency, diabetes type II and morbid obesity. The care plan dated 6/9/23 identified Resident #1 had a fracture of the left tibia shaft with interventions that included to check circulation, sensation and motion of the affected extremity every shift. A skin check dated 6/9/23 identified no new skin alterations and Resident #1 had a left lower extremity cast in place for fractured tibia surgery. Physician's orders dated 6/9/23 directed to monitor skin integrity under/around the cast every shift, monitor circulation, motion, sensation and pulse to Left Lower Extremity and diabetic foot checks every evening shift. A physician's order dated 6/10/23 directed Vitamin A & D ointment to feet and heels every evening shift in accordance with diabetes protocol. The admission MDS dated [DATE] identified Resident #1 had no impairments in cognition, required extensive assistance of two staff for bed mobility and transfers, did not have any unhealed pressure ulcers/injuries, was at risk of developing pressure ulcers/injuries and had a surgical wound. The care plan dated 6/20/23 identified Resident #1 was at risk of skin breakdown related to diabetes mellitus, impaired mobility and a surgical incision. Interventions included to assess for and provide pressure relieving devices as per PT/OT recommendations, complete skin risk assessments per facility policy and provide protective/preventative skin care. An outpatient orthopedic consultation report dated 6/22/23 identified Resident #1's sutures were removed, the cast was removed and a full cam boot was placed to the left lower extremity (LLE). It identified Resident #1 could remove the boot for hygiene and ROM and to follow up in four weeks. A physician's order dated 6/22/23 directed tall cam boot in place to LLE, may remove for shower and hygiene and to monitor skin integrity every shift. A skin check dated 6/23/23, completed by RN #1, identified no new issues, Resident #1's cam boot was in place to the LLE and the surgical incision was clean, dry and intact. A nursing progress note written by RN #4 dated 7/1/23 at 2:29 AM identified no new skin issues. A skin check dated 7/2/23 identified Resident #1 refused the skin check. Review of the Treatment Administration Record for July 2023 identified that the facility was removing the cam boot every shift to check the skin integrity and the resident's bilateral heels were elevated while in bed. A skin check dated 7/5/23 identified a new impairment was noted, a left heel abrasion, left toe abrasion of 2nd and 3rd digit, the supervisor was made aware. A wound RN note dated 7/5/23 identified Resident #1 was seen for newly noted areas, an abrasion to the left dorsal foot measuring 1.1 cm x 0.9 cm with no drainage or odor. The note further identified areas to the left heel measuring 0.5 cm x 0.3 cm and left toes measuring 0.3 cm x 0.2 cm with no drainage or odor noted. The physician was notified and ordered skin prep twice a day until the areas were resolved. A physician's order dated 7/5/23 directed skin prep to left heel, left toes and top of foot every day and evening shift for abrasions to heel/toes/foot. A nursing progress note dated 7/6/23 at 11:49 AM identified a message was left for the orthopedic surgeon to notify him of the new skin irritation to Resident #1's left heel/toes/foot. An occupational therapy encounter note dated 7/12/23 identified Resident #1's family member reported skin integrity concerns with Resident #1's left foot. It identified nursing was made aware. A Wound RN note dated 7/12/23 identified Resident #1's dorsal foot, left heel and left toes were resolved. Resident #1 had no further documentation of wounds and/or pressure ulcers. Review of the out of facility release form for Resident #1 identified on 7/13/23 Resident #1's family member signed Resident #1 out of the facility and returned at 2:00 PM. An outpatient orthopedic consultation report dated 7/13/23 identified Resident #1 was seen in the clinic for follow up to a left leg injury. Resident #1 returned to the clinic earlier than scheduled because he/she reported pressure sores developing secondary to the boot. It further identified a pressure ulcer noted to the dorsal midfoot as well as a large pressure ulcer noted to the posterior heel and appeared to have eschar. Although the facility was doing skin checks every week, diabetic foot checks every day and daily skin checks around the area of the cam boot, review of Resident #1's clinical record identified Resident #1 failed to identify any skin impairments documented after Resident #1's areas resolved on 7/12/23 Resident #1's orthopedic surgeon identified on 7/13/23 Resident #1 had a pressure ulcer on his/her's dorsal mid-foot and posterior heel. A skin check dated 7/16/23, completed by RN #3, identified Resident #1's skin was intact. Review of the out of facility release form for Resident #1 identified on 7/19/23 Resident #1's family member signed Resident #1 out of the facility and returned at 4:29 PM. Review of the after-visit summary from the outpatient wound clinic, maintained in Resident #1's clinical record dated 7/19/23 identified Resident #1 had a pressure injury of the left anterior foot and the left heel that was to be dressed three (3) times a week with santyl and foam cover. Review of the outpatient wound clinic consultation dated 7/19/23 identified Resident #1 had a pressure injury to the left anterior foot that was red, ecchymotic and measured 1.4 cm x 2 cm x 0.1 cm. Resident #1 had a pressure injury to the left heel that was stage as a deep tissue pressure injury that was blanchable, black and measured 4 cm x 4.7 cm x 0.1 cm. The discharge instructions identified for the left anterior foot to apply xeroform and foam three times a week and for the left heel to apply santyl and foam cover three times a week and to offload heels when in bed. Review of Resident #1's medical chart failed to identify Resident #1 had a pressure ulcer to the dorsal midfoot and posterior heel and failed to identify monitoring of pressure ulcers. Review of the physician orders failed to identify the outpatient wound clinic recommendations for treatment of Resident #1's pressure ulcers were followed. Review of Resident #1's facility discharge packet dated 7/24/23 identified Resident #1 had special care instructions to apply skin prep to his/her left heel, left toes and top of left foot to protect his/her skin while in the CAM boot. It failed to identified Resident #1 had pressure ulcer/injuries concerns. Interview with RN #1 on 11/9/23 at 2:00 PM, who completed Resident #1's skin check on 6/23/23, identified she would take off Resident #1's cam boot daily to monitor his/her skin. She further identified there were no issues observed on 6/23/23. Interview with RN #4 on 11/14/23 at 2:00 PM, who worked on 7/1/23, identified although he could not remember the exact details of Resident #1's skin check on 7/1/23, his practice would be to remove the cam boot to assess the skin underneath. Interview with LPN #1 on 11/9/23 at 2:30 PM, who worked 7:00 AM - 3:00 PM on 7/4/23, identified there no were skin issues identified on 7/4/23. He further identified he would removed the cam boot to check the skin underneath and check for bogginess. Interview with the outpatient wound physician on 11/22/23 at 12:58 PM identified she saw and assessed Resident #1 on 7/19/23. She identified Resident #1 had a thick, black, unstageable deep tissue injury to Resident #1's left heel. She identified Resident #1's injury had thick crusted black eschar that would not have developed in a few days and would have been present for a few weeks. She identified when she saw Resident #1 on 7/19/23 his/her pressure injury was deep, and they were just trying to salvage Resident #1's heel at that point. She identified Santyl was ordered as a debridement three times a week to allow for the scab to come off slowly and let the wound heal below. She identified the heel is close to bone and could have gotten worse if not treated properly. She further identified the visit report was sent with Resident #1. Interview with the Wound RN on 11/29/23 at 11:45 AM identified