Every finding on record at Plaza West Healthcare and Rehab

Based on observations, interviews, and record review, the facility failed to promote and facilitate the residents' right to self-determination and choices when the facility restricted the food items available to residents who chose to dine in their room in order to compel them to come to the dining room, though that was not their preference for dining/eating. Findings included:- Review of the facility la Carte Menu Dining Room documented the following:Hot sandwiches: Hamburger, Cheeseburger, Grilled Cheese, and Hot Deli. Entrees: Chicken Tenders, Fish Sticks, and Chef Salad. Cold Sandwiches: Deli (Turkey or Ham), Peanut Butter & Jelly, Chicken Salad, and Egg Salad. Sides: Mashed Potatoes, Crinkle Cut Fries, Potato Chips, and Cottage Cheese. Review of the facility la Carte Menu Room Tray documented the following:Cold Sandwiches: Deli (Turkey or Ham), Peanut Butter & Jelly, Chicken Salad, and Egg Salad. Sides: Mashed Potatoes, cheese Puffs, and Potato Chips. Entrees: Cottage Cheese Plate and Chef Salad. And at the bottom it reads More options available in Dining Room On 08/10/2026 at 10:20 AM, Resident (R) 1 stated that she has had trouble getting her meals on time. R1 stated it had been getting better, but she was frustrated with the options that were given to her because she chose to eat in her room instead of the dining room with other residents. R1 stated that if she ordered a hamburger, she could only receive the hamburger only if she goes to the dining room. R1 stated she felt that was unfair. R1 then revealed that the same type of scenario existed for breakfast. She said if she wanted an egg over easy or poached, she could not get that in her room. R1 said she questioned the facility staff, but the only reply that she ever gets is that the food has to go out at a certain temperature and that what she wants can only be served in the dining room. R1 asked what the difference was between scrambled eggs and a poached or over easy egg, and the staff and management told her that those eggs just can not hold the heat, nor can a hamburger. R1 stated that if she asked for biscuits and gravy or a donut, she was told she had to go to the dining room for breakfast in order to get that. R1 expressed feeling exasperated, putting her hands up and stating shockingly, A donut! On 08/10/2026 at 10:22 AM, R2 stated that she does not understand the difference between the temperature and not being good enough for a hamburger to be served to residents who chose to dine in their rooms versus stroganoff, which was served on a room tray. R2 stated that if she wanted a special-order breakfast, she had to go to the dining room. On 08/10/2026 at 12:10 PM, Dietary CC pulled out a covered chef salad from the tray delivery container. Dietary CC gathered the salad, drink, and wrapped silverware and proceeded to R1's room to deliver the meal. Dietary CC then pulled a plate from the tray delivery container out with a plate warmer below the plate of beef stroganoff with green vegetables. Dietary CC measured the food's serving temperature and documented it prior to allowing floor staff to assist in delivering the plate of food. On 08/10/2026 at 12:22 PM, Dietary CC stated the different menus for the dining room and the room trays had to do with the grill rule and the fried food rule. Dietary CC stated facility administrative staff established limited choices for room trays in to get better interactions for the residents. Dietary CC stated the limitations had been in effect for approximately eight months. On 08/10/2026 at 12:23 PM, Licensed Nurse (LN) G stated the facility was trying to say the restrictions placed on residents who chose to dine in their room were an incentive for the residents to come out of their rooms. LN G further stated that if a resident did not want to get up and go to the dining room, that resident should get the same food as everyone else. LN G stated that the floor staff did not necessarily agree with the situation and felt that it was the residents' right to stay in their room if they chose to do that. On 08/10/2026 at 02:35 PM, Dietary BB stated that the differences between the room tray à la carte and the dining room à la carte menus were designed to encourage the residents to come out of their rooms and get to the dining room. Dietary BB stated that every day there was a special meal in the morning for breakfast to encourage the residents to come to the dining room to get the freshest, hottest food right out of the kitchen. The facility had a room tray Performance Improvement Plan (PIP), and the purpose was to get the residents to come out of their rooms. Dietary BB stated that she tried to get the residents' food that they would like and said she has listened to every concern and has tried to go to those residents to see what they would like to eat. Dietary BB stated the restricted menu for room trays was implemented prior to her becoming the dietary manager, and she further stated that she did not ask questions, she just did what she was told. Dietary BB stated that every resident can get a hot meal; the residents who ate in their rooms just could not get a hot à la carte meal. Dietary BB stated that she was told to do a job, and that is what she does. On 08/10/2026 at 03:06 PM, Administrative Staff A stated that the facility had set up the PIP to encourage the residents to leave their rooms and to improve social interactions. Administrative Staff A stated the dietary program struggled with room trays and the facility was trying to make the room trays more efficient and give out better quality of food. Administrative Staff A stated the facility had a dining room menu and a room tray menu, and both menus were geared towards meeting nutritional requirements. Administrative Staff A stated the facility was brainstorming ways to improve dietary performance but could not remember if residents' rights had come up for consideration or not. Administrative Staff A said he would love to be able to provide residents with their preferred style of eggs even if they chose to dine in their room but was unable to say if the facility actually did provide the preferred egg on a room tray. The facility's Dining Options for Meal Service guideline and procedure manual copyrighted 2020 documented that dining service times were planned in accordance with resident preference and staffing available at scheduled mealtimes. The facility's Resident Rights policy, implemented on 03/05/2026, documented the resident had the right to, and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the resident having the right to make choices about aspects of his or her life in the facility that are significant to the resident.

