Every finding on record at Pine Tree Lodge Nursing Center

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #1) and 4 of 4 staff ( CNA D, LVN C, LVN B, ADON) reviewed for infection control. The facility failed to ensure CNA D wore gloves carrying a soiled brief in the hallway on 6/24/2026. The facility failed to ensure LVN C washed hands prior to care, placed gloves on while walking to Resident #1's room, and wore proper PPE while transferring Resident #1 on/off toilet on 6/24/2026. The facility failed to ensure ADON wore proper PPE while assisting Resident #1 with transfer on/off toilet on 6/24/2026. The facility failed to ensure LVN B wore a gown and gloves during an observation of Resident #1's skin assessment. These failures could place residents at risk for cross-contamination, increased risk of infection and the spread of infection.Findings included: Record review of Resident #1's face sheet dated 6/24/2026 indicated Resident #1 was a [AGE] year-old, female and readmitted on [DATE] with a diagnosis of chronic non-pressure ulcer of right and left foot (an open sore on the foot that does not heal due to poor circulation, nerve damage, or repeated pressure). Record review of Resident #1's quarterly MDS dated [DATE], indicated Resident #1 was understood and understood others. Resident #1 had a BIMS score of 2 indicating she had severe cognitive impairment. The MDS also indicated Resident #1 required moderate assistance with toileting. The MDS indicated Resident #1 had 1 unhealed pressure ulcer. Record review of Resident #1's care plan initiated 3/4/2026 indicated Resident #1 had surgical site to right inferior breast with interventions to observe for signs and symptoms of infection, report to physician if noted, observe for signs and symptoms of pain during treatment and medicate as needed per physician orders, surgeon follow up as needed, assist resident, RP with scheduling/transportation as needed and complete wound care per orders. There were no care plan or orders for enhanced barrier precautions for Resident #1 with chronic wounds. During an observation on 6/24/2026 at 9:29 AM, CNA D was observed walking down the hallway with a mask on with gloves holding a soiled brief in her hands. CNA D removed gloves and threw them in the trash.During an observation on 6/24/2026 at 9:40 AM, LVN C was observed walking down hallway putting on her gloves prior to arriving to Resident #1's room. LVN C was observed cleaning Resident #1's toilet with cleaning wipes. LVN C then left Resident #1's room and removed gloves outside the room while walking down the hallway. LVN C was observed returning to Resident #1's room and new gloves placed on prior to arriving to room. LVN C did not wash her hands or apply PPE while transferring Resident #1 to the toilet. LVN C was contacted for a phone interview on 6/25/2026 at 3:54 PM and did not receive a return call at end of investigation.During an observation on 6/24/2026 at 9:45 AM, ADON arrived at Resident #1's room. ADON did not wash hands prior to assisting LVN C transferring Resident #1 on/off the toilet. ADON was not wearing PPE while assisting Resident #1 who was on Enhanced Barrier Precautions.due to chronic wound to right breast. ADON left the room with gloves on and trash from resident room. ADON removed gloves in hallway while throwing away the trash and then used hand sanitizer. ADON returned to Resident #1's room with briefs and gloves to assist with applying new brief. ADON did not apply PPE during brief change.During a telephone interview on 6/24/2026 at 10:39 AM, Resident # 1's RP said staff had not been wearing PPE while providing care.During an interview on 6/25/2026 at 8:15 AM, Resident #1 said she had a wound to her right breast and stated it had been there for a while. Resident #1 said the staff were performing wound care daily. Resident #1 said the staff did not wear PPE while providing care.During an observation and interview on 6/25/2026 at 3:13 PM, LVN B was requested by RP to check Resident #1's skin to her bottom. LVN B arrived at Resident #1's room and applied gloves. LVN B assisted Resident #1 from her wheelchair to her bed by pivoting her with close contact and direct assistance. LVN B was asked to step out of room prior to skin assessment. LVN B was made aware of EBP. LVN B said she got distracted and forgot to put on PPE. LVN B returned to room after applying PPE and new gloves. RP asked LVN B why she was wearing PPE and informed LVN no staff had used gowns while assisting Resident #1. LVN B explained PPE was worn while providing direct care contact for residents who had IV therapy, catheters, or wounds. LVN B told RP the precautions were to protect the residents from staff germs.During an interview on 6/25/2026 at 3:20 PM, LVN B said she should have applied PPE prior to entering Resident #1's room. LVN B said Resident #1 could get an infection. LVN B said staff should not wear gloves while walking down the hallway or removing gloves or PPE in the hallway. LVN B said it could cause cross contamination. LVN B said she had been in-serviced on PPE and EBP. LVN B said everyone was responsible for ensuring PPE was worn while providing care to residents on EBP precautions.During an interview on 6/25/2026 at 3:44 PM, CNA D said she should not have worn gloves in the hallway. CNA D said she was going to take her gloves off, but she had a soiled brief in her hand. CNA D said someone had removed her barrel and she took the soiled brief back in the resident's room and took gloves off to get the barrel. CNA D said the soiled brief should have been in a trash bag then placed in the barrel. CNA D said it was an infection control issue and wearing gloves and having a soiled brief spread infection. CNA D said she did wash her hands after she threw the brief away. CNA D said she had only worked at the facility for a couple of weeks. CNA D said she had been trained on EBP and PPE. CNA D said she did not know what types of residents required PPE. CNA D said she had a couple of residents who were on precautions and staff put on gowns while care provided. CNA D said a staff should wear PPE while assisting a resident on EBP to the bathroom. CNA D said she was responsible for ensuring EBP precautions were followed. CNA D said not following EBP could negatively impact a resident and could cause a spread of infection or bacteria to a resident.During an interview on 6/25/2026 at 4:15 PM, the ADON said she should have worn PPE while providing care to Resident #1. ADON said LVN C should have worn PPE while she was providing care with Resident #1. The ADON said residents with chronic wounds, foley catheters (a medical procedure that involves inserting a catheter into the bladder to drain urine), Gastrostomy tubes (a soft, flexible tube that goes through the abdominal wall directly, creating an opening for feeding and medication delivery), or Jackson Pratt (JP) drains (a surgical device use to remove excess fluid from a wound after surgery) require EBP and staff should be washing their hands and applying gloves and PPE. The ADON said the PPE should be worn while transferring a resident to the toilet. The ADON said she should have been prepared. The ADON said residents on EBP have a sign on the door. The ADON said staff should not apply gloves in the hallway or remove gloves in the hallway. The ADON said the staff should be washing hands in resident room before coming out of the room. The ADON said it was all the team's responsibility to ensure PPE was being worn properly. The ADON said she was responsible for the in-services. The ADON said not following EBP could cause the spread of infection causing a resident to become sick. The ADON said gloves and briefs should not be removed outside a resident room unless in a trash bag and placed in the gray barrel.During a phone interview on 6/25/2026 at 4:31 PM, the DON said PPE should be worn with residents with wound care or had if a staff would be in contact with bodily fluids. The DON said PPE should be worn with residents with chronic wounds. The DON said she expected staff to follow EBP. The DON said the staff are starting to get back in the habit of wearing PPE and she said she had observed staff follow EBP. The DON said she expected staff to know what types of residents required EBP and she expected staff to wear PPE. The DON said staff should not be wearing gloves or carrying soiled briefs in the hallway. The DON said she expected the nurse to wash hands and apply gloves prior to care and stated the gloves were at the door. The DON said she expected the nurse to remove their gloves prior to leaving the resident room. The DON said the nurse should have worn PPE while providing a skin assessment. The DON said she was responsible for educating and ensuring staff were wearing proper PPE and following EBP. The DON said it could cause a resident to get an infection or spread to other residents.During an interview on 6/25/2026 at 4:42 PM, the ADM said she expected staff to wear PPE and following EBP. The ADM said the department heads, nursing and Infectious Disease Preventionist was responsible for ensuring PPE was worn and EBP was followed. The ADM said she expected staff to wash their hands before and after caring for a resident and for staff not to be wearing PPE in the hallway. The ADM said if staff were not wearing PPE while providing care, staff members could cross-contaminate the resident receiving care.Record review of a facility policy titled Enhanced Barrier Precautions dated 4/1/2025 indicated .Multidrug-resistant organism (MRDO) transmission is common in long term care (LTC) facilities.Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targets gown and glove during high contact resident care activities.EBP are used in conjunction with standard precautions and expand the use of PPE. EBP are indicated for residents with any of the following: .colonization with SDS-targets MDRO when contact precautions do not otherwise apply.wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO.Donning PPE for Residents on EBP based on Activity provided/assistance while in resident room.performing wound care: any opening requiring a dressing.transfer a resident. changing briefs or assisting with toileting.turn and repositioning or assist with bed mobility.bathing/showering.providing hygiene.changing linens.device care.any high contact.Disposal of PPE.PPE used during resident care, including care of residents placed on Enhanced Barrier Precautions are not regulated medical waste requiring disposal in a biohazard bag, and should be disposed as routine non-infectious waste.Communication to Staff.facility will utilize posting outside the room and EMR to communicate to staff if a resident requires EBP. Record review of a facility policy titled Fundamentals of Infection Control Precautions dated undated indicated .A variety of infection control measures are used for decreasing the risk and transmission of microorganisms in the facility.Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene.coming on duty.visibly soiled.before performing any invasive procedure.before entering isolation precaution setting.eating or handling food.before and after assisting resident with personal care.before inserting indwelling catheter.after handling soiled or used linens, dressings, soiled equipment.after removing gloves or aprons.Recommended techniques for washing hands with soap and water.Gloving are worn for three important reasons.1. To provide protective barrier and prevent gross contamination of the hands when touching blood, body fluids, secretions.2. To reduce likelihood of that microorganism, present on the hands of personnel will be transmitted to resident's mucous membranes.3. To reduce the likelihood of that hands of personnel contaminated with microorganisms from a resident or a fomite can transmit these microorganisms to other residents.

Based on interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 3 residents reviewed for ADLs. (Resident #2)The facility failed to ensure Resident #2 received a bath or shower on 05/18/26, 05/22/26, and 05/27/26.This failure could place residents at risk of not receiving care and services to meet their needs, which could result in poor care, feelings of poor self-esteem, and lack of dignity and health.Findings included:Record review of a face sheet, dated 05/28/26, revealed Resident #2 was an [AGE] years old female, admitted [DATE], with diagnoses including recurrent depressive disorders (a mood disorder characterized by repeated episodes of major depression interspersed with periods of normal mood), and stroke (a medical emergency that occurs when blood flow to a part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients), and aphasia following a stroke (a communication disorder caused by a lack of blood flow to the language centers of the brain).Record review of an annual MDS assessment, dated 03/06/26, indicated Resident #2 had a BIMS of 99 which indicated the resident was unable to complete the interview. The MDS indicated Resident #2 required maximal assistance to being dependent on staff for ADLs. Record review of Care Plan last revised on 04/06/26 indicated Resident #2 had an ADL self-care performance deficit related to stroke and limited range of motion on the right sided extremities. There were interventions to assist with personal hygiene as required and bathing required assistance from 1 staff member.Record review of an ADL Task documentation in the electronic health record for Resident #2, dated 04/29/26 - 05/28/26, indicated no baths documented for 05/18/26, 05/22/26, and 05/27/26. Record review of Interdisciplinary Progress Notes, dated 04/29/26 - 05/28/26, did not indicate Resident #2 refused to be bathed or showered.During an interview on 05/28/26 at 10:03 a.m., Resident #2's Family Member #1 said she felt the resident was not being kept clean and was not being bathed.During an interview on 05/28/26 at 11:58 a.m., Resident #2's Family Member #2 said the facility was not keeping the resident clean. The family member said the resident had only had one bath since the first of the year. The family member said the resident did not communicate well.During an interview on 05/28/26 at 12:23 p.m., CNA A said Resident #2 was bathed on Mondays, Wednesdays, and Friday. She said when she worked, she gave the resident her baths. She said all baths were to be documented in the resident's electronic health record. She said she did not know why Resident #2 did not get the baths on 05/18/26, 05/22/26, or 5/27/26. She said Resident #2 was bathed on the shifts she worked.During an interview on 05/28/26 at 1:44 p.m., the DON said it was the CNAs and charge nurses' responsibility to make sure residents were receiving their baths. She said then it was the responsibility of herself and the wound care nurse to make sure residents received their scheduled baths. She said she would expect refusals to be documented in the progress notes. She said she expected all baths to be documented in the ADL tracking in the resident's electronic health record. She said she knew Resident #2 got a shower on 05/27/26. She said she saw the CNA taking Resident #2 into the shower, but she did not document the shower.During an interview on 05/28/26 at 1:55 p.m., the Administrator said she expected residents to be showered or bathed on their scheduled day. She said the CNA should report any refusals to the charge nurse. She said the charge nurse should chart refusals in the progress notes. She said the refusal could also be documented under the ADL task documentation in the resident's electronic health record. She said she would expect all showers to be documented. She said not being bathed was a dignity issue. She said you felt better if showered and clean. She said bathing prevented odor and infection.Record review of an undated, Bath, Tub/Shower facility policy indicated, .Bathing by tub bath or shower is done to remove soil, dead epithelial cells, microorganisms from the skin, and body odor to promote comfort, cleanliness, circulation, and relaxation.Although a daily bath or shower is preferred and necessary for some, the aging skin can be maintained by bathing every two day or with partial baths as needed.The resident will experience improved comfort and cleanliness by bathing.The resident will maintain intact skin integrity.The resident will be free from soil, odor, dryness, and pruritus (itching) following bathing.

Based on observation, record review, and interview, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 4 residents reviewed for resident rights. (Resident #1)The facility failed to treat Resident #1 with dignity and respect by CNA B not providing privacy during an incontinent change on 05/28/26.This failure could place residents at risk for decreased quality of life, decreased self-esteem and increased anxiety.Findings included:Record review of a face sheet, dated 05/28/26, indicated Resident #1 was a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes (a chronic condition where your body either doesn't make enough insulin or can't use it effectively), recurrent depressive disorders (a mood disorder characterized by repeated episodes of major depression interspersed with periods of normal mood), and stroke(a medical emergency that occurs when blood flow to a part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients).Record review of an annual MDS assessment, dated 04/21/26, revealed Resident #1 had a BIMS of 08, which indicated moderate impaired cognition. Resident #1 was dependent on staff with toileting hygiene.Record review of a care plan, revised on 04/17/26, indicated Resident #1 was incontinent of bowel and bladder. There was an intervention to check the resident and assist with toileting as needed per facility protocols and procedures.During an observation on 05/28/26 at 11:03 a.m., Resident #1 was provided with incontinent care by CNA B. There was no curtain in the middle of the room, and the resident could be seen by her roommate and surveyor. At one point the resident said she wished there was a curtain and CNA B apologized to the resident.During an interview on 05/28/26 at 11:03 a.m., Resident #1 said she was really bothered by there not being a curtain and her roommate could see her being changed. She said it bothered her a lot. She said she was embarrassed.During an interview on 05/28/26 at 11:12 a.m., CNA B said there was no middle curtain between the beds of Resident #1 and her roommate. She said she was unable to pull a curtain between them because there was not one. She said during the care the resident told her she wished there was a curtain. She said she felt bad.During an interview on 05/28/26 at 1:44 p.m., the DON said she expected for privacy to be provided for Resident #1. She said she expected CNA B to have moved blankets to provide privacy or come and got one of them since there was no middle curtain. She said one of them could have held something up to have provided privacy. She said privacy was important because it was Resident #1's right.During an interview on 05/28/26 at 1:55 p.m., the Administrator said staff should always provide privacy for residents. She said there was no curtain in Resident #1's because the room was recently converted for short stays with one resident per room. She said she still would have expected the CNA to have provided privacy or gotten someone to come hang a curtain. She said it was important to save them from being embarrassed. She said residents might have a poor body image.Record review of an undated Resident Rights facility policy indicated, .The resident has a right to a dignified existence.A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life.The facility must protect and promote the rights of the resident.The resident has a right to personal privacy.Personal privacy includes accommodations.personal care.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, and dispensing of all drugs and biologicals to meet the needs of each resident for 1 of 13 (Resident #49) residents reviewed for pharmacy services. 1. The facility failed to ensure Resident #49 received her scheduled oxycodone (narcotic pain medication) on 10/21/25, 11/03/25, 11/13/25, 11/23/25, and 03/23/26. 2. The facility failed to ensure Resident #49's oxycodone was re-ordered timely to prevent missed doses on 11/03/25, 11/13/25, and 03/23/26. 3. The facility failed to ensure a system was in place for medication reconciliation of narcotic medications and count sheets. 4. The facility failed to recognize and prevent Resident #49's oxycodone (narcotic pain medication) from discrepancies on the Individual Control Drug Record form, on 12/24/25 and 03/14/26. 5. The facility failed to recognize and prevent Resident #49's Tylenol #4 (narcotic pain medication) from discrepancies on the Individual Control Drug Record form on 12/28/25, 02/12/26, and 03/21/26. An immediate jeopardy (IJ) was identified on 03/24/26 at 4:10 p.m. The IJ template was provided to the facility on [DATE] at 4:27 p.m. While the IJ was removed on 03/25/26 at 2:34 p.m., the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all nursing staff had not been provided education on pain management, notification of changes of condition, abuse, neglect, and medication administration policy. This failure could place residents at serious risk for decreased quality of life, increased in severe, uncontrolled pain, misappropriation of physician ordered medications, serious harm, injury, impairment, or death. The findings included: Record review of the face sheet, dated 03/24/26, reflected Resident #49 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of morbid (severe) obesity due to excess calories, opioid dependence with withdrawal (dependence on narcotic pain medication), and chronic pain. Record review of the admission MDS assessment, dated 10/07/25, reflected Resident #49 had clear speech, was understood, and was able to understand others. Resident #49 had a BIMS score of 14, which reflected no cognitive impairment. Resident #49 had no behaviors or refusal of care during the look-back period. Resident #49 received PRN pain medication and had occasional pain during the 5 day-look back period. The MDS reflected Resident #49 received opioid pain medication. Record review of the comprehensive care plan, dated 10/06/25, reflected Resident #49 had the potential for uncontrolled pain. Resident #49's pain goal was 0. The interventions included: anticipating the need for pain relief and responding immediately to any complaints of pain, evaluating the effectiveness of pain interventions, monitor/document for side effects of pain medication, and monitor/record/report non-verbal signs or symptoms of pain. Record review of Resident #49's order summary report, dated 03/24/26, reflected the following orders:1. Acetaminophen-Codeine 300-60 mg (Tylenol #4) - give 1 tablet by mouth every 8 hours as needed for pain, which was ordered on 12/24/25.2. oxycodone-Acetaminophen 10-325 mg - Give 1 tablet by mouth three times a day for moderate to severe pain, which was ordered on 10/07/25. Record review of Resident #49's Individual Control Drug Record form for oxycodone-acetaminophen, dated 10/14/25 reflected the following:1. An incorrect date of 10/17/25 was placed on the 6 a.m. dose administered on 10/20/25.2. The 6 a.m. dose given on 10/21/25 was filled out and then marked out as not given. Record review of Pain SBAR, dated 10/20/25, reflected Resident #49 had almost constant or frequent pain level of 5 - 9 moderate to severe pain on the 1 - 10 pain scale. The pain was to her lower back. The pain was described as aching and throbbing. She stated the pain was daily, but not constant and lasted 30 - 60 minutes. She stated medications helped relieve the pain. The Medical Director was notified on 10/20/25 at 3 p.m. with no new orders given. Record review of the Pain SBAR, dated 10/27/25, reflected Resident #49 had at least one episode of pain that was a 10 or it was described as very severe/horrible. The pain was to her lower back. The pain was described as aching and throbbing. She stated the pain was constant and lasted 30 - 60 minutes. She stated medications helped relieve the pain. The Medical Director was notified on 10/27/25 at 6 p.m. with no new orders given. Record review of Resident #49's MAR, dated October 2025, reflected the following:1. On 10/21/25 the 6 a.m. dose of oxycodone was signed out as given, which did not match the Individual Control Drug Record form. Record review of Resident #49's Individual Control Drug Record form for oxycodone-acetaminophen, dated 10/22/25, reflected the following:1. A dose of oxycodone-acetaminophen was administered at 5:30 a.m. on 11/03/25 and was the last pill on that card of medication. Record review of Resident #49's Individual Control Drug Record form for oxycodone-acetaminophen, dated 11/03/25, reflected the following:1. The card of medication was received on 11/03/25 at 2:15 p.m. and had 30 pills. The first dose of oxycodone-acetaminophen was administered at 10 p.m. on 11/03/25. Resident #49 missed her 2 p.m. dose.2. A dose of oxycodone-acetaminophen was administered at 2 p.m. on 11/13/25 and was the last pill on that card of medication. Record review of Resident #49's Individual Control Drug Record form for oxycodone-acetaminophen, dated 11/14/25, reflected the following:1. The card of medication was received on 11/14/25 and had 30 pills. The first dose of oxycodone-acetaminophen was administered at 6 a.m. on 11/14/25. Resident #49 missed her 10 p.m. dose on 11/13/25.2. On 11/23/25, Resident #49's 6 a.m. dose was not signed out as given. Record review of the Pain SBAR, dated 11/22/25, reflected Resident #49 had almost constant or frequent pain level of 5 - 9 moderate to severe pain on the 1 - 10 pain scale. The pain was generalized and was described as dull, throbbing, tingling. The frequency of pain was less than daily and lasted 30 - 60 minutes. The pain affected sleep, appetite, physical activity, relationships, emotions, and concentration. She stated medications helped relieve the pain. The Medical Director was notified on 11/22/25 at 11:00 a.m. with orders to continue current medications. Record review of the Pain SBAR, dated 11/30/25, reflected Resident #49 had almost constant or frequent pain level of 5 - 9 moderate to severe pain on the 1 - 10 pain scale. The pain was to her right lower leg/foot, left lower leg/foot, and generalized. She described the pain as aching, throbbing, burning, and tingling. The frequency of the pain was daily, but not constant and lasted 1 - 2 hours. She stated the pain was affected by increased sadness and emotions. She said the pain affected her sleep, appetite, physical activity, emotions, and concentration. She stated medications helped relieve the pain. The Medical Director was notified on 12/01/25 at 12:00 a.m. (midnight) with no new orders. Record review of Resident #49's MAR, dated November 2025, reflected the following:1. On 11/03/25 the 2 p.m. dose of oxycodone-acetaminophen was not given because medication was unavailable.2. On 11/13/25 the 10 p.m. dose of oxycodone-acetaminophen was not given because the medication was unavailable.3. On 11/23/25 all three doses of oxycodone-acetaminophen were signed out as given, which did not match the Individual Control Drug Record form.3. On 11/26/25 the 6 a.m. dose of oxycodone-acetaminophen was not given because Other/see nurses note. Record review of the nursing progress notes, dated 11/21/25 to 12/22/25, reflected no nursing notes were dated for 11/26/25. Record review of Resident #49's Individual Control Drug Record form for oxycodone-acetaminophen, dated 11/23/25, reflected the following:1. An incorrect date of 12/03/25 was placed on the 6 a.m. dose administered on 12/04/25.2. An incorrect date of 12/09/25 was placed on the 10 p.m. dose administered on 12/08/25.3. The last pill was signed out as given on 12/24/25 at 6 a.m. Record review of Resident #49's Individual Control Drug Record form for oxycodone-acetaminophen, dated 12/24/25, reflected the following:1. The first pill of 90 was signed out as given on 12/24/25 at 6 a.m., which was the second dose of medication signed out for the same date and time.2. An incorrect date of 01/07/26 was placed on the 6 a.m. dose administered on 01/08/26. Record review of Resident #49's Individual Control Drug Record form for acetaminophen-codeine, dated 12/23/25, reflected the following:1. An incorrect date of 12/27/25 was placed on the 2:20 a.m. dose administered on 12/28/25.2. The 6 p.m. dose on 12/28/25 was filled out and then marked out as not given. There was no explanation for the mark through by LVN H. The 6 p.m. dose was immediately signed out again on the next line, but the count continued and 1 pill was unaccounted for. Record review of the Pain SBAR, dated 12/27/25, reflected Resident #49 had almost constant or frequent pain level of 5 - 9 moderate to severe pain on the 1 - 10 pain scale. The pain was to her right and left lower leg/foot. The pain was described as throbbing, burning, tingling, sharp, shooting. The frequency of pain was daily, but not constant and lasted 1 - 2 hours. She said the pain affected her sleep, emotions, and concentration. She said the pain was relieved with medications. The Medical Director was notified on 12/27/25 at 12 a.m. (midnight) with no new orders. Record review of Resident #49's MAR, dated December 2025, reflected no doses of oxycodone-acetaminophen were missed. There were zero doses of acetaminophen-codeine signed out as given on the MAR, which did not match the Individual Control Drug Record form. Record review of Resident #49's Individual Control Drug Record form for acetaminophen-codeine, dated 01/01/26, reflected the following:1. An incorrect date of 01/04/26 was placed on the 2 a.m. dose administered on 01/05/26.2. An incorrect date of 01/07/26 was placed on the 2 a.m. dose administered on 01/08/26. Record review of Resident #49's Individual Control Drug Record form for acetaminophen-codeine, dated 01/23/26, reflected the following:1. An incorrect date of 01/25/26 was placed on the 2 a.m. dose administered on 01/26/26. Record review of Resident #49's MAR, dated January 2026, reflected no doses of oxycodone-acetaminophen were missed. The MAR reflected Resident #49's acetaminophen-codeine 300-60 mg was given 10 times for the month, which did not match the Individual Control Drug Record form. Record review of Resident #49's Individual Control Drug Record form for oxycodone-acetaminophen, dated 01/23/26, reflected the following:1. An incorrect date of 02/12/26 was placed on the 10 p.m. dose administered on 02/11/26.2. An incorrect date of 02/20/26 was placed on the 6 a.m. dose administered on 02/21/26. Record review of Resident #49's Individual Control Drug Record form for oxycodone-acetaminophen, dated 02/03/26, reflected the following:1. An incorrect date of 02/09/26 was placed on the 2 a.m. dose administered on 02/10/26.2. The last pill was signed out as given on 02/12/26 at 6 p.m. Record review of Resident #49's Individual Control Drug Record form for oxycodone-acetaminophen, dated 02/11/26, reflected the following:1. The first pill of 30 was signed out as given on 02/12/26 at 6 p.m., which was the second dose of medication signed out for the same date and time.2. An incorrect date of 02/15/26 was placed on the 2 a.m. dose administered on 02/16/26.3. An incorrect date of 02/21/26 was placed on the 2 a.m. dose administered on 02/22/26. Record review of Resident #49's MAR, dated February 2026, reflected the 10 p.m. dose of Resident #49's oxycodone on 02/08/26 was not signed out as given. The MAR reflected Resident #49's acetaminophen-codeine was only given 4 times during February, which did not match the Individual Control Drug Record form. Record review of Resident #49's Individual Control Drug Record form for acetaminophen-codeine, dated 02/24/26, reflected the following:1. An incorrect date of 03/07/26 was placed on the 10 a.m. dose administered on 03/06/26.2. An incorrect date of 03/07/26 was placed on the 6 p.m. dose administered on 03/06/26.3. An incorrect date of 03/08/26 was placed on the 2 a.m. dose administered on 03/09/26.4. An incorrect date of 03/09/26 was placed on the 2 a.m. dose administered on 03/10/26.5. An incorrect date of 03/18/26 was placed on the 2 a.m. dose administered on 03/19/26.6. An incorrect date of 03/19/26 was placed on the 2 a.m. dose administered on 03/20/26.7. The 6 p.m. dose on 03/21/26 was filled out and then marked out as not given. There was no explanation for the mark through LVN H. The 6 p.m. dose was immediately signed out again on the next line, but the count continued and 1 pill was unaccounted for. Record review of Resident #49's Individual Control Drug Record form for oxycodone-acetaminophen, dated 02/21/26, reflected the following:1. An incorrect date of 03/05/26 was placed on the 10 p.m. dose administered on 03/04/26.2. An incorrect date of 03/08/26 was placed on the 6 a.m. dose administered on 03/09/26.3. On 03/14/26, three extra doses of medication were signed out at 7 a.m., 3:09 p.m., and 5:40 p.m.4. The last dose of medication was given on 03/22/26 at 10 p.m. Record review of Resident #49's Individual Control Drug Record form for oxycodone-acetaminophen, dated 03/23/26, reflected the following:1. The first pill of 90 was given on 03/23/26 at 3 p.m. when the medication arrived. Resident #49 missed the 6 a.m. dose on 03/23/26. Record review of Resident #49's MAR, dated March 2026, reflected the following:1. On 03/05/26, Resident #49's 6 a.m. dose of oxycodone-acetaminophen was not given because she was sleeping. 2. On 03/23/26, Resident #49's 6 a.m. dose of oxycodone-acetaminophen was not given because Other/see nurses note.The MAR reflected Resident #49's acetaminophen-codeine was given only 3 times, which did not match the Individual Control Drug Record form. Record review of the nursing progress notes, dated 02/22/26 to 03/25/26, reflected on 03/23/26 LVN H documented While awaiting pharmacy to deliver [resident] oxycodone, may give [resident] Tylenol #4 as a replacement to ensure [resident] is not in any pain per [doctor]. During an observation and interview on 03/23/26 beginning at 2:32 p.m., Resident #49 was lying in her bed with the head of her bed elevated slightly. She had a family member in the room during the interview. Resident #49 reported she had not received her scheduled pain medications on several different occasions since she was admitted to the facility. Resident #49 said there was not a place on her body that did not hurt. She said she depended on and needed her pain medication to keep the pain controlled. She said the pharmacy the facility used was in another city and the medications were not readily available. Resident #49 started sobbing. She said she was waiting for her medication that was due at 2 p.m. and had been in pain since this morning. She stated she received a lower level pain pill at 6 a.m. that worked for a short time but had completely worn off during the interview. She stated her pain currently was 10 out of 10 on the pain scale. She said she would never kill herself, but she begged God to take her. She said her pain was exacerbated every time she missed her scheduled pain medication. She said her pain was tolerable at a 4 or 5 on the pain scale. She reported her pain was well-controlled when she received her pain medications as prescribed. Resident #49 stated she felt the facility did not understand her pain and did not try to accommodate her pain needs. She said she was constantly checking with the nurses to ensure she had enough pain medication and would not run out. She said when she runs out of pain medication she becomes frantic and thinks to herself not again, please, not again. During the interview at 3:04 p.m. LVN H knocked, entered Resident #49's room and reported that her pain medication had arrived at the facility and she was going to bring the pill to her. Resident #49 cried with relief that her pain medication was at the facility. During an interview on 03/24/26 beginning at 7:23 a.m., LVN K said Resident #49 complained of pain constantly and took her scheduled and PRN pain medication regularly. She said her pain level was anywhere from 1-10 on the 1-10 pain scale. LVN K stated she had asked the doctor to schedule her PRN pain medication, but he did not want to schedule them. LVN K was unsure if Resident #49 saw a pain management doctor. LVN K stated she was aware two times Resident #49 had run out of her scheduled pain medication but was unaware if Resident #49 had any increased pain. LVN K stated pain was what the patient stated it was. She said Resident #49 needed her pain medications because she constantly hurt. She said she should not have run out of her pain medications, but they frequently ran out of medications before the pharmacy delivered them. She said the doctor or an agent of the doctor had to call the narcotic medications in or re-order them. She said the only agent at the facility she was aware of was the ADON. LVN K said when she noticed the narcotic pain medication was running low, she clicked re-order in the electronic charting system, which sends an alert to the pharmacy. She said after that, she called the ADON, who called the pharmacy for refills. She said if there were no refills left; the doctor had to send a new triplicate to the pharmacy. LVN K stated this process was usually completed timely, but the pharmacy did not deliver medications timely. She said the pharmacy was in another city, which was a couple hours away. LVN K said there was really no system for following up with the pharmacy after the medication had been ordered. LVN K said schedule II narcotics like oxycodone were not kept in the emergency medication kit provided by the pharmacy. During an interview on 03/24/26 beginning at 9:32 a.m., the ADON stated the nurses were responsible for re-ordering narcotic pain medications. She said during the medication pass, if they noticed a medication was getting low, the nurses could go into the electronic charting system and click re-order for the medications that were needed and it would have sent an alert to the pharmacy. She stated if the pain medication had no refills left, then she would have called the pharmacy for approval. She said if a new triplicate was needed, then the doctor had to directly send that to the pharmacy. The ADON stated the doctor usually sent the triplicate for pain medication directly to the pharmacy without any issues. She said if pain medication did run out, the facility had an emergency kit, which had pain medications in it. She said the emergency kit did not have scheduled II medications like oxycodone. She said she was unaware of any residents who had run out of scheduled pain medication. She stated Resident #49's oxycodone had been re-ordered on 03/20/26 but the delivery drivers' car had broken down on the way. During an interview on 03/24/26 beginning at 12:16 p.m., LVN H stated she did not normally have issues with receiving medication from the pharmacy. LVN H said Resident #49 had run out of scheduled pain medication at least twice that she was aware. LVN H stated if the pharmacy did not get the electronic prescription from the doctor by Friday, then the medication would not have been sent until Monday. LVN H stated Resident #49 received scheduled pain medication three times a day. She said if the nurses waited until the medication card was in the blue (8 pills left) to re-order her medication, then she would not have had enough to last the weekend. LVN H stated she worked on 03/21/26 and realized Resident #49 was not going to have enough medication to last the weekend. LVN H stated she called the pharmacy several times over the weekend, but the pharmacy did not deliver medications on the weekend. She said the medication was supposed to have come in earlier on 03/23/26 but the delivery driver had car trouble. LVN H stated Resident #49 was obsessed with her pain medication. She stated Resident #49 had chronic pain and she received her scheduled and PRN pain medications around the clock to keep her pain under control. She said when Resident #49 did not receive her pain medication, her pain became out of control and took a while to get back under control. She said on 03/23/26 she obtained an order for acetaminophen-codeine 300-60 mg x 1 dose to give in place of her missed oxycodone. She stated Resident #49 reported the pill was effective. She said as soon as Resident #49's oxycodone arrived from the pharmacy, she administered it. LVN H stated there were no set days to re-order medication, but the medications were re-ordered as it was noticed they were getting low. During an interview on 03/24/26 beginning at 1:09 p.m., the DON stated there was no system in place for reviewing or monitoring the Individual Controlled Drug Record forms. She said when the last medication was given off the medication card, the Individual Controlled Drug Record forms were given to medical records to file. The DON stated she did not review the forms for discrepancies or errors. She said she expected the nurses to sign out narcotic pain medications as they were given. She said if an error occurred on the narcotic count sheet or a staff member dropped a pill, she expected the reason it was marked out indicated on the count sheet. She stated she expected 2 nurse signatures if the medication was wasted. She said it was important to ensure the narcotic control records were accurate to prevent drug discrepancies, which placed the resident at risk for a drug diversion or medication errors. The DON stated she was aware that Resident #49 had run out of medication on 03/23/26. She said the facility attempted to get the medication STAT 'ed but the driver had car trouble. She said she was unaware Resident #49 was having severe, uncontrolled pain because she had missed her pain medication. She was unaware of any other times Resident #49 had gone without her pain medication. The DON stated any missed dose of pain medication would have made it harder to maintain her desired pain level. She stated pain was what the resident said it was. She said pain was monitored every shift and when any pain medication was administered. The DON stated this was documented on the MAR. She stated severe or uncontrolled pain should have been reported to the doctor. The DON stated when the nurses were passing medications and the medications were getting low; they should have marked re-order in the electronic charting system. She stated the recommended re-order time was when the medication had approximately 8 pills left. She said marking re-order in the electronic charting system, sent the order directly to the pharmacy. She stated the cut off time for re-ordering medications was 6 p.m., so she expected staff to ensure ordering was completed before 6 p.m. She said no medications were delivered on the weekend, unless they were ordered STAT and the facility paid a fee. She said if the medication required a triplicate, the nurses should have notified the Medical Director so he could send the triplicate to the pharmacy. The DON stated the Medical Director did not send Resident #49's triplicate to the pharmacy until 8 or 9 p.m. on 03/20/26, which was past the cut off time, so it was not scheduled for delivery until 03/23/26. She said it was important to ensure medications were ordered timely, so they did not run into issues with medications running out. During an interview on 03/24/26 beginning at 1:31 p.m., the Administrator stated she expected pain was what the patient said it was. She stated she expected resident's pain to be controlled and kept under control. She said the nurses were responsible for monitoring to ensure resident's pain was kept under control. She said she expected the nurses to monitor the resident's pain at least every shift. She said she expected the nurses to ensure severe or uncontrolled pain was reported to the doctor immediately. She said the ADON and DON were responsible for monitoring the nurses. The Administrator stated it was important to ensure pain was kept under control to maintain a resident's pain at a lower level. She said once a resident's pain becomes severe, it was harder to get it back under control. The Administrator was unsure if the DON had a system in place for monitoring narcotic count sheets or medication reconciliation. The Administrator stated she expected narcotic pain medications to be reconciled and given the way they were ordered. She stated she expected the narcotic pain medications to have been counted each shift and notify the DON of any discrepancies. She said if discrepancies were identified an investigation should have been conducted. She said it was important to ensure medication reconciliation was accurate to prevent medication errors or drug diversion. She said the nurses should have been reviewing the narcotic count sheets for discrepancies, each time a medication was given or during shift change. During an interview on 03/24/26 beginning at 2:00 p.m., the Medical Director stated when a medication that required a triplicate was running low, the facility notified him by telephone or fax. He said he liked the facility to send the request at least 24 hours in advance, so he had time to complete the request. The Medical Director stated the facility was pretty good about letting him know ahead of time but there have been a few instances where he was not notified timely. He was unsure of any incidents recently with Resident #49. He believed the facility did not have a systemic issue. The Medical Director stated he had sent a triplicate for Resident #49 within the last week but was unsure if she went without any medication. The Medical Director stated he was unaware Resident #49 had been in severe, uncontrolled pain. He said he would like to have been notified if a resident's pain medication were unavailable. He said he could have found alternate ways to obtain the medications even during the weekend. The Medical Director stated it was important to ensure pain medication was given as ordered to prevent an increase in pain symptoms. He stated it was important to maintain resident's pain at a comfortable level and pain was what the patient said it was. During an interview on 03/24/26 beginning at 2:12 p.m., the policy for medication reconciliation and pharmacy services were requested from the Regional Compliance Nurse. She said the facility did not have a general policy for pharmacy services. She provided the following policies. Record review of the Medication Orders policy, dated 2025, reflected Each medication order is documented in the resident's medical record with the date, time, and signature of the person receiving the order. The order is recorded on the current physician order sheet, the telephone order sheet, if it is a verbal order, and the MAR. Record review of the Receiving Medication from Pharmacy policy, dated 2025, reflected Medications and related products are received form the pharmacy supplier on a timely basis. The facility maintains accurate records of medications ordered and receipt of. The policy did not address pharmacy services of receiving or dispensing medication. The Administrator was notified on 03/24/26 at 4:25 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided with the Immediate Jeopardy template on 03/24/26 at 4:27 p.m. and a plan of removal was requested. The following plan of removal was submitted by the facility and accepted on 03/25/26 at 11:12 a.m. and included the following: Interventions:Resident #49 was assessed for pain by the ADON. The [Medical Director] was notified. No complaints of pain or additional issues noted. Resident #49 has pain medication ordered and in facility. No new or worsening pain nor emotional stress at this time. Completion date 03/24/26.All residents in the facility were assessed for any increased pain by the DON and Charge Nurses as of 03/24/26. No additional residents with new or uncontrolled pain were identified. Completion date 03/24/26.A narcotic count/MAR reconciliation was completed by the DON/ADON/Regional Compliance nurse, and all discrepancies were addressed through the medication error process. Residents that receive narcotic medications were audited by the DON/ADON/Regional Compliance Nurse to ensure that at least a 7 day supply are available on the medication carts. All residents have the appropriate amount of medications available as of 03/24/26. Completion date 03/24/26.The DON/ADON/or designee will be responsible for counting all narcotic medications daily to ensure at least a 7 day supply is available on the medication carts and reviewing for discrepancies to ensure accuracy of narcotic count sheets before being filed in medical records. Completion 03/24/26.The DON/ADON/or designee will be responsible for calling the physician when a 10 day supply of medication is on the cart to obtain the triplicates needed to reorder narcotic medications to ensure a 7 day supply is available. A triplicate/refill request form will be completed and available for review to ensure staff know that medications have been reordered. DON/ADON/or designee will review form daily until medication is delivered and marked as received. Completion 03/24/26. The DON/ADON/designee will monitor the refill process for all medications including the weekends. Medications are available in the ekit, if unavailable, medications can be stat (immediately) delivered from the pharmacy or called to a local pharmacy.In-services: The Compliance Nurse will in-service the Administrator/DON/ADON 1:1 (one on one) on the following topics on 03/24/26.1. Administering pain medication for residents with signs and symptoms of pain.2. Pain management Policy -Signs and symptoms of pain verbally and non-verbal. (Change in behaviors such as crying, whining, groaning, facial expressions, grimacing, frowning, protecting body movements, guarding, or clutching)3. Notification of a Change of Condition Policy- to the charge nurse or physician immediately including signs and symptoms of increased pain. 4. Abuse and Neglect Policy - to include failure to administer pain medications could be considered neglect.5. Medication Administration Policy- to include controlled medications, medication reconciliation, and documentation both on the MAR and count sheet.All charge nurses and medication aides were in-serviced on 03/24/26 by the Compliance Nurse/DON/ADON regarding the following topics below. All charge nurses, including agency staff, new hires and PRN charge nurses not in-serviced by 03/24/26 will not be allowed to work in their assigned position until completion of these in-services: Completion as of 03/25/26 DON and ADON were in-service by Compliance Nurse.1. Administering pain medication for residents with signs and symptoms of pain.2. Pain management Policy -Signs and symptoms of pain verbally and non-verbal. (Change in behaviors such as crying, whining, groaning, facial expressions, grimacing, frowning, protecting body movements, guarding, or clutching)3. Notification of a Change of Condition Policy- to the charge nurse or physician immediately including signs and symptoms of increased pain. 4. Abuse and Neglect Policy - to include failure to administer pain medications could be considered neglect.5. Medication Administration Policy- to include controlled medications, medication reconciliation, and documentation both on the MAR and count sheet.The medical director was notified on 03/24/26 on the immediate jeopardy situation by the Administrator.An AD HOC QAPI meeting was held on 03/24/26 by the Interdisciplinary Team to discuss the immediate jeopardy and review the plan of removal for pain. The Administrator and DON will implement this written Plan of Removal and will continue to monitor completion and compliance of this written Plan of Removal. On 03/25/26 the surveyor confirmed the facility implemented their plan