on 7/5/23 Resident #1 was seen after wound rounds for abrasions to the left dorsal foot, left heel and left toes. She identified the wound physician, MD #1, did not see Resident #1 because he had already left the building. She identified on 7/12/23 Resident #1's left dorsal foot, left heel and left toes were resolved. She identified the MD #1 did not see Resident #1 on 7/12/23 because his/her areas were resolved. She further identified she was not aware of the wound report from 7/19/23 did not see Resident #1 after his/her skin areas were resolved on 7/12/23 because no new skin issues were reported to her. Interview with Resident #1 on 11/29/23 at 12:30 PM identified on 7/12/23 occupational therapy identified a black area on his/her heel with pain. Resident #1's family member called the orthopedic surgeon on 7/12/23. Interview with OT #1 on 11/29/23 at 1:10 PM identified she worked with Resident #1 on 7/12/23. She identified the wife reported a new skin integrity concern to Resident #1's left foot. She identified she could not remember if she saw Resident #1's left foot, she told Resident #1's nurse, however OT #1 could not remember who it was she told. Interview with RN #3, who completed the skin check dated 7/16/23 and was one of Resident #1's primary nurses during the 7:00 AM - 3:00 PM shift, on 11/29/23 at 2:26 PM identified she could not remember if she looked at Resident #1's heels when completing his/her skin check and diabetic foot checks. She further identified she could not remember if Resident #1 had any skin impairments. She identified when doing a diabetic foot check the ideal process was to remove the cam boot and check the skin on the top of the foot, lift the foot and assess the bottom and in-between the toes. She further identified if a new skin concern was identified, a change of condition form would be done and the wound team would be notified. Interview with LPN #3, who was one of Resident #1's primary nurses during the 3:00 PM - 11:00 PM shift, and Resident #1's nurse on 7/12/23 from 7:00 AM - 11:00 PM, on 11/29/23 at 2:30 PM identified she could not remember if Resident #1 had any skin concerns. She identified when completing a foot check she would look for open wounds, cuts, assess the toes. She would then hold the resident's legs up to apply the skin prep. She identified if there were new skin concerns identified, she would tell the supervisor and complete a change in condition Interview with the DNS on 11/29/23 at 10:00 AM identified she was not aware of Resident #1's medical appointments and consultations reports from 7/13/23 and 7/19/23. She identified Resident #1's post visit report from 7/19/23 was scanned into the resident's chart on 7/21/23 (a Friday) and Resident #1 was discharged on [DATE] (a Monday). She identified she does not know who Resident #1 and/or his/her family member gave 7/19/23 wound consultation summary report to. She identified the process for the summary to be placed in the MD bin for review where it is then signed and uploaded into the resident's chart. She identified it was not signed by the physician; therefore it was never placed in the MD bin for review. She further identified a pressure ulcer/injury is different from a skin abrasion and would be a change in condition. Review of the pressure injury prevention and management policy directed after completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. It further directed the treatment decisions will be based on the characteristics of the wound, including the stage, size, exudate (if present), presence of pain, signs of infection, wound bed, wound edge and surrounding tissue. The attending physician will be notified of the presence of a new pressure injury upon identification and the progression towards healing, or lack of healing, of any pressure injuries weekly. Review of the notification of changes policy directed the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Review of the skin integrity foot care policy directed that the facility will use a systematic approach for the prevention and management of foot ulcers, including efforts to identify risk; stabilize, reduce or remove underlying risk factors; monitor the impact on the interventions; and modify the interventions as appropriate. It further directed RN's and LPN's will participate in the management of medical conditions by following physicians orders, assessment of residents, and reporting changes in condition to the residents' physicians. Referrals to other interdisciplinary team members will be made as appropriate.

Based on clinical record review, facility documentation, facility policy, and interviews, for one (1) of three (3) residents for reviewed for allegations of abuse, (Resident #1), the facility failed to implement their abuse policy following an allegation of abuse, the Nurse Aide was allowed to work on another unit taking care of other residents although the policy directed to suspend immediately. In addition, the same NA returned to work following the facilities investigation despite an active police investigation with pending charges including abuse against an elderly person. As a result, Immediate Jeopardy was identified on 5/26/22. The facility submitted an immediate action plan that addressed failures to follow the abuse policy. On 6/2/22, during an onsite visit, the action plan was verified as implemented and Immediate Jeopardy was removed as of 5/28/22. The findings include: Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual Minimum Data Set assessment (MDS) dated [DATE] identified that the resident had severely impaired cognition, without behaviors, and required extensive assistance with bed mobility and transfers. A care plan dated 5/3/22 identified Resident #1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan further identified Resident #1 with a self-care performance deficit with interventions that included bilateral quarter side rails up for safety during care provision, to assist with bed mobility. a. A nurse's note dated 5/8/22 at 8:39 AM written by Registered Nurse (RN) #1 (the 11:00 PM to 7:00 AM nursing supervisor) identified at approximately 4:15 AM Nurse Aide (NA) #1 called her from the unit and stated that she was trying to perform care on Resident #1 and the resident became belligerent, verbally abusive, and threw an over bed table and a full urinal at her. Upon reaching the unit, NA#1 told her what had happened with Resident #1, NA#'s clothing was soaked with urine. Upon entering Resident #1's room the resident was bleeding from the right hand, the bridge of h/her nose, and the right ear. When Resident #1 was questioned about why h/she was bleeding, the resident replied that woman just beat the sh** out of me. An assessment identified the resident's right hand had five (5) very small open areas, and blood was wiped from the bridge of the resident's nose and the right ear. A reportable event dated 5/8/22 at 5:00 AM identified that Resident #1 alleged that Nursing Assistant (NA) #1 physically assaulted h/her, the physician, family, and the police were notified, and an investigation was initiated. The reportable event further identified that Resident #1 stated that NA#1 beat the s*** out of him, abrasions were noted to right hand, right ear, and right temple. Further review of the reportable event identified that the conclusion to the facility's investigation was that the facility was unable to substantiate allegation of physical and verbal abuse by NA#1, however, the incident remained an active police investigation, and if new information was found regarding criminal activity appropriate action would be taken. A nurse's note dated 5/8/22 at 10:15 AM identified that the resident was lying in bed and stated one of your staff beat me up. The resident was noted with dried blood over the bridge of h/her nose and down the right side of his/her right cheek and ear with right sided facial swelling around the right ear and jaw, which was red and tender to the touch. The physician was informed and STAT X-rays were ordered. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note dated 5/8/22 at 12:48 PM identified that the resident continued to have intermittent bleeding from the abrasion to the right ear and bridge of nose, neurological exams remained within normal limits. The Advanced Practice Registered Nurse (APRN) was made aware of the continued bleeding at the site of the abrasions, and gave new orders to hold the [MEDICATION(S)] (a blood thinner) for 2 days, and to use liquid skin (a liquid dressing that binds skin) if the areas start bleeding again. A nurse's note dated on 5/8/22 2:35 PM identified that upon entry into Resident #1's room the resident stated one of your staff beat me up. The resident was medicated for head pain rated on the pain scale as 10 out of 10 (with 10 being the worst possible pain). A progress note written by the Administrator on 5/8/22 at 3:20 PM identified that she had called the family member to follow up on the incident, and informed the family member that there was an ongoing investigation by the police department. A nurse's note dated 5/9/22 at 8:50 AM identified that the APRN evaluated the resident for the incident that occurred on 5/8/22. The facial and ear abrasions persisted and there was noted swelling to the right side of the face, the APRN ordered the resident to be sent to the hospital for a probable head CT scan, since the X-rays were negative. An APRN progress note dated 5/9/22 identified that the resident had complained of right sided facial and ear pain which started 24 hours prior. The resident alleged that a staff member assaulted h/her with an object, and the resident was distressed over the incident. The resident was in a great deal of pain to the right side of his jawline to his/her ear, and was very difficult to touch or examine closely due to the discomfort. The resident was noted to have multiple areas on the right side of the face with cuts, dried blood and bruising. The resident had significant soft tissue swelling on the right side of the face, and although the facial X- rays were negative there was a concern that the injury may not be apparent on X-rays, the resident was sent to the emergency department for evaluation of the injuries and will likely require CT scans. Review of hospital documentation dated 5/9/22 identified that the resident reported that s/he had been struck with a coffee mug several times in the hands and face, multiple bruises on bilateral hands at varying degrees of healing with some generalized tenderness. There are also some superficial scratches with dried blood to the right side of the noise and some swelling to the wrist and the face. A CT scan of the face was negative for any acute process. An interview with NA#1 on 5/12/22 at 11:10 A.M. identified that she entered Resident #1's room on 5/8/22 at approximately 4:00 A.M. and Resident #1 requested food and soda, NA#1 stated that she would assist h/her when she had completed rounds, and continued on to toilet Resident #1's roommate. NA#1 stated that she noted that Resident #1's call light was noted to be on again, so she went back into the room and Resident #1 was yelling at her and stating, I am going to tear this place apart. NA#1 identified that she turned to leave the room, when she felt a wheel hit her back foot, and felt a wet cold liquid on the back side of her leg. NA#1 identified that she turned to see what the object thrown at her was, and urine was thrown in her face by Resident #1. NA#1 further identified she yelled at Resident #1, what the F***, you threw piss in my face. NA#1 further identified she yelled for help and another nursing assistant (NA#2) arrived and NA#1 left Resident #1's room, and notified the nursing supervisor immediately. NA#1 identified that she has not had touched Resident #1 either time she entered the room that morning, and never re-entered the room after the incident. NA#1 further identified that RN#1 met her at the unit's nurses' station and told informed NA#1 of Resident #1's allegation of verbal and physical abuse. NA#1 identified that she then went to another unit (A-2) to assist another aide transfer a resident. Interview with NA #2 on 5/13/22 at 11:50 A.M. identified that she entered Resident #1's room on 5/8/22 at approximately 4:30 A.M. after hearing a loud crash and yelling. NA#2 further identified upon entering the room she saw Resident #1 in bed and NA#1 at the bottom left corner of Resident #1's bed screaming at the top of her lungs at Resident #1 you f****** a****** you threw piss at me, with her right hand extended towards Resident #1 and left hand on her hip. NA#2 identified that the resident's top sheet was covered in blood, and Resident #1 was yelling get her out of here, she is crazy she just attacked me. NA#2 further identified she never saw NA#1 touch or strike Resident #1 upon entrance to the room, and noted that NA#1 had left the room after she entered. NA#2 identified that along with water and urine on the floor there was Resident #1's water pitcher and urinal. NA#2 further identified Resident #1's left bedside table was also on the floor on its side. Interview with Registered Nurse (RN, Supervisor) #1 on 5/12/22 at 2:45 P.M. RN#1 identified that she arrived on the unit shortly after the incident and found NA#1 at the nurse's station, upset, with her clothes wet and smelling like urine. RN #1 identified that NA#1 stated Resident #1 had thrown urine in her face. RN#1 stated she assessed Resident #1 who was upset, and had blood and abrasions noted to the right side of Resident #1's face, and Resident #1 claimed that NA#1 beat the s*** out of me, can't you see that. RN#1 identified that Resident #1's left bedside table was on the ground and urine and water were all over the floor. RN#1 identified that she informed NA#1 that Resident#1 accused her of hitting him/her and believed NA#1 left the building, however she did not ensure that NA#1 had left the building. Interview with Police Officer (PO) #1 on 5/19/22 at 1:41 P.M. identified that a call came into the police department on 5/8/22 at 7:45 A.M. and he was at the facility by 7:59 A.M. PO #1 identified that Resident #1 stated that h/she was struck with the top or bottom of a cup by NA#1. PO #1 further identified that he had applied for two warrants for NA#1, disorderly conduct, and assault to the elderly that had been sent to the prosecutor for review, but were still pending. Interview with the Administrator and Director of Nursing Services on 5/25/22 at 10:00 A.M. identified that although the resident had no history of accusatory behaviors, they were unable to substantiate verbal or physical abuse, because the facility believed it to be a dignity issue not a verbal abuse issue, as the comments were a reaction to having urine thrown on her and not necessarily directed towards the resident. The resident's alleged allegation that NA#1 struck the resident with a water pitcher repeatedly could not be substantiated because the injuries were not consistent with such activity and could have been self-inflicted and the right side of his/her face hit the side rail when the resident was agitated and was throwing things at NA #1. Review of NA#1's time card for 5/8/22 identified that she had punched out of the building at 6:57 AM (2 hours and 45 minutes after the allegation of abuse had been made by Resident #1. Interview with NA #3 on 5/25/22 at 1:05 P.M. and NA #4 on 5/26/22 at 4:18 PM identified that sometime after 5:30 A.M. on 5/8/22 (an hour after the abuse allegation had been made), NA#2 and NA#4 asked NA#1 to assist with transferring a resident from a power wheelchair to a regular wheelchair. During a subsequent Interview with NA#2 on 5/26/22 at 11:18 A.M., she identified that she last saw NA#1 on 5/8/22 after 6:30 A.M. (2 hours after the allegation of abuse had been made by Resident #1) on A-1 unit on the phone speaking with the DNS. Further interview with the Nursing Supervisor, RN#1 on 5/25/22 at 1:50 P.M. identified that she did not follow-up to ensure NA#1 left the building following the abuse allegation, and if she had known she was still in the building, she would have informed her she had to leave immediately. Subsequent interview with Director of Nursing