The facility had a census of 130 residents. The sample included 27 residents. Based on observation, record review, and interview, the facility failed to ensure adequate daily nursing staff were always available to meet the needs of the residents who resided in the facility. Findings included: - The Facility Assessment, revised 12/19/24, documented staffing needs and assignments vary based on the census and acuity level of the resident in the facility. Resident preference additional staffing during certain times as indicated and as available per resident preferences. The facility would designate consistent hall assignments for individual staff as able to ensure continuity of care. Full-time staff would work weekend days as well as weekdays to ensure continuity of care throughout the week. Review of the nursing daily staffing schedules from 12/01/24 to 03/18/25 revealed numerous slots in the schedule with open in app in different halls at different times for nurses, certified nurse aides (CNA), and certified medication aides (CMA). The schedules lacked documentation these slots were filled with another staff member. 03/19/25 at 07:37 AM, CMA T stated she was responsible for completing the facility's daily nursing staffing. CMA T stated if she is not on duty in the facility and staff call in, or do not show up, or there is a need for nursing staff the charge nurse or Administrative Nurse D would call or text staff to replace them. Sometimes they fail to add the replacement staff to the schedules. 03/19/25 at 02:50 PM, CMA RR she was usually scheduled as administrating medications but must help CNAs because the facility is short-staffed 50% of the time. Upon request, the facility failed to provide a staffing policy. The facility failed to ensure adequate nursing staff was available daily to meet the needs of the residents who resided in the facility. This placed the 130 residents at risk of waiting a long time for their needs.

The facility had a census of 130 residents. Based on observation and interview, the facility failed to maintain a clean homelike environment free of odor-free environment for one of the nine halls. This deficient practice placed the resident at risk for unhomelike, unsanitary conditions. Findings included: - On 03/17/25 at 08:30 AM the entirety of Hall 400 emanated a strong urine odor which continued throughout the day. The odor could be detected before entering the hallway in the commons area. On 03/18/25 at 07:05 AM the entirety of Hall 400 emanated a strong urine odor which continued throughout the day. The odor could be detected before entering the hallway in the commons area. On 03/17/25 at 08:30 AM, the Hall 400 commons area had two blue-colored couches that had brown stains on both. On 03/19/25 at 02:31 PM, Administrative Staff A verified the odor. Administrative Staff A stated he would notify the floor maintenance staff and housekeeping to check and clean where the possible odor was coming from and the couches. Administrative Staff A stated the facility had purchased 30 new mattresses and would check to see if the mattress had been put into place. Upon request, the facility failed to provide a clean environment policy. The facility failed to provide the residents located on hall 400 with a clean, odor-free environment. This deficient practice placed the residents at risk for an unhomelike stay.

The facility identified a census of 130 residents. The sample included 27 residents reviewed for baseline care plans. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 78, R98, and R13 baseline care plans were developed and implemented to provide effective and person-centered care that included interventions with staff direction for the resident's needed cares of their activities of daily living (ADL). The facility failed to develop a baseline care plan that included care areas and interventions for R295's ADLs and her dialysis (a procedure where impurities or wastes are removed from the blood) care. The facility failed to develop a baseline care plan that included dialysis care and treatment. This deficient practice placed these residents at risk of delayed care, possible decline, and injuries. Findings included: - R78 admitted to the facility on [DATE]. R78's baseline care plan in the Electronic Medical Record (EMR) that was initiated on 02/11/25 lacked a care area for ADLs and interventions to direct staff for basic care needs for the resident. R98 admitted to the facility on [DATE]. R98's baseline care plan in the EMR that was initiated on 02/13/25 lacked a care area for ADLs and interventions to direct staff for basic care needs for the resident. R13 admitted to the facility on [DATE]. R13's baseline care plan initiated in the EMR that was on 02/26/25 but lacked a care area for ADLs and interventions to direct staff for basic care needs for the resident. R346 admitted to the facility on [DATE]. R346's baseline care plan in the EMR was initiated on 03/08/25 but lacked a care area for ADLs and interventions to direct staff for basic care needs for the resident. R346's baseline care plan lacked a care area for dialysis. R347 admitted to the facility on [DATE]. R347's baseline care plan in the EMR that was initiated on 03/12/25 lacked a care area for ADLs, colostomy care, wound vac care, and interventions to direct staff for the care needs of the resident. On 03/19/25 at 10:30 AM, Certified Nurse Aide (CNA) O stated each resident's care plan should have how much assistance was needed with their ADLs for each resident. CNA O stated the nurses would typically tell staff when a new resident arrived how much assistance that resident needed or if a lift was required for transfers. CNA O could not state why these residents did not have ADL interventions in their care plans but did say that staff did complete ADLs on these residents that included toileting, bathing, and other basic needs. On 03/19/25 at 12:30 PM, Licensed Nurse (LN) J stated she was the nurse on the unit for these residents. LN J stated she was not the staff that did the baseline care plans for the residents, but she did know that the residents had received the basic care needed to be cared for. LN J stated the unit manager was typically responsible for getting the care plan completed and she would inform the staff of the resident's ADLs during their morning meeting. On 03/19/25 at 02:53 PM, Administrative Nurse D stated the unit manager, or the Minimum Data Set (MDS) Coordinator was responsible for completing and putting the baseline care plan into the EMR. Administrative Nurse D expected new admission residents to have a baseline care plan that included ADL care, and any specific care areas for dialysis, or wound care and colostomy care. Administrative Nurse D said she would speak with her staff to ensure that this was being completed. The facility's Baseline Care Plans policy implemented on 02/01/20 documented the facility would develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet the professional standards of quality care. The baseline care plan would be developed within 