Based on observation, interview, and record review the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preference for 1 of 13 residents (Resident #49) reviewed for pain management. The facility failed to ensure Resident #49 received her scheduled pain medication (oxycodone) on the following dates and times:1. On 11/03/25, Resident #49 missed her 2 p.m. dose, which resulted in moderate 5 out of 10 pain on the 1-10 pain scale.2. On 11/13/25, Resident #49 missed her 10 p.m. dose, which resulted in severe 9 out of 10 pain on the 1-10 pain scale.3. On 03/23/26, Resident #49 missed her 6 a.m., dose, which resulted in severe 10 out of 10 pain on the 1-10 pain scale before her medication arrived from the pharmacy. An immediate jeopardy (IJ) was identified on 03/24/26 at 4:10 p.m. The IJ template was provided to the facility on [DATE] at 4:27 p.m. While the IJ was removed on 03/25/26 at 2:34 p.m., the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all nursing staff had not been provided education on pain management, notification of changes of condition, abuse, neglect, and medication administration policy. These failures could place residents at risk of severe, uncontrolled pain, severe mental anguish or emotional distress that could have led to serious harm, injury, impairment, or death. The findings included: Record review of the face sheet, dated 03/24/26, reflected Resident #49 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of morbid (severe) obesity due to excess calories, opioid dependence with withdrawal (dependence on narcotic pain medication), and chronic pain. Record review of the admission MDS assessment, dated 10/07/25, reflected Resident #49 had clear speech, was understood, and was able to understand others. Resident #49 had a BIMS score of 14, which reflected no cognitive impairment. Resident #49 had no behaviors or refusal of care during the look-back period. Resident #49 received PRN pain medication and had occasional pain during the 5 day-look back period. The MDS reflected Resident #49 received opioid pain medication. Record review of the comprehensive care plan, dated 10/06/25, reflected Resident #49 had the potential for uncontrolled pain. Resident #49's pain goal was 0. The interventions included: anticipating the need for pain relief and responding immediately to any complaints of pain, evaluating the effectiveness of pain interventions, monitor/document for side effects of pain medication, and monitor/record/report non-verbal signs or symptoms of pain. Record review of Resident #49's order summary report, dated 03/24/26, reflected an order for oxycodone-Acetaminophen 10-325 mg - Give 1 tablet by mouth three times a day for moderate to severe pain, which was ordered on 10/07/25. Record review of Resident #49's Individual Control Drug Record form for oxycodone-acetaminophen, dated 10/14/25 reflected the 6 a.m. dose given on 10/21/25 was filled out and then marked out as not given. There was no explanation or reason for the mark out. Record review of Pain SBAR, dated 10/20/25, reflected Resident #49 had almost constant or frequent pain level of 5 - 9 moderate to severe pain on the 1 - 10 pain scale. The pain was to her lower back. The pain was described as aching and throbbing. She stated the pain was daily, but not constant and lasted 30 - 60 minutes. She stated medications helped relieve the pain. The Medical Director was notified on 10/20/25 at 3 p.m. with no new orders given. Record review of the Pain SBAR, dated 10/27/25, reflected Resident #49 had at least one episode of pain that was a 10 or it was described as very severe/horrible. The pain was to her lower back. The pain was described as aching and throbbing. She stated the pain was constant and lasted 30 - 60 minutes. She stated medications helped relieve the pain. The Medical Director was notified on 10/27/25 at 6 p.m. with no new orders given. Record review of Resident #49's MAR, dated October 2025, reflected on 10/21/25 the 6 a.m. dose of oxycodone was signed out as given, which did not match the Individual Control Drug Record form. Record review of Resident #49's Individual Control Drug Record form for oxycodone-acetaminophen, dated 11/03/25, reflected the card of medication was received on 11/03/25 at 2:15 p.m. and had 30 pills. The first dose of oxycodone-acetaminophen was administered at 10 p.m. on 11/03/25. Resident #49 missed her 2 p.m. dose. Record review of Resident #49's Individual Control Drug Record form for oxycodone-acetaminophen, dated 11/14/25, reflected the card of medication was received on 11/14/25 and had 30 pills. The first dose of oxycodone-acetaminophen was administered at 6 a.m. on 11/14/25. Resident #49 missed her 10 p.m. dose on 11/13/25. The 6 a.m. dose of oxycodone-acetaminophen was not signed out on 11/23/25. Record review of the Pain SBAR, dated 11/22/25, reflected Resident #49 had almost constant or frequent pain level of 5 - 9 moderate to severe pain on the 1 - 10 pain scale. The pain was generalized and was described as dull, throbbing, tingling. The frequency of pain was less than daily and lasted 30 - 60 minutes. The pain affected sleep, appetite, physical activity, relationships, emotions, and concentration. She stated medications helped relieve the pain. The Medical Director was notified on 11/22/25 at 11:00 a.m. with orders to continue current medications. Record review of the Pain SBAR, dated 11/30/25, reflected Resident #49 had almost constant or frequent pain level of 5 - 9 moderate to severe pain on the 1 - 10 pain scale. The pain was to her right lower leg/foot, left lower leg/foot, and generalized. She described the pain as aching, throbbing, burning, and tingling. The frequency of the pain was daily, but not constant and lasted 1 - 2 hours. She stated the pain was affected by increased sadness and emotions. She said the pain affected her sleep, appetite, physical activity, emotions, and concentration. She stated medications helped relieve the pain. The Medical Director was notified on 12/01/25 at 12:00 a.m. (midnight) with no new orders. Record review of Resident #49's MAR, dated November 2025, reflected the following:1. On 11/03/25, the 2 p.m. dose of oxycodone-acetaminophen was not given because medication was unavailable. A tramadol 50 mg (low dose pain medication) was given at 2 p.m. Her pain level was a 5 on 1-10 pain scale.2. On 11/13/25 the 10 p.m. dose of oxycodone-acetaminophen was not given because the medication was unavailable. There was no evidence of additional pain medication given in place of oxycodone on 11/13/25. Resident #49's pain level was not documented. The next pain assessment on 11/14/25 at 6 a.m. indicated her pain level was at a 9 on the 1-10 pain scale.3. On 11/23/25 the 6 a.m. dose of oxycodone-acetaminophen was signed out as given, which did not match the narcotic count sheet. Record review of the Pain SBAR, dated 12/27/25, reflected Resident #49 had almost constant or frequent pain level of 5 - 9 moderate to severe pain on the 1 - 10 pain scale. The pain was to her right and left lower leg/foot. The pain was described as throbbing, burning, tingling, sharp, shooting. The frequency of pain was daily, but not constant and lasted 1 - 2 hours. She said the pain affected her sleep, emotions, and concentration. She said the pain was relieved with medications. The Medical Director was notified on 12/27/25 at 12 a.m. (midnight) with no new orders. Record review of Resident #49's Individual Control Drug Record form for oxycodone-acetaminophen, dated 03/23/26, reflected the first pill of 90 was given on 03/23/26 at 3 p.m. when the medication arrived. Resident #49 missed the 6 a.m. dose on 03/23/26. Record review of Resident #49's MAR, dated March 2026, reflected on 03/23/26, Resident #49's 6 a.m. dose of oxycodone-acetaminophen was not given because Other/see nurses note. LVN H signed out a dose of acetaminophen-codeine 300-60 mg dose on 03/23/26 at 6 a.m. Her pain level reflected it was at a 5 on the 1 - 10 pain scale. Record review of the nursing progress notes, dated 02/22/26 to 03/25/26, reflected on 03/23/26 LVN H documented While awaiting pharmacy to deliver [resident] oxycodone, may give [resident] Tylenol #4 [acetaminophen-codeine 300-60 mg] as a replacement to ensure [resident] is not in any pain per [doctor]. During an observation and interview on 03/23/26 beginning at 2:32 p.m., Resident #49 was lying in her bed with the head of her bed elevated slightly. She had a family member in the room during the interview. Resident #49 reported she had not received her scheduled pain medications on several different occasions since she was admitted to the facility. Resident #49 said there was not a place on her body that did not hurt. She said she depended on and needed her pain medication to keep the pain controlled. She said the pharmacy the facility used was in another city and the medications were not readily available. Resident #49 started sobbing. She said she was waiting for her medication that was due at 2 p.m. and had been in pain since this morning. She stated she received a lower level pain pill at 6 a.m. that worked for a short time but had completely worn off during the interview. She stated her pain currently was 10 out of 10 on the pain scale. She said she would never kill herself, but she begged God to take her. She said her pain was exacerbated every time she missed her scheduled pain medication. She said her pain was tolerable at a 4 or 5 on the pain scale. She reported her pain was well-controlled when she received her pain medications as prescribed. Resident #49 stated she felt the facility did not understand her pain and did not try to accommodate her pain needs. She said she was constantly checking with the nurses to ensure she had enough pain medication and would not run out. She said when she runs out of pain medication she becomes frantic and thinks to herself not again, please, not again. During the interview at 3:04 p.m. LVN H knocked, entered Resident #49's room and reported that her pain medication had arrived at the facility and she was going to bring the pill to her. Resident #49 cried with relief that her pain medication was at the facility. During an interview on 03/24/26 beginning at 7:23 a.m., LVN K said Resident #49 complained of pain constantly and took her scheduled and PRN pain medication regularly. She said her pain level was anywhere from 1-10 on the 1-10 pain scale. LVN K stated she had asked the doctor to schedule her PRN pain medication, but he did not want to schedule them. LVN K was unsure if Resident #49 saw a pain management doctor. LVN K stated she was aware two times Resident #49 had run out of her scheduled pain medication but was unaware if Resident #49 had any increased pain. LVN K stated pain was what the patient stated it was. She said Resident #49 needed her pain medications because she constantly hurt. She said she should not have run out of her pain medications but they had trouble getting them from the pharmacy sometimes. During an interview on 03/24/26 beginning at 9:32 a.m., the ADON stated the nurses were responsible for re-ordering narcotic pain medications. She said during the medication pass, if they noticed a medication was getting low, the nurses could go into the electronic charting system and click re-order for the medications that were needed and it would have sent an alert to the pharmacy. She stated if the pain medication had no refills left, then she would have called the pharmacy for approval. She said if a new triplicate was needed, then the doctor had to directly send that to the pharmacy. The ADON stated the doctor usually sent the triplicate for pain medication directly to the pharmacy without any issues. She said if pain medication did run out, the facility had an emergency kit, which had pain medications in it. She said the emergency kit did not have scheduled II medications like oxycodone. She said she was unaware of any residents who had run out of scheduled pain medication. She stated Resident #49's oxycodone had been re-ordered but the delivery drivers' car had broken down on the way. During an interview on 03/24/26 beginning at 12:16 p.m., LVN H stated she did not normally have issues with receiving medication from the pharmacy. LVN H said Resident #49 had run out of scheduled pain medication at least twice that she was aware. LVN H stated if the pharmacy did not get the electronic prescription from the doctor by Friday, then the medication would not have been sent until Monday. LVN H stated Resident #49 received scheduled pain medication three times a day. She said if the nurses waited until the medication card was in the blue (8 pills left) to re-order her medication, then she would not have had enough to last the weekend. LVN H stated she worked on 03/21/26 and realized Resident #49 was not going to have enough medication to last the weekend. LVN H stated she called the pharmacy several times over the weekend, but the pharmacy did not deliver medications on the weekend. She said the medication was supposed to have come in earlier on 03/23/26 but the delivery driver had car trouble. LVN H stated Resident #49 was obsessed with her pain medication. She stated Resident #49 had chronic pain and she received her scheduled and PRN pain medications around the clock to keep her pain under control. She said when Resident #49 did not receive her pain medication, her pain became out of control and took a while to get back under control. She said on 03/23/26 she obtained an order for acetaminophen-codeine 300-60 mg x 1 dose to give in place of her missed oxycodone. She stated Resident #49 reported the pill was effective. She said as soon as Resident #49's oxycodone arrived from the pharmacy, she administered it. LVN H stated there were no set days to re-order medication, but the medications were re-ordered as it was noticed they were getting low. During an interview on 03/24/26 beginning at 1:09 p.m., the DON stated she was aware that Resident #49 had run out of medication on 03/23/26. She said the facility attempted to get the medication STAT 'ed but the driver had car trouble. She said she was unaware Resident #49 was having severe, uncontrolled pain because she had missed her pain medication. She was unaware of any other times Resident #49 had gone without her pain medication. The DON stated any missed dose of pain medication would have made it harder to maintain her desired pain level. She stated pain was what the resident said it was. She said pain was monitored every shift and when any pain medication was administered. The DON stated this was documented on the MAR. She stated severe or uncontrolled pain should have been reported to the doctor. The DON stated when the nurses were passing medications and the medications were getting low; they should have marked re-order in the electronic charting system. She stated the recommended re-order time was when the medication had approximately 8 pills left. She said marking re-order in the electronic charting system, sent the order directly to the pharmacy. She stated the cut off time for re-ordering medications was 6 p.m., so she expected staff to ensure ordering was completed before 6 p.m. She said no medications were delivered on the weekend, unless they were ordered STAT and the facility paid a fee. She said if the medication required a triplicate, the nurses should have notified the Medical Director so he could send the triplicate to the pharmacy. The DON stated the Medical Director did not send Resident #49's triplicate to the pharmacy until 8 or 9 p.m. on 03/20/26, which was past the cut off time, so it was not scheduled for delivery until 03/23/26. She said it was important to ensure medications were ordered timely, so they did not run into issues with medications running out. During an interview on 03/24/26 beginning at 1:31 p.m., the Administrator stated she expected pain was what the patient said it was. She stated she expected resident's pain to be controlled and kept under control. She said the nurses were responsible for monitoring to ensure resident's pain was kept under control. She said she expected the nurses to monitor the resident's pain at least every shift. She said she expected the nurses to ensure severe or uncontrolled pain was reported to the doctor immediately. She said the ADON and DON were responsible for monitoring the nurses. The Administrator stated it was important to ensure pain was kept under control to maintain a resident's pain at a lower level. She said once a resident's pain becomes severe, it was harder to get it back under control. During an interview on 03/24/26 beginning at 2:00 p.m., the Medical Director stated when a medication that required a triplicate was running low, the facility notified him by telephone or fax. He said he liked the facility to send the request at least 24 hours in advance, so he had time to complete the request. The Medical Director stated the facility was pretty good about letting him know ahead of time but there have been a few instances where he was not notified timely. He was unsure of any incidents recently with Resident #49. He believed the facility did not have a systemic issue. The Medical Director stated he had sent a triplicate for Resident #49 within the last week but was unsure if she went without any medication. The Medical Director stated he was unaware Resident #49 had been in severe, uncontrolled pain. He said he would like to have been notified if a resident's pain medication were unavailable. He said he could have found alternate ways to obtain the medications even during the weekend. The Medical Director stated it was important to ensure pain medication was given as ordered to prevent an increase in pain symptoms. He stated it was important to maintain resident's pain at a comfortable level and pain was what the patient said it was. Record review of the Pain Management, Assessment Scale policy, undated, reflected Pain is a subjective sensation of discomfort derived from multiple sensory, nerve interactions generated by physical, chemical, biological, or psychological stimuli. complaints of pain will be assessed accordingly by the nurse and effectively managed through prescribed medications, and comfort measures, and all available resources of the facility. assess resident's physical symptoms of pain, physical complaints, and daily activities. perform comfort measures to promote relaxation.ask resident to help establish goals and develop plan for pain control.this gives the resident sense of control.assist the resident in maintaining a pain management. medication regimen.monitor for effectiveness of pain interventions. The Administrator was notified on 03/24/26 at 4:25 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided with the Immediate Jeopardy template on 03/24/26 at 4:27 p.m. and a plan of removal was requested. The following plan of removal was submitted by the facility and accepted on 03/25/26 at 11:12 a.m. and included the following: Interventions:Resident #49 was assessed for pain by the DON. The [Medical Director] was notified. No complaints of pain or additional issues noted. Resident #49 has pain medication ordered and in facility. No new or worsening pain nor emotional stress at this time. Completion date 3/24/26.Psychological services were provided to Resident # 49 to address any psychological effects related to not receiving pain medications. A telehealth visit was completed on 3/24/26 with the resident and no further orders received. Resident initially started on this service 1/8/26 and a new referral was made 3/24/26 by DON to address any psychological issues related to not receiving scheduled pain medication.A trauma informed care assessment was completed on 3/24/26 by the social worker on Resident #49 for any psychological effects related to not receiving pain medications. No additional psychological effects were expressed or identified. No additional residents were identified as not receiving medications.All residents in the facility were assessed for any increased pain by the DON and Charge Nurses as of 3/24/26. No additional residents with new or uncontrolled pain were identified. Completion date 3/24/26.All residents that receive narcotic medications were audited by the DON/ADON/Regional Compliance Nurse to ensure that at least a 7 day supply are available on the medication carts. All residents have the appropriate amount of medications available as of 3/24/26. Completion date 3/24/26.The DON/ADON/or designee will be responsible for counting all narcotic medications daily to ensure at least a 7 day supply is available on the medication carts. Completion 3/24/26.The DON/ADON/or designee will be responsible for calling the physician when a 10 day supply of medication is on the cart to obtain the triplicates needed to reorder narcotic medications to ensure a 7 day supply is available. Completion 3/24/26.In-services: The Compliance Nurse will in-service the Administrator/DON/ADON 1:1 on the following topics on 3/24/26.Administering pain medication for residents with signs and symptoms of pain and monitoring for effectiveness of PRN medications.Pain management Policy -Signs and symptoms of pain verbally and non-verbal. (Change in behaviors such as crying, whining, groaning, facial expressions, grimacing, frowning, protecting body movements, guarding, or clutching)Notification of a Change of Condition Policy- to the charge nurse or physician immediately including signs and symptoms of increased pain. Abuse and Neglect Policy - to include failure to administer pain medications could be considered neglect.Medication Administration Policy- to include controlled medications, medication reconciliation, and documentation both on the MAR and count sheet.All charge nurses and medication aides were in-serviced on 3/24/26 by the Compliance Nurse/DON/ADON regarding the following topics below. All charge nurses, including agency staff, new hires and PRN charge nurses not in-serviced by 3/24/26 will not be allowed to work in their assigned position until completion of these in-services: Completion as of 3/25/26 DON and ADON were in-service by Compliance Nurse.Administering pain medication for residents with signs and symptoms of pain and monitoring for effectiveness of PRN medications.Pain management Policy -Signs and symptoms of pain verbally and non-verbal. (Change in behaviors such as crying, whining, groaning, facial expressions, grimacing, frowning, protecting body movements, guarding, or clutching)Notification of a Change of Condition Policy- to the charge nurse or physician immediately including signs and symptoms of increased pain. Abuse and Neglect Policy - to include failure to administer pain medications could be considered neglect.Medication Administration Policy- to include controlled medications, medication reconciliation, and documentation both on the MAR and count sheet.The medical director was notified on 3/24/26 of the immediate jeopardy situation by the Administrator.An AD HOC QAPI meeting was held on 3/24/26 by the Interdisciplinary Team to discuss the immediate jeopardy and review the plan of removal for pain. The Administrator and DON will implement this written Plan of Removal and will continue to monitor completion and compliance of this written Plan of Removal. On 03/25/26 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the immediate jeopardy (IJ) by: 1. Record review of Resident #49's pain assessment, dated 03/24/26, reflected Resident #49 had the ability to communicate and her pain was an 8 on the 1-10 pain scale at the time of the assessment. Her pain intensity was at a 10 on the 1-10 pain scale in the last 24 hours. The pain was all over and in her lower back. She described the pain as sharp and constant, lasting 2-4 hours. The pain affected sleep, appetite, physical activity, and emotions. Interventions included scheduled & PRN medications. 2. Record review of the Trauma Informed PRN Assessment, dated 03/24/26, reflected Resident #49 had had a mental disorder but no diagnosis of post-traumatic stress disorder. The assessment did not indicate Resident #49 had any psychological effects from pain. 3. Record review of Resident #49's nursing progress note, dated 03/25/26, reflected the DON had documented Counseling services completed a telehealth session with resident at 6 p.m. on 03/24/26. Resident requested that this nurse stay present in the room. Upon beginning of session, resident asked the counselor if he was the person she could get to order her something stronger than [Tylenol #4], if they make a [Tylenol #5], that would be great. When questioned on her pain at the time of the session, resident stated that she currently didn't have any pain as she had received her PRN medication about 40 minutes prior to start of session, but stated that at the time of receiving the PRN, her pain was a 5. During speaking with the counselor, they spoke of depression symptoms and that he would likely recommend medications. Resident requested that she have time to research the medication that he recommends before starting, counselor agreed. After completion of session, received counselor's recommendation to add Venlafaxine to medication regimen. Resident notified and states she will begin to research the medication. [Medical Director] made aware of recommendation, awaiting response. Resident with no [signs or symptoms] of distress this morning, sleeping in bed. 4. Record review of the Assessment History Pain-Assessment report, dated 03/25/26, reflected 60 residents were assessed for pain on 03/24/26. 10 residents complained of low to moderate pain and were provided interventions. 5. Record review of the Narcotic Card Count Sheet audit forms completed on 03/24/26, reflected a medication audit was completed for every narcotic pain medication. 11 medications were re-ordered to ensure a 7 day supply were in the facility. 6. Record review of the pharmacy receipts, dated 03/24/26 and 03/25/26, reflected 11 medications were received from the pharmacy. 7. Record review of the Triplicate/Refill Request form, reflected blanks for the following items: medication requested/refilled, strength, amount, directions, name of physician notified for triplicate request, designated agent calling in to refill to pharmacy, pharmacy name/number to fax, pharmacy name/address to mail, last fill date, staff member requesting the triplicate/refill, date medication received in facility, and staff member verifying medication in facility. 8. During an interview on 03/25/26 at 1:30 p.m., the ADON said she was provided with an in-service education on administering pain medications to residents with signs and symptoms of pain to include monitoring for effectiveness of PRN medications, medication re-ordering, and medications not on hand. She said a 10 day supply of medication should be maintained on the carts for narcotic pain medication. She stated a triplicate request form will now be filled out for each medication requested and will be filled out and monitored by the ADON or DON. She verbalized if a medication was not on hand or in the emergency kit, then it would be sent by the pharmacy immediately. She stated she was provided with in-service education on the pain management policy to include signs and symptoms of verbal and non-verbal pain. She said examples included: change in behaviors such as crying, groaning, or facial grimacing. She said pain was what the patient said it was and should be treated. She stated she was provided education on notification of change of condition policy to include notifying the doctor immediately of any new or increased pain. She said failure to provide pain medication could have been considered neglect. The ADON stated controlled pain medications must be documented and reconciled on both the MAR and count sheet. She said the count sheets were to be monitored and counted daily for discrepancies. 9. During an interview on 03/25/26 at 1:56 p.m., the DON stated she was provided with an in-service education on administering pain medications to residents with signs and symptoms of pain to include monitoring for effectiveness of PRN medications, medication re-ordering, and medications not on hand. She said a 10 day supply of medication should be maintained on the carts for narcotic pain medication. She stated a triplicate request form will now be filled out for each medication requested and will be filled out and monitored by the ADON or DON. She verbalized if a medication was not on hand or in the emergency kit, then it would be sent by the pharmacy immediately. She stated she was provided with in-service education on the pain management policy to include signs and symptoms of verbal and non-verbal pain. She said examples included: change in behaviors such as crying, groaning, or facial grimacing. She said pain was what the patient said it was and should be treated. She stated she was provided education on notification of change of condition policy to include notifying the doctor immediately of any new or increased pain. She said failure to provide pain medication could have been considered neglect. The ADON stated controlled pain medications must be documented and reconciled on both the MAR and count sheet. She said the count sheets were to be monitored and counted daily for discrepancies. 10. Record review of the in-service forms, dated 03/24/26, reflected the following one-on-one in-service education was provided to the ADON, DON, and the Administrator:*Administering pain medication for resident with signs and symptoms of pain*Pain management policy*Notification of change of condition policy*Abuse and Neglect policy*Controlled Medication Administration policy 10. Record review of the in-service forms, dated 03/24/26, reflected the following in-service education was provided to the nursing staff:*Administering pain medication for resident with signs and symptoms of pain. There were 11 nurses' signatures.*Pain management policy. There were 16 nurses' signatures.*Notification of change of condition policy. There were 15 nurses' signatures.*Abuse and Neglect policy. There were 16 nurses' signatures.*Controlled Medication Administration policy. There were 11 nurses' signatures. 11. During an interview on 03/25/26 between 1:20 p.m. and 2:06 p.m., LVN C, LVN D, LVN K, LVN M, MDS Coordinator L, and MDS Coordinator O stated they were provided with an in-service education on administering pain medications to residents with signs and symptoms of pain to include monitoring for effectiveness of PRN medication re-ordering, and medications not on hand. The nurses stated a triplicate request form will now be filled out for each medication requested and will be filled out and monitored by the ADON or DON. They verbalized that any pain medication not available at the facility could be obtained by the pharmacy even during weekends. They were able to verbalize non-verbal indicators of pain or discomfort to include change in behaviors such as crying, groaning, or facial grimacing. All staff stated pain was what the patient said it was and should be treated. The nurses said the doctor was to be immediately notified of any new or increased pain. They verbalized any failure to provide pain medication could have been considered neglect. The nurses stated controlled pain medications must be documented and reconciled on both the MAR and count sheet. She said the count sheets were to be monitored and counted daily for discrepancies. 12. Record review of the off cycle quality assurance meeting, dated 03/24/26, reflected the plan of removal was discussed with the interdisciplinary team to include the Medical Director, and 10 other team members. 13. During an interview on 03/25/26 at 2:12 p.m., the Medical Director stated he was notified of the immediate jeopardy and the plan of removal. The Administrator was informed the IJ was removed on 03/25/26 at 2:34 p.m. The facility remained out of compliance at a scope of pattern and a severity level of no actual harm with a potential for more than minimal harm

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (Residents #33 and #58) reviewed for infection control practices during medication pass. 1. The facility failed to ensure LVN C performed hand hygiene before or after passing medication to Resident #58, before checking Resident #33's blood sugar and administering insulin, and after leaving Resident #33's room on 03/24/26. 2. The facility failed to ensure LVN C sanitized the blood glucometer machine before and after checking Resident #33's blood sugar. 3. The facility failed to ensure LVN C sanitized the top of the insulin vial before drawing up Resident #33's insulin. This failure could place residents and staff at risk for cross contamination and the spread of infection.The findings included: 1. Record review of the face sheet, dated 03/25/26, reflected Resident #58 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of dementia (loss of memory, language, problem-solving and other thinking abilities that interfere with daily life), type 2 diabetes (high blood sugar), and morbid (severe) obesity due to excess calories. Record review of the quarterly MDS assessment, dated 02/03/26, reflected Resident #58 had clear speech, was understood, and was able to understand others. Resident #58 had a BIMS score of 15, which indicated no cognitive impairment. She had no behaviors or refusal of care. Record review of the comprehensive care plan, last reviewed 03/06/26, reflected Resident #58 had diabetes (high blood sugar), received diuretic (medication for edema (swelling)) therapy, had liver disease related to cirrhosis (scarring or inflammation of the liver), had hypertension (high blood pressure), received antiplatelet medication (blood thinner), had a mood problem, received anti-anxiety medications, received anti-depressant medication, and potential for uncontrolled pain. The interventions included: administer medication per orders. Record review of Resident #58's order summary report, dated 03/25/26, reflected the following orders:1. Advair Diskus 250 MCG/ACT - 1 puff inhale orally two times a day for wheezing, which was ordered on 11/15/23.2. Aspirin 81 mg chewable - Give 1 tablet by mouth one time a day for blood thinner, which was ordered on 04/14/25.3. Carafate 1 GM - Give 1 tablet by mouth two times a day for gastroesophageal reflux disease, which was ordered on 07/03/25.4. Famotidine 20 mg - Give 1 tablet by mouth two times a day for gastroesophageal reflux disease, which was ordered on 10/13/24.5. Fluticasone Propionate nasal suspension 50 MCG/ACT - Give 2 sprays in both nostrils one time a day for other allergic rhinitis (immune response which causes sneezing, nasal congestion, itchy, and runny nose), which was ordered on 11/15/23.6. glipizide 5 mg - Give 1 tablet by mouth two times a day for type 2 diabetes, which was ordered on 03/26/24.7. Lactulose 10 GM/15 mL - Give 30 mL by mouth two times a day for cirrhosis of liver, which was ordered on 01/25/26.8. Multivitamin - Give 1 tablet by mouth one time a day for vitamin deficiency, which was ordered on 04/14/25.9. Potassium Chloride ER 10 MEQ - Give 1 tablet by mouth two times a day for hypokalemia (low potassium level), which was ordered on 05/22/25.10. Protonix DR 40 mg - Give 1 tablet by mouth once a day for gastroesophageal reflux disease, which was ordered on 12/17/25.11. venlafaxine 75 mg - Give 1 tablet by mouth two times a day for depression, which was ordered on 01/09/26. Record review of Resident #58's MAR, dated March 2026, reflected Advair Diskus, aspirin, Carafate, famotidine, fluticasone propionate nasal spray, glipizide, lactulose, multivitamin, potassium chloride, Protonix, and venlafaxine were given in the morning on 03/24/26 by LVN C. 2. Record review of the face sheet, dated 03/25/26, reflected Resident #33 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of type 2 diabetes (high blood sugar). Record review of the quarterly MDS assessment, dated 02/09/26, reflected Resident #33 had clear speech, was understood, and was able to understand others. Resident #33's BIMS score was 15, which indicated no cognitive impairment. She had no behaviors or refusal of care. Resident #33 received insulin injections 7 out of 7 days during the look back period and had 2 insulin order changes. Record review of the comprehensive care plan, last reviewed 02/18/2026, reflected Resident #33 had diabetes (high blood sugar). The interventions included: medications as ordered and fasting blood sugar as ordered. Record review of Resident #33's order summary report, dated 03/25/26, reflected the following orders:1. Novolin 70/30 subcutaneous suspension 100 unit/mL - inject 20 units subcutaneously one time a day related to diabetes, which was ordered on 02/05/26. Record review of the MAR, dated March 2026, reflected Resident #33's blood sugar was 148 and 20 units of Novolin 70/30 was given on 03/24/26 in the morning by LVN C. During an observation on 03/24/26 between 6:52 a.m. and 7:01 a.m., the following occurred during medication pass:1. LVN C did not perform hand hygiene before or after administering Resident #58's medication.2. LVN C did not perform hand hygiene before or after checking Resident #33's blood sugar.3. LVN C did not sanitize the glucometer (machine used to check blood sugars) before or after checking Resident #33's blood sugar.4. LVN C did not sanitize the top of the insulin (blood sugar medication) vial before using the insulin needle to draw up 20 units of medication.5. LVN C did not perform hand hygiene before or after administering Resident #33's insulin. During an interview on 03/25/26 at 3:02 p.m., LVN C stated hand hygiene should have been performed before and after passing medications, before and after checking blood sugar, and before and after giving insulin. LVN C stated the blood glucose machine should have been sanitized before and after checking blood sugar. LVN C stated the insulin vial should have been cleaned prior to drawing up the insulin. LVN C stated she was nervous with the state surveyor watching and just forgot to use hand sanitizer, clean the glucometer, and clean the top of the insulin vial. LVN C stated failing to follow the infection control practices during medication administrations could have led to cross contamination or the spread of infection. During an interview on 03/25/26 at 3:39 p.m., the DON stated she expected the nurses to follow the infection control practices during medication administration. The DON stated she expected the nurses to perform hand hygiene before and after medication administration, sanitize the blood glucometer before and after use, and clean the insulin vial before drawing up insulin. The DON stated the pharmacy consultant was responsible for monitoring to ensure infection control practices were followed during medication administration. The DON stated the pharmacy consultant had not identified any issues with infection control during her visits. The DON stated it was important to ensure infection control practices were followed during medication administration to prevent the spread of infection or cross contamination. During an interview on 03/25/26 at 3:45 p.m., the Administrator stated she expected the nursing staff to ensure hand hygiene was performed before and after medication administration, before and after checking blood sugar, and before and after giving an insulin injection. The Administrator stated she expected the blood glucose machine to be sanitized before and after checking blood sugar. She stated she expected the top of the insulin vial to be cleaned before drawing up the insulin. The Administrator stated the ADON or DON were responsible for monitoring to ensure infection control practices were followed during the medication pass. She stated it was important to ensure infection control practices were followed to prevent the spread of infection. Record review of the Fundamental of Infection Control Precautions policy, undated, reflected Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situation that require hand hygiene: . Before and after direct patient care. Before and after performing any invasive procedure (e.g., fingerstick blood sampling) . Record review of the Glucometer policy, undated, reflected .clean and inspect meter exterior with each use. Meter will be cleaned with a germicidal and allowed to air dry between patient testing. Record review of the Novolin 70/30 insulin manufacturer instructions, revised November 2022, reflected .wipe the rubber stopper with an alcohol swab.

Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications for 1of 1 resident (Resident #40) reviewed for enteral nutrition. The facility failed to ensure Resident #40's physician's order for his enteral feedings (a form of nutrition that is delivered into the digestive system as a liquid form via the feeding tube) was administered during the scheduled amount of time. This failure could affect residents by placing them at risk of dehydration and weight loss.The findings included: Record review of the face sheet, dated 3/24/26, reflected Resident #40 was a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of severe protein-calorie malnutrition, encounter for surgical aftercare following surgery on the digestive system, gastrostomy (a surgical opening for long-term enteral nutrition) and dysphagia (difficulty swallowing). Record review of the nursing home MDS assessment, dated 3/9/26, reflected Resident #40 had unclear speech, was usually understood by others, and was usually able to understand others. Resident #40 had a BIMS score of 4, which indicated severe cognitive impairment. Resident #40 usually required total assistance from staff with ADLs and was always incontinent of bowel and bladder. Nutritional: Malnutrition. Additional active diagnoses: Gastrostomy. Record review of the comprehensive care plan, dated 2/21/26, reflected Resident #40 has potential fluid deficit. Interventions include administering medications as ordered, monitoring, document for side effects and effectiveness. Record review of the comprehensive care plan, dated 3/6/26, reflected Resident #40 requires tube feeding related to dysphagia, swallowing problem. The interventions included: the resident is dependent on tube feeding and water flushes. See medical director's orders for current feeding orders. Registered Dietician to evaluate quarterly and PRN, monitor calorie intake, estimate needs, make recommendations for changes to tube feeding as needed. Record review of Resident #40's order summary report, reflected Isosource (nutritionally complete tube feeding formula) 1.5 calorie at 55 cc/hour via per peg-tube (a flexible feeding tube inserted through the abdomen into the stomach) 22 hours every shift related to gastrostomy status, start date 3/15/26. During an observation on 3/24/26 at 11:20 A.M., Resident #40 was lying in bed resting with peg-tube (a flexible feeding tube inserted through the abdomen into the stomach) hooked to enteral feeding bag and pump, with head of bed elevated. Resident feeding pump displayed Notice Pump Inactive. Pump has been idle for 10 minutes. Press Continue. The feeding pump was beeping with an orange and green light blinking. There was a small amount of liquid in the feeding bag which indicated there was not enough feeding in the bag to supply the pump. During an observation on 3/24/26 at 1:59 P.M., Resident #40 laid in bed with feeding bag and pump connected to peg-tube (a flexible feeding tube inserted through the abdomen into the stomach). The feeding pump continued to display Notice Pump Inactive. Pump has been idle for 10 minutes. Press Continue. The feeding pump was beeping with an orange and green light blinking. There was a small amount of liquid in the feeding bag which indicated there was not enough feed in the bag to supply the pump. During an interview on 3/24/26 at 2:03 P.M. LVN D stated Resident #40 should be getting his feeding all day. She stated that this was her first time changing his feeding and she was about to do it now. She stated the last time she checked his feeding was about 12:00 P.M. when she was passing out hall trays and it was not beeping. She stated his order and said he was supposed to be getting the peg-tube feeding 22 hours a day. During an interview on 3/24/26 at 3:51 P.M., the Assistant Director of Nursing stated when she went into Resident #40's room LVN D had already removed the old bag from the pump and spiked the new bag for the feeding pump. She stated she watched LVN D start the feeding without any assistance. The Assistant Director of Nursing stated Resident #40 was on 22 hours of peg-tube (a flexible feeding tube inserted through the abdomen into the stomach) feeding everyday with 2 hours of downtime with therapy, showers and gut rest. She stated his feeding should have been running from 11:20 A.M. to 2:03 P.M. She stated LVN D did not tell her that it was Resident #40's down time. She stated she expects him to down time during the day, her expectation was 3 hours was more down time than it should be. During an interview on 3/25/26 at 2:13 P.M., CNA E stated she remembered Resident #40's pump beeping yesterday. She stated she did not remember how long the pump was beeping. She stated she did round every 2 hours, and she observed the pump beeping during that time. She stated she did not remember what time she went in Resident #40's room. She stated when the pump was beeping it did not display Notice Pump Inactive. Pump has been idle for 10 minutes. Press Continue, when she was there. She stated the feeding was low in the bag when she was in the room and the tubbing from the pump was connected to Resident #40. She stated most of the time the feeding pump was running. She stated she did not honestly know the negative effect of the feeding not running when it should be. During an interview on 3/25/26 at 3:54 P.M., the Director of Nursing stated Resident #40 does have downtime. She sated Resident #40 had weight loss during his hospital stay. She said from 11:19 A.M.to 2:03 P.M. was not Resident #40's scheduled downtime. She stated she would expect his feeding to be running during that time. She stated the charge nurse on the floor was responsible for ensuring the feeding was running. She stated the negative effect was a potential weight loss. During an interview on 3/25/26 at 4:10 P.M., the Administrator stated she expected the feeding to be administered for the number of hours ordered. She stated the charge nurse, Assistant Director of Nursing and Director of Nursing were responsible for ensuring that the feeding was running appropriately. She stated the negative effect was that the resident weight could go down, and they may not get the effective nutrition for the day. Record review of the facility's policy Enteral Nutrition undated, indicated . We will provide nutritionally complete enteral or parental feedings as ordered by the physician for the nourishment of the residents who are unable to eat by mouth.1. The Nursing Services Department is responsible for all feeding equipment and the administration of tube feeding.5. Problems with the administration of the tube feeding are monitored and corrected by nursing.

Based on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 2 of 18 residents reviewed for respiratory care. (Resident #22 and Resident #55)The facility failed to ensure Resident #22's and Resident #55's oxygen concentrator had a clean filter.This failure could place residents at risk of respiratory complications or respiratory infection. Findings included: 1. Record review of a face sheet dated 03/24/26 indicated Resident #22 was [AGE] years old and admitted on [DATE] with diagnoses including dementia, chronic obstructive pulmonary disease (chronic lung disease), and acute and chronic respiratory failure.Record review of a physician's Order Summary Report dated 03/24/26 for Resident #22 did not include an order for cleaning the oxygen concentrator filter .Record review of a quarterly MDS dated [DATE] indicated Resident #22 understood others and was understood. The MDS indicated a BIMS of 12 indicating moderate cognitive impairment. The MDS indicated Resident #22 received oxygen therapy while she was a resident in the facility. Record review of a care plan last revised on 09/23/25 indicated Resident #22 had a diagnosis of chronic obstructive pulmonary disease with an intervention to give oxygen therapy as ordered by the physician. Record review of a Treatment Administration Record for Resident #22 dated 03/01/26 - 03/31/26 indicated an order to change or clean the filter of the nebulizer machine as needed on Sunday night. There was no documentation that the filter had been changed or cleaned from 03/01/26 - 03/25/26.During an observation on 03/23/26 at 9:56 a.m., Resident #22 was in bed. She had on a nasal cannula that was connected to a running oxygen concentrator. There was a gray fuzzy substance on the filter on the concentrator.During an observation on 03/24/26 at 8:27 a.m., Resident #22 was in bed. She had on a nasal cannula that was connected to a running oxygen concentrator. There was a gray fuzzy substance on the filter on the concentrator.During an observation on 03/25/26 at 9:17 a.m., Resident #22 was in bed. She had on a nasal cannula that was connected to a running oxygen concentrator. There was a gray fuzzy substance on the filter on the concentrator.2. Record review of a face sheet dated 03/24/26 indicated Resident #55 was [AGE] years old and admitted on [DATE] with diagnoses including dementia, chronic respiratory failure with hypoxia (low oxygen saturation), and diabetes.Record review of a physician's Order Summary Report dated 03/24/26 for Resident #55 did not indicate an order to change or clean the filter of the oxygen concentrator. There was an order for oxygen 3 liters per minute every shift with a start date of 11/01/25.Record review of a quarterly MDS dated [DATE] indicated Resident #55 understood others and was understood. The MDS indicated a BIMS of 13 indicating intact cognition. The MDS indicated Resident #55 received oxygen therapy while she was a resident in the facility. Record review of a care plan last revised on 10/22/25 indicated Resident #55 received oxygen therapy. There were no interventions concerning oxygen concentrator filters. Record review of a Treatment Administration Record for Resident #55 dated 03/01/26 - 03/31/26 did not indicate an order to change or clean the filter of the oxygen concentrator. There was no documentation that the filter had been changed or cleaned from 03/01/26 - 03/25/26.During an observation on 03/23/26 at 9:53 a.m., Resident #55 was sleeping in bed. She had on a nasal cannula that was connected to a running oxygen concentrator. There was a gray fuzzy substance on the filter on the concentrator.During an observation on 03/23/26 at 12:47 p.m., Resident #55 was in bed. She had on a nasal cannula that was connected to a running oxygen concentrator. There was a gray fuzzy substance on the filter on the concentrator.During an observation on 03/24/26 at 8:29 a.m., Resident #55 was asleep in bed. She had on a nasal cannula that was connected to a running oxygen concentrator. There was a gray fuzzy substance on the filter on the concentrator.During an observation on 03/25/26 at 9:20 a.m., Resident #55 was asleep in bed. She had on a nasal cannula that was connected to a running oxygen concentrator. There was a gray fuzzy substance on the filter on the concentrator.During an interview on 03/25/26 at 10:00 a.m., LVN C said the night shift nurses were responsible for cleaning the concentrator filters. She said the filters were supposed to be cleaned on Sunday nights. She said she had never checked to see if this had been done. She said it was important for clean filters to be on the concentrators because it filtered out infection, dust, polluted air, and kept the lungs clean. During an interview on 03/25/26 at 3:04 p.m., the DON said oxygen concentrator filters should be cleaned on Sunday nights by nursing staff. She said she would have expected for the filters for Resident #22 and Resident #55 to have been cleaned Sunday, 03/22/26. She said filters being cleaned was for infection control. She said cleaning filters was to make sure residents were not breathing in the wrong stuff and to make sure the concentrator continued to work properly. During an interview on 03/25/26 at 3:13 p.m., the Administrator said the night nurse on Sundays were responsible for washing and cleaning oxygen concentrator filter. She said she would have expected for the filters for Resident #22 and Resident #55 to have been cleaned this last Sunday night, 03/22/26. She said it was important for the filters to be clean because they catch all of the impurities and so that the air that was filtered through it was clean. Record review of an undated Oxygen Administration facility policy indicated, .Change or clean oxygen concentrator filters according to manufacturers' instructions.Record review of an undated Oxygen Services Customer Handbook by Mayo Clinic indicated on page 5, .Oxygen Concentrator.Once a week, the filter/intake of the concentrator should be cleaned or vacuumed.

Based on observation, interview and record review the facility failed to ensure residents had the right to be treated with respect and dignity for 1 of 1 residents reviewed for resident rights. (Resident #1)The facility failed to ensure Resident #1's catheter bag had a privacy cover in place.This failure could cause residents to feel embarrassed and lower their quality of life.Findings included:Record review of Resident #1's face sheet, dated 12/17/25, indicated Resident #1 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included Urinary Tract Infection (a bacterial infection in the urinary system, commonly causing burning pain during urination, frequent urges to pee, and cloudy or bloody urine),.Record review of Resident #1's admission MDS, dated [DATE], indicated Resident #1 usually understood others and made himself understood. Resident #1 had a BIMS score of 11, which indicated his cognition was moderately impaired. The MDS revealed that Resident #1 used a catheter. Record review of Resident #1's comprehensive care plan, dated 12/17/25, indicated Resident #1 had an indwelling catheter. Indicated that Resident #1 would be free from catheter-related trauma.Record review of a physician's order dated 12/26/2025 shows that Resident #1 had an order that said, Ensure foley bag is in privacy bag while in bed or wheelchair.During an interview and observation on 3/23/26 at 9:30 a.m., Resident #1 had a catheter bag attached to the side of his bed. It could be observed from the entrance of the room. The catheter bag did not have a privacy cover on. Urine was observed inside his bag. Resident #1 said that it bothered him that his urine was visible to anyone that could walk by.During an observation on 3/24/26 at 12:22 p.m. Resident #1's catheter bag was seen from the hallway without a privacy cover on. During an interview on 3/25/26 at 10:03 a.m. CNA G said that it was the responsibility of CNAs and Nurses to ensure that privacy covers were on catheter bags. She said that if a resident did not have their privacy cover on it could be embarrassing to them.During an interview on 3/25/26 at 3:12 p.m. the Director of Nurses said that it was the responsibility of all nurses to ensue that residents who use a catheter bag have a privacy cover on that bag. She said that residents could potentially be embarrassed if their urine could be seen by anyone in the facility. She said she was unsure if there was a specific policy that stated residents required a privacy cover over their catheter bag.During an interview on 3/25/26 at 3:27 p.m. the Administrator said that Nurses and CNAs are responsible to ensure that privacy covers were placed on catheter bags. She said that residents could be placed at risk for embarrassment if their privacy cover was not on.Record review of an undated facility policy titled, Catheter Care revealed there was no information regarding a privacy cover.

Based on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff through a communication system which relays the call directly to a centralized staff work area for 1 of 18 (Resident #5) residents reviewed for call lights.The facility failed to ensure Resident #5 had a functioning call light.This failure could place residents at risk for a delay in assistance and decreased quality of life, self-worth, and dignity. Findings included: Record review of Resident 5's face sheet dated 03/24/26 indicated the resident was [AGE] years old and originally admitted to the facility on [DATE]. Resident #5 had diagnoses which included diabetes, chronic pulmonary edema (a condition caused by too much fluid in the lungs), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).Record review of Resident #5's annual MDS assessment dated [DATE] indicated the resident was understood and understood others. Resident #5 had a BIMS score of 15, which indicated intact cognition. The MDS indicated Resident #5 required moderate assistance with toileting and supervision with other ADLs.Record review of Resident #5's care plan last revised 03/18/26 indicated the resident had bowel and bladder incontinence. There was an intervention to assist with toileting as needed. The care plan indicated Resident #5 had an ADL self-care performance deficit and required assistance from one staff member for most ADLs.During an observation and interview on 03/23/26 at 10:34 a.m., Resident #5 was sitting in her wheelchair in her room. LVN A was in the room. Resident #5's call light cord was completely broken away from the plug. LVN A walked into the room and said she could not fix the call light.During an observation 03/23/26 at 11:58 a.m., Resident #5 was in bed. Her call light was plugged into the outlet. The cord was broken and was not connected to the plug. During an observation 03/23/26 at 2:09 p.m., Resident #5 was asleep in bed. Her call light was plugged into the outlet. The cord was broken and was not connected to the plug. During an observation 03/24/26 at 8:29 a.m., Resident #5 was awake in bed. Her call light was plugged into the outlet. The cord was broken and was not connected to the plug. During an observation 03/24/26 at 10:19 a.m., Resident #5 was awake in bed. Her call light was plugged into the outlet. The cord was broken and was not connected to the plug. During an observation and interview 03/24/26 at 2:20 p.m., Resident #5 was awake in bed. Her call light was plugged into the outlet. The cord was broken and was not connected to the plug. She said she did not know how long her call light had been broken. She said when she needed help, she just yelled until someone would come to her room.During an interview on 03/24/26 at 2:46 p.m., LVN A said she remembered being in Resident 5's room and finding the call light broken. She said she did not report it to anyone. She said she should have reported it to the maintenance department. She said she did not know the process of reporting issues to maintenance. During an interview on 03/24/26 at 2:53 p.m., CNA B said he was the CNA for Resident #5. He said he had been in her room several times and he had not noticed her call light being broken. He said that he had fed Resident #5 her lunch. He said if a staff member had noticed the call light being broken, they should have reported it to maintenance. He said there was a QR code (a barcode that appears in a square pattern and stores encoded data) that hung on the wall that you scan. Then maintenance issues were submitted electronically.During an observation 03/24/26 at 4:13 p.m., Resident #5 was in bed. Her call light cord was completely broken away from the plug in the outlet.During an interview on 03/24/26 at 4:20 p.m., the Area Maintenance Supervisor said he needed to check the maintenance system to see if Resident 5's call light had been reported to the maintenance department. He said if staff were aware of the call light being broken on 03/23/26, he would have expected for it to have been reported then. He said when staff find maintenance issues, they should be scanning in the QR Code posted on the wall near the nurse's station to submit a maintenance request. He said the request then goes into the maintenance care system to create a work order. He demonstrated how to enter the request by putting in a request for Resident 5's call light to be repaired. During an interview on 03/24/26 at 4:34 p.m., the Area Maintenance Supervisor said he had checked the maintenance system, and no staff member had entered a maintenance request until he did during the earlier demonstration. He said the call light had been repaired and the staff had been educated. During an interview on 03/25/26 at 3:04 p.m., the DON said she would have expected LVN A to have reported the call light being broken in Resident 5's room on 03/23/26. She said LVN A was new but the procedure for reporting maintenance issues had been covered in orientation. She said normally when a call light was not functioning, they provided the resident with a cow bell until it was repaired. She said it was important for residents to have a functioning call light so that they could notify staff that they were needing assistance.During an interview on 03/25/26 at 3:13 p.m., the Administrator said all call lights were supposed to function and if not, they were supposed to be reported to herself or the nurse. Then staff should put a repair request into the maintenance care system electronically. She said staff could verbally tell the Maintenance Supervisor. She said it was important for residents to have a call light so that they have a way to alert the staff if they have a need. During an interview on 03/25/26 at 3:31 p.m., the Regional Compliance Nurse said the facility did not have a functioning call light policy. Record review of an undated Resident Rights facility policy indicated, .The right to reside and receive services in the facility with reasonable accommodation of resident needs.

Based on observation, record review and interview the facility failed to store all drugs and biologicals in locked compartments for 1 of 1 residents (Resident #54) reviewed for drug storage. The facility failed to securely store over the counter medications, (Nystatin Topical Powder) for Resident #54.This failure could place residents at risk for adverse reactions.Findings included:Record review of the face sheet dated 10/03/25 indicated Resident #54 was [AGE] years old female who was admitted on [DATE] with diagnoses including Hypothyroidism (an underactive thyroid condition where the gland fails to produce enough hormones to meet the body's needs, causing metabolism to slow), Hyperlipidemia (a common condition characterized by high levels of lipids (fats), such as cholesterol or triglycerides, in the blood, which can lead to plaque buildup in arteries), Bipolar Disorder (a chronic mental health condition characterized by extreme, often debilitating shifts in mood, energy, and activity levels, alternating between manic highs and depressive lows).Record review of the MDS dated [DATE] indicated Resident #54 was understood and understood others. The MDS indicated a BIMS score of 15 indicating Resident #54 was cognitively intact.Record review of a care plan revised on 10/06/25 indicated Resident #54 had an activities of daily livingself care performance Deficit.During an observation on 3/23/26 at 9:35 a.m. Resident #54 had two bottles of Nystatin Topical Powder in her room. She was not in the room to interview.During an interview and observation on 3/23/26 at 3:00 p.m. it was observed that Resident #54, had two bottles of Nystatin Topical Powder in her room. She said that she wanted to keep the powder in her room so she could use it herself. She said that staff had not taken it from her or told her she could not have it in the room.During an interview on 3/25/26 at 10:06 a.m. LVN C said that residents are not allowed to keep any medications in their room of any kind including nystatin topical powder. She said that residents could potentially misuse the medications or someone could come into the room who was allergic to the medications and misuse them. She said that all staff are responsible to ensure that medications are not left in residents' rooms and were stored properly.During an interview on 3/25/26 at 3:15 p.m. the Director of Nurses said that all medications should be stored in the medication or treatment cart. She said that it was the responsibility of nurses to ensure medications are stored properly. She said residents could be placed at risk if they misused the medications. During an interview on 3/25/26 at 3:27 p.m. the Administrator said that medications should always be kept in the medication cart when not being used by staff. She said that residents could be placed at risk if they misused the medications. She said that it was everyone's responsibility to ensure medications are not left in residents' rooms.Review of a facility policy titled, Medication Storage In the Facility reflected Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.The facility dispenses medications in containers that meet legal requirements, including requirements of good manufacturing practices where applicable. Medications are kept and stored in these containers. Transfer of medications from one container to another is done only by a pharmacist.Only licensed nurses, the Consultant Pharmacist, and those lawfully authorized to administer medications are allowed unsupervised access to medications. Medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access.

Based on observation, interviews, and record review, the facility failed to ensure a resident with urinary incontinence, based on the resident's comprehensive assessment, received appropriate treatment and services to prevent urinary tract infections (UTI) for 1 of 18 resident (Residents #30) reviewed for urinary incontinence. The facility failed to ensure staff assisted Resident #30 with using her pure wick system (urine collection system). This failure could place residents at risk for pain, urinary tract infections and a decreased quality of life. Findings included: Record review of Resident #30's face sheet dated 3/24/26 indicated a 65-years-old female admitted to the facility on [DATE]. Resident #30 had diagnoses including: morbid (severe) obesity with alveolar hypoventilation (a condition where severely obese individuals cannot breathe deeply), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side (a form of paralysis causing total or partial loss of muscle function) and unspecified fall. Record review of the comprehensive MDS dated [DATE] indicated Resident #30 had clear speech, understood others, and was understood by others. The MDS indicated she had a BIMS score of 14 indicating moderate cognitive impairment. Resident #30 required maximal assistance from staff for toileting hygiene and personal hygiene. The MDS indicated Resident #30 was always incontinent of bladder and continent of bowel. Record review of the care plan dated 3/6/26 indicated Resident #30 has an ADL self-care performance deficit. Interventions include: Toilet use: requires staff x2 for assistance. Encourage the resident to discuss feelings about self-care deficit. Record review of the care plan revised dated 3/24/26 indicated Resident #30 has bladder incontinence and uses the pure wick system (urine collection system) for elimination. Interventions include nursing will monitor at least every 2 hours to ensure system is working and resident does not need to be cleansed and changed due to leakage. Staff will empty pure wick cannister as needed. Record review of Resident #30's Order Summary Report dated 3/24/26 indicated Resident #30 may use pure wick system (urine collection system) with a start date of 3/24/26. During an observation and interview on 3/23/26 at 10:12 A.M., Resident #30 was lying in bed resting. Resident has a pure wick system (urine collection system) on top of a portable tote in her room. Resident #30 stated staff did not know how to use it and they did not try to use the system per her and family request. During an interview on 3/24/26 at 10:54 A.M., a family member of Resident #30 stated she came last night and hooked the pure wick system (urine collection system) up for the resident. A family member of Resident #30 stated the day she brought the system to the facility a nurse stated the pure wick system was an amazing thing, but last night the nurse stated she was not sure if Resident #30 could use it in the facility. A family member of Resident #30 stated she was not sure if the staff knew how to use the system. A family member of Resident #30 stated Resident #30 really wanted to use the pure wick system (urine collection system), because the staff in the hospital used it on her and she loved it. During an interview on 3/25/26 at 9:12 A.M., Resident #30 lying in bed. Resident #30 stated that someone that was not a facility employee set up the pure wick system (urine collection system) for her, put it on her and it worked. Resident #30 stated that the nurse came in to change her stated the pure wick system (urine collection system) was not her favorite. Resident #30 stated she told the nurse she got the pure wick system (urine collection system) because she wanted to use it and it was better to use than urinating on herself. Resident #30 stated it made her mad that she had the pure wick system (urine collection system) and the staff do not want to use it. During an interview on 3/25/26 at 12:58 P.M., LVN F stated she knew a family member of Resident #30 brought the pure wick system (urine collection system) to the facility, but staff did not use those in our facility. LVN F stated Resident #30 said another staff member told her family she could use the pure wick system (urine collection system). LVN F stated she did not know anything about the pure wick system (urine collection system) until a family member of Resident #30 addressed it to her. LVN F stated no management told her the pure wick system (urine collection system) could not be used in the facility. She just told a family member of Resident #30 and the resident that the system could not be used, because she had never used one in a nursing facility. LVN F stated she was not aware that Resident #30 had an order for the pure wick system (urine collection system) to be used. LVN F stated she had never used one and she did not know how to use it. During an interview on 3/25/26 at 2:33 P.M., the Assistant Director of Nursing stated a family member of Resident #30 came and asked her about the system, and we explained to them our concerns about the system. The Assistant Director of Nursing stated the CNAs and nurses helped Resident #30 use the pure wick system. She stated she had seen the canister full, but she had not used the system on her Resident #30 herself. She stated the negative effect of not using the system at the resident's request was the consequences of incontinence. During interview on 3/25/26 at 3:54 P.M., the Director of Nursing stated Resident #30 could have the pure wick system if the family provided the supplies. The Director of Nursing stated a family member of Resident #30 verified the resident could use the system and she could instruct staff on where it needed to be placed. The Director of Nursing stated the aides were the staff placing the pure wick system (urine collection system) for Resident #30 with her guidance. She stated the negative effect of staff not helping Resident #30 use the system was she would have an incontinent episode that would require her to be changed if the system was not placed properly. During an interview on 3/25/26 at 4:10 P.M., the Administrator stated the facility was trying to get a policy for the pure wick system (urine collection system). She stated a family member of Resident #30 notified us the resident wanted to use the system; and she was taught in the hospital how to use it. The Administrator stated the nursing staff was responsible for emptying the canister. She stated Resident #30 was responsible for placing or assisting with the placement of the pure wick system (urine collection system), because she was taught how to use when she was in the hospital. She said she did not personally see a negative effect of staff not assisting the resident with the device. She said she thought it was more of a dignity issue for the resident. During an interview on 3/25/26 at 4:10 P.M., the Administrator stated the facility did not have a policy on pure wick system.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 1 of 18 residents (Resident #40) reviewed for the physical environment. The facility failed to ensure Resident #40's room had adequate lighting. This failure could place residents at risk of falls, a decreased quality of life and an unsafe environment. The findings included: Record review of the face sheet, dated 3/24/26, reflected Resident #40 was a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of severe protein-calorie malnutrition, muscle wasting and atrophy(wasting due to lack of use or malnutrition), muscle weakness (generalized) and other abnormalities of gait and mobility, and other lack of coordination. Record review of the nursing home MDS assessment, dated 3/9/26, reflected Resident #40 had unclear speech, was usually understood by others, and was usually able to understand others. Resident #40 had a BIMS score of 4, which indicated severe cognitive impairment. Resident #40 usually required total assistance from staff with ADLs and was always incontinent of bowel and bladder. Record review of the comprehensive care plan, dated 2/21/26, reflected Resident #40 was at risk for falls. The interventions included: low bed, floor mat to bed side, anticipate and meet the resident's need, educate the resident, family, caregivers about safety reminders and what to do if a fall occurs. Record review of the fall incident report, dated 3/13/26, reflected Resident #40 had an unwitnessed fall in his room; no injuries sustained. Record review of the fall incident report, dated 3/16/26, reflected Resident #40 had an unwitnessed fall in his room; no injuries sustained. Record review of the fall incident report, dated 3/17/26, reflected Resident #40 had an unwitnessed fall in his room; no injuries sustained. During an observation on 3/23/26 at 10:38 A.M., Resident #40 was lying in bed watching T.V. with feeding running, with head of bed elevated. When the main light in resident's room was turned on it was not working. The room was very dark. During an observation and interview on 3/24/26 at 9:28 A.M., Resident #40 was lying in bed resting while feeding running. When the main light in resident's room was turned on it was very dim. Resident #40 said he did not like the room to be that dark. During an observation on 3/24/26 at 11:20 A.M., Resident #40 was lying in bed resting. When the main light in Resident #40's room was turned on it was very dim and the room was dark. During an observation on 3/25/26 at 9:02 A.M., Resident #40 was lying in bed resting while feeding running. Resident #40's main light in room continues to shine dim. During an interview on 3/25/26 at 2:13 P.M., CNA E stated she noticed the main light in Resident #40's room was very dim. She stated she notified the nurse yesterday about the dim light. She stated the Maintenance Supervisor was waiting on the bulbs. She stated he had ordered the bulbs, but they had not come in yet. She stated the negative effect of the dim light was it makes it hard to see in Resident #40's room. During an interview on 3/25/26 at 2:22 P.M., LVN D stated she had noticed the light in Resident #40 room. She stated she put in a maintenance note yesterday about the dim light. She stated maintenance was responsible for replacing the lights. She stated a negative effect of the light being dim was Resident #40 could not see, and it was dark in his room without the main light functioning properly. During an interview on 3/25/26 at 2:29 P.M., Maintenance Supervisor stated he was notified about the dim light in Resident #40 room yesterday. He stated he was dealing with the state inspection guy yesterday and he had another priority issue to fix. He stated he would fix the light in Resident #40's room next. He stated the negative effect on the dim light was it could affect Resident #40's vision for him to see adequately. During an interview on 3/25/26 at 2:33 P.M., the Assistant Director of Nursing stated she had not noticed the light in Resident #40's room. She stated maintenance was responsible for changing the light bulbs in the resident's room. She stated the negative effect was a more somber mood (feeling sadness or gloom) for Resident #40 and made the residents want to sleep more. During an interview on 3/25/26 at 3:54 P.M., the Director of Nursing stated the light should be available to the residents if they wanted them. She stated maintenance was responsible for ensuring the residents had efficient light in the rooms. She stated the negative effect was it could affect Resident' #40's sleep schedule, being in a dark room. During an interview on 3/25/26 at 4:10 P.M., the Administrator stated she expected the residents' rooms to be well lit. She stated everyone was responsible and especially the Maintenance Supervisor when he was aware. She stated staff should notify maintenance. She stated the negative of the dim light was that the resident could become depressed or trip and fall. Record review of the Resident Rights policy, undated, reflected The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

Based on observation, interview, and record review, the facility failed to ensure dialysis services were provided consistently with professional standards of practice for 1 of 1 resident reviewed for dialysis services. (Resident #21) 1. The facility failed to ensure the dialysis communication forms were fully completed to include the post dialysis assessment for Resident #21. 2. The facility failed to ensure the dialysis order was updated when Resident #21's dialysis days changed on [DATE]. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs. The findings included: Record review of Resident #21's face sheet, dated [DATE], reflected Resident #21 was a [AGE] year-old female who initially admitted to the facility on [DATE] with a diagnosis of end stage renal disease (occurs when chronic kidney disease - the gradual loss of kidney function - reaches an advanced state). Record review of the significant change MDS assessment, dated [DATE], reflected Resident #21 had clear speech and was understood by staff. The MDS reflected Resident #21 was able to understand others. The MDS reflected Resident #21 had a BIMS score of 12, which indicated moderately impaired cognition. The MDS reflected Resident #21 had no behaviors or refusal of care. The MDS reflected Resident #21 received dialysis while a resident at the facility. Record review of the comprehensive care plan, last revised on [DATE], reflected Resident #21 received hemodialysis two times per week on Tuesday and Thursday. Record review of the Pre/Post Dialysis Communication Report forms for Resident #21, from [DATE], [DATE], and [DATE], reflected Resident #21 had a missing post dialysis assessment (completed by the facility staff) for the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Record review of the order summary report, dated [DATE], reflected Resident #21 had an order for Hemodialysis on Monday, Wednesday, and Friday effective [DATE]. Record review of the social service progress note, dated [DATE], reflected Resident #21's dialysis chair time was changed effective [DATE] to Tuesday, Thursday, and Saturday. Record review of the nursing progress note, dated [DATE], reflected Resident #21's dialysis chair time was decreased to 2 times per week on Tuesday and Saturday. During an observation and interview on [DATE], beginning at 10:22 AM, Resident #21 stated she received dialysis two times per week on Tuesday and Saturday. Resident #21 stated she recently started dialysis in the last few months. Resident #21's dialysis catheter was located on her chest, which was completely covered by a dressing dated [DATE]. Resident #21 stated the dialysis center changed the dressing. Resident #21 stated the facility staff looked at her port but did not mess with it. Resident #21 stated she took the dialysis communication forms with her to the dialysis and returned them to the facility staff when she arrived back at the facility. Resident #21 was unsure if a post-dialysis assessment was completed when she returned to the facility. During an interview on [DATE] beginning at 4:07 PM, LVN B stated when Resident #21 returned from dialysis she checked her vital signs and filled out the post dialysis communication form. LVN B stated Resident #21 recently changed her chair time and days of dialysis. LVN B stated prior to the last few weeks, Resident #21 returned from dialysis on the night shift around 7 PM. LVN B was unsure why the post-dialysis assessments were not completed. LVN B stated it was important to ensure a post-dialysis assessment was completed to monitor Resident #21's status after dialysis. LVN B said it was important to monitor Resident #21's condition because it could have changed quickly, and she could have died . LVN B stated the orders should have reflected Resident #21's current dialysis schedule. LVN B stated any nurse was responsible for ensuring the orders were updated and correct. LVN B said it was important to ensure the dialysis order was accurate so everyone was aware when Resident #21's dialysis should have been completed. LVN B said if the orders were not updated it placed Resident #21 at risk for missing dialysis treatment. During an interview on [DATE] beginning at 4:14 PM, the DON stated the nurse receiving Resident #21 back from dialysis was responsible for ensuring the post dialysis assessment was completed. The DON stated he expected the nurses to ensure the post dialysis assessments were completed and filled out on the dialysis communication form. The DON stated he currently had no process in place for monitoring to ensure post-dialysis assessments were completed. The DON stated it was important to ensure post dialysis assessments were completed and the communication forms were filled out for continuity of care and monitoring for changes in the resident's condition. The DON stated he expected the nurses to ensure the dialysis orders were updated and changed as ordered by the physician. The DON stated it was important to ensure dialysis orders were updated to prevent the residents from missing dialysis. The DON stated it placed the residents at risk for fluid overload and other issues caused from not receiving dialysis treatment. During an interview on [DATE] beginning at 4:31 PM, the Administrator stated she expected the nursing staff to ensure dialysis orders were updated and the post dialysis assessments were completed and documented on the dialysis communication form. The Administrator stated the nursing management was responsible for monitoring to ensure the orders were updated and the post dialysis assessment was completed and documented on the communication form. The Administrator stated it was important to ensure the post dialysis assessment was completed to monitor a change in the resident's condition. The Administrator stated it was important to ensure dialysis orders were updated to ensure compliance with the regulations. Record review of the Dialysis policy, revised ,d+[DATE], reflected review and confirm the physician's order for dialysis .the facility will establish baseline information from the dialysis center and will monitor changes from the baseline .the facility will assist the resident as needed with making an appointment at the dialysis center as specified by physician order .the facility will document the resident's vital signs, general appearance, orientation, and additional baseline data as needed. The resident's clinical record will be documented with this information .