Services (DNS) on 5/25/22 at 2:05 P.M. identified that on the morning of 5/8/22 she had awoken to text and phone messages from NA#1 and RN#1. The DNS further identified that she called the building first and spoke with RN#1 who informed her of the allegation of staff to resident abuse and that RN#1 had directed NA#1 to leave the facility. At approximately 6:30 AM the DNS identified that she had then called NA#1, who was still in the building, and informed at that time that she had to leave the building. The DNS identified that RN #1 should have verified that NA#1 had left the building immediately after the allegation had been made. The facility failed to ensure that once an allegation of abuse had been made, that the alleged staff member had been immediately removed from the building and not allowed to care for any other residents. A review of the facility's abuse policy identified each resident has the right to be free from abuse, neglect, and mistreatment. The policy defines verbal abuse defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or to others regarding the resident, or within the resident's hearing distance regardless of their age, ability to comprehend, or disability. The policy directs the facility to interview and suspend immediately any employee alleged to be involved in an instance of abuse and will not be permitted to return to work unless and until such allegations of abuse are unsubstantiated. b. Review of NA #1's time card dated 5/21/22 identified that NA #1 punched in at 11:00 PM and punched out at 7:08 AM, and on 5/22/22 NA#1 punched in at 11:19 PM and punched out at 7:11 AM. Interview with the Administrator on 5/26/22 at 10:00 AM identified that she was in contact with the Corporate office and their Human Resources Department to discuss if it was appropriate to allow NA#1 to return to work. The Administrator identified that NA#1 had already been suspended for 2 weeks, and although the police investigation was still ongoing, it could take a long time for the police investigation to be completed. The facility had completed their investigation and because they could not substantiate the physical abuse, and believed that the allegation of verbal abuse was more of a dignity issue with the resident, they allow NA#1 to return to the facility on [DATE]. NA #1 received education on customer service and dealing with a difficult resident, and worked on 5/21/22, and 5/22/22 on the 11:00 PM to 7:00 AM shift, on a different unit from where Resident #1 resided. During this period of time, no formal monitoring of NA#1 was completed during her 2 shifts. The Administrator identified that although the facility was aware there was a police investigation for abuse against an elderly person, they did not contact the police department prior to re-instating NA#1's employment to receive an update on the investigation. On 5/23/22 the facility contacted the police department and were informed that there was a pending arrest warrant for NA#1 for abuse against an elderly person, NA #1 was re-suspended as of 5/23/22 pending the outcome of the police investigation. Additionally, the Administrator identified that if the facility was aware that there were pending warrants for NA#1 they would not have allowed her to return to work. The Administrator identified that NA#1 would remain suspended until the police had completed the investigation. Interview with Police Officer #1 on 5/26/22 at 1:33 P.M. identified that he was contacted on 5/23/22 by the facility to inquire if any charges would be filed against NA#1. Officer #1 identified that he submitted an arrest warrant for NA#1 for disorderly conduct and abuse against an elderly person, however he had no updates on the status of the warrants. The facility allowed NA#1 to care residents although there was an active and ongoing police investigation for alleged abuse against Resident #1. On 5/26/22 the state agency requested an immediate action plan which included all supervisors to be educated on the immediate removal of an employee that has been allegedly accused of abuse, and ensure an employee does not perform resident care subsequent to the allegation. Education was provided to the management staff and human resources to sustain a staff member's suspension until a criminal police investigation is complete, all staff were educated on the abuse policies and procedures. Further, audits are being conducted of 24 hour reports and concern forms (grievance) to review any possible abuse allegations. All residents who were cared for by NA#1 on 5/21 and 5/22/22 were interviewed and no issues were identified. An onsite visit to the facility was conducted on 6/2/22 and identified that the facility implemented their action plan and Immediate Jeopardy was removed as of 5/28/22.

Based on clinical record review, facility documentation review and interviews for one of three residents (Resident #1) reviewed for medication administration, the facility failed to ensure a resident was free from a significant medication error that resulted in a hospitalization and a surgical procedure. The findings include: Resident #1 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital discharge summary dated 3/19/2021 and updated 3/20/2021 directed to administer [MEDICATION(S)] 40 milligrams (mg) daily for 14 days for [CONDITION(S)] (DVT) prophylaxis and then to resume Resident #1's home dose of [MEDICATION(S)]. The report further identified Resident #1's oxygen level was 94%. The admission nursing assessment dated [DATE] identified Resident #1 was alert and oriented, could communicate with staff easily, and received [MEDICATION(S)] anticoagulant therapy (blood thinner). The Resident Care Plan (RCP) dated 3/20/2021 identified Resident #1 received anticoagulant medication. Interventions directed to administer the anticoagulant as ordered, observe for side effects and effectiveness every shift, and to report adverse reactions such as blood in urine and stools, headaches, nausea, lethargy, shortness of breath or sudden changes. The physician's orders dated 3/20/2021 directed to administer [MEDICATION(S)] ([MEDICATION(S)]) 40 mg/0.4 millimeters (ml), inject 0.4 ml subcutaneously one time a day for 13 administrations for DVT prophylaxis. The nursing progress note and change in condition form dated 3/26/2021 at 4:33 PM identified Resident #1 became short of breath when transferring from the bed to the chair, and the shortness of breath was relieved with rest. Additionally, the oxygen level decreased to 86% in physical therapy and increased to 94-97% with rest. MD #1 was notified and a stat chest x-ray was ordered. Review of the Physicians orders dated 3/26/2021 directed a chest x-ray, and lab work to include a D-dimer blood test (to rule out a PE). The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was admitted to the facility with orders for [MEDICATION(S)] 40 mg for 14 days for DVT prophylaxis and then to resume [MEDICATION(S)]. Resident #1 had decreased oxygen levels earlier in the day with minimal exertion and with physical therapy. Resident #1 reported he/she did not receive the anticoagulation medication ([MEDICATION(S)]) and per review of the medical record it was noted that Resident #1 did not receive the [MEDICATION(S)] injections as ordered. Additionally, Resident #1 requested to be transferred to the hospital because he/she suspected a pulmonary embolism. The nursing change in condition progress note dated 3/26/2021 at 9 PM identified Resident #1 was concerned that his/her shortness of breath may be cause by a pulmonary embolism because he/she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, the note identified that [MEDICATION(S)] was not administered since admission. MD #1 was notified and Resident #1 was transferred to the hospital. Review of the Medication Administration Record (MAR) identified, the [MEDICATION(S)] was entered in the computer system correctly upon admission on 3/20/2021 and then was discontinued on 3/21/2021. Resident #1 received one dose of the [MEDICATION(S)] on 3/21/2021 at 9 AM and did not receive the [MEDICATION(S)] on 3/22, 3/23, 3/24, 3/25 and 3/26/2021 (a total of 5 missed doses). The facility incident report dated 3/26/2021 at 10:30 PM, and the facility medication variance report dated 3/27/2021 identified that a medication transcription error resulted in Resident #1's hospitalization . The report identified the error was related to a computer order entry error that may have contributed to, or resulted in, temporary resident harm and the resident required intervention. The medication review report identified the original [MEDICATION(S)] order was discontinued on 3/21/2021 and re-entered in the computer to start on 3/31/2021, which was an error (the [MEDICATION(S)] should have been administered daily through 3/31/2021). Review of the statement written by RN #3 dated 3/27/2021 identified Resident #1's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/21/2021, the facility received a call from the pharmacy requesting to clarify the [MEDICATION(S)] and [MEDICATION(S)] orders to determine if both medications (both anticoagulants) were being administered. RN #3 informed the pharmacy that only the [MEDICATION(S)] was being administered until 3/31/2021, and then the [MEDICATION(S)] would start after the [MEDICATION(S)] was discontinued. Additionally, in an attempt to assist to clarify the order for the pharmacy, RN #3 discontinued the original order in the electronic medical record (EMR) and re-entered the [MEDICATION(S)] order. When RN #3 re-entered the order, she inadvertently entered the [MEDICATION(S)] to begin on 3/31/2021, which should have been the end date. Resident #1 had received one dose of the [MEDICATION(S)] on 3/21/2021 before RN #3 re-entered the order incorrectly. Review of the one to one in-service record dated 3/29/2021 and signed by RN #1 identified RN #3 received order transcription training related to safety and accuracy to prevent future errors. The hospital History and Physical dated 3/27/2021 identified Resident #1 had been discharged from the hospital to the nursing home after an elective surgery with instructions for [MEDICATION(S)] 40 mg daily for 14 days and then to restart [MEDICATION(S)]. Resident #1 missed doses of [MEDICATION(S)] at the nursing facility. A Cat Scan [MEDICATION(S)] (CTA) identified multiple pulmonary emboli (blood clots) bilaterally and a saddle [CONDITION(S)] (a clot within the main and left pulmonary arteries). Resident #1 was admitted to the medical intensive care unit with a blood clot in the left leg and the multiple pulmonary embolisms and started on an intravenous [MEDICATION(S)] drip. An echocardiogram demonstrated evidence of right heart strain and Resident #1 was transferred on 3/27/21 to another hospital. Hospital [MEDICATION(S)] Radiology surgical note dated 3/27/2021 identified Resident #1 had a suction thrombectomy performed to remove a moderate volume of thrombus. A hospital progress note dated 3/29/2021 identified that a lower extremity ultrasound identified a non-occlusive [CONDITION(S)] (blood clot) of the left common femoral vein and the common femoral vein at the saphenofemoral junction. Resident #1 remained in the hospital during the survey. Interview with RN #3 on 3/30/21 identified the pharmacy called to question if the [MEDICATION(S)] and [MEDICATION(S)] were administered together because the pharmacy was unable to see the start and stop dates of medications in the facility electronic charting system (they could only see the list of medications ordered). RN #3 re-entered the [MEDICATION(S)] order in the EMR (thinking it would clarify the dates for the pharmacy) and she incorrectly entered the start date as the 3/31/2021. RN #3 identified the intention was to send a note to the pharmacy in the note box of the order screen that identified the stop dates, not to change the [MEDICATION(S)] administration order dates. Further, RN #3 identified it was the policy of the facility to print and flag any new orders in the chart for the night nurse to review for accuracy. She indicated that she did not flag the orders for review by another nurse because the order was not a new order, and no other nurse reviewed the order re-entry for accuracy. Interview with Pharmacist #1 on 3/30/2021 at 10:52 AM identified the start and stop dates of medication orders cannot be viewed on the pharmacy's computer screen when medication orders are electronically transmitted from the facility. Additionally, the pharmacy does not reconcile orders entered by the facility for accuracy because they do not have access to the facility electronic health record. Interview with the Administrator on 3/30/2021 at 11:45 AM identified the facility completed an immediate action plan for quality improvement when a medication error of clinical significance that resulted in hospitalization of a resident was identified. Additionally, the error was identified as a transcription error and RN #1 received 1:1 education regarding transcriptions. An audit was completed of all residents in the facility who received anticoagulation medication to ensure orders were transcribed accurately, and no issues were identified. Additionally, the Administrator indicated that all staff will be educated on the medication transcription process and the need to have a second nurse verify all new and/or changed orders. The facility developed a new tool to audit anti-coagulation medication orders. Further, the facility has consulted the pharmacy to determine if anything could have been done differently to prevent the error. Interview with the DNS on 3/30/21 at 11:50AM identified the supervisors were responsible to enter physician orders in the computer, print the order and flag them in the resident's charts and the night shift nurse was responsible to verify all orders for accuracy. RN #3 did not print the order and flag the order that she re-entered for verification. The DNS indicated that RN #3 should have flagged the order for verification because she made a change to the order and all changed orders should be flagged. Interview and record review with MD #1 on 3/30/2021 at 12:13 PM identified that Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was mobile while at the facility, and although Resident #1 missed the five (5) doses of [MEDICATION(S)] while at the facility, he/she could have developed the blood clots even if the [MEDICATION(S)] was administered. Interview with the Orthopedic Surgeon (MD #2) on 3/31/2021 at 2:27 PM identified that Resident #1's routine dose of [MEDICATION(S)] was stopped two (2) days prior to the elective surgery. MD #2 further identified that Resident #1 was at high risk for blood clots due to his/her prior history of clots, and that although the five (5) days of missed [MEDICATION(S)] doses could have contributed to the development of the blood clots and pulmonary embolisms he was unable to identify if the missed doses caused the blood clots. MD #2 indicated that it was unlikely that Resident #1 had the blood clots and pulmonary embolism before he/she was admitted to the nursing facility on 3/20/2021. MD #2 identified that a pulmonary embolism was a blood clot in the lung which was a serious issue that could lead to death. MD #2 further indicated that although Resident #1 should have received the medication as ordered, he could not say with 100% certainty that the missed [MEDICATION(S)] doses caused the blood clots due to Resident #1's history of clots. Review of the facility policy entitled Receiving Physician Orders dated January, 2012 directed in part, the entire process of medication administration must be handled with the utmost degree of care, from the time the order is received and until the time it is delivered to the patient, accuracy is very important and it is the responsibility of the licensed professional to ensure residents receive the correct medication. The receiving nurse will transcribe the order on the medication administration record (MAR) and the order should include date, time, dosage, route, frequency, diagnosis, physician signature, duration, lab monitoring and notes on use of E-KIT. Additionally, every transcribed order must have a start date and a stop date if indicated and documented on the MAR.