48 hours of the resident's admission and would include the minimum healthcare information necessary to properly care for a resident including, but not limited to: initial goals based on admission orders; physician orders; dietary orders; therapy orders; and social services. The admitting nurse, or supervising nurse, shall gather information from the admission physical assessment, hospital transfer information, physician order, and discussion with the resident and resident representative, if applicable. Once gathered initial goals shall be established that reflect the resident's stated goals and objectives. Interventions shall be initiated that address the resident's current needs including any health and safety concerns to prevent decline or injury; any identified needs for supervision, behavioral interventions, and assistance with ADL; and any special needs such as for intravenous (IV) therapy, dialysis, or wound care. The facility failed to ensure staff developed and implemented a baseline care plan that included the instruction needed to provide effective and person-centered care that included ADL care for dialysis care, wound care, and colostomy care for residents. This deficient practice placed these residents at risk of delayed care, possible decline, and injury. 37450 - Resident (R) 295 Electronic Medical Record (EMR) included diagnoses of fracture (broken bone) of left tibia (bone of the lower leg), arteriovenous fistula (AV - a surgically created connection between an artery and a vein), dependence on renal (pertaining to kidneys) dialysis, end-stage renal disease, bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder. The Minimum Data Set (MDS) had not been completed due to recent admission and had not met the criteria for completion or submission. R295's Baseline Care Plan dated 03/12/25, lacked documentation regarding R295's dialysis process or directed staff of care. The Physician Orders lacked orders for dialysis. The Progress Notes lacked documentation of the need or participation in the dialysis process. On 03/18/25 at 07:43 AM, Certified Medication Aide (CMA) S reported that R295 went to dialysis on Mondays and Fridays. On 03/18/25 at 08:29 AM, R295 stated she had been at the facility for over three weeks and went to dialysis on Mondays and Fridays. R295 stated the facility staff had not assessed the AV shunt when returning to the facility following dialysis treatment. R295 also reported the facility had not sent a communication sheet with her to dialysis. On 03/19/25 at 03:15 PM, Administrative Nurse D verified the baseline care plan should include R295's dialysis care and treatment. The facility's Baseline Care Plan policy, dated 02/01/20, documented the facility would develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care. The facility failed to include R295's dialysis care and treatment in the care plan. This deficient practice placed the resident at risk of unmet care needs.

The facility had a census of 130 residents. The sample included 27 residents, with 15 reviewed for bathing. Based on observation, record review, and interview, the facility failed to provide consistent bathing for seven sampled residents, Resident (R) 48, R99, R117, R125, R71, and R121. This placed the residents at risk for poor hygiene. Findings included: - The Electronic Medical Record (EMR) for R48 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) without behavioral disturbance, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypertension (high blood pressure), and chronic kidney disease (the kidneys are damaged and can't filter blood as well as they should) stage three. The Admission Minimum Data Set (MDS), dated [DATE], documented R48 had severely impaired cognition. R48 required partial assistance from staff for toileting hygiene, dressing, and personal hygiene, and R48 refused showers. The Quarterly MDS, dated [DATE], documented R48 had severely impaired cognition. R48 required set-up assistance from staff for eating, oral hygiene, toilet hygiene, and partial assistance with bathing. R48's Care Plan, dated 01/28/25, initiated on 12/24/24, documented R48 often refused bathing/showers and directed staff to continue to offer and remind her of the importance of hygiene. R48 could request a bath or shower at any time and staff would do their best to accommodate her. Staff were directed to offer R48 wash clothes and soapy water for sponge bathing if she continued to refuse a bath or shower. The January 2025 Bathing and Facility Bathing Sheets, documented R48 had requested showers on Monday and Thursday dayshift and documented R48 had not received a bath or shower during the following days from 01/10/25 through 01/31/25 (22 days). The EMR documented R48 refused her baths on 01/16/25, 01/20/25, 01/23/25, 01/27/25, and 01/30/25 and was not offered other bathing alternatives or different times to take a bath or shower. The February 2025 Bathing and Facility Bathing Sheets, documented R48 had requested showers on Monday and Thursday dayshift and documented R48 had not received a bath or shower during the following days from 02/01/25 through 02/28/25 (28 days). The EMR documented R48 refused her baths on 02/03/25, 02/06/25, 02/10/25, 02/17/25, 02/20/25, 02/24/25, 02/27/25 and was not offered other bathing alternatives or different times to take a bath or shower. The March 2025 Bathing and Facility Bathing Sheets, documented R48 had requested showers on Monday and Thursday dayshift and documented R48 had not received a bath or shower during the following days from 03/01/25 through 03/18/25 (18 days). The EMR documented R48 refused her baths on 03/03/25, 03/10/25, 03/13/25, and 03/17/25 and was not offered other bathing alternatives or different times to take a bath or shower. On 03/18/25 at 09:15 AM, R48 had on a gray top and pants, her hair was greasy and slicked back out of her face. On 03/19/25 at 08:52 AM, R48 had on the same gray top and pants as the previous day, her hair was greasy and slicked back out of her face. On 03/18/25 at 08:00 AM, Certified Nurse Aide (CNA) M stated if R48 refused her shower, they try again later. CNA M further stated shower sheets were filled out and given to the charge nurse. On 03/19/25 at 12:00 PM, Licensed Nurse (LN) H stated some residents refused and would get angry with staff. R48 was more independent, and she would wash her face and armpits but was unsure if her perineal area was being washed. On 03/19/25 at 2:55 PM, Administrative Nurse D stated she expected staff to follow R48's care plan and to offer her a washcloth so she could wash up. Administrative Nurse D further stated there should be follow-up documentation of the attempts taken to give her a shower. The facility's Bathing a Resident policy, dated 03/19/25, documented the facility assisted the residents with bathing to maintain proper hygiene and help in the prevention of skin issues. The policy directed staff to assist the residents with showering as needed and have the residents participate as much as possible. Staff were to provide clean washcloths to cleanse