Based on observation, interview, and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records are in order and that an account of all controlled drugs was maintained and periodically reconciled for 1 of 1 storage area reviewed for expired and discontinued medications and for the accuracy of administering drugs and biologicals to meet the needs of each resident for 1 of 8 residents (Resident #10) reviewed for insulin administration. 1.The facility failed to keep a record of a receipt of controlled medications awaiting disposition to allow accurate and periodic reconciliation. 2. The facility failed to ensure LVN E primed Resident #10's insulin pen of Fiasp (a rapid-acting insulin) before given. These failures could place residents at risk of not receiving the therapeutic benefit of medications, loss of prescribed medications and drug diversion. Findings included: 1.During an observation and interview on [DATE] at 1:05 p.m., the following unlogged medications were observed in the controlled medications storage area waiting to be disposed of: *Tylenol/Codeine ,d+[DATE] milligrams--- 58 tablets *Hydrocodone ,d+[DATE] milligrams---32 tablets *Temazepam 30 milligram 8 tablets *Tramadol HCL 50 milligram 30 tablets *Morphine Sulfate ER 60 milligram 28 tablets *Hydrocodone Tylenol ,d+[DATE] milligrams 30 tablets *Lyrica 75 milligram 6 capsules *Tramadol HCL 50 milligram---9 tablets *Tylenol/codeine ,d+[DATE] milligram---39 tablets *Lorazepam 0.5 milligram ---45 tablets *Morphine Sulfate Solution ,d+[DATE] milligram--- 19 milliliters *Zolpidem 10 milligrams ---12 tablets *Lorazepam 0.5 milligram --- 41 tablets *Tramadol HCL 50 milligram ---42 tablets *Tramadol HCL 50 milligram ---30 tablets *Morphine Sulfate Solution ,d+[DATE] milliliters --- 29 milliliters *Hydromorphone 2 milligrams --- 30 tablets *Tylenol/Codeine ,d+[DATE] milligram--- 32 tablets *Tramadol HCL 50 milligram--- 23 tablets *Morphine Sulfate ER 60 milligram--- 30 tablets *Morphine Sulfate Solution ,d+[DATE] milliliters --- 30 milliliters *Lorazepam 0.5 milligram--- 21 tabs *Hydrocodone ,d+[DATE] milligrams---30 tablets During an interview on [DATE] at 1:05 p.m., the DON said the process for reconciled medications that needed to be disposed of was for the nurses to let him know when a medication had been discontinued or a resident had expired. He said he would get the medication and sign off on the narcotic sheet with the nurse indicating how many medications were left, he said then he would log the medication. The DON opened his locked cabinet and revealed an unknown number of medications that were not logged on the drug destruction sheet. The DON said he had not had time to log the medication, therefore the medication log was not up to date. He said his last drug destruction was on [DATE] and no meds had been logged since then. He said he was not sure about the destruction policy, but he said he would look. He said he always tried to log the medications when he received them, but he had a lot of residents who either discharged or expired. The DON said he was responsible for logging the medication when it was brought to him. The DON said by not logging the medications there was a risk for medications to come up missing. Record review of the facility's medication destruction binder on [DATE] indicated the last medication destruction was completed on [DATE]. 2. Record review of Resident #10's face sheet, dated [DATE], indicated a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Metabolic encephalopathy (a condition where the brain does not function properly due to an imbalance in the body's metabolism), Diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), and high blood pressure. Record review of Resident #10's quarterly MDS assessment, dated [DATE], indicated Resident #10 understood and was understood by others. Resident #10's BIMS score was 11, which meant she was moderately cognitively impaired. The MDS indicated Resident #10 required help with toileting, dressing, and bathing. The MDS indicated she took insulin medication during the 7-day look-back period. Record review of Resident #10's Physician order dated [DATE] indicated: Fiasp FlexTouch Subcutaneous Solution Pen-injector 100 units per milliliter (Insulin Aspart (with Niacinamide), Inject 12 units subcutaneously three times a day related to diagnosis of Diabetes. Record review of Resident #10's comprehensive care plan, dated [DATE], indicated Resident #10 had Diabetes Mellitus. The interventions were to administer medication as ordered and monitor/document for side effects and effectiveness. During an observation and interview on [DATE] at 4:45 p.m., LVN E went to take Resident #10's blood sugar. The reading was 340. She reviewed the order and it read to give 12 units of Fiasp. LVN E turned the insulin pen to 12 units and gave the insulin to Resident #10. LVN E did not prime the insulin pen. LVN E said she had never primed her insulin pen and was not aware she needed to. During a phone interview on [DATE] at 1:32 p.m., the facility's Pharmacist said nurses should check the blood sugar and then the order. She said they should then prime the insulin pen to ensure it was working properly. She said failure to check the insulin pen before use could cause the insulin pen not to deliver the correct dose. She said the DON was responsible for overseeing the expired or discontinued medications. She said then the DON was responsible for logging it on the destruction sheet and keeping it under double lock until she came to destroy it . During an interview on [DATE] at 2:48 p.m., the DON said he expected the nurses to administer the insulin correctly. He said they should verify the order, wipe the end of the insulin pen, apply the needle, and give the medication. The DON said he was not aware that the nurses should prime the insulin pen before use. He said after reading the guidelines about how the insulin pen should be primed first, he said it was important for the residents to receive the correct amount of insulin to prevent hyper (too high blood sugar) or hypoglycemia (too low blood sugar). He said he had not done any skill checkoff since employment 5 weeks ago, but he had done periodical checks on staff. He said skill checks should be done yearly and as needed. During an interview on [DATE] at 3:10 p.m., the Administrator said she expected the expired or discontinued narcotics to be given to the DON with the narcotic count sheet. She said she expected the DON to log the narcotic medications as soon as possible and give her a copy each time. She said it was the DON's responsibility to ensure the process was being completed. She said failure to follow the process could lead to medications being taken, lost, or not destroyed properly. The Administrator said she expected staff to administer insulin correctly. She said if they did not prime or check the insulin pen it could deliver too much or not enough medication which could cause the resident sugar to rise or be lowered. She said the ADON/DON was the overseer of the insulin process. Record review of the facility policy titled, Drug Destruction Policy, from the Pharmacy Policy & Procedure Manual 2003, revised [DATE], indicated It is the policy of this facility to destroy dangerous and controlled medications according to the State of Texas law. 2. Drugs to be destroyed will be destroyed under the supervision of a consultant pharmacist and at least one of the following: Director of Nursing, Assistant Director of Nursing, or Administrator. 3. Nursing staff will submit to the Director of Nursing any medication and any applicable log that has expired, been discontinued by the physician or that had been prescribed to a resident who no longer resides at the facility. 4. The nurse submitting the discontinued medication, will verify along with the Director of Nursing that the amount of medication remaining matches the log. After verification, both the nurse and the Director of Nursing will sign the log. 5. The nurse will make a copy of the signed log and provide it to the administrator. The Director of Nursing will maintain the original log and medication. 6. The Director of Nursing will log medications submitted for destruction. All medications submitted to the Director of Nursing will be kept under double-lock system Record review of the facility policy titled, Insulin pen Use from the Pharmacy Policy & Procedure Manual 2003 revised [DATE], indicated, Always attach a new needle before each use. Always perform the safety test before each injection. Do not select a dose or press the injection button without a needle attached. This pen is only for one resident's use. Never use an insulin pen if it is damaged or if you are not sure that it is working properly. Never withdraw insulin from the insulin pen with a needle and syringe this will affect the structural integrity of the insulin pen and could possibly introduce contaminates. Step 1 Check the insulin, Step 2. Attach the needle. Step 3. Perform a Safety test: Always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by: ensuring that pen and needle work properly and removing air bubbles. A. Select a dose of 2 units by turning the dosage selector. B. Hold the pen with the needle pointing upwards. C. Tap the insulin reservoir so that any air bubbles rise towards the needle. D. Press the injection button all the way in. Check if insulin comes out of the needle tip. You may have to perform the safety test several times before insulin is seen. If no insulin comes out, check for air bubbles, and repeat the safety test two more times to remove them. If still no insulin comes out, the needle may be blocked. Change the needle and try again

Based on observations, interviews, and record review the facility failed to ensure all drugs were only accessible by authorized personnel, for 1 of 6 residents (Resident #54), 3 of 6 medication carts (Halls 500, 100, and 200), and 1 of 1 treatment cart reviewed for storage of medications. 1. The facility did not ensure medication was not left unattended on Resident #54's bedside table. 2. The facility failed to ensure LVN E kept the 500-hall medication cart secured and was unable to be accessed by unauthorized personnel. on 01/14/25. 3. The facility failed to ensure LVN A kept the Hall 1 and 2 nurse medication carts locked or within her line of sight when not in use on 01/13/25. 4. The facility failed to ensure the Treatment Nurse locked the treatment cart when she left it unattended in the hallway on 01/15/25. These failures could place residents at risk of not receiving the therapeutic benefit of medications, harm or misuse of medication, drug diversions, and adverse reactions to medications due to improper storage. Findings included: 1.Record review of Resident #54's face sheet, dated 01/15/25, indicated a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory, language, problem-solving, and other thinking abilities that were severe enough to interfere with daily life), bipolar disorder (a chronic mental health condition characterized by extreme mood swings between periods of mania (elevated mood) and depression (low mood), schizophrenia (a chronic mental illness characterized by disruptions in thought processes, perceptions, emotions, and social interactions), and high blood pressure. Record review of Resident #54's quarterly MDS assessment, dated 10/29/24, indicated Resident #54 understood and was understood by others. Resident #54's BIMS score was 08, which meant she was moderately cognitively impaired. The MDS indicated Resident #54 required help with toileting, bed mobility, dressing, transfers, personal hygiene, and eating. The MDS indicated she took antidepressant medication during the 7-day look-back period. Record review of Resident #54's Medication Administration Record for the 6 pm-6 am shift dated 01/01/25 thru 01/31/25 indicated: Mirtazapine Oral Tablet 15 MG (Mirtazapine), Give 1 tablet by mouth one time a day related to unspecified protein-calorie malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets). Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen), Give 1 tablet by mouth two times a day for pain related to orthopedic surgery. Trazodone HCl Oral Tablet 50 MG (Trazodone HCl), Give 0.5 tablet by mouth at bedtime for insomnia (a sleep disorder that makes it hard to fall or stay asleep). Record review of Resident #54's comprehensive care plan, dated 07/02/24, indicated Resident #54 had impaired cognitive function or impaired thought processes related to a dementia diagnosis. The interventions were to administer medications as ordered. During an observation and interview on 01/14/25 at 9:46 a.m., Resident #54 was in her bed and 3 unidentified pills were noted sitting in a cup on her bedside table. Resident #54 said LVN G had given her those medications last night, but she refused to take them. LVN F came into the room and verified Resident #54 had 3 unidentified pills sitting on her bedside table. LVN F reviewed Resident #54's medication and identified 1 pill as Mirtazapine because of its oval shape and a V symbol printed on the pill. LVN E was unable to identify the other 2 pills. LVN F said it was important to stay with the resident until they took their medication to prevent another (confused) resident from wandering and taking the wrong medication. During an attempted phone interview on 01/14/25 at 10:53 a.m., called LVN G with no answer, a message was left. During an interview on 1/15/25 at 2:48 p.m., the DON said he expected staff not to leave medication at the bedside unattended. The DON said the nurse who gave the medication was responsible for ensuring the resident took his or her medication before leaving the room. He said he would do an in-service. He said during the investigation process he had identified LVN H and not LVN G as the nurse who left the medication at the bedside. He said he had not done checkoffs on medication administration with the nurses since he had started working for the facility 5 weeks ago. He said if medications were left at the bedside, then the intended resident would not receive their medication which could cause physical or psychological effects depending on the medication(s) ordered. During an attempted phone interview on 01/15/25 at 3:04 p.m., called LVN H, and a message was left. During an interview on 01/15/25 at 3:10 p.m., the Administrator said she did not expect medication to be left at the bedside because part of medication administration was to ensure the resident took or refused his or her medication. She said if medication was left at the bedside, then other residents were at risk of getting medication that was not ordered for them or even staff. She said they verified staff was competent through medication passes on hire, annual, and visual checks. 2. During an observation and interview on 01/14/25 at 9:52 a.m., LVN E was standing at the 500-hall medication cart and walked away. This state surveyor observed a resident, CNA I, and a maintenance person walk by the unlocked cart. LVN E then went to another cart on the hallway and retrieved medication to give to Resident #46. LVN E walked into Resident #46's room to administer his medication while leaving the 500-hall medication unlocked and out of her sight. LVN E said she should have locked her cart when not using the cart for the safety of others. 47006 3. During an observation on 01/13/25 beginning at 9:52 AM, Hall 1 and 2 nurses medication cart was sitting in front of the nurses' station and was not locked. There were 2 nurses sitting behind the nurses' station and unable to visualize the front of the cart from the sitting area. Multiple staff members, residents, and visitors passed by the unlocked cart. During an interview on 01/13/25 beginning at 9:58 AM, LVN A stated she was unaware her medication cart was unlocked. LVN A immediately locked the medication cart. LVN A stated she had just given her keys to the corporate lady because she was looking at the expiration dates. LVN A stated she threw the keys back at her when she was done looking through it but must have forgotten to lock it. LVN A stated she did not check to ensure the medication cart was locked. LVN A stated she did not normally leave her cart unlocked. During an observation on 01/13/25 at 11:11 AM, Hall 1 and 2 nurses medication cart was sitting in front of the nurses' station and was not locked. LVN A had exited the bathroom and stated the DON was going to get onto her. LVN A stated she had just given him some discontinued narcotic medication off the cart and forgot to lock it. LVN A immediately locked the medication cart. 46928 4. During an observation and interview on 01/15/25 at 10:48 AM, the Treatment Nurse left the treatment cart unlocked and unattended on hall 2, when she left to find a staff member to assist her in providing a wound care treatment for a resident. The Treatment Nurse said she started on Monday 01/13/25 and she did not have a key to the treatment cart until that morning. She said she was responsible for ensuring the cart was locked when left unattended. She said by leaving the cart unlocked someone could get in, steal a medication, or consume something dangerous, or something they were allergic to. During an interview on 01/15/25 beginning at 1:16 PM, the Pharmacy Consultant stated she had observed unlocked medication and treatment carts at the facility during her visits. The Pharmacy Consultant stated she expected the nursing staff to ensure their medication or treatment carts were locked when they were not being used. The Pharmacy Consultant stated it was important to ensure medication and treatment carts were locked to prevent unauthorized persons from taking medications. The Pharmacy Consultant stated a resident could have taken medications from the cart if it was unlocked. During an interview on 01/15/25 beginning at 4:14 PM, the DON stated he expected medication or treatment carts to remained locked when the nursing staff were not actively using the cart or when they walked away from the cart. The DON stated everyone was responsible for monitoring to ensure medications or treatment carts were locked. The DON stated it was important to ensure medication and treatment carts remained locked to prevent a drug diversion or residents from taking medications that could have caused harm. During an interview on 01/15/25 beginning at 4:31 PM, the Administrator stated she expected nursing staff to ensure the medication or treatments carts remained locked if they were not standing at the cart working. The Administrator stated nursing management was responsible for monitoring to ensure medication and treatment carts were locked. The Administrator stated she was responsible for overseeing the nursing management team. The Administrator stated it was important to ensure medication or treatment carts to remained locked for resident safety. During an interview on 01/15/25 beginning at 5:14 PM, LVN A stated she was unsure what the corporate lady's name was. LVN A stated she was busy and nervous on 01/13/25 when the medication carts were left unlocked. LVN A stated it was important to ensure the medication carts remained locked when not in use to prevent missing medications or resident injury. During an interview on 01/15/25 beginning at 5:17 PM, the Corporate Nurse stated she did not believe she was the one who left the medication cart unlocked on 01/13/25. The Corporate Nurse stated she was looking in the Hall 1/2 medication nurse cart with the DON and it could have been either one of them. The Corporate Nurse stated she expected the medication carts to be locked at all times. The Corporate Nurse said it was important to ensure medication carts were kept locked to prevent hazards. Record review of the Storage of Medication policy, year dated 2003, reflected Medication rooms, carts, and medication supplies are locked and attended by persons with authorized access .

Based on interviews and record review, the facility failed to act upon the recommendations of the pharmacist report of irregularities for 3 of 5 residents (Resident's #17, #52, and #56) reviewed for (DRR) Drug Regimen Review. 1. The facility failed to provide documentation of the pharmacy recommendation or rationale for an attempted gradual dose reduction for Resident #17's risperidone (antipsychotic medication), Resident #52's buspirone (antianxiety medication), and Resident #56's paroxetine (antidepressant medication). 2. The facility failed to ensure the Pharmacist Consultant addressed Resident #56's buspirone (antianxiety medication) for a gradual dose reduction. This failure could place residents at risk for receiving unnecessary medications at the most effective dosage. The findings included: 1. Record review of the face sheet, dated 01/15/25, reflected Resident #17 was a [AGE] year-old female who initially admitted to the facility on [DATE] with a diagnosis of bipolar disorder (mental health condition characterized by significant mood swings). Record review of the quarterly MDS assessment, dated 01/07/25, reflected Resident #17 had clear speech and was understood by others. The MDS reflected Resident #17 was ablet to understand others. The MDS reflected Resident #17 had a BIMS score of 12, which indicated moderately impaired cognition. The MDS reflected Resident #17 had no behaviors or refusal of care. The MDS reflected Resident #17 had an active psychiatric/mood disorder. The MDS reflected Resident #17 was taking an antipsychotic medication during the 7-day look-back period. Record review of the order summary report, dated 01/15/25, reflected Resident #17 had an order for risperidone 1 mg (antipsychotic medication) give 1 tablet by mouth twice a day related to bipolar disorder effective 12/09/23. Record review of the MAR, dated January 2025, reflected Resident #17 received risperidone (antipsychotic medication) twice a day. Record review of the comprehensive care plan, reviewed 12/31/2024, reflected Resident #17 required antipsychotic medication. The interventions included: consult with pharmacy .consider dosage reduction when clinically appropriate. Record review of the psychotropic medication utilization report dated 11/06/24, reflected Resident #17 had an order for antipsychotic medication, risperidone, with an ordered date of 12/09/23 and a GDR date of 11/05/24. The report indicated the next GDR request was on 11/30/25. The pharmacy GDR recommendation for Resident #17's antipsychotic could not be located in the pharmacy recommendations nor Resident #17's electronic medical records. 2. Record review of the face sheet, dated 01/15/25, reflected Resident #52 was an [AGE] year-old female who initially admitted to the facility on [DATE] with a diagnosis of unspecified dementia with no behaviors (loss of cognitive functioning that interferes with daily life and activities). Record review of the significant change MDS assessment, dated 11/30/24, reflected Resident #52 had clear speech and was understood by others. The MDS reflected Resident #52 was able to understand others. The MDS reflected Resident #52 had a BIMS score of 10, which indicated moderately impaired cognition. The MDS reflected Resident #52 had no behaviors or refusal of care. The MDS reflected Resident #52 received an antianxiety medication during the 7-day look-back period. Record review of the order summary report, dated 01/15/25, reflected Resident #52 had an order for buspirone (antianxiety medication) 5 mg - give one tablet by mouth two times a day for anxiety. Record review of the MAR, dated January 2025, reflected Resident #52 received an antianxiety medication twice a day. Record review of the comprehensive care plan, reviewed on 12/11/24, reflected Resident #52 used antianxiety medications for adjustment issues and anxiety disorder. The interventions included: give medications as ordered by the physician and monitor and document side effects and effectiveness. Record review of the psychotropic medication utilization report dated 11/06/24, indicated Resident #52 had an order for an antianxiety medication, buspirone with an ordered date of 05/29/23 and a GDR date of 11/05/24. The report indicated the next GDR request was on 11/30/25. The pharmacy GDR recommendation for Resident #52's buspirone could not be located in the pharmacy recommendations nor Resident #52's electronic medical records. 46928 3. Record review of Resident #56's face sheet dated 01/15/25, indicated a [AGE] year-old female who initially admitted to the facility on [DATE]. Resident #56's diagnoses included dementia (memory loss), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and depression (persistent feeling of sadness and loss interest that interferes with day-to-day activities). Record review of Resident #56's quarterly MDS assessment dated [DATE], indicated Resident #56 was able to make herself understood and understood others. The MDS assessment indicated Resident #56 had a BIMS score of 11, indicating her cognition was moderately impaired. The MDS indicated Resident #56 had active diagnoses of anxiety and depression. The MDS indicated Resident #56 had received antianxiety and antidepressant medications within the last 7 days of the 7-day of the look back period. Record review of Resident #56's order summary report dated 01/15/24, indicated Resident #56 had orders the following orders: 1. Buspirone 10mg give 2 tablets by mouth 3 times a day for anxiety disorder with a start date of 11/15/23. 2. Paroxetine 10mg give one tablet by mouth one time a day for other specified depressive disorders with a start date of 11/16/23. Record review of Resident #56's medication administration record dated 01/01/25-01/31/25, indicated Resident #56 had received paroxetine 10mg one time a day for other specified depressive disorders and buspirone 10mg 2 tablets by mouth three times a day for anxiety disorder. Record review of Resident #56's comprehensive care plan dated 07/30/24, indicated Resident #56 had a mood problem with interventions to administer medications as ordered. Record review of the psychotropic medication utilization report dated 11/06/24, indicated Resident #56 had an order for antidepressant medication, paroxetine, 10mg give one tablet by mouth one time a day for other specified depressive disorders with an ordered date of 11/16/23 and a GDR date of 11/05/24. The report indicated the next GDR request was on 05/30/25. The pharmacy GDR recommendation for Resident #56's paroxetine could not be located in the pharmacy recommendations nor Resident #56's electronic medical records. During an interview on 01/15/25 beginning at 12:45 PM, the Administrator stated the facility staff were unable to locate the pharmacy recommendations for November 2024. The Administrator stated she was unsure if any changes or gradual dose reductions for psychotropic medications were implemented or if a rational was documented by the physician. During an interview on 01/15/25 beginning at 1:16 PM, the Pharmacy Consultant stated the timeframe for implementing a gradual dose reduction or pharmacy recommendation was 24 to 48 hours. The Pharmacy Consultant stated the facility has had some turnover recently with the DONs and she believed the ADON had been working night shift a lot. The Pharmacy Consultant stated she has had to teach the process for pharmacy recommendations with each new DON and believed the lack of consistent staff had made it hard to implement and monitor the pharmacy recommendations. The Pharmacy Consultant stated she expected the facility staff to ensure the physician was reviewing the recommendations and documenting a rational for non-attempts of gradual dose reduction. The Pharmacy Consultant stated it was important to ensure pharmacy recommendations were followed up on and gradual dose reductions were documented to make sure the residents were monitored. The Pharmacy Consultant stated it was important to ensure the residents were taking the least amount of medication at the most therapeutic dosage for them. The Pharmacy Consultant stated she was unaware Resident #56 was taking buspirone. The Pharmacy Consultant stated buspirone was an antianxiety medication. The Pharmacy Consultant stated a gradual dose reduction should had been attempted twice in the first year it was prescribed and then annually thereafter. The Pharmacy Consultant stated it was important to ensure psychotropic drug monitoring was implemented to ensure the resident needed the medication and to monitor for side effects related to drug use. During an interview on 01/15/25 beginning at 2:01 PM, the Medical Director stated he spent most of his time at the facility completing and signing the pharmacy recommendations. The Medical Director stated the facility staff tracked him down to ensure the recommendations were signed and completed. The Medical Director stated if he disagreed with the recommendations for a gradual dose reduction, he always documented a rational. The Medical Director stated he expected the facility staff to ensure pharmacy recommendations were included as part of the medical record. The Medical Director stated it was important to ensure documentation of the pharmacy recommendations were kept as proof the residents' medications were being monitored. During an interview on 01/15/24 beginning at 3:27 PM, the DON said GDR reductions should be completed by the physician. The DON said the residents' medications should be reviewed for possible dosage reduction. The DON said the process when pharmacy recommendations were received was as follows: the DON received the recommendations from the Pharmacy Consultant, he then made a copy of the recommendations and sent one to the physician and kept one for himself, as signed recommendations came in, he would then check them off. The DON said the physician had to review them within 30 days or before the next recommendations were received. The DON said by not completing a gradual dose reduction a resident could be receiving a medication that could be therapeutic at a lesser dose, be more alert and more active. The DON said he was responsible for ensuring the pharmacy recommendations were being implemented. During an interview on 01/15/24 at 04:02 PM, the Administrator said she expected the residents' medications to be reviewed monthly by the Pharmacy Consultant. The Administrator said the pharmacy recommendations for gradual dose reductions should be discussed with the physician and the physician should provide a rationale for his decisions. The Administrator said the Pharmacist should have been aware Resident #56 had been receiving buspirone. The Administrator said failure to address medications for gradual dose reductions could place residents at risk for not having a medication regiment that was optimal to receive the best outcomes. The Administrator said the pharmacy recommendations were received by the ADON and the DON should have ensured the accuracy. The Administrator said they currently did not have an ADON. During an interview on 01/15/25 beginning at 4:31 PM, the Administrator stated the Pharmacy Consultant should have reviewed the resident's medications every month and sent a list of pharmacy recommendations to the nurse management. The Administrator stated the nursing management was responsible for ensuring the Medical Director reviewed, signed, and documented a rational on the recommendations. The Administrator stated the nursing management was responsible for ensuring pharmacy recommendations were carried out. The Administrator stated after all the steps were completed the recommendations should have been uploaded into the medical record. The Administrator stated it was important to ensure gradual dose reductions were attempted on psychotropic medications or a rational was documented to ensure residents were receiving the optimal dosage of medication for good outcomes. Record review of the facility's policy, Psychotropic Drugs, revised 10/25/17, indicated . The intent of this policy is that each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing, the facility implements gradual dose reductions (GDR) . A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic . The facility will ensure that .2. Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; (Refer to Medication Review policy and behavior management policy) . The purpose of tapering a medication is to find an optimal dose or to determine whether continued use of the medication is benefiting the resident . During the monthly medication regimen review, the pharmacist evaluates resident-related information for dose, duration, continued need, and the emergence of adverse consequences for all medications .Within the first year in which a resident is admitted on a psychotropic medication or after the prescribing practitioner has initiated a psychotropic medication, the facility must attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, a GDR must be attempted annually, unless clinically contraindicated .

Based on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 1 of 3 meals reviewed. The dietary staff failed to provide food that was palatable for 1 of 3 meals observed on 1/14/25 (lunch) meal. These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: Record review of the menu indicated the lunch meal items on 1/14/25 included beef steak, mash potatoes, spinach, dinner roll, and cheesecake. Record review of the Dietary staff in-services indicated Recipe in-service was last completed on July 2, 2024. During an interview on 01/13/2025 beginning at 10:09 AM, Resident #43 stated the food was too salty. During an interview on 1/13/25 at 11:18a.m., Resident # 38 stated the food was not good. During an interview on 1/13/25 at 11:23 a.m., Resident # 50 stated the food was cold. During an interview on 1/14/25 at 08:56 a.m., Resident #268 stated the food was not warm when he got it. During an interview on 1/14/25 at 2:34 p.m., Resident #50 stated her spinach was too salty but everything else was good for the lunch meal served on 1/14/25. During observation and tasting of lunch meal on 1/14/25 at 12:26 p.m., the Dietary Manager stated the beef steak was cooked good and the beef steak did not taste salty to her; the spinach was good and not salty; mash potatoes were warm and good; cheesecake was good; and the dinner roll was buttery. During observation and tasting of lunch meal on 1/14/25 at 12:26 p.m., four State Surveyors stated beef steak was too salty; the mash potatoes were good and warm; the spinach was warm but salty; cheesecake was good; and the dinner roll was good and buttery. During an interview on 1/15/25 at 11:07 a.m., the Dietary Manager stated she had been the Dietary Manager for 5 years. The Dietary Manager stated the Administrator oversaw her at the facility. The Dietary Manager stated she tasted the food all the time prior to serving. The Dietary Manager stated staff had been in-serviced on following the recipe book in the past. The Dietary Manager stated she handled all food complaints. The Dietary Manager stated if a resident stated they did not like the meal serving that she would always offer a substitute meal. The Dietary Manager stated she always had a regular and alternate meal at every lunch and dinner. The Dietary Manager stated the cook was upset that the meat and spinach were too salty. The Dietary Manager stated it was important to ensure the food was palatable, attractive, and appetizing to the resident so the residents will eat the foods and not lose weight. During an interview on 1/15/25 at 1:44 p.m., the Administrator stated she had been employed since July 2024. The Administrator stated she oversaw the Dietary Manager. The Administrator stated she had ordered test trays from the kitchen at least quarterly. The Administrator stated she based her test tray assessment from the residents. The Administrator stated the residents in the past had complained of the food at the facility. The Administrator stated the Dietary manager handled all complaints at the facility. The Administrator stated in-services on following the recipe book, she believed had been completed within the last 6 months. The Administrator stated, It was important to ensure the food was palatable, attractive, and appetizing because so many things surround nutrition and when food was palatable, attractive, and appetizing then the residents were more likely to eat the food and avoid negative outcomes. The Administrator stated the facility did not have policy on palatability. The Administrator stated, Regarding palatability, we follow the recipe. 47006

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in (1 of 1) kitchen reviewed for dietary services. 1) The facility failed to dispose of expired food items. 2) The facility failed to clean the bread [NAME] storage container, microwave, can opener, and utensil drawer. These failures could place residents at risk for food contamination and foodborne illness. The findings included: During an observation in the kitchen of Refrigerator 1 of 2 on [DATE] at 9:56 a.m., the following were observed: -(1) container of carrots had a prep date of [DATE] and use by date of [DATE]. (expired) During observation in the kitchen dry storage area on [DATE] at 10:15 a.m., the following were observed: -(1) container of bread crumps was empty; container had not been cleaned. During an observation in the kitchen on [DATE] at 10:20 a.m., the following were observed: - Dirty can opener with food debris on the can opener knife. - Utensil drawer had food debris inside the drawer. -The microwave had food debris on the plate and in the inside of the microwave. During an interview and observation of the kitchen and dry storage area on [DATE] at 10:15 a.m., the Dietary Manager stated the food items did not have to include a use by or expiration date. The Dietary Manager stated the can opener was dirty and needed to be cleaned. The Dietary Manager stated the utensil drawer needed to be cleaned. The Dietary Manger stated staff had just wasted crumbs in the utensil drawer and the utensil drawer would be cleaned today ([DATE]). The Dietary Manager stated the microwave needed to be cleaned and was last used today on [DATE]. The Dietary Manager stated the Dietary staff should have cleaned the can opener and microwave after each use. During a follow up visit of the kitchen on [DATE] at 11:34 a.m., the utensil drawer had not been cleaned. During observation and interview on [DATE] at 11:34 a.m., the Dietary Manager stated the cook had forgot to clean the utensil drawer yesterday (on [DATE]). The Dietary Manager was observed cleaning the utensil drawer. During an interview on [DATE] at 11:11 a.m., The Dietary Manager stated the Administrator oversaw her. The Dietary Manager stated she had been employed at the facility for 5 years. The Dietary Manager stated that the dietary staff did label and date the food. The Dietary Manager stated the dietary staff never put open date on the food. The Dietary Manager stated she oversaw the dietary staff. The Dietary Manager stated she was responsible for ensuring expired foods were exposed of and the kitchen was cleaned daily. The Dietary Manager stated staff sometimes was in a hurry and did stupid stuff. The Dietary Manager stated she was not aware of when in-services were last completed on discarding expired food items, labeling, and dating. The Dietary Manager stated she conducted walk throughs in the kitchen every morning. The Dietary Manager stated she saw the expired carrots in the refrigerator prior to survey but saw a one for the month and not a 12 as listed on the carrots. The Dietary Manager stated left over food was good for 7 days. The Dietary Manger stated that the mistake of leaving the expired carrots in the refrigerator was on her and not the dietary staff. The Dietary Manager stated it was important to ensure the food items were labeled, dated, and expired foods were discarded to make sure the dietary staff were not serving bad foods. During an interview on [DATE] at 1:51 p.m., the Administrator stated she had been employed since July of 2024. The Administrator stated she oversaw the Dietary Manager. The Administrator stated all food items were to be discarded at expiration date. The Administrator stated she conducted walk throughs in the kitchen at least 4 times a week. The Administrator stated she was not made aware of the finding found in the kitchen prior to survey. The Administrator stated she expected the Dietary staff to follow the dietary policy. The Administrator stated she expected the Dietary Manager to report all findings found in the kitchen. The Administrator stated, It was important that staff were cleaning the kitchen a discarding expired foods to prevent negative resident outcome. During record review of the Dietary Services Policy & Procedure Manual dated 2012 revealed, (6) When items are received from the vendor, they should be first examined for expiration date, and if an expiration date is present, it is beneficial to mark it by circling it so it is readily visible and noticeable. It is important to distinguish between an expiration date and a production date, or a best by or use by date. Production dates indicate when the product was manufactured, not when it expires and should not be interpreted as a best by or use by date. Best by or use by dates indicate when a product will have best flavor or quality and are not an indicator of the product's safety. As the quality may deteriorate after the date passes, the dietary manager should closely inspect any products that are past the best by date to determine if they are still good quality. If in doubt, discard the product. If any stamped date is unclear, contact the food vendor for clarification. If an item does not have a date designated by the manufacturer as an expiration date, then the item should be dated as to when it is received, and shelf-stable items will be stored in a first in, first out manner, to be used within one year. After one year, any product that is shelf stable will be inspected by the dietary manager to ensure that it is good quality before it is used. Any product with a stamped expiration date will be discarded once that date passes.