Based on review of the clinical record, review of facility documentation and interviews for 1 of 3 sampled residents (Resident #2[AGE]) reviewed for accidents and required the assistance of two staff members for care, the facility failed to ensure that two staff were in place when care was being provided, resulting in a fall with an injury. The findings include: Resident #2[AGE] [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified moderately impaired cognition, no behavioral symptoms, required extensive assistance of at least two persons for all ADL care with the exception of eating, did not ambulate, was unsteady with surface to surface transfers and only able to stabilize with staff assistance, had range of motion limitations on one side of the upper and lower extremities, utilized a wheelchair for mobility and had not fallen in the last three months. The care plan dated 8/21/19 identified an ADL self-care performance deficit related to [MEDICAL CONDITION] with care plan interventions which identified the resident required two staff to turn and reposition in bed every two hours and as necessary. Review of a reportable event dated 9/3/19 at 8:30 PM identified the resident was receiving care in his/her bed and sustained a fall out of the bed. The report identified the resident sustained [REDACTED]. A reportable event dated [DATE] at 7:30 PM identified the resident reported pain to the left knee. It further identified that an X-ray was obtained which identified an acute [MEDICAL CONDITION] distal femur. Resident #2[AGE] was transferred to the emergency room for an evaluation and returned to the facility on [DATE] with an immobilizer to the left lower extremity and instructions to follow up with an orthopedic physician. Review of the radiology report dated [DATE] identified an acute fracture involving the left distal femur with modest displacement. A nurse's note dated 9/3/19 at 10:56 PM identified that the resident slid off of the bed to the floor while a nurse aide was providing care. RN assessment of resident and resident was Hoyer lifted (mechanical lift) off of the floor with the assistance of three staff. The note further identified an abrasion to the left 2nd toe and left anterior shin and no complaints of pain following the fall. A nurse's note dated [DATE] at 1:24 PM identified Resident #2[AGE] was complaining of increased left knee pain. The note identified that the knee was free of redness, swelling and bruising. It noted that the range of motion was at baseline. It further noted that the APRN also assessed the resident's left knee, following which an X-ray of the knee was ordered as well as [MEDICATION NAME] [MED] 10 mg every for hours as needed for pain. A review of the clinical record identified [MEDICATION NAME] was administered five times between [DATE] and 9/6/19 with effect. A nurse's note dated [DATE] at 8:31 PM identified that the x-ray results were positive for a left distal femur fracture. The physician was notified and the resident was sent to the hospital to be evaluated. Interview on [DATE] at 11:23 AM with the DNS identified on 9/3/19 nurse aide (NA) #1 was in the resident's room to assist with repositioning a pillow behind the resident's back. She further identified the resident participated with re-positioning by grabbing onto the bed rail with his/her right hand and pulling him/herself over. The DNS identified the resident rolled off the bed to the floor. She identified NA #1 attempted to assist the resident down to the floor as he/she was falling but the resident slipped off the bed, while still holding onto the bed rail. She further noted that a mechanical lift was used to transfer the resident off the floor and the resident was placed back in bed following an RN assessment. Interview [DATE] at 3:45 PM with NA #1 identified on 9/3/19 at 8:30 PM Resident #2[AGE] called NA#1 into his/her room to reposition the pillow behind his/her back. NA #1 identified that she was familiar with the resident and had taken care of the resident on previous occasions and was aware that the resident required two staff for the majority of her care. NA#1 identified she was on one side of the bed behind the resident( without the benefit of another staff member ) and the resident used his/her right hand to grasp the side rail to pull himself/herself over in the bed towards the left and as the resident pulled, NA#1 pushed the pillow behind the resident's back. NA #1 identified Resident #2[AGE]'s legs and abdomen just kept going out of the bed and she rushed to the other side of the bed and guided the resident to the floor while the resident was still grasping the side rail. NA #1 identified that although she was aware Resident #2[AGE] required assist of two with care, she thought that just repositioning the pillow was a task that did not require two people. A review of the facility lift, transfer and repositioning policy identified direct care staff will be responsible for lifting and transferring residents in accordance with the plan of care. The facility failed to ensure that two staff members were utilized when the resident required repositioning in the bed resulting in a left femur fracture following the fall out of bed.

Based on review of the clinical record, review of facility documentation, and interview for one sampled resident (R#104), the facility failed to ensure the resident received the appropriate medications as ordered by the physician. The findings include: Resident # 104's [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE]identified the resident had moderately impaired cognition and required extensive assistance with ADL's. The Resident Care Plan dated 8/28/13 directed the staff to provide assistance with ADL's as needed. Change in Condition documentation dated 9/11/13 identified that at 11:45 AM while on the toilet the resident vomited and became unresponsive. Vital Signs were assessed and a low blood pressure (BP) of 63/30 and a pulse of 62 were noted. The APRN was on site and evaluated the resident who was also complaining of left chest wall pain. It was determined that the following medications were administered to the resident in error at 10:20 AM; Magnesium 800mg, [MEDICATION NAME] XL 50 mg, Lisinipril 20mg, [MEDICATION NAME] 5mg and [MEDICATION NAME] 50mg. The APRN progress note dated 9/11/13 identified a usual BP of 128/70 that dropped to 68/40 after receiving the wrong medications. At 12:05 the BP increased to 78/44 and the resident was transferred to the ER for evaluation of pain and a low BPs. . A Hospital Discharge Summary dated 9/14/13 identified [DIAGNOSES REDACTED]. Interview, review of the clinical record and review a Medication Variance Report dated 9/14/13 on 12/2/13 at 1:30 PM, with the DNS identified that the nurse who administered the wrong medication failed to check the resident's name band and/or photo prior to administering the medications.