the perineal area. The facility failed to provide consistent bathing for cognitively impaired R48. This placed her at risk for poor hygiene. - The Electronic Medical Record (EMR) for R99 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), atrial fibrillation (rapid, irregular heartbeat), adult failure to thrive (includes not doing well, feeling poorly, weight loss, and poor self-care that could be seen in elderly individuals), and chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Annual Minimum Data Set (MDS), dated [DATE], documented R99 had severely impaired cognition. R99 required supervision with eating, oral hygiene, and toileting hygiene. R99 was dependent upon staff for bathing. The Quarterly MDS, dated [DATE], documented R99 had severely impaired cognition. R99 required substantial assistance with dressing and personal hygiene. R99 was dependent upon staff for bathing. R99's Care Plan, dated 01/07/25, initiated on 12/24/24 documented R99 often refused bathing/showers and directed staff to continue to offer and remind her of the importance of hygiene. R99 could request a bath or shower at any time and staff would do their best to accommodate her. Staff were directed to offer R99 wash clothes and soapy water for sponge bathing if she continued to refuse a bath or shower. The March 2025 Bathing and Facility Bathing Sheets, documented R99 had requested showers on Tuesday and Friday dayshift and documented R99 had not received a bath or shower during the following days from 03/01/25 through 03/18/25 (18 days). The EMR documented R99 refused her shower on 03/04/25 and 03/07/25. R99 was not offered other bathing alternatives or different times to take a bath or shower. On 03/19/25 at 08:46 AM, for three of three days onsite, R99 had on the same purple sweatshirt and gray pants. R99's hair was smashed down to the back of her head, and not combed. On 03/18/25 at 08:00 AM, Certified Nurse Aide, (CNA) M stated if R99 refused her shower, they try again later. CNA M further stated shower sheets are filled out and given to the charge nurse. On 03/19/25 at 12:00 PM, Licensed Nurse (LN) H stated some residents refused, would get angry with staff, and staff would try again later. On 03/19/25 at 2:55 PM, Administrative Nurse D stated she expected staff to follow R99's care plan. Administrative Nurse D further stated there should be follow-up documentation of the attempts taken to give her a shower. The facility's Bathing a Resident policy, dated 03/19/25, documented the facility assisted the resident with bathing to maintain proper hygiene and help in the prevention of skin issues. The policy directed staff to assist the resident with showering as needed and have the resident participate as much as possible. Staff were to provide clean washcloths to cleanse the perineal area. The facility failed to provide consistent bathing for cognitively impaired R99. This placed her at risk for poor hygiene. - The Electronic Medical Record (EMR) for R117 documented diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and epilepsy (brain disorder characterized by repeated seizures). The Annual Minimum Data Set (MDS), dated [DATE], documented R117 had severely impaired cognition. R117 was dependent upon staff for all activities of daily living (ADL). R117 was always incontinent of bladder and bowel. The Quarterly MDS, dated [DATE], documented R117 had severely impaired cognition. R117 was dependent upon staff for all ADLs. R117 was always incontinent of bladder and bowel. R117's Care Plan, dated 01/20/25, initiated on 02/07/24, documented R 117 often refused bathing/showers and directed staff to continue to offer and remind her of the importance of hygiene. R 117 could request a bath or shower at any time and staff would do their best to accommodate her. Staff were directed to offer R117 washcloths and soapy water for sponge bathing if she continued to refuse a bath or shower. The February 2025 Bathing and Facility Bathing Sheets, documented R117 had requested showers on Sunday and Thursday dayshift and documented R117 had not received a bath or shower from 02/07/25 through 02/19/25 (13 days). The EMR lacked documentation R117 refused her shower and lacked documentation R117 was not offered other bathing alternatives or different times to take a bath or shower. On 03/18/25 at 07:40 AM, R117's hair was uncombed, disheveled, and in her face. On 03/18/25 at 08:00 AM, Certified Nurse Aide (CNA) M stated if R117 refused her shower, they try again later. CNA M further stated shower sheets are filled out and given to the charge nurse. On 03/19/25 at 12:00 PM, Licensed Nurse (LN) H stated some residents refused, would get angry with staff, and staff would try again later. On 03/19/25 at 2:55 PM, Administrative Nurse D stated she expected staff to follow R117's care plan. Administrative Nurse D further stated there should be follow-up documentation of the attempts taken to give her a shower. The facility's Bathing a Resident policy, dated 03/19/25, documented the facility assisted the resident with bathing to maintain proper hygiene and help in the prevention of skin issues. The policy directed staff to assist the resident with showering as needed and have the resident participate as much as possible. Staff were to provide clean washcloths to cleanse the perineal area. The facility failed to provide consistent bathing for cognitively impaired R117. This placed her at risk for poor hygiene. - The Electronic Medical Record (EMR) for R125 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), hyperlipidemia (condition of elevated blood lipid levels), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Admission Minimum Data Set (MDS), dated [DATE], documented R125 had severely impaired cognition. R125 required set-up assistance from staff for eating, dressing, personal hygiene, and supervision with showers. R125's Care Plan, dated 01/28/25, initiated on 12/24/24, documented R125 often refused bathing/showers and directed staff to continue to offer and remind her of the importance of hygiene. R125 could request a bath or shower at any time and staff would do their best to accommodate her. Staff were directed to offer R125 washcloths and soapy water for sponge bathing if she continued to refuse a bath or shower. The February 2025 Bathing and Facility Bathing Sheets, documented R125 had requested showers on Thursday and Sunday dayshift and documented R125 had not received a bath or shower from 02/07/25 through 02/28/25 (22 days). The EMR lacked documentation refused her shower and lacked documentation R125 was not offered other bathing alternatives or different times to take a bath or shower. On 03/18/25 at 07:27 AM, R125 wore the same shirt as the day before and her hair was greasy with white, flaky substance throughout her hair. On 03/18/25 at 08:00 AM, Certified Nurse Aide, (CNA) M stated if R125 refused her shower, they try again later. CNA M further stated shower sheets are filled out and given to the charge nurse. On 03/19/25 at 12:00 PM, Licensed Nurse (LN) H stated some residents refused, would get angry with staff, and staff would try again later. On 03/19/25 at 2:55 PM, Administrative Nurse D stated she expected staff to follow R125's care plan. Administrative Nurse D further stated there should be follow-up documentation of the attempts taken to give her a shower. The facility's Bathing a Resident policy, dated 03/19/25, documented the facility assisted the resident with bathing to maintain proper hygiene and help in the prevention of skin issues. The policy directed staff to assist the resident with showering as needed and have the resident participate as much as possible. Staff were to provide clean washcloths to cleanse the perineal area. The facility failed to provide consistent bathing for cognitively impaired R125. This placed her at risk for poor hygiene. 