Based on interviews and record reviews the facility failed to coordinate assessments with pre-admission screening and resident review (PASRR) program under Medicaid to the maximum extent practicable to avoid duplicative testing and effort which included referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 of 5 residents (Resident #61) reviewed for PASRR Level I screenings. The facility failed to ensure the correct PASRR (a preliminary assessment completed for all individuals before admission to a Medicaid-certified nursing facility to determine whether they might have a mental illness or intellectual disability) Level 1 Screening was submitted to the local authority for Resident #61 who had a diagnosis of mental illness upon admission. This failure could place residents at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings include: Record review of Resident #61's face sheet dated 01/15/25, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (lung diseases that block airflow and make it difficult to breathe), bipolar disorder (mental illness that causes extreme shifts in mood, energy, and activity levels), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and depression (persistent feeling of sadness and loss of interest that can interfere with daily activities). Record review of Resident #61's admission MDS assessment dated [DATE], indicated Resident #61 was able to make herself understood and understood others. Resident #61 had a BIMS score of 10, indicating her cognition was moderately impaired. The MDS indicated Resident #61 had an active diagnosis of bipolar disorder and had received antipsychotic medication within the last 7 days of the 7-day look back period. Record review of Resident #61's comprehensive care plan dated 12/29/24, indicated Resident #61 required anti-psychotic medications. The care plan interventions included to administer medications as ordered, monitor/record occurrence of target behavior symptoms, and to monitor/record/report to medical director as needed side effects and adverse reactions of psychoactive medications. Record review of Resident #61's PASRR Level 1 Screening form dated 11/20/24, indicated Resident #61 had no evidence or indicator of a mental illness. Record review of Resident #61's order summary report dated 01/15/25, indicated she had an order for quetiapine (antipsychotic medication) 100mg give one tablet by mouth one time a day for anxiety related to bipolar disorder with an order date of 11/27/24. Record review of Resident #61's medication administration record dated 01/01/25- 01/31/25, indicated she had received quetiapine 100mg one tablet by mouth daily for anxiety related to bipolar disorder. During an interview on 01/15/25 at 10:22 AM, MDS Coordinator D said when a resident admitted to the facility and their PASRR did not indicate they had a mental illness, they would not know if a corrected PASRR Level 1 needed to be completed. MDS Coordinator D said since Resident #61 had a diagnosis of mental disorder then a Form 1012 or a new PASRR level 1 screening form should have been completed. MDS Coordinator D said since she missed Resident #61 diagnosis of bipolar disorder, Resident #61 did not have a positive PASRR level 1 screening. This placed Resident #61 at risk for not receiving PASRR services through the local authority. MDS Coordinator D said she was responsible for ensuring the PASRR Level 1 Screening forms were completed correctly . During an interview on 01/15/25 at 3:27 PM, the DON said he was not familiar with the PASRR process. The DON said the MDS Coordinator was responsible for completing the PASRR Level 1 Screening forms accurately. The DON said by not completing the PASRR Level 1 screening correctly and the resident was positive for a mental illness they could fail to address the resident's mental health. During an interview on 01/15/25 at 4:02 PM, the Administrator said she expected the policy for PASRR to be followed as well as the regulation. The Administrator said if a resident had a history of mental health, then the PASRR Level 1 screening should be addressed and followed up on. The Administrator said the MDS Coordinator was responsible for ensuring the PASRR Level 1 Screenings were completed accurately so the residents received the services they need to maintain their highest level of functioning. Record review of the facility's policy and procedure, PASRR Level 1 Screen Policy and Procedure, indicated . it is the policy of [same corporate owned healthcare facilities] to obtain a PL1 screening form from the referring entity prior to the Nursing Facility . The PASRR Program is important because it provides options for individuals to choose where they live, who they live with and the training and therapy they need to live as independently as possible . 3. The facility will review the PL1 Screening Form for completion and correctness prior to admission and submit the PL1 form per regulations . review each item on the PL1 to ensure accuracy and prevent a regulatory problem .

Based on interview, and record review the facility failed to immediately consult with the resident physician when there was significant change in the resident physical condition for 1 of 4 residents reviewed for change in condition. (Resident #1) The facility failed to notify the physician when Resident #1 experienced 35 elevated blood pressure readings in the month of [DATE] . The facility failed to notify the physician when Resident #1 had an unwitnessed fall on [DATE] at approximately 080:00, her BP reading was ,d+[DATE]. Resident #1 had a change in condition and was sent out to the hospital at approximately 10:45 a.m., her BP reading at that time was ,d+[DATE], she died at the hospital the following day. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 6:00 p.m. While the IJ was removed on [DATE] at 4:15 p.m., the facility remained out of compliance at actual harm with a scope of pattern due to the facilities need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk of not having their physician consulted on changes in condition requiring medical intervention, caused harm, and could result in the death. of another resident. Findings included: Record review of Resident #1's face sheet dated [DATE] indicated she was a [AGE] year-old female who admitted on [DATE] with the diagnoses of high blood pressure, liver disease, and Lupus (a chronic disease, an autoimmune disease with systemic manifestations including skin rash, erosion of joints or even kidney disease. Record review of a Quarterly MDS dated [DATE] indicated Resident #1 was understood and understood others. The MDS indicated Resident #1's BIMS score was 12 indicating moderate cognitive impairment. The MDS indicated in Section Rejection of Care Resident #1 had not demonstrated any behaviors. The MDS indicated Resident #1 required supervision of one staff with transfers, and dressing, she required limited assistance of one staff with locomotion. Resident #1 required extensive assistance of one staff with personal hygiene. In Section I Active Diagnosis hypertension was marked (high blood pressure). Record review of Resident #1's comprehensive care plan dated [DATE] indicated Resident #1 did not have a care plan for high blood pressure (hypertension). Record review of the consolidated physician orders dated [DATE], indicated Resident #1 was ordered amlodipine 10 milligrams one tablet by mouth two times daily for high blood pressure with the parameters to hold if the systolic blood pressure was less than 100 or the diastolic blood pressure was less than 60 on [DATE]. Resident #1 had a physician order dated [DATE] for Clonidine 0.1 milligram one tablet by mouth every 24 hours as needed for elevated blood pressure with a parameter of administer for a systolic blood pressure greater than 160 or a diastolic blood pressure greater than 90. Record review of the MAR dated [DATE] revealed Resident #1's blood pressures were for the administration of the amlodipine: [DATE] and [DATE] Resident #1 out of the facility *[DATE] AM ,d+[DATE] and PM ,d+[DATE] *[DATE] AM ,d+[DATE] and PM ,d+[DATE] *[DATE] PM ,d+[DATE] *[DATE] AM ,d+[DATE] and PM ,d+[DATE] *[DATE] PM ,d+[DATE] *[DATE] PM ,d+[DATE] *[DATE] AM ,d+[DATE] *[DATE] AM ,d+[DATE] and PM ,d+[DATE] *[DATE] AM ,d+[DATE] and PM ,d+[DATE] *[DATE] PM ,d+[DATE] *[DATE] AM ,d+[DATE] [DATE] - [DATE] Resident #1 out of the facility *[DATE] AM ,d+[DATE] and PM ,d+[DATE] *[DATE] AM ,d+[DATE] and ,d+[DATE] *[DATE] AM ,d+[DATE] and ,d+[DATE] *[DATE] AM ,d+[DATE] and PM ,d+[DATE] *[DATE] PM ,d+[DATE] *[DATE] AM ,d+[DATE] and PM ,d+[DATE] *[DATE] AM ,d+[DATE] and PM ,d+[DATE] *[DATE] AM ,d+[DATE] and PM ,d+[DATE] *[DATE] - [DATE] Resident #1 out of facility *[DATE] AM ,d+[DATE] *[DATE] AM ,d+[DATE] *[DATE] AM ,d+[DATE] and PM ,d+[DATE] *[DATE] AM ,d+[DATE] Record review of the MAR for Clonidine 0.1 milligram indicated Resident #1 had no administrations for the entire month of [DATE]. Record review of an Event Nurses Note dated [DATE] at 8:00 a.m., indicated CNA B notified the nurse that Resident #1 was in the floor. RN A documented when she arrived at the room, Resident #1 was in the floor at the foot of her bed in a large puddle of urine. RN A documented Resident #1 was assisted up to the bathroom. RN A documented Resident #1 was alert and oriented with no neurological deficits. The Event Note indicated Resident #1 fell in her room, the fall was unwitnessed, and there were no injuries, and no pain. The section for orthostatic blood pressures was left blank. The most recent blood pressure was documented sitting to her left arm with the results of ,d+[DATE] and the heart rate was 92 and her respirations were 26. The event note indicated the initial treatment was monitoring only, and the area for any new physician's orders was left blank. In the area of Notification of the physician this area was blank on the name of the physician, the time, the responsible party notification and time of notification was all left blank. The intervention prior to the fall was documented by RN A as a low bed, with additional interventions documented with a scheduled toileting program. The Event nurses note indicated there were no physical factors. The Event nurses note indicated in the other information section the responsible party was called several times and the phone number was disconnected. The note indicated RN A called the hospice provider of the fall. Record review of a Fall report dated [DATE] 10:04 a.m., RN A documented Resident #1 attempted to get to the bathroom without assistance and urinated on the floor then slipped in the urine and landed on her buttocks. Resident #1 reported she was trying to go to the bathroom and slipped and fell on to her buttocks. Resident #1 reported no injuries and no pain at this time. Resident #1 reported she did not hit her head. The report indicated Resident #1 was at her baseline status. The report indicated the immediate action taken was Resident #1 was assisted off the floor, taken to the bathroom, incontinent care provided, vital signs obtained and assisted back to her bed. The report indicated Resident #1's skin was assessed for injury and was found to have none. The report indicated Resident #1 ambulated back to bed freely. The report indicated Resident #1 was oriented to time, place, situation and person. The report indicated she was alert. The report indicated there were no environmental factors, and her gait imbalance was the predisposing physiological factor. The report indicated her blood pressure was assessed at 8:45 a.m. and was ,d+[DATE] with a heart rate of 88. The report indicated the predisposing factors was Resident #1 ambulated without assistance and urine on the floor may have caused her to slip. The report indicated there were no witnesses to this fall. The fall report indicated the hospice provider was notified at 10:30 a.m. and the family member was notified at [DATE] at 10:19 a.m. The report failed to indicate the resident's primary physician, designee, or the medical director was notified. Record review of the Neurological assessment dated [DATE] indicated the neurological assessment was initiated by RN A at 8:00 a.m. with the blood pressure being ,d+[DATE] with the heart rate of 92. The Neurological Assessment failed to provide any vital signs for the 8:15 a.m., and the 8:30 a.m. time frames. The next set of vital signs appearing on the Neurological Assessment was at 8:45 a.m., the blood pressure was ,d+[DATE] and the heart rate was 90. The next set of vital signs appearing on the Neurological Assessment was blocked off during the time of 9:45 a.m. - 11:45 a.m. indicating there was one set of vital signs of ,d+[DATE] and a heart rate of 90. The assessment indicated Resident #1 eyes opened spontaneously until 10:45 a.m., her verbal response was oriented until 10:45 a.m., her motor responses were obeyed commands, and her pupils were reactive to light until 10:45 a.m. and the hand grips were equal until 10:45 a.m. Record review of a SBAR (a verbal or written communication tool used to help provide essential, concise information, usually during crucial situations) note dated [DATE] at 10:35 a.m., RN A documented Resident #1 had a change of mental status, change of function status, and change of behavior status. The documented blood pressure was ,d+[DATE] and the heart rate was 92, respirations were 26, the temperature and oxygen saturation were not obtained on this day. RN A documented Resident #1's blood glucose level was 108. The mental status change was documented as decreased level of consciousness by RN A. The Functional change was documented as falls, swallowing difficulty, and weakness. RN A documented she notified 911 and Resident #1 was sent to the hospital. The SBAR note indicated in the section of physician or designee notification, date and time was all left blank. Record review of an eTransfer dated [DATE] indicated Resident #1 was transferred to the local hospital. The transfer note indicated the reason for the transfer was Resident #1 was found to be unable to speak, change of level of consciousness, and excessive saliva at her mouth. The transfer note indicated Resident #1 was transferred on [DATE] at 10:25 a.m. as an emergency transfer. The transfer note indicated Resident #1's blood pressure was ,d+[DATE] with her heart rate of 92 and respirations of 26 per minute. The transfer note indicated Resident #1 was lethargic, not oriented, unclear or no speech, urine incontinence, swallowing problems, unable to bear weight, and her current status was not her baseline. The transfer note indicated in the area of primary physician notification the hospice provider was listed not a physician. Record review of the progress notes dated [DATE] at 10:15 a.m., RN A documented Resident #1 was found lying sideways on her bed, with excessive saliva at her lips. The progress notes further indicated Resident #1 was unable to verbally respond, but does open her eyes, vital signs were obtained, and the crash cart was taken to Resident #1's room. RN A said she was unable to obtain an oxygen saturation due to the equipment not reading on her fingertip. RN A documented Resident #1's blood pressure was ,d+[DATE], heart rate 92, and blood glucose was 108. RN A documented EMS was notified and on the way. RN A documented oxygen was applied at 2 liters per nasal cannula. Record review of a hospital record of a CT (imaging test that helps detect diseases and injuries)/Brain scan without contrast medium dated [DATE] at 11:25 a.m., revealed Resident #1 had a massive acute central deep brain hemorrhage with marked intraventricular extensions as above extending into the midbrain. Resident #1 also had a moderate sized acute left external capsule hemorrhage. The results note indicated Resident #1's hemorrhages were both likely hypertensive in etiology. The findings indicated Resident #1 had a massive deep right cerebral hemorrhage present measuring roughly 4.8 x 4.6 x 4.7 centimeters. The included the right basal ganglia, thalamus, surrounding white matter and the midbrain. Extensive intraventricular extension was present, with blood throughout the lateral, third, and fourth ventricles, and fourth ventricular outlet foramina. A second smaller acute parenchymal hemorrhage was present along the left external capsule measuring approximately 3.0 x 2.5 x 1.2 centimeters. During an interview on [DATE] at 1:45 p.m., the Corporate Compliance Nurse said Resident #1's life support was removed, and she expired today. During an interview on [DATE] at 1:58 p.m., the DON said on [DATE] around 8:00 a.m. - 8:15 a.m. the staff heard something and walked into Resident #1's room. The DON said Resident #1 was found to have fallen. The DON said Resident #1 indicated she had not hurt herself. The DON said within a couple of hours Resident #1 was having seizure like activity and was sent to the local emergency room . The DON indicated after reviewing Resident #1's reports of her brain scans Resident #1 had two brain hemorrhages attributed to high blood pressure. During an interview on [DATE] at 2:07 p.m., RN B said CNA C alerted her Resident #1 fell . RN B said she went to get RN A. RN B said RN A was the charge nurse assigned to Resident #1. RN B said the fall occurred around 8:00 a.m. on [DATE]. RN B said Resident #1 was at the end of her bed and was on the floor in urine. RN B said RN A asked Resident #1 if she hit her head and Resident #1 indicated she had not. RN B said she assisted RN A to ambulate Resident #1 to the bathroom. RN B said she informed RN A to be sure and start her neurological assessments. During an interview on [DATE] at 2:13 p.m., CNA C said she was passing ice on [DATE] and had just provided ice to Resident #1 and greeted her good morning. CNA C said she exited the room and was directly across the hall when she heard a loud noise and saw Resident #1 at the foot of her bed going down. CNA C said the room was dark, but she ran over and advised Resident #1 to stay seated she would get the nurse. CNA C said she ran and alerted RN B. During an interview on [DATE] at 3:42 p.m., RN B said neurological checks should be completed when a resident falls. RN B said neurological checks included a full set of vital signs. RN B said the facility does have medication aides who pass medications to 2 of the halls and the nurses give medications on one hall each. During an interview on [DATE] at 3:45 p.m., MA D said she had passed medications to Resident #1. MA D said she had alerted the nurse of past abnormal blood pressures but was never instructed to administer the ordered clonidine. MA D said she was unsure of which nurse she had notified in the past. During an interview on [DATE] at 3:54 p.m., LVN E said today was the first day she had worked in several months. LVN E said she would expect the medication aides to alert her of an abnormal blood pressure. LVN E said she would notify the physician and obtain orders after she rechecked the blood pressure with a manual blood pressure device. LVN E said she would also review the medication record to see what medications were available to lower blood pressures and administer as ordered. LVN E said if she was unable to reach the physician, she would send the resident to the hospital for evaluation. LVN E said when obtaining neurological assessment, a full set of vital signs were required. During an interview on [DATE] at 3:59 p.m., the ADON said she expected the medication aides to alert the nursing staff when they obtain abnormal vital signs. The ADON said then she expected the nurse to review the orders to administer an as needed medication if applicable. The ADON said she expected the nurses to notify the MD with abnormal vital signs. The ADON said chronic high blood pressure could damage the kidneys, cause strokes, and heart attacks. The ADON said neurological assessments populate when you complete the risk management form. The ADON said when the nurse marks a resident had not hit their head then the neurological assessments do not populate. The ADON said this was the reason for neurological assessments on paper as a backup tool. The ADON said she had instructed RN A to notify the physician, the family, and the hospice provider. During an interview on [DATE] at 4:17 p.m., RN A said she was down another hall when RN B came to alert her of Resident #1's fall. RN A said when she entered the room Resident #1 was sitting on the floor at the end of her bed in urine. RN A said she completed an assessment and assisted Resident #1 up and Resident #1 ambulated to the restroom. RN A said Resident #1 indicated she had not hit her head. RN A said she assisted Resident #1 with incontinent care and assisted her back to bed. RN A said she obtained Resident #1's blood pressure and the reading was elevated but she said she contributed the elevated blood pressure to the fall. RN A said she rechecked Resident #1's blood pressure approximately 45 minutes later. RN A said she checked Resident #1 every 15 minutes for her neurological checks but was not monitoring her vital signs every 15 minutes. RN A said around 9:45 a.m. to 10:45 a.m., the Social Worker alerted her to Resident #1 was not responding correctly. RN A said when she entered the room Resident #1 appeared to have a seizure like activity, frothy salvia from the mouth, and not responding although her eyes were open. RN A said EMS was alerted. RN A said she was never taught by the facility to complete any of the forms for the fall nor the neurological assessments. RN A said her work history included emergency room nursing where the patients were monitored by equipment and in the facility, there was not any of this equipment. RN A said she notified the hospice provider of the fall and spoke to Resident #1's routine nurse. RN A said she thought notification to the hospice provider was sufficient. RN A said no one advised her to notify Resident #1's provider or the medical director of the facility. During an interview on [DATE] at 4:37 p.m., the DON said normally the neurological assessments included a full set of vital signs. The DON reviewed the form RN A completed for neurological assessments and indicated she was unsure why this form was used. The DON said the form RN A documented neurological assessments on did not include an area to enter a set of vital signs. The DON said RN A had not completed the SBAR when she had not notified Resident #1's physician or the medical director. The DON reviewed the blood pressures with the surveyor and agreed the blood pressures for [DATE] were elevated and the physician should have been consulted. The DON said high blood pressures over time could lead to strokes. The DON said the computerized medical record system also had alerts set up to notify the nurses when the residents have abnormal findings. The DON said she had in-serviced the medication aides on when to notify the nurses regarding blood pressures and was in the process of in-servicing the nurses on the use of the alerts in the computer system as well as communicating with the medication aides. During an interview on [DATE] at 4:10 p.m., the medical director indicated he had been notified of the immediate jeopardy by the Administrator and this was discussed in a meeting with the team. The medical director said he was not Resident #1's primary physician. The medical director said he expected the hospice physician to have oversight of Resident #1's care. During a return call on [DATE] at 11:45 a.m., Resident #1's identified physician on her face sheet indicated he was not the primary physician for Resident #1 he was the hospice physician only. The physician said he expected the medical director of the facility to have oversight of Resident #1's care. The physician indicated he was the physician who would address any palliative needs. The physician said although he believed he was not Resident #1's primary physician he said he as a physician he would expect Resident #1 to have received any as needed medications to lower her blood pressure. The physician indicated the blood pressure readings were abnormal and he believed over time these abnormal findings could lead to complications related to neurologic incidents (stroke) or cardiovascular incidents (heart attack). Record review of a Notifying the Physician of Change in Status policy dated 2003 indicated the nurses should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate medical attention. This facility utilizes the interact tool, Change in Condition-When to Notify the physician, nurse practitioner, or physician's assistant to review resident conditions and guide the nurse when to notify the physician. This tool informs the nurse if resident condition requires immediate notification of the physician or non-immediate/Report on Next Workday notification of the physician. 1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record .5. The resident's family member or legal guardian should be notified of significant change in resident's status unless the resident has specified otherwise. The Administrator was notified on [DATE] at 6:00 p.m. that an immediate jeopardy situation was identified due to the above failures. The Administrator was provided the template on [DATE] at 6:03 p.m. The POR was submitted by Administrator and accepted on [DATE] at 12:01 and indicated the following: Alleged Issues: The facility failed to: 1.36 opportunities to administer a Clonidine for systolic blood pressure of >160 or a diastolic blood pressure of > than 90 in the month of October. 2.Hypertensive post fall on [DATE] blood pressure ,d+[DATE]. Plan of Removal: Actions: 1.As of [DATE] resident was transferred to the hospital for evaluation. 2.All residents who had an unwitnessed fall in the last 30 days were assessed for any neurological deficits by Compliance Nurse, DON, and ADON on [DATE] to include vital signs. No additional findings were discovered. 3.The Regional Compliance Nurse and Director of Nursing reviewed blood pressures with pulses for all residents over the last 30 days on [DATE] and the physician was notified for all elevated blood pressures and pulses. No additional blood pressures or pulses were identified that were outside of ordered parameters for physician notification. 4.The Regional Compliance Nurse and Director of Nursing completed an audit for all anti-hypertensive medications on [DATE] to ensure parameters were in place. In-services: 1.All charge nurses were in-serviced on [DATE] by the Administrator, DON, and ADON regarding the following and all nurses including agency staff, new hires, and PRN staff not in-serviced on [DATE] will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. The Admin and DON will be in-serviced by the Regional Compliance Nurse. A) Abuse and Neglect to include Failure to recognize and treat an elevated blood pressure and notify the physician of a change in condition. B) Fall prevention policy to include assessing for change in condition that could contribute to a fall. C) Completing entries into Risk Management of PCC for Falls and completing Fall Event Note and Fall Risk assessment. D) Neurological checks including vital signs will be performed by the charge nurse on all residents who have an unwitnessed fall or hit their head during the fall. E) Promptly and correctly assessing a resident when a change of condition has been identified and Notification of change of condition to the DON, Physician, RP immediately including any change in neurological status. Ex: altered level of consciousness, behavior/mood changes, headaches, decrease in decreased mobility, or a change in eating habits after a fall, increased or decreased BP/Pulse, etc. F) Checking clinical alerts and addressing them timely. G) Following parameters when administering medications to identify when a PRN medication needs to be administered. Additional instructions will be included for the CMA on the EMAR to notify the charge nurse when parameters are met for PRN medication administration. 2.All Certified Medication Aides were in-serviced on [DATE] by the Administrator, DON, and ADON regarding the following and all CMAs including agency staff, new hires, and PRN staff not in-serviced on [DATE] will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. The Admin and DON will be in-serviced by the Regional Compliance Nurse. A.Abuse and Neglect to include Failure to recognize and an elevated blood pressure and notify the charge nurse of a change in condition. B.Fall prevention policy to include notifying the charge nurse of change in condition that could contribute to a fall. C.Notification of change of condition to the Charge Nurse including any change in neurological status. Ex: altered level of consciousness, behavior/mood changes, headaches, decrease in decreased mobility, or a change in eating habits. D.Notification of the charge nurse when holding medications due to vital signs being outside of parameters. Also, notification of the charge nurses when parameters are met for a PRN medication to be administered. 3) All other clinical staff were in-serviced on [DATE] by the Administrator, DON, ADON regarding the following and all clinical staff including agency staff, new hires, and PRN staff not in-serviced on [DATE] will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. A.Abuse and Neglect to include notifying the charge nurse of a change in condition. B.Fall prevention policy to include notifying the charge nurse of change in condition that could contribute to a fall. C.Notification of change of condition to the Charge Nurse including any change in neurological status. Ex: altered level of consciousness, behavior/mood changes, headaches, decrease in decreased mobility, or a change in eating habits. D.The Medical Director was notified by the Administrator on [DATE] of the facility failures. E.The Regional Compliance Nurse visited the facility [DATE] to review all audits and provide additional training as needed regarding Abuse & Neglect, Neuro checks, and notifying the physician on change in status. F.An AD HOC QAPI meeting will be held on [DATE] by the Interdisciplinary Team to discuss the facility failures and plan of correction. G.The Administrator and DON will implement this written Plan of Removal and will continue to monitor for completion and compliance. Plan of removal date: [DATE] On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: 1.During an interview on [DATE] at 4:10 p.m., the Medical Director confirmed he was notified of the IJ situation and an interim QAPI meeting was completed. 2.Record review of an Off Cycle QA Meeting Document dated [DATE] indicated the committee reviewed the company nursing practices relate to notification of the physician, neurological checks, monitoring medications, incident and accident policy and procedure and noted a need for immediate change process. The QA meeting documented the facility had a system failure related to a resident fall incident that resulted in the hospitalization and subsequent death of the resident that resulted in an immediate need of review of this system. Areas of concern that were identified were listed for review: facility failed to check vital signs with neurological checks for a resident after a fall, facility failed to assess, identify, and document changes in the resident's neurological condition, facility failed to notify the physician of a change in the resident's condition related to elevated blood pressure and pulse and the facility failed to adequately control a resident's blood pressure and pulse by not administering an as needed medication as indicated by parameters ordered by the physician. The committee put in place the DON and Administrator would monitor the systems weekly to ensure continuous compliance was met. Committee members were reviewed as attending were the Medical Director, Administrator, the DON, ADON, Regional Compliance Nurse, Area Director of Operations, Clinical Services Directors, and the [NAME] President. 3.Record review of an undated Adverse Drug Reaction Monitoring policy indicated the policy of this facility to strive to avoid the occurrences of adverse drug reactions through the combined efforts of the physician pharmacist, and nursing staff. Any history of adverse drug reactions specific to individual resident are flagged in the medication administration record and clinical record. Medication reference materials are readily available to nursing staff. The Quality Assurance Committee evaluates all adverse drug reaction incidents. 4.Record review of an undated Event Reporting policy and procedure indicated the facility will complete an event report on variance that occur with the facility. Variances included falls, skin tears, bruises, abrasions, lacerations, fractures, choking, burns, elopement or behavior that affects other All events resulting in a change in status of a resident must be reported immediately to the attending physician and family member/legal representative of the resident any physician's orders should be followed. 5.Record review of a Neurologic Checks policy and procedure dated 2003 indicated neurologic checks are a combination of objective observations and measurements done to monitor neurologic status. The results of the checks assist to determine nervous system damage and/or deterioration 4. Assess vital signs- pulse, respirations, and blood pressure. 5. Assess eye response 6. Assess best verbal response .7. Assess best motor response .8. Use a penlight to check response of the pupils. 9. Check grip of hand and ability to squeeze hand. 10. All deteriorations in neurological status will be immediately report to the physician. The nurse will document assessment and the time of physician notification in the clinical record. 6.Record review of a Fall/Ambulation Difficulty policy dated 2003 indicated More than half of falls are related to medically diagnosed conditions. Many residents will have more than one diagnosed condition Assess risk factors .risk factors identified for all residents .Reducing environmental hazards .assessment of gait/balance .evaluate footwear .Review medications .review daily routines .prevention of unsafe transfers/ambulation address social and psychological needs . 7.Record review of a Preventive Strategies to Reduce Fall Risk dated 2003 and revised on [DATE]. The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors whole maintaining or improving the resident's mobility. 8.Record review of a Notifying the Physician of Change in Status policy dated 2003 indicated the nurses should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate medical attention. This facility utilizes the interact tool, Change in Condition-When to Notify the physician, nurse practitioner, or physician's assistant to review resident conditions and guide the nurse when to notify the physician. This tool informs the nurse if resident condition requires immediate notification of the physician or non-immediate/Report on Next Workday notification of the physician. 1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record .5. The resident's family member or legal guardian should be notified of significant change in resident's status unless the resident has specified otherwise. 9.Record review of a Medication Administration Policy dated 2003 indicated all medication are administer by licensed medical or nursing personnel. 7. All as needed medication orders must specify the reason and frequency for use. As needed medications are to be charted on the medication administration record. And explanation as to symptoms prior to administration and results are to be documented. 10. Record review of the undated Abuse Neglect Policy indicated the resident has the right to be free from abuse, neglect, misappropriatio [TRUNCATED]

Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 4 (Resident #1) residents reviewed for medication errors. The facility failed to administer Resident #1's physician ordered Clonidine for high blood pressure 35 times during the month of [DATE] that resulted in the death of Resident #1. An Immediate Jeopardu (IJ) situation was identified on [DATE] at 6:00 p.m. While the IJ was removed on [DATE] at 4:15 p.m., the facility remained out of compliance at actual harm with a scope of pattern due to the facilities need to evaluate the effectiveness of the corrective systems. This failure could place residents not receiving blood pressure medications as prescribed at risk for strokes, heart attacks, kidney damage, and even death. Findings included: Record review of Resident #1's face sheet dated [DATE] indicated she was a [AGE] year-old female who admitted on [DATE] with the diagnoseis of high blood pressure, liver disease, and Lupus (a chronic disease, an autoimmune disease with systemic manifestations including skin rash, erosion of joints or even kidney disease). Record review of a Quarterly MDS dated [DATE] indicated Resident #1 was understood and understood others. The MDS indicated Resident #1's BIMS score was 12 indicating moderate cognitive impairment. The MDS indicated in Section Rejection of Care Resident #1 had not demonstrated any behaviors. The MDS indicated Resident #1 required supervision of one staff with transfers, and dressing, she required limited assistance of one staff with locomotion. Resident #1 required extensive assistance of one staff with personal hygiene. In Section I Active Diagnosis hypertension was marked (high blood pressure). Record review of Resident #1's comprehensive care plan dated [DATE] indicated Resident #1 did not have a care plan for high blood pressure (hypertension). Record review of the consolidated physician orders dated [DATE], indicated Resident #1 was ordered amlodipine 10 milligrams one tablet by mouth two times daily for high blood pressure with the parameters to hold if the systolic blood pressure was less than 100 or the diastolic blood pressure was less than 60 on [DATE]. Resident #1 had a physician order dated [DATE] for Clonidine 0.1 milligram one tablet by mouth every 24 hours as needed for elevated blood pressure with a parameter of administer for a systolic blood pressure greater than 160 or a diastolic blood pressure greater than 90. Record review of the MAR dated [DATE] revealed Resident #1's blood pressures were for the administration of the amlodipine: [DATE] and [DATE] Resident #1 out of the facility *[DATE] AM ,d+[DATE] and PM ,d+[DATE] *[DATE] AM ,d+[DATE] and PM ,d+[DATE] *[DATE] PM ,d+[DATE] *[DATE] AM ,d+[DATE] and PM ,d+[DATE] *[DATE] PM ,d+[DATE] *[DATE] PM ,d+[DATE] *[DATE] AM ,d+[DATE] *[DATE] AM ,d+[DATE] and PM ,d+[DATE] *[DATE] AM ,d+[DATE] and PM ,d+[DATE] *[DATE] PM ,d+[DATE] *[DATE] AM ,d+[DATE] [DATE] - [DATE] Resident #1 out of the facility *[DATE] AM ,d+[DATE] and PM ,d+[DATE] *[DATE] AM ,d+[DATE] and ,d+[DATE] *[DATE] AM ,d+[DATE] and ,d+[DATE] *[DATE] AM ,d+[DATE] and PM ,d+[DATE] *[DATE] PM ,d+[DATE] *[DATE] AM ,d+[DATE] and PM ,d+[DATE] *[DATE] AM ,d+[DATE] and PM ,d+[DATE] *[DATE] AM ,d+[DATE] and PM ,d+[DATE] *[DATE] - [DATE] Resident #1 out of facility *[DATE] AM ,d+[DATE] *[DATE] AM ,d+[DATE] *[DATE] AM ,d+[DATE] and PM ,d+[DATE] *[DATE] AM ,d+[DATE] Record review of the MAR for Clonidine 0.1 milligram indicated Resident #1 had no administrations for the entire month of [DATE]. Record review of a hospital record of a CT (imaging test that helps detect diseases and injuries)/Brain scan without contrast medium dated [DATE] at 11:25 a.m. revealed Resident #1 had a massive acute central deep brain hemorrhage with marked intraventricular extensions as above extending into the midbrain. Resident #1 also had a moderate sized acute left external capsule hemorrhage. The results note indicated Resident #1's hemorrhages were both likely hypertensive in etiology. The findings indicated Resident #1 had a massive deep right cerebral hemorrhage present measuring roughly 4.8 x 4.6 x 4.7 centimeters. The included the right basal ganglia, thalamus, surrounding white matter and the midbrain. Extensive intraventricular extension was present, with blood throughout the lateral, third, and fourth ventricles, and fourth ventricular outlet foramina. A second smaller acute parenchymal hemorrhage was present along the left external capsule measuring approximately 3.0 x 2.5 x 1.2 centimeters. During an interview on [DATE] at 1:45 p.m., the Corporate Compliance Nurse said Resident #1's life support was removed, and she expired today. During an interview on [DATE] at 1:58 p.m., the DON said on [DATE] around 8:00 a.m. - 8:15 a.m. the staff heard something and walked into Resident #1's room. The DON said Resident #1 was found to have fallen. The DON said Resident #1 indicated she had not hurt herself. The DON said within a couple of hours Resident #1 was having seizure like activity and was sent to the local emergency room . The DON indicated after reviewing Resident #1's reports of her brain scans Resident #1 had two brain hemorrhages attributed to high blood pressure. During an interview on [DATE] at 3:45 p.m., MA D said she had passed medications to Resident #1. MA D said she had alerted the nurse of past abnormal blood pressures but was never instructed to administer the ordered clonidine. MA D said she was unsure of which nurse she had notified in the past. During an interview on [DATE] at 3:54 p.m., LVN E said today was the first day she had worked in several months. LVN E said she would expect the medication aides to alert her of an abnormal blood pressure. LVN E said she would notify the physician and obtain orders after she rechecked the blood pressure with a manual blood pressure device. LVN E said she would also review the medication record to see what medications were available to lower blood pressures and administer as ordered. LVN E said if she was unable to reach the physician, she would send the resident to the hospital for evaluation. LVN E said when obtaining neurological assessment, a full set of vital signs were required. During an interview on [DATE] at 3:59 p.m., the ADON said she expected the medication aides to alert the nursing staff when they obtain abnormal vital signs. The ADON said then she expected the nurse to review the orders to administer an as needed medication if applicable. The ADON said she expected the nurses to notify the MD with abnormal vital signs. The ADON said chronic high blood pressure could damage the kidneys, cause strokes, and heart attacks. The ADON said neurological assessments populate when you complete the risk management form. The ADON said when the nurse marks a resident had not hit their head then the neurological assessments do not populate. The ADON said this was the reason for neurological assessments on paper as a backup tool. The ADON said she had instructed RN A to notify the physician, the family, and the hospice provider. During an interview on [DATE] at 4:37 p.m., the DON said normally the neurological assessments included a full set of vital signs. The DON reviewed the form RN A completed for neurological assessments and indicated she was unsure why this form was used. The DON said the form RN A documented neurological assessments on did not include an area to enter a set of vital signs. The DON said RN A had not completed the SBAR when she had not notified Resident #1's physician or the medical director. The DON reviewed the blood pressures with the surveyor and agreed the blood pressures for [DATE] were elevated and the physician should have been consulted. The DON said high blood pressures over time could lead to strokes. The DON said the computerized medical record system also has alerts set up to notify the nurses when the residents have abnormal findings. The DON said she had in-serviced the medication aides on when to notify the nurses regarding blood pressures and was in the process of in-servicing the nurses on the use of the alerts in the computer system as well as communicating with the medication aides . During an interview on [DATE] at 4:10 p.m., the medical director indicated he had been notified of the immediate jeopardy by the Administrator and this was discussed in a meeting with the team. The medical director said he was not Resident #1's primary physician. The medical director said he expected the hospice physician to have oversight of Resident #1's care. During a return call on [DATE] at 11:45 a.m., Resident #1's identified physician on her face sheet indicated he was not the primary physician for Resident #1 he was the hospice physician only. The physician said he expected the medical director of the facility to have oversight of Resident #1's care. The physician indicated he was the physician who would address any palliative needs. The physician said although he believed he was not Resident #1's primary physician he said he as a physician would expect Resident #1 to have received any as needed medications to lower her blood pressure. The physician indicated the blood pressure readings were abnormal and he believed over time these abnormal findings could lead to complications related to neurologic incidents (stroke) or cardiovascular incidents (heart attack). Record review of the undated Abuse Neglect Policy indicated the resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation as defined in this subpart 7. Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Prevention: 4. The facility will be responsible to identify, correct and intervene.10. in situations of possible abuse/neglect occurrences, patterns, trends that may constitute abuse. Record review of a Medication Administration Policy dated 2003 indicated all medication are administer by licensed medical or nursing personnel. 7. All as needed medication orders must specify the reason and frequency for use. As needed medications are to be charted on the medication administration record. And explanation as to symptoms prior to administration and results are to be documented. The Administrator was notified on [DATE] at 6:00 p.m. that an immediate jeopardy situation was identified due to the above failures. The Administrator was provided the template on [DATE] at 6:03 p.m. The facility's plan of removal was accepted on [DATE] at 12:21 p.m. and included the following: Alleged Issues: The facility failed to: 1.36 opportunities to administer a Clonidine for systolic blood pressure of >160 or a diastolic blood pressure of > than 90 in the month of October. 2.Hypertensive post fall on [DATE] blood pressure ,d+[DATE]. Plan of Removal: Actions: 1.As of [DATE] resident was transferred to the hospital for evaluation. 2.All residents who had an unwitnessed fall in the last 30 days were assessed for any neurological deficits by Compliance Nurse, DON, and ADON on [DATE] to include vital signs. No additional findings were discovered. 3.The Regional Compliance Nurse and Director of Nursing reviewed blood pressures with pulses for all residents over the last 30 days on [DATE] and the physician was notified for all elevated blood pressures and pulses. No additional blood pressures or pulses were identified that were outside of ordered parameters for physician notification. 4.The Regional Compliance Nurse and Director of Nursing completed an audit for all anti-hypertensive medications on [DATE] to ensure parameters were in place. In-services: 1.All charge nurses were in-serviced on [DATE] by the Administrator, DON, and ADON regarding the following and all nurses including agency staff, new hires, and PRN staff not in-serviced on [DATE] will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. The Admin and DON will be in-serviced by the Regional Compliance Nurse. A) Abuse and Neglect to include Failure to recognize and treat an elevated blood pressure and notify the physician of a change in condition. B) Fall prevention policy to include assessing for change in condition that could contribute to a fall. C) Completing entries into Risk Management of PCC for Falls and completing Fall Event Note and Fall Risk assessment. D) Neurological checks including vital signs will be performed by the charge nurse on all residents who have an unwitnessed fall or hit their head during the fall. E) Promptly and correctly assessing a resident when a change of condition has been identified and Notification of change of condition to the DON, Physician, RP immediately including any change in neurological status. Ex: altered level of consciousness, behavior/mood changes, headaches, decrease in decreased mobility, or a change in eating habits after a fall, increased or decreased BP/Pulse, etc. F) Checking clinical alerts and addressing them timely. G) Following parameters when administering medications to identify when a PRN medication needs to be administered. Additional instructions will be included for the CMA on the EMAR to notify the charge nurse when parameters are met for PRN medication administration. 2. All Certified Medication Aides were in-serviced on [DATE] by the Administrator, DON, and ADON regarding the following and all CMAs including agency staff, new hires, and PRN staff not in-serviced on [DATE] will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. The Admin and DON will be in-serviced by the Regional Compliance Nurse. A. Abuse and Neglect to include Failure to recognize and an elevated blood pressure and notify the charge nurse of a change in condition. B. Fall prevention policy to include notifying the charge nurse of change in condition that could contribute to a fall. C. Notification of change of condition to the Charge Nurse including any change in neurological status. Ex: altered level of consciousness, behavior/mood changes, headaches, decrease in decreased mobility, or a change in eating habits. D. Notification of the charge nurse when holding medications due to vital signs being outside of parameters. Also, notification of the charge nurses when parameters are met for a PRN medication to be administered. 3) All other clinical staff were in-serviced on [DATE] by the Administrator, DON, ADON regarding the following and all clinical staff including agency staff, new hires, and PRN staff not in-serviced on [DATE] will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. A. Abuse and Neglect to include notifying the charge nurse of a change in condition. B. Fall prevention policy to include notifying the charge nurse of change in condition that could contribute to a fall. C. Notification of change of condition to the Charge Nurse including any change in neurological status. Ex: altered level of consciousness, behavior/mood changes, headaches, decrease in decreased mobility, or a change in eating habits. D. The Medical Director was notified by the Administrator on [DATE] of the facility failures. E. The Regional Compliance Nurse visited the facility [DATE] to review all audits and provide additional training as needed regarding Abuse & Neglect, Neuro checks, and notifying the physician on change in status. F. An AD HOC QAPI meeting will be held on [DATE] by the Interdisciplinary Team to discuss the facility failures and plan of correction. G. The Administrator and DON will implement this written Plan of Removal and will continue to monitor for completion and compliance. Plan of removal date: [DATE] On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: 1. During an interview on [DATE] at 4:10 p.m., the Medical Director confirmed he was notified of the IJ situation and an interim QAPI meeting was completed. 2. Record review of an Off Cycle QA Meeting Document dated [DATE] indicated the committee reviewed the company nursing practices relate to notification of the physician, neurological checks, monitoring medications, incident and accident policy and procedure and noted a need for immediate change process. The QA meeting documented the facility had a system failure related to a resident fall incident that resulted in the hospitalization and subsequent death of the resident that resulted in an immediate need of review of this system. Areas of concern that were identified were listed for review: facility failed to check vital signs with neurological checks for a resident after a fall, facility failed to assess, identify, and document changes in the resident's neurological condition, facility failed to notify the physician of a change in the resident's condition related to elevated blood pressure and pulse and the facility failed to adequately control a resident's blood pressure and pulse by not administering an as needed medication as indicated by parameters ordered by the physician. The committee put in place the DON and Administrator would monitor the systems weekly to ensure continuous compliance was met. Committee members were reviewed as attending were the Medical Director, Administrator, the DON, ADON, Regional Compliance Nurse, Area Director of Operations, Clinical Services Directors, and the [NAME] President. 3. Record review of an undated Adverse Drug Reaction Monitoring policy indicated the policy of this facility to strive to avoid the occurrences of adverse drug reactions through the combined efforts of the physician pharmacist, and nursing staff. Any history of adverse drug reactions specific to individual resident are flagged in the medication administration record and clinical record. Medication reference materials are readily available to nursing staff. The Quality Assurance Committee evaluates all adverse drug reaction incidents. 4. Record review of an undated Event Reporting policy and procedure indicated the facility will complete an event report on variance that occur with the facility. Variances included falls, skin tears, bruises, abrasions, lacerations, fractures, choking, burns, elopement or behavior that affects other All events resulting in a change in status of a resident must be reported immediately to the attending physician and family member/legal representative of the resident any physician's orders should be followed. 5. Record review of a Neurologic Checks policy and procedure dated 2003 indicated neurologic checks are a combination of objective observations and measurements done to monitor neurologic status. The results of the checks assist to determine nervous system damage and/or deterioration 4. Assess vital signs- pulse, respirations, and blood pressure. 5. Assess eye response 6. Assess best verbal response .7. Assess best motor response .8. Use a penlight to check response of the pupils. 9. Check grip of hand and ability to squeeze hand. 10. All deteriorations in neurological status will be immediately report to the physician. The nurse will document assessment and the time of physician notification in the clinical record. 6. Record review of a Fall/Ambulation Difficulty policy dated 2003 indicated More than half of falls are related to medically diagnosed conditions. Many residents will have more than one diagnosed condition Assess risk factors .risk factors identified for all residents .Reducing environmental hazards .assessment of gait/balance .evaluate footwear .Review medications .review daily routines .prevention of unsafe transfers/ambulation address social and psychological needs . 7. Record review of a Preventive Strategies to Reduce Fall Risk dated 2003 and revised on [DATE]. The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors whole maintaining or improving the resident's mobility. 8. Record review of a Notifying the Physician of Change in Status policy dated 2003 indicated the nurses should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate medial attention. This facility utilizes the interact tool, Change in Condition-When to Notify the physician, nurse practitioner, or physician's assistant to review resident conditions and guide the nurse when to notify the physician. This tool informs the nurse if resident condition requires immediate notification of the physician or non-immediate/Report on Next Workday notification of the physician. 1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record .5. The resident's family member or legal guardian should be notified of significant change in resident's status unless the resident has specified otherwise. 9. Record review of a Medication Administration Policy dated 2003 indicated all medication are administer by licensed medical or nursing personnel. 7. All as needed medication orders must specify the reason and frequency for use. As needed medications are to be charted on the medication administration record. And explanation as to symptoms prior to administration and results are to be documented. 11. Record review of an in-service Abuse and Neglect dated [DATE] indicated: Charge Nurses-Abuse and Neglect including failure to recognize and treat an elevated blood pressure and notify the physician of the change in condition. Medication Aides: Abuse and Neglect including failure to recognize and an elevated blood pressure and notify the charge nurse of a change of condition. All other clinical staff: Abuse and Neglect including notifying the charge nurse in a change of condition. The in-service sign in page indicated 29 staff members were in-serviced. 12. Record review of an in-service Vital Signs and Parameters dated [DATE] indicated: respiratory rate ,d+[DATE] breaths per minute; temperature for elderly 97.8 - 99 degrees Fahrenheit; Blood pressure hypertension considered any measurement greater than ,d+[DATE] and hypotension was any blood pressure reading below ,d+[DATE]. Normal blood pressure for the elderly ,d+[DATE] and pre-hypertension was 121 - 139. Pulse normal heart rate for elderly ,d+[DATE] beats per minute. Medication Aides: notify your charge nurse with vital signs outside of the parameters. Charge nurses: check for any PRN meds. Find out the doctors preferred parameters .Notify the doctors with vital signs outside of these parameters. The in-service sign in page indicated 13 nurses and mediation aides signed the in-service. 13. Record review of an in-service Fall Prevention dated [DATE] indicated 1. Ask the resident immediately after their fall if they were hungry, pain, bored, or needed the bathroom. Look: at the footwear, bed, equipment, call light, belongings, and incontinent. Ask yourself: was there a change, what was the resident doing, was there a recent change in lab work, a recent acute illness, medication factors, new medications, education to staff, and prevention. The in-service indicated 25 staff members signed the in-service. 14. Record review of an in-service dated [DATE] Clinical Alerts-Nurses: in-service on the use of clinical alert notifications on the facility's clinical chart dashboard. The in-service indicated 9 nurses signed the in-service. 15. Record review of an in-service dated [DATE] Incident Reports: in-service provided step by step instructions on completing the incident report. The in-service indicated 11 nurses were in-serviced. 16. Record review of an in-service dated [DATE] Neurological Checks including vital signs indicated neuros must be started immediately with all unwitnessed falls or witnessed falls with head involvement. This included the face, scalp, ear or mouth. Neurological assessments may be completed on paper, but they must be entered into the computer to the end of the shift. Ensure in report the neurological checks were passed to the next nurse. The in-service provided a paper copy of the neurological assessments with a vital sign section at the top. The in-service was signed by 11 nurses. 17. Record review of an in-service Notification dated [DATE] indicated if a resident had a change of condition, whether it is from a fall or having abnormal vital signs, you must contact the doctor first, then their hospice, and family. If you are not able to reach them, then you should keep trying until you do. An instruction list was provided indicating to promptly and correctly assess a resident when a change of condition had been identified/reported This in-service was signed by 11 nurses. Record review of a Medication Administration Policy dated 2003 indicated all medication are administer by licensed medical or nursing personnel. 7. All as needed medication orders must specify the reason and frequency for use. As needed medications are to be charted on the medication administration record. And explanation as to symptoms prior to administration and results are to be documented. During interviews on [DATE] between 2:45 p.m. and 4:10 p.m., LVN E, L, M and Q were able to correctly identify when to notify the physician, correctly identify a change of condition, identifying of abnormal vital signs, monitoring of abnormal findings using the facility's computerized system, steps to complete an incident report, identification of abuse and neglect situations, when to report abuse/neglect, administering as needed medications to alleviate symptoms such as hypertension. CNAs C, G, K, N, O, and P all could correctly identify abuse/neglect, process in identifying a change of condition with a resident, and prevention of falls. MA D could correctly identify parameters of vital signs, when to notify the charge nurses, fall prevention, process when noted changes of condition in a resident, and abuse and neglect. Activity staff H, and dietary staff F could identify abuse and neglect, and the process for alerting the nurse when a resident had a change of condition. The DON and ADON indicated they would be in-serving staff prior to their on coming shifts until all staff were in-serviced. The DON and ADON indicated they would be monitoring the clinical data dashboard to ensure changes of condition were recognized. The DON and Administrator would be monitoring all systems to ensure compliance. On [DATE] at 4:15 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope of pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, and administration of medications for 1 of 1 residents (Resident #1) reviewed for medication omission. 1. the facility failed to follow their protocol by failing to reorder a prescribed medication timely to prevent seizures, and Resident #1 missed two doses of medication, because his medication was not available and he had two back-to-back seizures and was taken to the hospital. (Clobazam (Onfi), used along with other medicines to treat seizures associated with Lennox-Gastaut syndrome, which is a severe condition characterized by repeated seizures (epilepsy) that begin early in life). 2. the facility did not reorder Resident #1's seizure medication until the day he went to the hospital and the facility did not notify his physician that he missed his medication. An IJ was identified on 5/17/23 at 2:30 p.m. The IJ was removed on 5/18/23 at 4:20 p.m. While the IJ was removed, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to monitor interventions and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of adverse medication effects and/or not receiving the therapeutic benefits of their medications, prescribed by the physician. Findings included: Record review of a face sheet dated 5/16/23 indicated Resident #1 was a [AGE] year-old male admitted to the facility 11/19/22 with diagnoses of epilepsy, unspecified intellectual disabilities, attention-deficit hyperactivity disorder, mild cognitive impairment of uncertain or unknown etiology, and presence of neurostimulator. Record review of an MDS assessment dated [DATE] indicated Resident #1 had moderate impaired cognition. He was independent with personal hygiene, and limited assistance with bathing. Record review of a care plan with a revision date of 03/08/23 indicated Resident #1 had a seizure disorder with an intervention to give seizure medication as ordered by the doctor. Physician orders dated 4/25/23 indicated Resident #1 was to receive Onfi 20mg tablet, 1 tablet at bedtime for prevention of seizure. Record review of Medication Administration Record dated May 2023 indicated Onfi oral tablet 20 mg, give 1 tablet by mouth at bedtime. Last documented dose was given on 5/11/23. Record review of nurses notes dated 5/13/23 indicated CMA C documented medication (Onfi) is not in, and is not in the pyxis (a cart used to store medications). Nurse progress notes dated 5/14/23 at 6:00 a.m. written by LVN B indicated Resident #1 was transferred to the hospital related to having two seizures back-to-back. During an interview on 5/16/23 at 12:07 p.m. Resident #1 was in his room eating lunch. Resident #1 said he was treated well by staff, and all his needs were met. Resident #1 said he received his medications, but sometimes they were late because of the pharmacy, but he always received them. Resident #1 said he had to go to the hospital recently due to having a seizure, but did not remember too much about it, but said he thought he had taken his medications. During an interview on 5/16/23 at 12:15 p.m. the Administrator said on Friday 5/12/23 Resident #1 said he did not get his seizure medication at bedtime. Administrator said LVN A signed it off as being given but signed it off before discovering the medication was not in the facility. The Administrator said Resident #1's medication was not reordered and caused harm to the resident. During an interview on 5/16/23 at 1:32 p.m. the ADON said medications were to be reordered 5-7 days before the last dose of medication . Narcotics needed to be reordered 3-5 days before the last dose of medication. ADON said there had never been a previous problem with meds not being reordered. The ADON said any of the nurses who passed Resident #1's medications could have reordered the medication for it ran out. During an interview on 5/16/23 at 2:28 p.m. CMA C said she had been a med aide for 17-[AGE] years and worked the 2-10 shift. CMA C said on 5/13/23 she documented in Resident #1's progress notes that his Onfi was not in the facility. CMA C said she was told the medication had been reordered but could not remember who told her. CMA C said she told the nurse working (could not remember her name) to check and see if the medicine was in the pyxis). CMA C said she did not think missing 1 dose would cause a seizure and did not check to see if the medication had been reordered. CMA C said she was aware how important this medication was for the resident to receive. During a phone interview on 5/16/23 at 2:46 p.m. LVN A said that on 5/12/23, CMA C asked her to check the pyxis to check to see if the Onfi for Resident #1 was in it. LVN A looked and the medication was not in there. LVN A said she asked LVN H about the medication and was told if it is not in the cart, we don't have it. LVN A said she thought the medication had been reordered but did not check to see if it was. LVN A said on the MAR for Resident #1, on 5/12/23, she signed off that she had given the Onfi prior to discovering she did not have the medication. LVN A stated the Onfi was not given on 5/12/23. LVN A stated the physician and DON were not notified. LVN A said she was not aware of any other resident missing a dose of medicine. During an interview on 5/16/23 at 3:15 p.m. the DON and the Compliance Nurse said LVN A had been suspended pending investigation. DON said any of the staff passing Resident #1's medications could have reordered the medication. Compliance nurse and DON confirmed Resident #1 missed his dose of Onfi on 5/12/23 and 5/13/23. The DON confirmed the dose of Onfi on 5/12/23 was signed off as being given by LVN A but had not been given, as LVN A signed the medication off prior to realizing the medication was not available. DON said someone who had been passing his meds should have checked to see if the medication had been reordered as it was very important for the resident to receive it. During a phone interview on 5/16/23 at 3:45 p.m. LVN B was questioned about documenting a 1 which signified away from facility with meds, on the MAR on 5/14/2023 for Resident #1's dose of Onfi. LVN B said it was incorrect documentation. LVN B said it was Resident #1's roommate who was actually out of the facility. LVN B said she did not know why she clicked on it (the 1). LVN B said the medication was given, and she was aware of how important this medications was. During a phone interview on 5/17/23 at 12:31 p.m. the facility Medical Director said there was a small potential that missing 2 doses of Onfi could have caused Resident #1 to have a seizure but fairly unlikely. During a phone interview on 5/17/23 at 1:47 p.m. the Neurologist assistant stated the physician said, if Resident #1 had missed 2 doses of his Onfi, there was the potential of that causing him to have a seizure, but Resident #1 , had seizures so it was hard to say it was the cause, we will never know. The neurologist assistant said the emergency room physicians did not know Resident #1's history, and that the Neurologist had treated Resident #1 for years, and as long as Resident #1 was on his medication, he was good, and not worried about it. Assistant said labs are not drawn routinely as long as Resident #1 was stable. Record review of hospital records dated 5/16/23 revealed Resident #1 was admitted to the hospital on 5/14/23 at 6:35 a.m. Hospital physician documentation indicated the following: At this time it is my impression patient had a seizure from the abrupt discontinuation of clobazam (Onfi) which is a known complication. Diagnoses included seizure, volume depletion, electrolyte abnormality and withdrawal from clobazam. Resident #1 was discharged back to the nursing home on 5/14/2023 9:13 a.m. Record review of an Ordering Medications policy dated 2003 indicated the following: .reorder medication three to five days in advance of need to assure and adequate supply is on hand . An Immediate Jeopardy (IJ) was identified on 05/17/2023 at 2:30 p.m., due to the above failures. The Administrator was notified of the IJ, and the IJ template was provided on 5/17/2023 at 3:02 p.m. The Plan of removal was accepted on 5/18/2023 at 3:26 p.m., and included the following: 5/18/20224 Plan of Removal Problem: F755 Pharmacy Services Resident #1 was transferred to the hospital on 5/14/2023. Resident #1 returned to the facility on [DATE]. All medications ordered for Resident #1 were audited and verified that adequate supply is present. Audit completed by DON/ADON as of 5/17/2023. Onfi was reordered and administered for resident #1 on 5/14/2023. Administrator/Regional Compliance Nurse/ DON/ADON reviewed Medication Reorder policy and Medication administration policy as of 5/17/2023. DON or designee will review all orders daily to assure policies and procedures are being followed. Interventions: As of 5/17/2023, 100% audit was completed on all resident medications including anticonvulsants to ensure residents are receiving the physician ordered dose. The audit was completed by DON, ADON and Regional Compliance Nurse. No additional omissions were discovered. All resident medications including anticonvulsant medications were verified that they match the ordered dose as of 5/17/2023 by DON, ADON and Regional Compliance Nurse. All resident seizure orders match current physician orders. A Medication error completed as of 5/17/2023 by DON utilizing the medication error form. Pharmacy Consultant was notified of med error as of 5/17/2023 by DON. Ad hoc QAPI meeting was completed with MD and IDT team as of 5/17/2023 to review med error and root cause analysis, and plan of removal. The following in-services were initiated by the DON, ADON and Regional Nurse and completed as of 5/17/23 at 6pm. All Licensed Nurses or Certified Medication Aides not in serviced by 5/17/23 will be in-serviced prior to starting their next shift. In-services will be ongoing for all new hires before they assume their duties. The DON/ADON/Regional Nurse are responsible for conducting these in-services. Licensed Nurses will be in-serviced on: 5 Rights of Medication administration Reporting Medication error that has occurred or found immediately to Physician and DON Re-ordering medications timely to ensure a 5-7-day supply is present. Charge nurses and med aides are both responsible for the re-ordering of medications. Charge nurses will be responsible for auditing carts and reviewing medication supply with Medication Aides three times a week to ensure medications are ordered when needed. Medications need to be re-ordered as indicated on the medication card. The Charge nurse/Medication Aide will review the order status in PCC under the residents MAR for medications needing to be reordered and reorder if needed. Notification of the MD and DON immediately for any resident medications that will not be administered as ordered. Certified Medication Aides will be in-serviced on: 5 Rights of Medication Administration Reporting Medication error that has occurred or found immediately to charge nurse and DON. Re-ordering medications timely to ensure a 5-7 day supply is present. Charge nurses and med aides are both responsible for the re-ordering of medications. Charge nurses will be responsible for auditing carts and reviewing medication supply with Medication Aides three times a week to ensure medications are ordered when needed. Medications need to be re-ordered as indicated on the medication card. The Charge nurse/Medication Aide will review the order status in PCC under the residents MAR for medications needing to be reordered and reorder if needed. Notify the MD and DON immediately for any resident medications that will not be administered as ordered. The DON and ADON will be in-serviced by the regional nurse on 5/18/23 on pulling the electronic transmission report to show which medications have been reordered and the status of the pharmacy refilling the medication. The medical director was notified of med error and immediate jeopardy as of 5/17/2023. Monitoring The DON / designee will review the med administration audit report 5 days per week to ensure all meds are administered as ordered. Review of the med administration audit report will be a permanent process that will occur indefinitely. This report includes all resident medications. The DON/ADON/Designee will review the electronic transmission report 5 days per week for the status of re-ordered medications. This report shows if there is a new pharmacy order or reorder and the date/time it occurred. This will become a permanent process that will occur indefinitely. The DON/ADON/Designee will audit all resident medications twice per week to ensure a 5-7 day supply of medication are present and maintained. Auditing and monitoring will be a permanent process that will occur indefinitely. This report includes all resident medications. The QA committee will review the findings monthly x 3 months and make changes as needed. Verification of Plan of Removal was as follows: a. Reviewed in-service training initiated on 5/16/2023: the 5 rights of medication administration for all nurses and CMAs. b. Reporting to doctor, DON, and ADON any medication errors for all nurses and CMAs. c. Ordering medications for all nurses and CMAs. d. Seizure activity and documentation for all nurses. e. Electronic Transmission Report with inbound and outbound messages, clinical dashboard, integrated pharmacy alerts for DON and ADON. f. Reviewed monitoring tool for medication administration audits. Interviews conducted 5/18/2023 between 2:50 p.m. and 4:15 p.m. revealed LVNs D, E, G, and CMA F had received in-service training and were able to verbalize the 5 rights of medication administration, had knowledge and understanding of when and who needed to be notified in the event of a med error, the process of when and how to reorder medications, and who was responsible to do so. The DON was knowledgeable of the Electronic Transmission Report with inbound and outbound messages, clinical dashboard, integrated pharmacy alerts that she and the ADON would be responsible for. On 5/18/2023 at 4:20 p.m., the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1of 18 residents reviewed for quality of care. (Residents #40) The facility failed to assess and document Resident #40's neurological checks after she was found in the floor with obvious trauma to her forehead. This failure could cause a resident to have an unrecognized head trauma leading to serious impairment and even death. Findings included: Record review of a face sheet dated 09/13/22 indicated Resident #40 was [AGE] years old, admitted on [DATE] and readmitted on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of an Admission MDS assessment dated [DATE] indicated Resident #40 understands and was understood. Resident #40's BIMs score was 5 indicating severe cognition impairment. The MDS indicated Resident #40 required limited assistance of one staff for bed mobility, walking in room, locomotion on the unit. She required extensive assistance of one staff for dressing, eating, toileting, personal hygiene, and total dependence on one staff for bathing. The MDS indicated Resident #40 was continent of bowel and bladder. The MDS did not reflect a history of falls. Record review of an undated comprehensive care plan indicated Resident #40 was at risk for falls. The goal was Resident #40 would be free from falls with the interventions of anticipating needs, the call light within reach, safety reminders, encourage activities, wear appropriate footwear, lock furniture, bed in low position, therapy to evaluate, one staff to assist with transfers, and adequate lighting. Record review of an event nurses note dated 08/26/22 at 9:20 p.m., Resident #40 was found on the floor with bed linen wrapped around her. The note indicated Resident #40 had a bruise with swelling on her right forehead above the eye. The event note indicated Resident #40 was independent with bed mobility, one staff to assist with toileting, and independent with transfers and walking. Record review of an incident report, dated 08/26/22 at 9:20 p.m., indicated Resident #40 was on the floor wrapped in bed linen. The report indicated the immediate action was Resident #40 was assessed for injuries and assisted back to bed. The report indicated the injuries observed at the time of the incident was a hematoma to Resident #40's face. The report indicated there were no witnesses to the incident. Record review of a hospital discharge summary dated 08/28/22 indicated Resident #40 was admitted on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The date of discharge was 8/28/22 with the final diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #40's electronic medical record did not reflect any neurological checks after she was found on the floor with a bruised and swollen area to her forehead. During an interview on 09/13/22 at 10:45 a.m., the Regional nurse F indicated Resident #40's fall on 8/26/22 was unwitnessed. During an interview on 09/13/22 at 11:03 a.m., Regional Nurse F indicated because the nurse inadvertently marked the fall as witnessed the electronic record did not initiate neurological checks to denote changes in Resident #40's status. Regional Nurse F indicated unwitnessed falls and witnessed falls with head injuries require neurological checks. Regional Nurse F validated there were no neurological checks completed for Resident #40. During an interview on 09/13/22 at 2:47 p.m., LVN A indicated he was told in morning report by LVN B, Resident #40 had a witnessed fall on 8/26/22. LVN A indicated he had not done neurological checks on Resident #40 because he was told the fall was a witnessed fall during morning report. LVN A indicated on the morning after the fall Resident #40 was not herself. LVN A indicated when Resident #40 was assisted up she seemed more confused and increased drowsiness. LVN A said Resident #40's gait was shuffled, and her right eye was bruised down her check. LVN A indicated neurological checks should have been initiated with an unwitnessed fall to monitor for a head injury or a brain bleed. LVN A indicated he sent Resident #40 to the hospital due to her change in condition on 8/26/22. During an interview on 09/14/22 at 8:34 a.m., LVN B indicated she had been working at the facility since July. LVN B indicated Resident #40 had an unwitnessed fall on 8/26/22. LVN B said she had mistakenly marked the wrong box (witnessed fall) on the electronic record indicating the fall was witnessed when it was unwitnessed. LVN B indicated she was unsure why the computer did not automatically initiate the neurological checks. LVN B said she had completed neurological checks and had documented them in her personal records. LVN B indicated she had since thrown away the neurological checks. When asked why she did not document them somewhere in the electronic record, she indicated she did not think of it at the time. LVN B indicated monitoring the neurological status of a resident consisted of monitoring of the pupil dilation, and hand and foot grips. LVN B indicated neurological changes could indicate a stroke or a brain bleed. During an interview on 9/14/22 at 12:39 p.m., the corporate nurse indicated she had just completed a mock survey and identified the nursing staff were not detailing the incident reports well including witness statements and other interviews. The Corporate nurse indicated she expected the DON to review the incident and accidents in the morning meeting, care plan the interventions, and implement the interventions. The Corporate nurse indicated there were difficulties maintaining the morning meetings related to staffing and the director of nurses turnover of 4 times in a year. A request was made for the nurse's check off for LVN A and LVN B during the survey, but was not provided before exit. During an interview on 09/15/22 at 9:45 a.m., the ADON indicated the process for falls included a call to herself from the nurse on duty The ADON indicated when she received calls related to a fall, she would implement notification of the abuse coordinator to ensure proper reporting, and implementation of interventions including neurological checks. Record review of a skin assessment, dated 09/13/22 at 6:26 p.m., indicated LVN B documented normal skin color with normal temperature for Resident #40. LVN B documented no bruising. In the area of other skin findings, LVN B documented an open area to left lower buttock with wound care orders in place, and a diabetic ulcer to the right foot second toe with wound care orders in place. Record review of a Neurologic Checks policy dated May 2016 indicated neurologic checks were a combination of objective observations and measurements done to evaluate neurologic status. The results of the checks assist to determine nervous system damage and/or deterioration. The goal was the caregiver would identify changes indicating progressive improvement or deterioration in neurologic status. 4. Obtain vital signs: pulse, respirations, and blood pressure. 5. Assess eye response. 6. Assess verbal response. 7. Assess best motor response. 8. Use a pen light to check response of pupil to light. 9. Check hand grips. 10. Frequency of neuro checks after initial neuro check: every 15 minutes times 4; every 30 minutes times two; every one-hour times two, every two hours times two, then every shift time 48 hours. 11. All deteriorations in neurologic status will be immediately reported to the physician. The nurse will document assessment and the time of the physician notification in the clinical record. During an interview on 09/15/22 at 12:30 p.m., the Regional Nurse F indicated there was no policy and procedure for quality of care.