Based on clinical record review, observation, and interview for the only sampled resident with surgical wound of the foot (R#264), the facility failed to ensure that the wound was assessed on admission and as needed thereafter and/or that appropriate interventions were initiated to protect the resident's foot from pressure and/or contamination resulting in a finding of immediate jeopardy. In addition for 3 sampled residents (R#12, 40, 265) with arterial/ vascular ulcers, the facility failed to implement interventions to promote healing and/or prevent development of further wounds, and/ or for the only sampled resident receiving [MEDICAL TREATMENT] (R#125), the facility failed to document the monitoring of the resident's [MEDICAL TREATMENT] access device. The findings include: 1. Resident #264 was admitted to the facility on [DATE]. The hospital discharge summary dated 7/19/11 noted the resident had a prolonged hospital stay after suffering a [MEDICAL CONDITION] infarction with cardiogenic shock. The resident ' s left foot became ischemic and gangrene was noted of the toes resulting in a transmetatarsal amputation of the toes. The discharge summary directed non weight bearing for 3 weeks and every other day [MEDICATION NAME] paint with dry sterile dressing for wound care to the left foot amputation site. The nursing admission assessment dated [DATE] identified that the resident was alert and oriented, 5 feet 10 inches tall, 285 pounds, and required extensive assistance with bed mobility and transfers. Physical therapy notes dated 7/20/11 directed to transfer the resident with a Hoyer lift. physician progress notes [REDACTED]. The entire heel was covered with an intact deep tissue injury/eschar. Physician orders [REDACTED]. Orders dated 7/20/11 directed painting the left heel and foot wound with [MEDICATION NAME], wrap with ace wrap foot to knee, turn and reposition every 2 hours, apply a foot cradle, and place on a low air loss mattress. A pressure sore assessment dated [DATE] described the left heel/bottom of foot with a 12 by 10 cm black, deep tissue injury with no drainage. Stage 2 pressure sores were also noted on the right and left buttocks on admission. No assessment of the incision/amputation site was noted except to state that sutures were present on 7/19/11. Observations on 7/25/11 at 11:10 AM during resident interview, noted the resident attempting to move self while in bed. Upon surveyor inquiry the resident stated that he/she was uncomfortable and noted that his/her feet hurt. The resident stated that he/she had informed the staff about sliding down in the bed and the inability to move back up. The resident ' s feet were noted pressing up against the foot board of the bed with the heels/legs directly on the mattress without the benefit of offloading. The left leg was noted wrapped in an ace bandage up to the base of the toes exposing the amputation site which was not covered by a dressing. Sutures were visible with the surgical area noted pressing against the footboard. Eschar was visible on the bottom of the foot below the suture line. Surveyor informed the resident that she would seek help from staff. RN#1 was notified by surveyor at 11:20 AM that the resident had pain and had feet pressing against the footboard of the bed. RN#1 responded that she would take care of it. At 11:30 AM, observations noted the resident continued to have the feet pressing against the footboard. At 11:45 AM, the surveyor accompanied RN#1 into the resident ' s room and observed the suture area uncovered with the feet pressing against the footboard. No offloading of the feet was evident in the bed and the sheet was not placed on the bed cradle that was present. RN#1 stated that she would have the nurse aides pull the resident up in bed. At 12 noon, two nurse aides repositioned the resident. At 12:10 PM observation with MD#1 noted dried drainage and skin stuck to the footboard where the resident ' s feet had been. Subsequent to surveyor inquiry, MD#1 ordered a dressing applied to the suture line, repositioning every 2 hours, and the footboard of the bed removed. Observations on 7/27/11 at 9:30 AM noted a large area of eschar on the left heel extending up through the mid foot region, multiple small open areas between the eschar and the amputated toes, and 17 sutures in place. An area of eschar was noted on the inner ankle, and left calf. Assessments were lacking in the record for the amputation site, and the inner ankle eschar. Interview and review of the clinical record with the DNS on 7/27/11 at 10 AM failed to provide documentation that the suture line had been assessed since admission, or that interventions to alleviate pressure to the foot had been initiated. Interview with MD #1 on 7/27/11 at 12 PM noted that upon observation with the surveyor on 7/25/11, the resident ' s skin and drainage were noted on the footboard. The physician noted that alleviating pressure was important. Subsequent to surveyor inquiry, a bed extension was placed on the bed to prevent pressure to the feet. A bariatric bed was subsequently ordered. 2. Resident # 12's [DIAGNOSES REDACTED]. A nursing admission assessment dated [DATE] identified a dry scab to the toe. A quarterly assessment dated [DATE] identified the resident was moderately cognitively impaired, and required extensive assistance with ADL's including bed mobility. A readmission history and physical dated 5/11/11 identified there was "still" eschar on the top of a few toes on the right foot. The RCP dated 5/14/11 identified a potential for skin impairment related to impaired mobility, altered sensory perception and a history of "Trash Emboli". Interventions included the use of a multipodus boot for 4 hours while in bed, elevate heels while in bed at all times, and document observation of any non-pressure related skin impairments on facility Non-Pressure Ulcer Wound documentation form. Physician orders [REDACTED]. Observation on 7/27/11 at 10 AM with the unit manager (RN#2) identified the resident in bed without the benefit of the multipodus boot (which was located on the bedside chair and a wedge cushion), a foam bootie was present on the resident's right foot, and both heels where positioned directly on the mattress surface. Further observation identified small black areas of eschar on the top of the residents 2nd, 3rd, and 4th toes of the right foot. Interview, review of the clinical record and facility documentation at that time with RN#2 identified that although the RCP and Physicians Orders directed the use of the multipodus boot for 4 hours, the orders failed to identify what hours of the day the resident was to utilize the boot. The clinical record and the Wound Committee's Pressure and Non-Pressure Logs were reviewed at that time and failed to provide documentation that the three areas on the resident's toes had been assessed by the wound team on weekly rounds. 3. Resident #265's [DIAGNOSES REDACTED]. The nursing admission assessment dated [DATE] identified a boggy left heel. The initial plan of care dated 7/11/11 identified a surgical site. Interventions included monitoring wound healing, skin checks weekly per facility protocol, notify MD of changes and turn and reposition. Physician orders [REDACTED]. Review of the treatment kardexs for July 2011 identified that although a physician order [REDACTED]. Review of the nurse's notes and nursing daily skilled summary, from 7/11/11 (time of admission) thru 7/15/11 failed to identify any assesment of R #265's left heel until 7/15/11 on the 7 to 3 shift when R #265 complained of left heel discomfort and upon assessment, R#265 was noted to have a darkened area to the heel. Review of the Rehab notes dated 7/15/11 identified R #265 complained of left heel pain while donning a sock. Observation identified a deep purple area to the resident's left heel. Review of the weekly pressure ulcer record dated 7/15/11 noted a 5.0cm x 5.0cm red/ purple deep tissue injury to the left heel. Interview and review of R #265's clinical record with LPN #1 on 7/27/11 at 10:05 AM failed to provide documentation that any interventions for off loading of the heels had been implemented when the resident was admitted with the "boggy" heel on 7/11/11 until 7/15/11 when the left heel was noted with a deep tissue injury. Interview and review of R #265's clinical record with the DNS on 7/27/11 at 11:00 AM identifed that although R #265 was identified with boggy heels on admission, no interventions were implemented to off load the heels until 7/15/11 at which time the heels were noted with a 5.0 x5.0cm deep tissue injury. 