32358 - R71's Electronic Medical Record (EMR) documented she had diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), urge incontinence (involuntary passage of urine occurring soon after a strong sense of urgency to void), and intellectual disabilities (involuntary passage of urine occurring soon after a strong sense of urgency to void). R71's Annual Minimum Data Set(MDS), dated [DATE], documented that R71 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS also documented that the resident required partial, moderate staff assistance with bathing, and it was very important to choose the type of bathing. R71's Urinary Incontinence Care Area Assessment (CAA), dated 07/06/24, documented urinary incontinence, which would be addressed in the resident's care plan. The CAA instructed staff to monitor for signs and symptoms of incontinence complications, such as infection. The CAA instructed staff to encourage R71 to drink fluids to help prevent infection, and provide incontinence care as needed (PRN). R71's CAA lacked triggering for bathing. R71's Activities of Daily Living (ADL) Care Plan, revised 12/23/24, documented R71 preferred a shower twice a week in the evening and required substantial, maximal staff assistance with showering. The EMR Bathing Sheets revealed R71 was scheduled for showers/baths every Tuesday and Friday days and received a bath on the following dates: 01/16/25 01/24/25 01/28/25 01/31/25 02/07/25 02/14/25 02/28/25 03/07/25 03/14/25 R71 refused on the following dates: 01/14/25 01/15/25 02/04/25 02/11/25 02/21/25 02/25/25 03/04/25 On 03/17/25 at 03:55 PM, R71 sat in a chair at the dining room table with greasy hair. On 09/11/23 at 01:19 PM, Certified Nurse Aide (CNA) M stated R71 frequently refused baths and said she would try to get R71 to bathe at least once a week. On 03/19/25 at 12:25 PM, Licensed Nurse (LN) L stated R71 had refused showers and if a resident refused a shower staff have them sign a bathing sheet, then offer on a different day. On 03/19/25 at 03:05 PM, Administrative Nurse D stated R71 refused baths, and administration had recently employed a bath aide. Administrative Nurse D stated if a resident refused a bath, staff should offer other forms of bathing. The facility's Bathing a Resident Policy, implemented 03/19/25, documented it was the practice of the facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues. The facility failed to provide R71 provide bathing on a regular basis. This deficient practice placed the resident at risk for poor personal hygiene. 37450 - Resident (R) 121's Electronic Medical Recorded (EMR) documented diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), spastic hemiplegia (paralysis of one side of the body) affecting the nondominant side, dysphagia (swallowing difficulty), cognitive-communication deficit (an impairment in the organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and difficulty in walking. The Admission Minimum Data Set (MDS), dated [DATE], documented that R121 had intact cognition, felt down, depressed, and hopeless, and social isolation. R121 had no signs or symptoms of delirium (sudden severe confusion, disorientation, and restlessness), psychosis (any major mental disorder characterized by a gross impairment in reality perception), or exhibited behaviors. R121 had a functional range of motion impairment of one side upper extremity, was dependent on toileting, and lower body dressing, and required substantial/maximal assistance with mobility. The resident had frequent incontinence of urine. The MDS further documented that R121 had occasional mild pain and two non-injury falls since admission. The resident received speech, occupational, and physical therapy. The Functional Abilities Care Area Assessment (CAA), dated 06/29/24, documented R121 had been admitted following hospitalization with a diagnosis of cerebral infarction, requiring assistance of one to two staff members for activities of daily living and transfers, worked with physical and occupational therapies for strengthening and returning to his prior level of function. He used a wheelchair for mobility. The Quarterly MDS, dated [DATE], document R121 had intact cognition, had mood score of 01 with feeling down, depressed, or hopeless and socially isolated. The resident exhibited no delirium, psychosis, or behaviors. The MDS further documented R121 was dependent with toileting, bathing, upper and lower body dressing, and required substantial/maximal assistance with mobility. R121 was always incontinent of urine and bowel, had pain frequently which occasionally interfered with day-to-day activities, and had one non-injury fall. The Care Plan dated 06/21/24, documents R121 needed assistance with Activities of Daily Living (ADL) related to cerebral infarction and would like to shower on Wednesday and Sunday evenings, the care plan further instructed staff R121 required substantial/maximal assistance with his bathing task. On 03/17/25 at 10:38 AM, R121 looked disheveled and unshaven reporting it had been a while since his last bath/shower, and he would like them more frequently. Upon review of January 25, February 25, and up to 03/17/2025 bathing records revealed R121 had only received a bath on 01/08/25 and 01/22/25, but lacked bathing for February 25, and refused a bath on 03/12/2025. On 03/18/25 at 08:01 AM, Certified Nurse Aide (CNA) MM stated the resident who has a bath during the shift would show up on the dashboard of the computerized medical record, they check when they come to work. CNA MM reported the bath aide or the staff assigned to the hall were to give baths and if the resident refused a bath, they were to offer a different type of bath like a bed bath before recording the resident refusal. On 03/19/25 at 03:20 PM, Administrative Nurse D stated the facility's implementation of a bath aide to the nursing schedule. Administrative Nurse D verified the nurse aides assigned to the hall were also to give baths for the assigned days. The nursing staff were to offer alternative bathing options if the resident refused before recording if the resident refused. Upon request, the facility failed to provide a bathing policy. The facility failed to provide R121 assistance with bathing, which placed the resident at risk for poor hygiene.