Based on observations, interviews, and record reviews, the facility failed to ensure treatment and services were provided, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 16 residents reviewed for pressure injuries. (Resident #11) 1. The facility failed to obtain wound treatment orders for Resident #11's the left lateral distal foot DTI (deep tissue injury from pressure), the left distal 4th toe DTI (deep tissue injury from pressure), unstageable pressure ulcer on the left ball of foot, unstageable pressure ulcer to the left proximal heel, and unstageable pressure ulcer to the left distal heel. 2. The facility did not fully assess resident #11's foot upon re-admission from the hospital for pressure injuries. 3. The facility failed to follow their policy for new injuries found on Resident #11 on readmission. These failures could place residents at risk for worsening of existing pressure injuries, pain, and infection. Findings include: Record review of Resident #11's face sheet, dated 9/14//22, revealed the resident was originally admitted to the facility on [DATE] (readmission 9/11/22) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #11's Quarterly MDS assessment, dated 7/5/22, revealed the resident's BIMS score was 9, which indicated moderate cognitive impairment. The resident required extensive assistance (staff provide weight bearing support) with two persons physical assistance for bed mobility, and total dependence (full staff performance every time during entire 7-day period) with two persons physical assistance for transfers, dressing and toileting. Record review of Resident #11's care plan, revised 7/19/22, revealed Resident #11 had ADL (activities of daily living) functional/rehabilitation potential with a self-care deficit, and an intervention that stated required staff assistance times one for assist bars and times two to enable self-bed mobility. Resident #11 requireds a lift for all transfers and toilet use requires one staff assistance. Resident # 11 hads the potential for uncontrolled pain and an intervention that stated observe and report changes in unusual routine, sleep patterns, decrease in functional abilities, decrease range of motion, withdrawal, or resistance to care. Another intervention for this focus stated requireds monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria, nausea, vomiting, dizziness and falls. Resident #11 wasis a risk for falls with an intervention that stated be sure resident's call light wasis within reach and encourage the resident to use it for assistance as needed. Record review Resident #11's hospital records from recent hospitalization dated 9/09/22, in the discharge instructions, stated apply No Sting Skin prep to dried areas of the sacrococcygeal area and perineum, allow to dry, to help protect the skin once per day/ bedside nurse to perform dressing changes to right below the knee amputation and left heel. Record review of Resident #11's weekly ulcer assessment: **Dated 9/06/22 at 3:56 PM revealed stage two pressure ulcer to the sacrum with pillows to float heels. **Dated 9/6/22 at 4:26 PM revealed a non-pressure injury to the RLE (right lower extremity) **Dated 9/13/22 at 6:58 PM revealed an unstageable pressure ulcer to the left proximal lateral heel measuring at 0.8 centimeters in length, 0.5 centimeters in width, and 0.3 centimeters in depth. About 51-75 % amount necrotic tissue (slough). Air mattress and Podus boot are pressure reducing devices added. Notification to physician on 9/13/22 at 5:00 PM **Dated 9/13/22 at 7:07 PM revealed unstageable pressure ulcer to the left distal lateral heel measuring at 1.0 centimeters on length, 1.0 centimeters in width, and .03 centimeters in depth. About 51-75% amount necrotic tissue (slough). Air mattress and Podus boot are pressure reducing devices added. Notification to physician on 9/13/22 at 5:00PM **Dated 9/13/22 at 7:09 PM revealed deep tissue pressure injury to the left fourth toe measuring at 1.0 centimeters on length, 1.0 centimeters in width, and depth written at a 0 indicated unable to measure. Deep tissue without measurable depth. About 75-100% amount of necrotic tissue (eschar). Air mattress and Podus boot are pressure reducing devices added. Notification to physician on 9/13/22 at 5:00PM **Dated 9/13/22 at 7:12 PM revealed unstageable pressure ulcer to the ball of left foot measuring at, 2.0 centimeters on length, 2.0 centimeters in width, and 0.1 in depth. About 26-50% amount of necrotic tissue (eschar). Air mattress and Podus boot are pressure reducing devices added. Notification to physician on 9/13/22 at 5:00PM. **Dated 9/13/22 at 7:26 PM revealed deep tissue pressure injury to the left lateral distal foot measuring at 3.7 centimeters on length, 2.3 centimeters in width, and and depth written at a 0 indicated unable to measure. About 51-75% amount necrotic tissue (eschar). Air mattress and Podus boot are pressure reducing devices added. Notification to physician on 9/13/22 at 5:00PM During an observation and interview on 9/12/22 at 09:49 AM with Resident #11, she said that she required s assistance from staff with all tasks. She said that she staff do not come quickly when she pulleds her call light. She said she has had a stroke and her speech is challenged with remembering some words. She said that she was recently in the hospital and just returned yesterday. She said Dr. told her she has a staph infection from being wet all the time. She said that she has a pressure ulcer on her near her vaginal and anal area. She did not state she had any other open wounds or injuries. She said staff do not reposition her as often as they should, every 2 hours . She said she has a pillow under her left foot and that she has an amputation on her right side below her knee. Observation of the pillow under her foot revealed her foot was touching the footboard of the bed. She said that she was not in any pain in that area but that she does not have much feelings on the left side of her body due to her stoke. No Podus boot was observed on the foot and foot did not appear to be floated. During an observation and interview on 9/12/22 at 11:47 AM with Resident #11, she was being positioned in bed and she said she was coming in from taking a shower. Staff positioned the resident in upright position and placed a pillow under her heel. No Podus boot was observed on the foot and foot did not appear to be floated. During an observation on 9/12/22 at 02:34 PM with Resident #11, she was observed in bed asleep. She was in the same position as during lunch. She was in the sitting position with bed raised. Pillow could be observed under her right shoulder and left foot. Resident #11 foot was covered with the blanket so unable to see if a Podus boot was placed on her foot. During an observation and interview on 9/13/22 at 9:12 AM with Resident #11, she was seen watching TV. She said that she preferred to lay on her right side as she has more feelings on that side of her body. She said that her left shoulder bothers her too much to lay on that side. Resident was observed laying on her right side with a pillow under her right shoulder and left foot. She said that she was not in any pain and she had just had her morning medication pass. She said that the treatment nurse had not come in to treat her wounds yet. Her left foot was observed with a Podus boot and elevated by a pillow but not floated. The resident's left foot was touching the foot board of the bed. During an observation and interview on 9/13/22 at 11:38 AM with Resident #11, revealed she was in the upright position. She said staff had been in earlier to move her into that position for lunch. She was observed with her left foot in the Podus boot and elevated, but the foot was not floated. Her left foot was touching the foot board of the bed. During an observation on 09/14/22 at 10:30 a.m., RN R performed hand hygiene and entered into Resident #11's room with a treatment tray setup with clean dressings and supplies on top of plastic covered tray. RN R performed hand hygiene prior to treatments being performed. Resident #11 was laying on her right side with her left foot floated with a pillow. RN R performed wound treatment to all areas with good technique, using hand sanitizer and changing gloves at the proper times. The following observations of Resident #11's wounds included: * Left lateral distal foot appeared to be a DTI (deep tissue injury). The area had smooth, discolored skin, oval shaped, and the size of my thumb. The area was dark purple in color and non-blanchable with no drainage or open areas. * Left distal 4th toe appeared to be a DTI (deep tissue injury). The area had smooth, discolored skin, oval shaped, and the size of a dime. The area was dark purple in color and non-blanchable with no drainage or open areas. * Left ball of foot appeared to be an unstageable pressure ulcer (related to the black covered areas of the wound, making the stage undetermined). The middle of the ulcer was pink, moist, shiny, and the size of a quarter with black tissue covering the left and right edges of the wound about a centimeter out. A small amount of pink watery drainage was noted on the dressing that was removed. * Left proximal heel appeared to be an unstageable pressure ulcer with full thickness tissue loss and black eschar tissue in the middle of the ulcer. The ulcer was the size of a dime. * Left distal heel appeared to be an unstageable pressure ulcer with full thickness tissue loss and black eschar tissue covering the middle of the ulcer. The ulcer was about the size of a thumb. * Stage 2 ulcer to sacrum that had pink and healthy tissue. * Stage 2 to left buttock that had pink and healthy tissue. During an observation and interview on 9/14/22 at 11:19 AM with Resident #11, she said she did not have an air mattress nor the Podus boot on her left foot. She said that nursing and maintenance staff came in that morning to change her bed, remove the foot board, and place the Podus boot on her left foot. She said that this bed and cushion on her left foot made her feel better. She said that it took staff about 3-4 hours to come; never in two hours. She stated if they came, one will come and then go look for another staff to help since she required more than one staff assist with the Hoyer lift. She said she used to refuse repositioning but had not refused lately. She said that she asked nursing staff to reposition her now. She said she cannot feel pain but pressure on the left side of body. She said she can turn herself back to right side but not all the way. She said she preferred to lay on right side. Resident #11 said that she would yell out to get staff attention because her call light is not always within her reach. Call light was observed clipped on her gown on the right side. She said that staff did that this morning. During an interview on 9/14/22 at 11:42 AM with GVN V, she said she had worked at the facility for about two weeks and is a recent graduate. She said that she worke on hall four. She said that Resident #11 often pulls her call light for assistance. She said that she checked on her even without the call light notification. She said that Resident #11 had complained of pain in her left arm and on her incision from her right below knee amputation. She said that CNAs are the main staff responsible for ADLs (activities of daily living) but that charge nurses can and will assist as well. She said that whenever a staff member performed a task for the resident, they should have ensured the call light was accessible to the resident. She said that CNAs and charge nurses should also be repositioning the residents who cannot do so themselves every two hours. She said that the charge nurses are responsible for ensuring that the resident's feet are floated properly, if required. She said that floating is meant to not only elevate the feet but to ensure that they are not touching the bed or foot board. She said it should be like hanging off the pillow or wedge. She said that Resident #11 had her foot board removed from her bed, but she is not sure why as it happened when she was no longer on shift on 9/13/22. She said she was aware that Resident #11 had an open wound on her right leg from a recent amputation, sacrum, and left heel. She said that Resident #11 prefered to lay on her right side being that she has pain on her left side. She said that facility has a wound care nurse and that none of the charge nurses performed this task. She said that if a resident admitted during their shift, the charge nurse was responsible for completing head to toe skin assessments. During an interview on 9/14/22 at 12:17 PM with CMA P, she said she is a certified medication aid but that she does assist with ADLs as she is also a CNA. She said that she provided care for residents with pressure ulcers by ensuring that she does a visual skin assessment during incontinence care and transfers. She said that she was not familiar with every area a resident has a pressure ulcer until she was on duty because this was not a task that CNAs perform. She said that once they noticed an abnormality, they informed the charge nurse immediately. She said that CNAs are responsible for positioning and if a resident requires two persons assist, then she would get the charge nurse to assist. During an interview on 9/15/22 at 9:27 AM with LVN N, she said that CNAs and charge nurses are were each responsible for ADLs and assistance with repositioning of residents. She said that she feelt that it was the responsibility of the charge nurse to ensure that this was done every two hours. She said that if a resident required two persons assist, then she always assisted the CNA on her shift. She said that if a resident was known to have difficulty with positioning themselves, nursing staff should also float the resident's heels by elevating with a pillow or foam wedge and keep the feet from touching the foot board or bed. She said that Resident #11 is not on her hall and has no knowledge of her care. During an interview on 9/15/22 at 10:15 AM with LVN T, she said that worked with Resident #11. She said that when she admitted a resident, she was aware that she was supposed to complete the initial skin assessment from head to toe, assess for flight risks, medication ordered, and fall risks. She said that the assessments are logged into the resident's chart in the electronic charting system. She said that as a charge nurse, she would complete the skin assessment but not the ulcer assessment . She said that this was done by the treatment nurse or DON if no treatment nurse is available. She said that the Nurse Practitioner or Treatment Doctor would also complete if they are notified. She said that the Nurse Practitioner and Treatment Doctor came to the facility and performed care. This was done one a week. She said that there was no one person more responsible for ADLs, transfers, or repositioning. She said that she kept a timer on her iPad for every two hours to remind herself to check positioning of the residents that required assistance with that task. She said that when she admitted Resident #11 from her recent hospitalization on [DATE], she noted on her skin assessment that she had three wounds: one on her sacrum, one on her left foot on the bottom of the heel, and one on her amputation. She said that she did not note or notice any other skin issues on the left foot. She said the risk for not completing an accurate skin assessment was that the resident could become [CONDITION(S)], get an infection, or not receive the treatment they need. LVN T could not distinguish between floating and elevating the foot. She described twice placing a pillow under the ankle area. She said that the foot does not hang over the pillow. She said that she observed Resident #11 in an air flow bed but that she could not stay in the bed. She said it was the facilities policy to not have residents in these types of beds because they could slip and become a fall risk. During an interview on 9/15/22 at 10:37 AM with CNA W, she said she worked with Resident #11 and provided assistance with ADLs to residents. She said that she did incontinence care and if she notices any abnormality on the skin, she would inform the charge or treatment nurse immediately to come assess. She said that she was not responsible for wound care but that she can assist with positioning and repositioning if a resident needed it. She said that Resident #11 and two other residents required Hoyer transfer, and two person assists, and she would get the nurse to assist her with them. She said that repositioning should be done every two hours if a resident cannot do this themselves. She said that she had not noticed any abnormalities in Resident #11's skin and that she was aware that she had pressure ulcers on her sacrum, buttock, and an open wound from her amputation. During an interview on 9/15/22 at 11:22 AM with Regional Corporate RN E, she said was currently in the facility, as the DON was not available. She said that she expected whichever nurse admitted a resident, new or from the hospital, to complete a full skin assessment from head to two within 24 hours. She said the tool used for that assessment was located in the electronic records system. She said that any skin issues the nurse found should be discussed with the treatment physician, treatment nurse, ADON, and DON as soon as possible. She said the risk for that not being completed timely or accurately was that a resident could not receive care needed for something not identified, treatment could be delayed, or infection. She said that it was not currently in policy but she would expect the treatment nurse to also complete an assessment the next day if the charge nurse documented something on the skin assessment. She said that an ulcer assessment would then be done by the treatment nurse, ADON, or DON. She said that that assessment should be completed within 24 hours of the admission or knowledge of skin concern. She said that another risk could be that there was no clear identification of what care the resident needed, could have deteriorated, and it could be unknown the progression of the wound. She said that the DON and ADON has been off work since last Friday, 9/9/22 and that this was the day that Resident #11 readmitted from the hospital. She said that the facility had a treatment physician who came once a week to assess residents. She said that he was there on Monday, 9/12/22, but only assessed Resident #11 for her sacrum, buttocks, and amputation. She said that the initial assessment completed by the admitting charge nurse was inaccurate in that it read right foot (resident has below knew amputation) and there was no indication of any skin concerns on the left foot. She said that the resident did not have any treatment provided for the wounds on her left as a result of this error. She said that she knows floating to mean nothing underneath and elevating means that there can be something underneath the foot. During an interview on 9/15/22 at 12:22 PM with the Administrator, he said that he expected any nurse that admitted a resident, newly or from hospital, to complete a full initial skin assessment within 24 hours and accurately. He said that he expected it to be full head to toe assessment. He said the risk of that not being done accurately or timely would be that a resident could get an infection, not treated timely, and could result in [CONDITION(S)] and re-hospitalization . Record review of facility's policy titled, Skin Integrity Management dated 10/5/16, revealed that: 1. If wound is noted, perform an assessment, and initiate a treatment plan as soon as possible. Document in resident's chart, area of change, who you notified, and treatment applied. 3. Wound care should be performed as ordered by the physician. 5. Use pillows or foam wedges to keep bony prominences from direct contact. 20. Additional heel protection may be needed even if a resident is on a pressure reducing/relieving device. Use pillows to off-pressure heels. Record review of facility's policy titled, Skin assessment dated [DATE] revealed that It is the policy of this facility to establish a method whereby nursing can assess a resident's skin integrity to allow of appropriate intervention be initiated in a timely manner. Procedure: 1. All new admits and residents returning from a hospital stay will have a head-to-toe skin assessment completed. If the facility Treatment Nurse/designee is available, he/she should complete the assessment within four (4) yours of the resident's arrival at the facility. If the Treatment Nurse/designee isn't available, then the charge nurse should complete the assessment within four (4) hours of the resident's arrival at the facility .2. All residents should have a skin assessment on a weekly basis completed in PCC. 3. If the resident has any type of ulcer (pressure injury, arterial, venous, diabetic) an ulcer assessment should be completed at least weekly. Record review of facility's policy titled, Pressure Injury: Prevention, Assessment, and Treatment dated 8/12/16 revealed that 1. Nursing personnel will continually aim to maintain the skin integrity, tone, turgor, circulation to prevent breakdown, injury, and infection .

Based on interview and record review, the facility failed to ensure necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new pressure injuries from developing was provided for 1 of 4 residents reviewed for pressure injuries. (Resident # 1) The facility did not provide scheduled treatment for [REDACTED]. The facility did not complete 6 scheduled treatments between 1/5/21 and 1/15/21. The facility did not obtain a dietary consult for Resident #1 when he developed a pressure injury according to their facility policy. The facility did not identify and treat a pressure injury on Resident #1's right heel. This failure could place residents at risk for new development or worsening of existing pressure injuries, infection, pain, and decreased quality of life. Findings included: The face sheet for Resident #1 indicated he was admitted to the facility on [DATE], and readmitted on [DATE]. An order summary report dated 1/25/21 indicated Resident #1, re-admitted [DATE], was [AGE] years old and had [DIAGNOSES REDACTED]. An order dated 9/29/20 indicated Resident #1 may have pressure relieving mattress every shift. An order dated 1/17/21 indicated Resident #1 may have low air loss mattress set at 200 (units unspecified). The MDS dated [DATE] indicated Resident #1 was readmitted to the facility on [DATE] from a hospital. Resident #1 had impaired cognition, was usually understood and usually understood others. The assessment indicated Resident #1 did not reject evaluation or care. He was totally dependent on physical assistance of two staff for bed mobility, dressing, toileting, and bathing, and required extensive assistance of one staff for eating and drinking. Resident #1 was always incontinent of bowel and bladder. The assessment indicated Resident #1 was at risk of developing pressure injuries and had two Stage II pressure injuries that were not present on admission. A care plan reviewed by the facility 1/18/21 indicated Resident #1 had a potential for pressure ulcer development due to cardiac [DIAGNOSES REDACTED]. The care plan was revised on 1/21/21 (after surveyor intervention) to reflect an unstageable sacrum wound identified on 1/12/21. The care plan did not address the pressure injuries identified on the resident's buttocks and right heel on 12/30/20 and 1/1/20. A nursing progress note dated 12/21/20 at 11:35 a.m. indicated Resident #1 had tested positive for COVID-19, and that his responsible party had been notified. During an interview on 1/28/21, the administrator said Resident #1 was transferred to the COVID unit on 12/22/20. The administrator said Resident #1 was sent to the hospital on [DATE], and when he returned he was readmitted to the COVID unit and remained there until his transfer to the hospital on [DATE]. A progress note dated 12/30/20 at 6:41 p.m., indicated Resident #1 was transferred to the emergency room to evaluate and treat COVID-19 Positive Fatigue progressed to lethargic symptoms. A weekly skin assessment dated [DATE], completed by LVN A, indicated Resident #1 had a fluid filled blister to buttocks 3.1 x 4 cm and a burst blister 2.1 x 2 on the back of the right heel. During an interview on 1/21/21 at 4:01 p.m., LVN A said Resident # 1 was sent to the hospital via ambulance on 12/30/20 because he was not eating or drinking. She said she completed a skin assessment before he went to the hospital and noted a fluid filled blister on his buttocks and a burst blister on his right heel. She said the facility protocol was to apply skin prep (a liquid film-forming dressing that, upon application to intact skin, forms a protective film) to blisters. She said she followed the facility protocol. She said the NP was in the facility that day and was notified the resident was not eating or drinking and the blisters identified on his buttocks and heel. She said the NP said to send the resident to the hospital. During an interview on 1/21/21 at 6:00 p.m., LVN A said she did not document anything in her progress notes related to the blister on Resident #1's heel, or whether there were 1 or 2 blisters on his buttocks when she completed his skin assessment on 12/30/20. A nursing progress note dated 1/1/21 at 5:43 a.m., written by LVN B, indicated Resident #1 arrived at the facility from the hospital at 4:00 a.m. via EMS. The note indicated Resident #1 had a large skin break to his sacral area. An initial skin assessment dated [DATE] at 4:56 a.m. completed by LVN B indicated Resident #1 had a pressure skin tear to the sacral area on the left buttock measuring 7.0 x 7.5 cm and on the right buttock measuring 7.0.x 7.5 cm. The assessment indicated an ulcer assessment should be completed. The initial skin assessment did not include the stage of the wound, depth and description. The skin assessment did not include any information about the resident's right heel. During a telephone interview on 1/26/21 at 12:04 p.m., LVN B said she worked for a nurse staffing agency, and worked at the facility from 12/31/20 through 1/6/21 on the 6 p.m. to 6 a.m. shift. LVN B said she worked on the COVID-19 positive unit the during that time. LVN B said Resident #1 was transferred from the hospital to the facility on [DATE], and arrived at approximately 4:30 a.m. She said she completed a skin assessment and Resident #1 had two Stage 2 pressure ulcers on his coccyx, measuring 7.0 cm x 7.5 cm on the left buttock and 7.0 cm x 7.5 cm on the right buttock when he arrived from the hospital. LVN B said she could not accurately measure depth. She said there was no documentation regarding the wounds and no orders for wound care from the hospital. She said Resident #1 had a dressing on the wounds when he arrived. She said the dressings were removed and she observed the wounds. She said the wounds appeared red, had no necrotic (dead skin) area, no drainage, and no odor. She said they did not appear to be infected. LVN B said she used the term pressure skin tear because it was outside the scope of her practice to diagnose, so she tried to describe it as best she could. LVN B said based on her experience the wounds appeared to be pressure wounds and not skin tears. She said she was not aware an ulcer assessment was indicated due to the information she had entered on the skin assessment. LVN B said she did not complete an ulcer assessment for the wounds. LVN B said she continued to take care of him for three or four nights until his room assignment changed. She said she changed his dressing one other time about 2 days later, because it was soiled. LVN B said there was no change in the wound the second time she saw it. She said she looked at Resident #1's heels when she did the assessment on 1/1/21, but could not remember what they looked like. She said Resident #1 was being turned every 2 hours, and that he had a regular mattress both times she saw him. LVN B said there were no positioning aids or cushions being used to help offload pressure. She said staff was using pillows. She said staff tried to float Resident #1's heels, but the pillow supply was limited, so staff would alternate the pillow between his legs and his heels. LVN B said when the CNAs made rounds every two hours they would change the location of the pillow from his heels to his legs and vice versa. She said the CNAs were able to turn and reposition Resident #1 without her help. LVN B said alternating the placement of the pillow between Resident #1's heels and legs was just common sense, trying to work with what we had. A physician order [REDACTED]. A weekly skin assessment dated [DATE] at 2:53 p.m., completed by LVN A, indicated Resident #1 had a pressure ulcer, site unspecified, and that an ulcer assessment had been completed. The skin assessment did not include any findings regarding Resident #1's right heel. A weekly ulcer assessment dated [DATE] at 2:55 p.m., completed by LVN A, indicated Resident #1 had a Stage II pressure ulcer 7 cm x 7.5 cm x 0 depth on his left buttock. The assessment indicated the most severe tissue type present was [MEDICATION NAME] with new pink or shiny tissue, the amount of exudate (drainage) was light, the color of the exudate was bloody, and the character of the exudate was clear. The assessment indicated the surrounding skin color was pink, and a mild odor was present. The assessment indicated the wound had not declined and no new orders were received. The assessment indicated the wound was present on admission. A weekly ulcer assessment dated [DATE] at 3:04 p.m., completed by LVN A, indicated Resident #1 had a Stage II pressure ulcer 7 cm length x 7.5 cm wide x 0.1 cm depth on his right buttock. The assessment indicated the most severe tissue type present was [MEDICATION NAME] with new pink or shiny tissue, and there was no exudate. The assessment indicated the surrounding skin color was pink, and a mild odor was present. The assessment indicated the wound had not declined and no new orders were received. The assessment indicated the wound was present on admission. A review of weekly ulcer assessments for the week of 1/5/21 for Resident #1 did not contain an assessment for Resident #1's right heel. During an interview on 1/21/21 at 4:01 p.m., LVN A said she completed a weekly skin assessment and weekly ulcer assessment for Resident #1 on 1/5/21. LVN A said she called the DON because as an LVN she could not stage a pressure ulcer. She said the wounds did not look infected, but it was significantly larger than the fluid filled blister she documented during the skin assessment completed on 12/30/20 prior to the resident going to the hospital. LVN A said the wound did not have an odor and there was no drainage. She said she notified the DON via telephone. A Wound Administration Record (WAR) for Resident #1's for January 2021 indicated from 1/2/21 through 1/12/21, Resident # 1's wound care treatment was to cleanse with normal saline, apply silver with collagen and apply a dry dressing daily on the day shift. The WAR indicated there was no wound treatment administered on the following days: *1/7/21 *1/8/21 *1/9/21; and *1/10/21 An order recap record dated 1/1/21 through 1/31/21 for Resident #1 indicated the following: *1/12/21 apply Santyl (wound healing) topically to the sacrum 1 time daily with start date 1/13/21. * 1/13/21 discontinue Santyl topically to sacrum 1 daily. * 1/13/21 clean the sacrum with wound cleanser, pat dry, apply calcium alginate and [MEDICATION NAME] and cover with dry dressing every day. Start date 1/14/21. The WAR for January 2021 indicated Resident # 1's wound care treatment was wound cleanser, calcium alginate and [MEDICATION NAME] (wound healing), cover with dry dressing every day from 1/13/21 through 1/17/21 on the day shift. The WAR indicated there was no wound treatment completed on the following days: *1/14/21; and *1/15/21 Employee punch sheets dated 1/7/21 through 1/15/21 indicated the following: *LVN C worked 1/7/21 and 1/8/21 on the 6:00 a.m. to 6:00 p.m. shift; *LVN D worked 1/9/21, 1/10/21, 1/11/21, 1/14/21, and 1/15/21 on the 6:00 a.m. to 6:00 p.m. shift. During an interview on 1/21/21 at 5:53 p.m., LVN C said she worked for the facility and worked the 6:00 a.m. to 6:00 p.m. shift. She said she was Resident #1's nurse on 1/7/21 on the day shift. LVN C said she did not do any kind of wound treatment for [REDACTED]. LVN C said she thought whoever was looking at wounds was responsible for his wound care. LVN C said this was the first she heard of the resident having a wound. During a telephone interview on 1/22/21 at 5:40 p.m., LVN D said he did not recall the specific dates he had taken care of Resident #1. He said he completed Resident #1's wound care if it was ordered. He said Resident #1 had an open area on his coccyx, and he did not recall any other wound. LVN D said if Resident #1's wound was declining he would have noticed it. LVN D said he did not notice that the wound had an odor, but he might not have noticed it because he was wearing an N95 mask. He said none of the CNAs told him the wound was getting worse. LVN D said if the wound were worsening he wound have notified the ADON, the DON, and the doctor. He said there were also agency nursing staff working on the COVID-19 unit at times. He said if there was an agency nurse working, he would ask them to do the wound care. During an interview on 1/25/21 at 2:43 p.m., LVN D said he did not recall what dates he asked agency nurses to complete wound care. He said if the agency nurse had performed the wound care, it would be their responsibility to document. He said he heard there was a problem with agency staff documenting what they did, but he did not monitor to see if the agency staff were documenting the wound care. During an interview on 1/28/21 at 1:05 p.m., the ADON said she worked on the COVID unit on 1/7/21 and 1/8/21. She said she worked with LVN C to take care of residents. She said there were no assigned duties to indicate who was responsible for a specific task. The ADON said she did not know if wound treatments were completed or not, but that if she did not document it was done, she did not do it. A weekly skin assessment dated [DATE] at 3:11 p.m., completed by LVN A indicated Resident #1 had a bruise to his right heel measuring 3 cm x 0.8 cm and pink/purple in color. The assessment indicated Resident #1 had a pressure ulcer, and that an ulcer assessment should be completed. A weekly ulcer assessment dated [DATE] at 4:47 p.m., completed by LVN A, indicated Resident #1 had an unstageable pressure ulcer located in the sacral area. The assessment indicated the ulcer was 12 cm long x 12 cm wide, with a depth unable to determine. The most severe tissue type was eschar (black, brown, or tan tissue adhered to the wound), and other tissue types present included slough (yellow or white tissue adhered to the wound). The assessment indicated the amount of necrotic tissue was approximately 75%. The assessment indicated the wound had a moderate amount of yellow exudate which was opaque or purulent. The surrounding tissue was bright red, and a mild odor was present. The assessment indicated a pressure relieving cushion in his wheelchair and had pillows to float heels. The assessment did not indicate the resident had a pressure relieving mattress or low air loss mattress. During an interview on 1/21/21 at 4:01 p.m., LVN A said when she completed the ulcer assessment on 1/12/21. She said Resident #1's sacral ulcer had merged into one big wound. LVN A said the wound had an odor and contained yellow slough. LVN A said she notified the NP, who wanted to order Santyl for the wound, but the pharmacy indicated it would not be available for a couple of days. LVN A said the NP ordered [MEDICATION NAME], and instructed if the wound did not improve after a couple of days she would switch to Santyl. LVN A said the next time she did the treatment for [REDACTED]. LVN A said the skin on the right heel was not open, but there was a round bruise around it. LVN A said she continued to put skin prep on his right heel. The clinical record for Resident #1 from 1/12/21 to 1/17/21 did not indicate the NP or physician was notified the resident's wound was not improving. A Braden scale for predicting pressure sore risk dated 1/16/21 indicated Resident #1 was at high risk of developing pressure injuries. ADL documentation of meal intake for Resident #1, dated January 2021, indicated the following: *1/1/21 no meal intake documented *1/2/21 no meal intake documented *1/3/21 no meal intake documented *1/4/21 no meal intake documented for breakfast or lunch, dinner 76-100% eaten *1/5/21 no meal intake documented *1/6/21 no meal intake documented *1/7/21 no meal intake documented *1/8/21 breakfast 0% eaten, offered substitute or supplement; lunch 26-50% eaten; no meal intake documented for dinner *1/9/21 no meal intake documented *1/10/21 no meal intake documented for breakfast or lunch; 0% intake for dinner, offered substitute or supplement *1/11/21 no meal intake documented for breakfast or lunch; 0% intake for dinner, offered substitute or supplement *1/12/21 breakfast 51-75% eaten; lunch 76-100% eaten; dinner 0%, substitute or supplement offered *1/13/21 breakfast, lunch, and dinner all refused *1/14/21 breakfast 0% intake, substitute or supplement offered; lunch 51-75% eaten; dinner refused *1/15/21 breakfast refused, lunch 0% intake, dinner 76-100% eaten *1/16/21 breakfast 51-75% eaten; lunch 76-100% eaten; dinner 0% intake *1/17/21 breakfast 26-50 % eaten; lunch 0% intake, substitute or supplement offered; dinner refused A weight loss report, dated 1/25/21, indicated Resident #1 had an 11.1% weight loss (28.2 lbs.) when comparing his current weight (226.6 lbs., on 1/7/21) to his previous weight 254. 8 lbs. on 12/1/20. A progress note dated 1/17/21 at 5:58 p.m., indicated Resident #1 had been transferred to the hospital related to decrease oxygen levels, respiratory congestion, vomiting, elevated temperature and decreased blood pressure. An emergency room record dated 1/17/21 indicated Resident #1 had a urinary tract infection and altered mental status. The record indicated the resident had a decubitus wound located on the sacrum approximately 7.6 cm x 20 cm with [DIAGNOSES REDACTED]tous (red) edges, macerated edges (light colored and wrinkled, soft skin due to exposure to moisture) and eschar, and was draining moderate amount of malodorous (bad odor), purulent (containing pus) drainage. The record also indicated the resident had an approximately 1.5 cm x 2.5 cm wound on his right heel with eschar and purulent drainage. A hospital progress noted 1/18/21 indicated Resident #1 had a wound on his coccyx that appeared quite deep, suspected to be a stage 4. The central area of the wound measured 6 x 6 cm and the entire area measured 15 x 15 cm. The note indicated the resident would receive debridement of the coccyx wound. A hospital debridement note dated 1/18/21 for Resident #1 indicated the physician completed a sharp debridement of the coccyx wound. The note indicated necrotic tissue was removed, but more needed to be removed. The note indicated Resident #1 could not maintain his oxygen saturation and his condition began to decline. A hospital debridement note dated 1/19/21 for Resident #1 indicated the physician completed a sharp debridement of the coccyx wound. The note indicated several layers of necrotic tissues was removed down to the level of the muscle. The note indicated the physician did not reach the base of the wound but could not finish due to resident having bowel movement and possible contamination of the wound. A hospital debridement note dated 1/20/21 for Resident #1 indicated the physician completed a sharp debridement of the coccyx wound. The note indicated he removed necrotic tissue down to the level of the muscle and the base of the wound was at the level of the bone. A hospital progress note dated 1/21/21 for Resident #1 indicted the wound was a stage 4 and was cleansed and packed with a wet to dry dressing. During an interview on 1/21/21 at 4:48 p.m., CNA E said she noticed a fluid filled blister near his gluteal fold, and a blister that had burst on his right heel on 12/30/21, before Resident #1 went to the hospital. CNA E said she notified LVN A who put something on it. CNA E said the next time she took care of Resident #1 was on 1/16/21. CNA E said there was a dressing on his bottom, and she did not see the wound. CNA E said she was not aware of any other wound on Resident #1. CNA E said the wound on Resident #1's bottom had a bad smell, like dead tissue. During an interview on 1/21/21 at 5:09 p.m., CNA F said she was working with CNA E to provide incontinent care when they saw the blister on his buttock on 12/30/20. CNA F said she did not recall exactly where the blister was located, just that it was somewhere on his bottom. CNA F said Resident #1 had to be turned every 2 hours, and at times he would resist and pull back or tighten up. CNA F said she did not recall any other wounds except for the wound on his bottom. CNA F said the sore on his bottom had a bad smell before he was transferred to the hospital on [DATE]. During an interview on 1/21/21 at 4:42 p.m., the regional nurse consultant said during the time Resident #1 was on the COVID unit, the treatment nurse was responsible for wound treatments, but she was unable to work because she had COVID-19. The nurse consultant said the charge nurses were responsible for completing wound care in the absence of the treatment nurse. The nurse consultant said according to the documentation, Resident #1's wound was getting worse between 1/5/21 and 1/12/21. She said she did not know if the policy indicated more frequent assessments if the wound was worsening, but whoever was doing the wound care should notify the physician if the wound was worsening. She said the care plan should be updated as soon as possible after a problem was identified. The nurse consultant said if there is no documentation, there is no evidence that the task has been completed. During an interview on 1/21/21 at 2:53 p.m., the DON said when the wound care or treatment record was blank, that meant the care was not done, or was not documented. The DON said skin assessments were supposed to be completed on every resident once a week. The DON said if a resident had an ulcer or wound there should be a separate assessment for each wound. The DON said it looked like the skin assessments and wound assessments were not being done. During an interview on 1/21/21, at 5:05 p.m., the ADON said she had not talked to the wound care doctor regarding Resident #1. The ADON said Resident #1 was not referred to a specialist for care of his sacral wound because he was on the COVID unit and the wound care physician would not come to the facility due to COVID-19. The ADON said the facility did not request a tele-med visit with the wound care specialist. During an interview on 1/22/21 at 12:41 p.m., the DON said her expectation was if a wound showed signs of getting worse, the nurse who noted the change should be responsible for notifying the physician at that time, rather than waiting for the next scheduled ulcer assessment. The DON said skin assessments were to be completed weekly, and if a resident had a pressure ulcer the ulcer assessment should be completed as well. The DON said when wound treatments are not completed they were flagged on the electronic Wound Administration Record (WAR). The DON said she did not know if the wound treatments had been completed for Resident #1 on 1/7/21, 1/8/21, 1/9/21, 1/10/21, 1/14/21, and 1/15/21, or the nurse failed to document the care. The DON said there should have been an ulcer assessment completed on 1/1/21 when LVN B documented the presence of an ulcer on the initial skin assessment completed on 1/1/21. During an interview on 1/22/21 at 1:19 p.m., the DON said the nurses assigned to care for Resident #1 were responsible for completing any wound care or treatments when he was on the COVID unit. The DON said signs of a pressure ulcer worsening would include an increase in size or depth, increased drainage, a foul odor, or change in color. The DON said any sign that a wound was worsening should prompt physician notification. The DON said for a referral to a wound care specialist, they would report findings to the resident's physician, and the physician would determine whether to make a referral or not. The care plan should be updated whenever a new problem becomes known. Resident #1's care plan should have been updated when the pressure ulcer was identified on 1/1/21, but it was not. The DON said the nurses are responsible for making sure skin and wound assessments are being completed. The DON said she started working at the facility on 1/4/21, and just learned how to run the report that showed uncompleted tasks on 1/19/21. The DON said the only pressure relieving device used for Resident #1 was an air mattress, and that he did not get out of bed. The DON said she was not sure if his heels were floated or not, because she did not see him. During an interview on 1/25/21 at 1:33 p.m., the administrator said she became the administrator for the facility on 12/28/20 but tested positive for COVID-19 the same day. The administrator said she worked on the COVID unit while she was positive and completed some administrative tasks. The administrator said the last day she worked on the COVID unit was 1/8/21. She said there were agency staff as well as facility staff working on the unit during that time. The administrator said LVN A or LVN D would be the facility nurses working on the unit, in addition to agency nurses. The administrator said it seemed as if they would divide the resident assignment among the agency nurses and the facility would stay at the station and follow up on things. The administrator said she was not aware of any issues with Resident #1 at the time. She said overall, like other residents with COVID-19, he did not have the will to move around and had no appetite. The administrator said, regarding resident care tasks, documentation is the proof of it being done. During an interview on 1/25/21 at 3:25 p.m., the nurse consultant said Resident #1's worsening pressure ulcer should have been detected before it became unstageable on 1/12/21. The nurse consultant said if the same person had done the wound care on a daily basis they should have recognized the wound was getting worse. The nurse consultant said the charge nurses assigned to the resident had personal responsibility for the wound treatment, but the ADON and DON should have been checking to make sure the treatments were completed. The nurse consultant said the facility did not refer Resident #1 to a wound care specialist because he resided on the COVID-19 positive unit and the wound care doctor would not go to the unit. The nurse consultant said the facility did not ask for a tele-med visit. The nurse consultant said Resident #1 was not referred for a dietary consult for wound care or weight loss. A facility policy titled Skin Integrity Management, revised 10/5/16 and presented to the surveyor as the facility policy for prevention and treatment of [REDACTED]. *If pressure causes changes in the resident's skin, it is the responsibility of the charge nurse to document on the 24 Hour Report form and initiate protocols for pressure sores. Notify the Treatment Nurse/designee, then do an assessment and initiate a treatment plan as soon as possible. Document in the resident's chart the area of change, who you notified, and treatment applied. *Correction of the resident's underlying medical, surgical, and/or nutritional problems must be accomplished if proper healing of pressure sores is to occur. See dietary Pressure sore/open wound protocols in the Dietary manual. Notify dietician of a resident at risk, or who has known skin breakdown. *Reposition residents at risk for pressure sore or with pressure sores at least every two hours. If unable to turn themselves, place on a specialty bed sleep surface. *Use pillows of foam wedges to keep bony prominences for direct contact *The Treatment Nurse/designee and the DON should add a written plan for the use of positioning devices and schedules to the care plan. *The presence of a pressure reducing device/specialty bed does not negate the need to turn/reposition the resident at least every two hours in order to prevent [MEDICAL CONDITION] and renal complications as well as pressure sores. *Any individual assessed to be at high risk for developing pressure ulcers should be placed when lying in bed on a pressure reducing device. *Additional heel protection may be needed even if a resident is on a pressure reducing/relieving device. Use pillows to off-pressure heel. *Care planning in response to risk prediction must be completed. Care planning in response to the presence of pressure sores must be completed. The DON or designee does this. *The Braden assessment should be completed on every resident on admission and as needed to assist in identifying potential at risk residents until completion of an MDS comprehensive assessment. The website http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ accessed 1/12/21 indicated: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue . Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed.