4. Resident #40 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Minimum data set assessment dated [DATE] identified that the resident was moderately cognitive impaired and required extensive assistance with activities of daily living (ADL) including bed mobility and transfers between surfaces, and the presence of 4 venous/ arterial ulcers. A nursing admission assessment dated [DATE] identified a 3.0 x 3.0 cm "open area with yellow eschar" located on R#40's right ankle. The RCP dated 7/10/11 identified actual arterial ulcers to the right 2nd and 5th toe and the right lateral malleolus. Interventions included bilateral foam heel lift boots, lambswool between great toes and a low air loss mattress. Physicians orders dated 07/11/11 directed the provision of a low air loss mattress (LAL) for "pressure relief", "check placement and settings every shift", cleanse open wound on the right lateral malleolus (ankle) and apply iodosol gel and a dry protective dressing every other day, turn and reposition resident every two (2) hours, apply heel lift boots to feet while in bed and lambs wool between great toes and second toes at all times. Observation of morning care on 07/27/11 at 11:28 AM noted NA# 1 providing care. The resident's heels appeared beefy red. The resident lacked heel lift boots and the feet were noted directly on the mattress. A low air loss mattress was lacking on the bed. Interview with NA#1 on 7/27/11 at 11:36 AM she indicated that she had not attempted to apply the foam boots that day because the resident frequently kicked them off. She also indicated that R#40 had not utilized a low air loss mattress for some time because the resident was sliding off of the mattress. Intermittent observation of R#40 on 07/27/11 from 10:25 AM through 2:30 PM identified the resident positioned on his/her back and/or with his/her heels directly on the mattress without the benefit of the foam heel boots, lambs wool between great toes and/or with the physician directed low air loss mattress bed. During an interview with LPN #2 on 07/27/11, she indicated that although she had signed off the treatment record as having checked for placement and proper settings she was unaware that the low air loss bed was not being utilized for R#40 and/or when the bed was removed from the resident's room. During an interview with the Unit Manager LPN #1 he failed to explain why the low air loss mattress was removed and/or when and/or by whom and/or how long it was not in place. 5. Resident #125 was admitted to facility on 07/01/11 with [DIAGNOSES REDACTED]. An admission assessment dated [DATE] identified the resident had no cognitive impairments, required extensive assistance with bed mobility, transfers, toilet use, personal hygiene and received surgical wound care. A nursing admission assessment dated [DATE] identified the presence of an intact "AV Fistula", located on the right chest wall and steri-strips on R#125's left lower extremity in place without signs or symptoms of infection. Physicians orders dated 07/01/11 directed that R#125 receive [MEDICAL TREATMENT] three (3) times a week on Tuesday, Thursday and Saturday. Resident care plan dated 07/08/11 identified that R#125 had a problem with "[MEDICAL CONDITION]", received [MEDICAL TREATMENT] three (3) times per week and utilized a "Perma Cath" access device. Interventions included monitoring the "Perma Cath" site every shift and record. Review of R#125's clinical record including treatment record and nurse's notes identified the lack of complete and/or consistent documentation of the resident's "Perma Cath". Review of nurse's notes from 7/02/11 to 7/26/11 identified that out of twenty-five (25) days (three shifts per day), the facility only documented four (4) complete days of an assessment every shift. Further review noted that the facility failed to document any assessments for seven (7) complete days. For eleven days (11) the facility only documented one (1) out of three (3) shifts and for three days documented an assessment for two (2) out of three (3) shifts. An interview and review of R#125's clinical record with RN# 3 and LPN# 1 on 07/28/11 at 10:08 AM failed to provide documentation that the resident's perma cath site was monitored/assessed every shift as directed.

Based on clinical record review, observation and staff interview for 1of 3 sampled residents with pressure ulcers ( R#40), the facility failed to implement interventions to promote healing and/or prevent development of pressure ulcers. The findings included; 1. Resident #40 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nursing admission assessment dated [DATE] identified the presence of pressure ulcers located on R#40's (mid) back that measured 3.0 x 3.0 CM and "many red areas" located on the buttocks. It further noted a 3.0 x 3.0 cm "open with yellow eschar" area located on R#40's right ankle. An MDS assessment dated [DATE] identified that the resident was moderately cognitive impaired, required extensive assistance with ADL's including bed mobility and transfers and had two (2) stage II pressure ulcers upon readmission. The care plan dated 7/10/11 identified a problem with skin integrity related to impaired mobility and pressure ulcers located on coccyx and mid spine stage II areas and an arterial ulcer on the right lateral malleolus (ankle). Interventions included turn and reposition every two hours, provision of bilateral heel lift foam boots while in bed, lambs wool between the great toes and a low air loss (LAL) mattress. Physicians orders dated 07/11/11 directed the use of a low air loss mattress (LAL) for "pressure relief" and to "check placement and settings every shift". Further orders directed to apply skin repair cream to the open areas on the mid-back and buttocks every shift and after each incontinent episode, turn and reposition the resident every two (2) hours, apply heel lift boots to feet while in bed and lambs wool between the great toes and second toes at all times. Review of the initial "medical nutritional therapy review" dated 7/14/11 noted that the Registered Dietician's (RD) assessment failed to identify that R#40 had skin conditions and/or pressure ulcers present and/or any related recommendations. Review of R#40's weekly pressure ulcer record dated 07/19/11 identified the presence of a stage II pressure area located on the coccyx that measured 0.4 x 0.4 x 0.1 CM with no exudates. Specialty interventions identified "low air loss" (LAL) mattress and "boots". Additionally dated 7/19/11, a stage II was present on R#40's mid spine that measured 1.0 x 1.0 x <0.1 CM. Observation of morning care on 07/27/11 at 11:28 AM noted NA# 1 providing care. A low air loss mattress was not on the bed. The resident had been incontinent of urine, and the brief was noted heavily saturated with yellow liquid. Open areas were noted on the mid back and at the coccyx. The coccyx wound was noted with green drainage within the wound bed. Both buttocks were noted with large, reddened, denuded areas and the resident's heels appeared beefy red. All of the open areas were without the benefit of a covering dressing or skin repair cream. NA# 1 was observed to proceed washing through and over the open areas and then observed applying an "anti-fungal cream" onto the open, draining coccyx and buttock areas. Interview with NA# 1 on 7/27/11 at 11:36 AM indicated that she had not attempted to apply the foam boots that day because the resident frequently kicked them off. She also indicated that R#40 had not utilized a low air loss mattress for some time because the resident was sliding off of the mattress. Intermittent observation of R#40 on 07/27/11 from 10:25 AM through 2:30 PM identified the resident positioned on his/her back and/or with his/her heels directly on the mattress without the benefit of the foam heel boots, lambs wool between great toes and/or with the physician directed low air loss mattress bed. Review of a skin assessment with LPN #1 on 07/27/11 identified that the coccyx area pressure ulcer had "deteriorated" and now measured 1.0 x 0.5 cm with "necrotic tissue surrounding areas of breakdown". The mid spine stage II area was identified during observation/assessment to now measure 2.0 x 2.0 CM. Three new open areas were identified on 07/27/11 including the right side of the coccyx stage II, measured 0.5 x 0.8 CM, the right (buttock) ischium to coccyx stage II, measuring 6.0 x 1.0 x <0.1 CM, and a "deep tissue injury" (DTI) located on the right lateral heel that measured 0.5 x 0.5 CM. The assessment identified "Heels boggy, blanching except for a small darkened area at lateral aspect". During an interview with LPN # 2 on 07/27/11 she indicated that although she had signed off the treatment record as having checked for placement and proper settings of the low air loss mattress, she was unaware that the low air loss bed was not being utilized for R#40 and/or when the bed was removed from the resident's room. She further indicated that the NA did not report the newly identified pressure areas. During a subsequent interview with NA#1 she indicated that she had not reported the condition of the resident's skin because it was not a change and had been that way for awhile. During an interview with the Unit Manager, LPN #1 he was unable to explain why the low air loss mattress was removed and/or when and/or by whom and/or how long it was not in place.