The facility had a census of 130 residents. The sample included 27 residents, with five residents sampled for assessments, interventions placed timely, and follow-up for Resident (R) 35, R117, R128, R142, and R13. This placed the residents at risk for lack of quality of care. Findings included: - R35's Electronic Medical Record (EMR) documented R35 had diagnoses of cerebral infarction (stroke - the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), atrial fibrillation (rapid, irregular heartbeat), and gastrostomy tube (G-tube - tube surgically placed through an artificial opening into the stomach). R35's Quarterly Minimum Data Set (MDS), dated [DATE], documented R35 had. The MDS documented R9 required extensive staff assistance with short and long-term memory problems and severely impaired cognition. The MDS documented R35 dependent on staff assistance with activities of daily living (ADL). The MDS documented R35 received 51% of total calories and fluid intake through tube feedings. R35's Care Plan, dated 03/09/25, documented R35 was dependent on staff with ADLs. The plan documented R35 required tube feedings and instructed staff to check for tube placement and gastric contents/residual (the amount of fluid or contents remaining in the stomach after a feeding) volume per facility protocol, record findings, and hold feeding if the residual was greater than 60 cubic centimeters (cc). The plan instructed staff to monitor, document, and report as needed (PRN) any signs or symptoms of fever, tube dislodged, infection at tube site, abnormal breath/lung sounds, abnormal lab values, abdominal pain, and distension. The Nurse's Note dated 01/17/25 at 02:30 PM documented the resident being hospitalized . The Progress Note dated 01/22/25 at 07:55 PM documented Social Service Staff X e-mailed the discharge transfer and bed hold form to a family member. The EMR lacked a nurse assessment or note regarding why or when the resident was discharged to the hospital. The Nutrition/Dietary Note dated 1/24/2025 at 12:15 PM documented R35 readmitted from the hospital. On 03/17/25 at 03:50 PM, R35 rested quietly in bed with eyes closed. On 03/19/25 at 03:05 PM, Administrative Nurse D stated she would expect the nurse to complete an interactive transfer form in the progress notes, which addressed an assessment of the resident before transferring a resident to the hospital. The facility's Transfer and Discharge Policy, revised 01/09/24, documented for emergency transfers, and discharges, staff would document resident assessment findings and other relevant information regarding the transfer in the medical record. The facility staff failed to document R35's assessment with relevant information regarding her transfer to the hospital on 01/22/25. This placed R35 at risk for lack of quality of care. 32360 - The Electronic Medical Record (EMR) for R117 documented diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and epilepsy (brain disorder characterized by repeated seizures). The Annual Minimum Data Set (MDS), dated [DATE], documented R117 had severely impaired cognition. R117 was dependent upon staff for all activities of daily living (ADL). R117 had upper one-side functional impairment and had no skin issues. The Quarterly MDS, dated [DATE], documented R117 had severely impaired cognition. R117 was dependent upon staff for all ADLs. R117 had lower functional impairment on both sides and had no skin issues. R117's Care Plan, dated 01/20/25, initiated on 08/05/23, documented R117 was at risk for alterations in skin integrity and directed staff to educate R117 and her family about the causes of skin breakdown. The staff were directed to encourage R117 to report any pain with repositioning, were pressure relief boots as tolerated, obtain a low air loss mattress, and provide treatment as ordered. The care plan lacked direction to staff on interventions to prevent skin tears and bruises. On 03/18/25 at 09:20 AM, observation revealed R117 had a red, bloody area on her left forearm. The area had a clear bandage on top of it that wrapped around the inner aspect of her forearm. R117's EMR lacked documentation of an assessment of the area or a description of what caused the area. On 03/18/25 at 09:25 AM, Licensed Nurse G stated R117 she was unsure what happened to R117's arm but stated, R117 often scratched herself and that the area had been there for a couple of days. On 03/18/25 at 09:30 AM, Administrative Staff A stated he was unable to find an assessment or paperwork regarding the skin tear. Administrative Staff A had talked with LN G who was aware of the skin tear and an assessment would be completed and the physician notified. On 03/19/25 at 02:55 PM, Administrative Nurse D stated staff should complete skin assessments when there are skin tears or bruises. The facility's Skin Assessment, policy, dated 03/19/25, documented, that the policy of the facility was to perform a thorough examination of the resident's skin, looking for any skin conditions Staff are to pay close attention and note any skin conditions such as redness, bruising, rashes, skin tears, blisters, open areas, ulcers, and lesions. The policy directed staff to document observations of the skin condition, type of wound, description of wound, and any other information as indicated or appropriate. The facility failed to identify, assess, and implement interventions to prevent skin tears for R117, who obtained a skin tear to her left forearm. This placed the resident at risk of further injury. - The Electronic Medical Record (EMR) documented R128 was admitted into the facility on [DATE] with Hospice- specialized care that mainly aims to provide comfort and dignity to the patients, by providing physical comfort and emotional, social, and spiritual support for people nearing the end of life.) services. R128 had diagnoses of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) type two, hypertension (high blood pressure), and bradycardia (low heart rate, less than 60 beats per minute). A Minimum Data Set was not completed as R128 was only in the facility two days before he transferred out of the facility. The EMR lacked an admission nursing assessment as well as any nursing assessments, including a baseline care plan, prior to his discharge from the facility on 02/22/25 On 03/12/25 at 0:39 AM, Administrative Nurse D verified she was unable to find any nursing assessment or nursing documentation related to R128's care while in the facility. Administrative Nurse D stated the nurse on duty, Licensed Nurse (LN) GG, was a new nurse and did not understand that she needed to document everything. Administrative Nurse D was unable to provide a reason that the EMR lacked any nursing assessments or documentation of care provided while R128 was in the facility. On 03/19/25 at 11:28 AM, Licensed Nurse (LN) I stated nursing assessments were completed upon admission, and for at least every shift for the first three days. LN I verified there were no nursing assessments in the EMR for R128. The facility's Admission of a Resident policy, dated 02/01/20, documented the admission process was intended to obtain all the information possible about the resident, for the development of comprehensive plans of care, and to assist the resident in becoming comfortable with the facility. Residents are admitted