Based on observation, interview, and record review, the facility failed to ensure necessary treatment and services were provided, based on the comprehensive assessment, to prevent the development of new pressure ulcers and promote healing for 1 of 9 residents reviewed for pressure ulcers. (Resident #2) The facility did not provide interventions to prevent Resident #2 from developing an avoidable facility acquired unstageable pressure ulcer and 2 stage 2 pressure ulcers. The facility did not identify the unstageable pressure ulcer until the wound care physician identified it. Resident #2 was a high risk for developing pressure ulcers and had a history of [REDACTED]. This failure could place 31 residents who received preventive skin care at risk for the development of new pressure ulcers and 7 residents with pressure ulcers at risk for the development of new pressure ulcers or worsening of current pressure ulcers. Findings included: Physician orders [REDACTED].#2 was [AGE] years old, 1/20/17, with [DIAGNOSES REDACTED]. The orders indicated treatments for 2 stage 2 pressure ulcers with a start date of 5/6/17: Cleanse left and right buttock wound with wound cleanser and apply [MEDICATION NAME] dressing every 3 days and as needed. An MDS dated [DATE] indicated Resident #2 had clear speech, was understood, and had clear comprehension with moderate cognitive impairment. There were no indicators of resistance to care. She required extensive assistance of 2 for bed mobility, transfers, and was frequently incontinent of bowel and bladder. She had a stage 2 pressure ulcer identified on 3/9/17. Skin and ulcer treatments included a pressure reducing device for her bed and pressure ulcer care. Turning and repositioning and providing a pressure reducing device for her chair were left unchecked. A Care Plan with an initiation date of 11/22/16 indicated Resident #2 had bowel and bladder incontinence at times and would be free of skin breakdown. Interventions included check for resident every two hours and apply barrier cream after each incontinent episode. The care plan did not address the 2 stage 2 pressure ulcers on the resident's buttocks or the stage unstageable pressure ulcer of the sacrum. Nursing notes dated 5/6/17 at 3:33 p.m. indicated Resident #2 had 2 'new' open wounds on the resident's buttock identified during incontinent care. The resident's left buttock wound measured approximately 1.0 cm x 2.5 cm and her right buttock wound measured approximately 0.5 cm x 0.5 cm. New orders were received to cleanse with wound cleanser, pat dry, and apply [MEDICATION NAME] dressing every 3 days and as needed until resolved. There was no description of the surrounding skin, wound base, or depth of the 2 open wounds. A Braden Scale dated 5/26/ indicated Resident #2 was at mild risk for developing pressure ulcers. A Weekly-Ulcer Assessments dated 5/25/17 indicated Resident #2 had a stage 2 on her right buttock. There were no other pressure ulcers identified at the time of this assessment. A Weekly-Ulcer Assessments dated 5/29/17 indicated Resident #2 had a stage 2 on her left buttock. There were no other pressure ulcers identified at the time of this assessment. Nursing notes dated 5/31/17 at 4:41 p.m. (designated a late entry for 5/30/17) indicated wound care was provided Resident #2 for the pressure ulcers on her left and right buttock. There were no other pressure ulcers noted. Nursing notes dated 6/2/17 indicated Resident #2 had a noticeable decline in bed mobility, gait, transfers and wheelchair mobility requiring more assistance for ADLs. A Weekly-Ulcer Assessments dated 6/7/17 indicated Resident #2's left buttock pressure ulcer healed and the skin around the wound was clear; right buttock pressure ulcer healed and the skin around the wound was clear. During an interview on 6/13/17 at 10:55 a.m., LVN A said Resident #2 had skin breakdown on her buttocks that healed. She said she saw an area on her coccyx (sacral area), but she was not sure if the wound was a pressure ulcer or a shear. A Weekly-Ulcer assessment dated [DATE] indicated Resident #2 developed a new in-house unstageable pressure ulcer of the sacrum, measuring 6.0cm x 0.3.cm x 0.2 cm. The physician was notified and referred Resident #2 to be seen by a wound care physician. A Wound Care Specialist Initial Evaluation dated 6/7/17 indicated Resident #2 had the following pressure ulcer: Site #1 - *Unstageable DTI of her sacrum measuring 6.0cm x 0.3cm x 0.2 cm with light serous drainage. 70% of the wound bed was covered with thick necrotic tissue. The treatment was Santyl once daily covered with a dry protective dressing. The evaluation recommendations included to reposition per facility protocol and off-load the wound. The resident had surgical excisional debridement of the necrotic tissue. Nursing notes dated 6/7/17 at 8:25 a.m., the DON indicated new orders were received to discontinue treatment to Resident #2's right and left buttocks and to cleanse her coccyx (sacral area) with wound cleanser, pat dry, apply Santyl to crease of buttocks, and cover with dry dressing every day. During an observation on 6/13/17 at 9:05 a.m., 9:30 a.m., and 11:00 a.m., Resident #2 was sitting in a wheelchair, with a blue covered cushion in the seat. The cushion was flat with no significant pressure relief noted. During an observation on 6/13/17 at 12:30 p.m., Resident #2 was sitting in her wheelchair in the dining room and staff assisted with her meal. She was sitting on a thin flat cushion in her wheelchair, but it was not providing pressure relief. During an observation on 6/13/17 at 1:40 p.m. Resident #2 was sitting in her wheelchair outside the nursing station. During an interview on 6/13/17 at 2:00 p.m., CNA B indicated he was not sure what time he got Resident #2 out of bed to the wheelchair that morning. He said she should be turned every 2 hours and should not be in a sitting position for greater than an hour at a time without repositioning. CNA B did not affirm he repositioned Resident #2 every one hour while she was up that morning. During an observation and interview on 6/13/17 at 1:55 p.m., Resident #2 was in her bed lying on her back on a foam mattress with a mattress bolster cover. She responded that her pain in her buttocks was better since she was lying down. CNA B exposed Resident #2's sacral area after releasing the incontinent brief. Resident #2 had a large reddened area on her right ischium (buttock) and a large reddened area of the left ischium. The DON palpated the area of redness over the resident's right and left ischium with slow blanching noted. A dressing on Resident #2's sacral area was dated 6/12/17 with an area of redness noted at the top edge of the dressing. Resident #2 was positioned back onto her back with no off-loading for her sacral area provided. During an observation and interview on 6/13/17 at 3:17 p.m., Resident #2 was lying on her back in bed on a foam mattress with a mattress bolster cover. CNA D and LVN A repositioned Resident #2 onto her right side. LVN A cleansed the resident's sacral pressure ulcer. The skin around the sacral wound was macerated with slowly blanching dark redness surrounding the area measuring 10.0 cm x 7 cm. LVN A measured the following pressure ulcers: Site #1 *Unstageable on her sacral area measuring 1.5 cm x 1.3 cm x 0.2 cm with yellow slough covering 40 % of the wound bed. Site # 2 *New stage 2 on her sacral area (above the unstageable to the left) measuring 0.9 cm x 0.9 cm x < 0.1 cm, with well-defined wound margins and a red wound bed. Site #3 *New stage 2 on her right upper buttock measuring 0.3 cm x 0.3 cm x 0.1 cm with well-defined wound margins and a pink wound bed. LVN A said the discoloration and the two new open pressure ulcers were not present on Friday, June 9th. LVN A said they were getting Resident #2 up more often, but she should not be sitting on her buttocks with this skin breakdown. During an observation on 6/14/17 at 7:05 a.m., Resident #2 was sitting upright at 90º in her bed, head slumped forward sleeping. Resident #2 was on a foam mattress with a mattress bolster cover. During an interview on 6/14/17 at 7:35 a.m., the DON said Resident #2 was lying on a normal therapeutic mattress with a mattress bolster cover. During an observation and interview on 6/14/17 at 7:40 a.m., the wound care physician turned Resident #2 onto her right side and Resident #2 did not participate in the repositioning. The wound care physician assessed the resident's pressure ulcers as follows: Site #1 *Unstageable on her sacrum had defined wound edges and the wound bed was covered by yellow slough. The physician did not cleanse the wound prior to taking the following measurements: 1.4 cm x 1.2 cm. He said the depth was 0.2 cm, although he did not measure the depth. The resident's surrounding skin was red, dimpled, and macerated with peeling skin. The physician said the discoloration was most likely caused by the [MEDICATION NAME] dressing that was similar in size and shape to the macerated skin around the pressure ulcers. He said the area of the sacrum should be offloaded and Resident #2 should not be on her back or in a chair for more than two hours at a time. Site #2 *New stage 2 on her upper left sacral area measuring 1.0 cm x 0.5 cm x 0.1 cm with well-defined wound margins and a pink moist wound bed. Site #3- *The physician rubbed her right upper buttock stage 2 pressure ulcer. He said it was probably due to maceration. A Wound Care Specialist Initial Evaluation dated 6/14/17 indicated Resident #2 had the following pressure ulcers: Site #1 - *Unstageable (due to necrosis) of sacrum measuring 1.4 cm x 0.4 cm x 0.2 cm with light serous drainage. 90% of the wound bed had thick adherent necrotic tissue. The treatment was Santyl applied and covered with a dry protective dressing once daily. The evaluation recommendation included to reposition per facility protocol and off-load the wound. Site #2- Initial assessment 6/14/17 *Stage 2 (new) of the sacrum measuring 1.5 cm x 1.0 cm x 0.1 cm with light serous drainage. The treatment was to apply a dry protective dressing once daily. The evaluation recommendation included to reposition per facility protocol, off-load the wound, and a Group-2 mattress (low air loss mattress). Site #3- *The wound care physician did not address the stage 2 on her right upper buttock. During an observation on 6/14/17 at 7:55 a.m., Resident #2 was on her back with the head of bed elevated 90 degrees. The resident was not on a Group 2 (low air loss mattress). During an observation on 6/14/17 at 8:15 a.m., Resident #2 remained on her back with the head of bed elevated 90º. She had a glass of milk in her right hand and the glass began to tremble as she said her buttocks was hurting so bad. She said she was up in the wheelchair on 6/13/17 from breakfast until she was put to bed after lunch. During an interview on 6/14/17 at 8:10 a.m., CNA C said Resident #2 complained of pain in her buttock and she informed LVN A that Resident #2 needed pain medication. During an observation on 6/14/17 at 8:18 a.m., after surveyor intervention, the DON asked Resident #2 if she was in pain and Resident #2 said her buttocks was hurting. The DON let the head of the resident's bed down about 10º, but did not reposition the resident to off load her buttocks. The DON left the room to get the nurse. During an observation on 6/14/17 at 8:19 a.m., LVN A asked Resident #2 if she was having pain in her buttocks. Resident #2 said yes. LVN A left the room, but she did not off load Resident #2 off her buttocks or lower the head of bed. During an observation on 6/14/17at 8:52 a.m., 9:25 a.m., and 9:55 a.m., Resident #2 remained on her back with head of bed elevated. She still remained on a foam mattress with the mattress bolster cover. During an interview on 6/14/17 at 11:25 a.m., the DON said residents who have sacral ulcers should be offloaded to prevent further breakdown and repositioned every 2 hours. During an interview on 6/14/17 at 1:58 p.m., the MDS coordinator said she did not know about the pressure ulcers to Resident #2's sacral area. She said she was off last week and had not been informed. She said she wrote the care plans and had not addressed the pressure ulcers. During an interview on 6/14/17 at 3:40 p.m., the DON said she was unaware Resident #2's pressure ulcers were not care planned. She said she expected staff to turn and reposition residents who were not able to reposition themselves at least every 2 hours. The DON said she should have lowered the resident's bed when she complained of pain in her buttocks and she would in-service staff. During an interview on 6/14/17 at 1:59 p.m., the corporate LVN said she updated Resident #2's care plan to reflect the pressure ulcers on 6/13/17 after surveyor intervention. The website, www.npuap.org/resources, accessed 6/27/17 indicated: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed . A Wound Care Poly and Procedure with a revision date of 10/5/16 indicated: .Reposition residents at risk for pressure sore or with pressure sores at least every two (2) hours, if unable to turn themselves, place on a specialty bed sleep surface (i.e., equalizer, waffle mattress, etc.) .Use pillows or foam wedges to keep bony prominences from direct contact. .Maintain the head of the bed at the lowest degree of elevation consistent with medical conditions and other restrictions. Limit the time the head of bed is elevated. This position increases shearing forces and direct pressure over the sacral-coccyx area. (Not more than 30 degrees elevation recommended.) Any person at risk for developing a pressure ulcer should avoid uninterrupted sitting in any chair or wheelchair. The individual should be repositioned, shifting the points under pressure at least every hour or be put back to bed if consistent with overall resident management goals. Individuals who are able should be taught to shift weight every 15 minutes. For chair-bound individuals, the use of a pressure-reducing device such as those made of foam, gel, air, or a combination is indicated (waffle cushions, foam, etc.) . .Positioning of chair-bound individuals should include consideration of postural alignment, distribution of weight, balance and stability, and pressure relief. .The Treatment Nurse/designee and the DON should add a written plan for the use of positioning devices and schedules to the care plan. .The presence of a pressure reducing device/specialty bed does not negate the need to um/reposition the resident at least every two (2) hours in order to prevent [MEDICAL CONDITION] and renal complications as well as pressure sores. Consult the Treatment protocols for proper device to use . A CMS 672 dated 6/12/17 indicated 31 residents were receiving preventative skin care and 7 residents had pressure ulcers.

Based on observation, interview, and record review, the facility failed to ensure supervision and assistance devices were provided to prevent accidents, for 1 of 6 residents reviewed for accidents. (Resident # 1) The facility did not prevent Resident #1, who had a history of [REDACTED]. Resident #1 was found outside the facility. He had a broken jaw and facial injuries. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 6 residents with behaviors that included wandering at risk for accidents and injury. Findings included: 1. Physicians orders dated [DATE] indicated Resident #1 was an [AGE] year old male, readmitted on [DATE], with [DIAGNOSES REDACTED]. The current MDS, dated [DATE], for Resident #1 indicated he was independent for walking and locomotion, was often confused, and required a cane. A physician order [REDACTED].#1 had a wander guard in place due to increased confusion and exit seeking behaviors. The Care Plan, dated [DATE] indicated Resident #1 was an elopement risk / wanderer and had impaired safety awareness. Interventions to be used included: distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, provide structured activities; toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. On [DATE], the wander alert bracelet was put in place. A physician order [REDACTED].#1 was admitted to hospice with a [DIAGNOSES REDACTED]. During an interview on [DATE] at 1:45 p.m., the medical records manager said Resident #1 was moved to a different room on [DATE] and he was confused about where his room was. She said he kept going from door to door trying to find his room. She informed his aide to watch him because she knew the exit door on Hall 5 was being used as an exit and he appeared to be trying to leave. During an interview on [DATE] at 1:09 p.m., CNA C said on [DATE], Resident #1 kept asking where his room was because he had recently been moved and was confused. CNA C said she was told by the medical records manager to keep an eye on Resident #1 and she did the best she could. She said Resident #1 was very confused about where his room was, due to the renovation. During an interview on [DATE] at 9:46 a.m., LVN E said part of Resident # 1's behaviors were exit seeking and also roaming. She said on [DATE], she saw Resident # 1 come out of his room and turn toward the exit door so she verbally redirected him. She said he asked her later if he could go out the exit door and she told him no. LVN E said when she was called out to render aid to Resident #1 for his injuries, she exited through the Hall 5 exit door, but the alarm did not sound. During an interview on [DATE] at 12:37 p.m., Housekeeper B said she observed Resident #1 on [DATE] at the exit door on Hall 5. She said he appeared to be confused. Housekeeper B said Resident #1 had recently been moved to a different room. His room was previously located on Hall 4. During a telephone interview on [DATE] at 4:34 p.m., Housekeeper D said on [DATE], Resident #1 was standing by the exit door on Hall 5 when Housekeeper D came inside the door around 9:30 a.m. She said she took him by the hand and took him to the nursing station and told LVN E he is trying to get out. Housekeeper D said LVN E told staff to keep an eye on Resident #1. She said Resident #1 was confused. During an interview on [DATE] at 4:45 p.m., CNA A said on [DATE], she found Resident #1 on the ground at 12:35 p.m. She said she was on her way to another job and that is how she knew the time. CNA A said Resident # 1 was confused about where his room was because he had been moved due to facility renovations. She said he was more confused that day than normal and kept watching staff go in and out of the exit door on Hall 5. CNA A said Housekeeper D informed LVN E that Resident #1 was watching the door and was confused. She said the exit door on Hall 5 was not locked because she saw the maintenance supervisor unlock it to re-route the laundry attendants. An Incident Report, dated [DATE], indicated at 12:35 p.m., CNA A found Resident # 1 outside on the sidewalk near the Hall 5 exit door. CNA A entered the building through the exit door at the end of Hall 5 and the alarm did not sound. CNA A got the nurse and staff to assist Resident #1 was noted to have blood on his face and arms, a laceration to his left eyebrow, a hematoma to his left eye, and multiple skins tears to his bilateral upper extremities. Resident #1 was lying on his cane. Hospital records dated [DATE] indicated Resident #1 was admitted to the emergency roiagnom on [DATE] at 1:09 p.m. and discharged at 3:28 p.m. with a [DIAGNOSES REDACTED]. During an interview on [DATE] at 11:09 a.m., the DON said Resident #1 eloped out of the building. She said the alarm on the exit door was deactivated because maintenance turned it off. She said Resident #1 was on hospice and expired on [DATE]. During an observation on [DATE] at 12:00 p.m., the Hall 1 exit door would not close completely without manually grabbing the knob and pulling it shut. During an observation on [DATE] at 12:08 p.m., the Breezeway door, near the front entrance, would not latch securely in it's frame. An Elopement policy revised on [DATE] indicated, Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement . The administrator, DON, and area director of operations were notified on [DATE] at 10:38 a.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 1:36 p.m. and included: 1. Q 30 minute monitoring of Breezeway door for safety. Maintenance has repaired the doorway in breezeway on [DATE] @1:15 p.m. 2. Hall 1 emergency exit door was repaired on [DATE] at 12 pm. 3. 82% of residents have been assessed for Elopement Risk at 12:29 pm on [DATE] no further residents have been identified at risk, and 100% will be completed by 1 pm on [DATE] 4. Identify Resident's that are at risk for elopement and place face sheet with photo in binder at both nurses station. Complete by [DATE] 5. In-service in process of staff re: Elopement Prevention, Steps to Take for an Elopement, How to identify a resident at risk for elopement, Responding to door alarms. Will have all staff completed by [DATE]. 6. Residents identified for high risk of elopement will be listed and placed in breakroom, shower room as well as the binders located at both nurses station by 1 pm on [DATE]. 7. All alarms are active and being monitored daily. On [DATE] the surveyor confirmed the facility implemented their plan of removal to sufficiently remove the Immediate Jeopardy by: During an interview on [DATE] at 11:30 p.m., the administrator said the breezeway door was repaired and latches. The Hall 1 exit door was repaired and closes properly. The administrator said 100 percent of residents were assessed for elopement risk and residents that were identified had a face sheet with a photo at the nursing stations, break room, and shower room. The administrator said the door alarms would now be monitored daily by the manager on duty on the weekends and by the maintenance supervisor Monday through Friday. One dietary aide, one CNA, one nurse, one housekeeping aide, and the speech director said they received an in-service regarding elopement and alarm sounds. They were in-serviced that if a resident was missing they were to search inside and out and if they did not find the resident within 30 minutes, they were to contact the police. They were also in-serviced to redirect residents that were exit seeking by encouraging an activity. They were in-serviced to check alarm doors immediately when they alarm. During an observation on [DATE] at 12:20 p.m., an elopement risk list was posted in the break room. During an observation on [DATE] at 12:27 p.m., there was an elopement risk binder at Nursing Station 2 with a face sheet with the names and pictures of the residents at risk for elopement. During an observation on [DATE] at 12:34 p.m., there was an elopement risk binder at Nursing Station 1 with a face sheet with the names and pictures of the residents at risk for elopement. During an observation on [DATE] at 12:37 p.m., an elopement risk list was posted in the shower room. On [DATE] at 1:17 p.m., the administrator was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated [DATE] indicated 6 residents had exit-seeking and wandering behaviors.

Based on observation, interview, and record review, the facility failed to assess, evaluate, and revise pain relief interventions to ensure adequate pain relief for 1 of 6 residents reviewed for pain. (Resident # 1) Resident # 1 received services from Hospice. The resident had orders for [MEDICATION NAME] from a continuous infusion pump at 14 milligrams (mg) per hour and [MEDICATION NAME] under the tongue, as needed for pain. Resident #1 experienced an increased level of pain over the last month. The resident did not receive interventions to assess or relieve her pain. This failure likely contributed to Resident #1's pain. This failure could place 15 residents receiving pain management at risk for unrelieved pain. Findings included: Physician orders [REDACTED].#1 was admitted [DATE] was [AGE] years old with [DIAGNOSES REDACTED]. Resident # 1 received Hospice services and had a stage 4 pressure ulcer to the tailbone. Resident #1 was to receive a continuous infusion of [MEDICATION NAME] via a continuous infusion pump at a rate of 14 mg per hour (hr) and [MEDICATION NAME] 4 ml subcutaneous (under the tongue) every one hour as needed for breakthrough pain. Nursing staff was to conduct a pain assessment and follow-up evaluation of pain and record results with every administration of breakthrough pain medication. The most recent MDS dated [DATE] indicated Resident # 1 had clear speech, was able to make herself understood, responded adequately to simple, direct communication, and had pain frequently with an intensity rating of 8 on a 1 to 10 pain scale. A nursing care plan dated 3/12/2014 indicated Resident # 1 was on pain medication therapy. The goals were Resident # 1 would " ...be free of any discomfort or any adverse side effects from pain medication over the next 90 days ... " Interventions included " ...administer pain medication as ordered, review quarterly for pain medication efficacy and assess whether pain intensity acceptable to resident ... " During an observation and interview on 05/05/14, at 8:40 a.m., Resident # 1 was lying in bed on her right side. A continuous medication infusion pump was infusing [MEDICATION NAME] at a rate of 14 mg per hour. Resident #1 said she was not in pain. During an observation and interview on 5/5/14 at 10:30 a.m., Resident # 1 was lying in bed on her right side. Resident #1's daughter was at her bedside. The continuous pain medication infusion pump was alarming. Resident #1's daughter stated "the pump is empty." Resident # 1's daughter said Hospice was aware. She stated "they told me to push the stop button to make it quit beeping." Resident #1's daughter pushed a button on the infusion pump. The pump continued to alarm. The resident said she was not having pain. During an observation and interview on 5/5/14 at 11:15 a.m., Resident # 1 was lying on her right side. The continuous pain medication infusion pump was alarming and read "stopped." The resident stated "My back is a little sore. " During an observation and interview on 5/5/14 at 12:45 p.m. Resident # 1 was being fed by a Hospice CNA. The resident was gagging when she attempted to eat. After a couple of bites, Resident # 1 refused any further offer of food or drink. Resident #1 stated "My bottom hurts" when questioned about pain. The continuous pain medication infusion pump read "empty". During an observation and interview on 5/5/14 at 1:00 p.m., Resident # 1 was lying on left side. Resident # 1 stated "I'm sick to my stomach, my back hurts." The continuous pain medication infusion pump read " stopped " . During an interview on 5/5/14 at 1:06 p.m., LVN H said the Hospice CNA did not tell her Resident # 1 was nauseated. LVN H stated "I'll go talk to her about it." During an observation and interview on 5/5/14 at 2:26 p.m., Resident # 1 was grimacing, crying and moaning. Resident # 1 stated "I'm hurting all up and down my back. It hurts, I need some help." The continuous pain medication infusion pump continued to alarm and read "stopped." During an interview on 5/5/14 at 2:34 p.m., LVN H stated "I called Hospice this morning and told them the pump was empty." LVN H said the Hospice nurse said she would be here as soon as the [MEDICATION NAME] comes in. LVN H said she gave Resident # 1 some [MEDICATION NAME] (under the tongue pain medication) this morning and stated "It is really fast acting and only lasts an hour." LVN H stated "I guess I can call again." During the interview, the hospice nurse arrived. The Hospice nurse went into Resident # 1's room with a replacement bag of [MEDICATION NAME]. The Hospice nurse returned to the nursing station and stated to LVN H, "You may want to give her some [MEDICATION NAME], she is hurting ". LVN H stated "I will have to check her time, I just gave her some." During an observation on 5/5/14 at 3:30 p.m., Resident # 1 was lying on her left side. Resident # 1 was resting quietly with her eyes closed. No grimacing, moaning or crying was noted. The continuous pain medication infusion pump indicated it was infusing with no further alarming. During an interview on 5/6/14 at 9:45 a.m., LVN K said charge nurses assessed residents for pain by asking the resident. She said if the resident could not communicate, the charge nurse looked for signs like facial grimacing, facial expressions or moaning. LVN K said if the resident was in pain the charge nurse gave pain medication and should reassess the resident to see if the pain medication was effective. She said the charge nurse documented on the medication administration record if the medication was effective. LVN K said if the resident continued to have pain after all as needed medications were given as ordered, the charge nurse would call the Hospice nurse, if the resident was receiving Hospice services for a new order. LVN K said the facility staff did not touch the continuous infusion pump for Resident # 1. The charge nurse called Hospice if there was a problem with the pump. During an interview on 5/6/14 at 10:00 a.m., LVN H said she assessed residents pain by asking them, looking at facial expressions and restlessness. If the resident was in pain she would administer pain medication. LVN H said she reassessed for relief of pain using the same technique as initial assessment for pain, then recorded the effectiveness on the MARs. She said if the medication was not effective, she would call the Hospice nurse if the resident received Hospice services. LVN H said she would continue to call until she got a response from Hospice or the physician. LVN H said she did not manage the continuous infusion pump for Resident # 1. LVN H stated "the hospice nurse does everything, we let her know if there is a problem." During an interview on 5/7/14 at 9:30 a.m., the interim DON said Resident #1's pump was not empty and was still running on the morning of 5/5/14. The interim DON said sometimes when the line was kinked, the pump was still running and the resident still received medication. He said he did not know if the pump was still running when it read "stopped". He said he was there that morning and did not hear the pump alarming or see the resident in pain. The interim DON said nurses should assess pain by asking the resident if the resident was verbal. He said Resident # 1 was able to verbalize pain. He said if the resident was not able to verbalize, assessment should be from grimacing, restlessness, and moaning. He said if the resident had pain, as needed pain medication should be administered as ordered. T interim DON said the resident should be reassessed for pain. He said if pain continued after all as needed medications were given, nurse should call and get direction from the physician. The interim DON said facility staff did not manage Resident # 1 ' s continuous pain medication infusion pump. During an interview on 5/7/14 at 10:00 a.m., the Hospice nurse said she received a call on the morning of 5/5/14 from the facility that Resident #1 ' s continuous pain medication infusion pump was empty. She informed the charge nurse she would bring a [MEDICATION NAME] replacement bag when it was ready from pharmacy. She told the facility nurse to give the as needed medication until she got there. The Hospice nurse said sometimes the pump says "empty", but is still infusing. She said the pump should have still been running before she got here on the morning of 5/5/14. She said the pump was not running when it said "stopped." She said facility staff did not do anything with Resident # 1 ' s continuous infusion pump. The Hospice nurse said staff called her every time it alarmed, no matter what the reason, even if the line was kinked because they do not know how to fix it. The Hospice nurse said she did not keep a tracking log of how much medication had infused or how much was remaining in the bag. During an interview on 5/7/14 at 2:30 p.m., LVN K said a pain monitoring flow sheet for each month was located in Resident # 1 ' s MAR. She said the facility nurse was supposed to document pain administration and follow-up every time pain medication was administered. LVN K located the current pain assessment flow sheet for Resident # 1. The flow sheet had no documentation. LVN K said the sheet should be filled in. LVN K says the facility did not maintain a tracking log for continuous pain medication infusion pump for Resident # 1. During an interview on 5/7/14 at 2:39 p.m., LVN L located the pain assessment flow sheet for Resident # 1 dated 04/14. The assessment contained no documentation. LVN L said the flow sheet should be documented on each time a medication was given. The May 2014 MAR indicated Resident #1 received the following: 5/5/14 - [MEDICATION NAME] at 8:30 a.m. prior to the continuous infusion of [MEDICATION NAME] stopping. There was no documented pain assessment or effectiveness of the pain medication. 5/5/14 - [MEDICATION NAME] at 1:00 p.m. after the continuous infusion of [MEDICATION NAME] stopped. There was no documented pain assessment or effectiveness of the pain medication. 5/5/14 - [MEDICATION NAME] at 2:40 p.m. after the continuous infusion of [MEDICATION NAME] was re-started and Hospice nurse intervened and directed nurse to administer as needed medication. There was no documented pain assessment or effectiveness of the pain medication. Nursing notes for Resident #1 dated 5/5/14 did not document Resident # 1's pain level, treatment or follow-up. The note did not indicate any concerns regarding the continuous infusion pump. The MARs and pain assessment flow sheet dated April 2014 indicated Resident # 1 received [MEDICATION NAME] for pain management 39 times in the month of April. There were no assessments or follow-up for effectiveness documented. The MARs and pain assessment flow sheet dated May 2014 indicated Resident # 1 received [MEDICATION NAME] for pain management 10 times in the month of May. There were no assessments or follow-up for effectiveness documented. A communication note from Hospice dated 5/5/14 indicated Hospice nurse was notified by facility on 5/5/14 that " bag is empty. " Physician's telephone orders for Resident #1indicated the following: 3/26/14 - [MEDICATION NAME] sulfate infusion to 5mg/hr; 4/1/14 - [MEDICATION NAME] sulfate Sub Q (under the skin) infusion at 6 mg/hr; 4/3/14 - Increased [MEDICATION NAME] SQ gtt to 7.2 mg/hr indication pain; 4/4/14 - Increased [MEDICATION NAME] SQ gtt to 8.0 mg/hr for pain; 4/9/14 - increased gtt [MEDICATION NAME] to 8.8 mg/hr for pain; 4/10/14 - pre-medicate (Resident #1) with 4mg of [MEDICATION NAME] SL before WC (wound care); 4/10/14 - Finish 1mg/ml [MEDICATION NAME] SL bottle, Increase dose to 4mg/ml Q hr PRN (every hour as needed) for pain; 4/16/14 - Increase gtt to [MEDICATION NAME] SQ 9.6 mg/hr; 4/21/14 - Increase drip to [MEDICATION NAME] SQ 10.4 mg/hr; 4/23/14 - increase gtt [MEDICATION NAME] SQ 12.0 mg/hr; 4/23/14 - Please give 1 cc (cubic centimeter) [MEDICATION NAME] SL 4mg/ml now pt (Resident #1) moaning and in tears about pain 4/28/14 - Increase gtt to [MEDICATION NAME] 13 mg/hr SQ The Pain Management, Assessment Scale policy and procedure from Nursing Policy & Procedure Manual dated 2003 indicated the following: " Complaints of pain will be assessed accordingly by the nurse and effectively managed through prescribed medications, and comfort measures, and all available resources of the facility " . Goals 1. Residents identifies pain characteristics. 2. Resident articulated factors that intensify pain. 3. Resident expresses a feeling of comfort and relief from pain. 4. Resident states and carries out appropriate pain interventions from pain relief. 5. Cognitively impaired residents will demonstrate actions of pain relief. Procedure 1. Assess residents physical symptoms of pain, physical complaints, and daily activities. The nurse may use the Pain Assessment Tool to complete the residents complaint of pain. The completed tool will be placed in the residents clinical record. 2. Administer pain medications as prescribed. Monitor and record medications effectiveness and side effects. 3. Perform comfort measure to promote relaxation. 8. Help resident into a comfortable position and use pillows to splint or support painful areas as appropriate, to reduce muscle tension or spasm and to redistribute pressure on body part. 18. The care plan team will routinely assess the effectiveness of pain management interventions. Appropriate care plans will be maintained for the management of the residents pain. The CMS 672 form dated 5/5/14 indicated 15 residents were on a pain management program.