to the facility under the orders of the attending physician. The facility failed to obtain a nursing admission assessment and obtain the necessary nursing assessment to provide care and services for R128. This placed R128 at risk for inappropriate care and decline. - The Electronic Medical Record (EMR) for R142 documented diagnoses of epilepsy (brain disorder characterized by repeated seizures), dementia (a progressive mental disorder characterized by failing memory and confusion), obsessive-compulsive disorder (OCD - an anxiety disorder characterized by recurrent and persistent thoughts, ideas, and feelings of obsessions severe enough to cause marked distress, consume considerable time, or significantly interfere with the resident's occupational, social, or interpersonal functioning), and depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Annual Minimum Data Set (MDS), dated [DATE], documented R142 had severely impaired cognition. R142 was dependent upon staff for all activities of daily living (ADL). R142 had upper and lower functional impairment on both sides, was short of breath when lying flat, and was always incontinent of bladder and bowel. The Quarterly MDS, dated [DATE], documented R142 had moderately impaired cognition. R142 was dependent upon staff for all ADLs. R142 had upper and lower functional impairment on both sides, was short of breath when lying flat, and was always incontinent of bladder and bowel. R142's Care Plan, dated 11/20/24, initiated on 02/15/22, documented R142 was prescribed medication for her seizure disorder. Staff were directed to monitor for seizure activity, frequency, duration, and type. The staff were directed to monitor for anxiety (anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), drowsiness, and lethargy (lack of energy and motivation). Take medication as ordered, and monitor labs as ordered by the physician. The Hospital Transfer Form, dated 02/10/24 at 07:00 AM, documented R142 was transferred to the hospital for abnormal pulse oximetry (low oxygen saturation). Her vital signs (clinical measurements that indicate the state of the patient's essential body functions) were blood pressure (the pressure of the blood in the system), 118/67 millimeters of mercury (mmHg), heart rate was 110 beats per minute (bpm), oxygen saturation (percentage of oxygen in the blood) 74% (normal range is 95-100%). Review of the EMR lacked documentation of any nursing assessments prior to R142's discharge to the hospital or at the time of discharge. On 03/12/25 at 09:30 AM, Administrative Nurse D stated there had been some staffing changes related to the nurses that had been on duty for this resident. Administrative Nurse D further stated the nurse on duty when R142 went to the hospital was a new nurse and was unsure about what to document in the EMR. Administrative Nurse D further stated she thought R142 had been having respiratory issues and that there should have been nursing assessments on the resident. The facility's Transfer and Discharge (including AMA) policy, dated 02/01/20, documented that if the transfers were initiated by the facility for medical reasons, or the immediate safety and welfare of a resident, they would obtain a physician order, notify the family, and contact an ambulance service. The resident's current status, including baseline and current mental, behavioral, and functional status and recent vital signs. The facility would document assessment findings and other relevant information regarding the transfer in the medical record. The facility failed to document in the EMR, any nursing assessments prior to her hospital discharge, this placed R142 at risk for physical decline. 41713 - R13's Electronic Medical Record (EMR) documented an admission to the facility on [DATE] with diagnoses of fracture (broken bone) of the third lumbar vertebrae (spine bone), unsteadiness on the feet, and congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid). R13's Admission Minimum Data Set (MDS) was still in progress. R13's Care Plan initiated on 02/26/25 directed staff that she was a full code. Staff was directed to review the discharge plan quarterly in the care plan meetings. Staff were directed to assist with the goal of going home. R13's care plan lacked staff direction for her activities of daily living (ADL). R13's care plan lacked staff direction for care regarding her care for her vertebrae fracture. A hospital Discharge Summary dated 02/26/25 documented R13 had been admitted to the hospital on 02/19/25 after sustaining a closed compression fracture (occurs when one or more bones in the spine weaken and crumple) of the lumbar third (L3) vertebrae after a fall and hitting her back. Neurosurgery was consulted and placed a thoracic-lumbar-sacral orthosis (TLSO a brace that limits movement in your spine from the mid back to your tailbone) brace with recommendations to wear the brace when she was out of bed. Physical therapy and occupational therapy evaluation and therapy to be provided to maintain functional mobility. An inpatient post-acute setting is recommended. Patient to follow up with a physician in seven days following discharge and with neurosurgery in 12 weeks. R13's Order Summary documented an order dated 02/27/25 for physical therapy (PT) clarification order: PT to evaluate and treat five to seven times a week for 30 days. Treatment may include therapeutic exercises, therapeutic activities, neuromuscular reeducation, gait, and group therapy. R13's Order's tab of the EMR reviewed on 03/18/25 lacked a physician's order on admission for a back brace or instructions for its application and removal. On 03/17/25 at 02:17 PM, R13 sat in her wheelchair in her room. In the chair beside R13 was some sort of back brace. R13 stated she was supposed to wear the brace because she had a fracture to one of her bones in her spine. R13 stated she did not like to wear the brace. On 03/18/25 at 08:43 AM, R13 sat in her wheelchair at the dining table and had a back brace on. On 03/19/25 at 12:33 PM, Licensed Nurse (LN) J stated R13 has had the brace since she was admitted and was told she was to wear it when she was out of bed. LN J stated there should be an order or mention of the brace in the care plan. LN J could not say for certain without looking in R13's chart if there was in fact an order for the brace or if R13's care plan had staff direction for the use of the brace. On 03/19/25 at 02:53 PM, Administrative Nurse D stated R13 has had the brace since her admission and would expect there to be an order for the brace. Administrative Nurse D stated she would expect R13's care plan to reflect her lumbar fracture and the need for staff to put on and take off the brace. The facility policy Admission of a Resident implemented on 02/01/20 documented that the admission process was intended to obtain all the information possible about the resident, for the development of comprehensive plans of care, and to assist the resident in becoming comfortable in the facility. Residents were admitted to the facility under the orders of the attending physician. The facility failed to ensure staff entered R13's physician's order for her TLSO back brace and included instructions on when to put it on and when to remove the brace. This placed R13 at risk of unmet goals and delays in her recovery.

The facility had a census of 130 residents. The sample included 27 residents. Based on observation, record review, and interview, the facility failed to provide at regular times comparable to normal mealtimes for two dining room and room meal trays. This placed the residents at risk of meals by resident needs, preferences, requests, and plans of care for having to wait extended periods before receiving meals. Findings included: - The facility's posted lunch mealtime of 11:45 AM to 01:30 PM. On 03/17/25 at 11:57 AM, facility residents had been entering the large dining room toward the entrance of the facility independently and with staff assistance. One unidentified dietary staff provided residents with beverages and paper-wrapped silverware. Several residents lifted their arms and hands to gain attention from the one dietary staff member but would become fatigued and could not keep their hands and arms raised. On 03/17/25 at 12:11 PM, some residents asked when the food would be served. Dietary staff continued to provide beverages of choice and take the menu of some of the residents. On 03/17/25 at 12:17 PM, no food had been served to the residents, and dietary staff informed residents the computer system for taking their meal choices was not working correctly. On 03/17/25 at 01:04 PM, the first meal was brought out of the kitchen for the residents in the large dining room. On 03/17/25 at 01:09 PM, a table of three male residents left the dining room commenting it was taking too long to get their meal. On 03/17/25 at 01:13 PM, residents asked dietary staff about getting their menu order so they could receive their meal. Dietary Staff began taking meal preferences with paper and pencils. On 03/17/25 at 01:15 PM, staff walked by the dining room with two pizza boxes, and the front receptionist was the dietary staff to provide meal plates to the residents. Numerous residents voiced frustration about not having their meals by this time or being furnished with beverages. On 03/17/25 at 01:30 PM, most of the residents had been served their meal in the large dining room. Residents who had come to the dining room at later times got food before the residents who came early. Observation further revealed residents at the same table did not get served their meal at the same time. Residents would finish their meals and leave while the other residents at the table watched without getting their meals to eat. Meals were served randomly to tables. On 03/18/25 at 11:48 AM, observation of the large dining room revealed residents already in the dining room and staff assisting the residents to the dining room. Drink preferences were provided by two dietary staff. Some of the residents received disposable cups and silverware. One unidentified dietary member announced to several of the residents who inquired about the dishes, the dishwasher had conked out. Dietary staff were also taking menu selections on their tablets. On 03/18/24 at 12:10 PM, residents continued to enter the dining room. No food was served from the kitchen at that time. On 03/18/25 at 12:17 PM, one resident had been served their meal. On 03/18/25 at 12:30 PM, Resident (R) 19 who had been present in the dining room since before 11:48 AM was served. Residents were observed holding their arms and hands up to get the attention of staff in the room, but again the residents would become fatigued and lower their arms before staff would respond. On 03/18/25 at 12:49 PM, R298 and R250 who had been sitting in the dining room since 11:30 AM had not received their meal, reporting late meal serving was usual and it did not matter who came to the dining room early or later. At this time several residents had asked for a second soft beef taco and dietary staff informed the residents they would have to wait and see if there was enough for everyone to be served. On 03/18/25 at 01:38 PM, the room tray meal cart left the kitchen and was taken to Hall 400. Further observation revealed not all residents in the dining room had received their meal. Upon request, the facility failed to provide a policy for serving meals. The facility failed to provide regular times comparable to normal mealtimes for two dining rooms and room meal trays. This placed the residents at risk of meals by resident needs, preferences, requests, and plans of care for having to wait extended periods before receiving meals. 32360 - On 03/17/25 at 12:00 PM, residents were seated in the Memory Care Unit dining room. Staff provided residents with their drinks and health supplements. On 03/17/25 at 12:15 PM, the residents were still seated in the Memory Care Unit dining room without food. On 03/17/25 at 12:45 PM, residents continue to wait for their food in the Memory Care unit. Two residents at a table questioned staff when the food would be delivered, and staff could not provide an answer. On 03/17/25 at 01:15 PM, residents still had not received their food in the Memory Care Unit. On 03/17/25 at 01:40 PM, the residents received their meal in the Memory Care Unit. On 03/18/25 at 08:30 AM, residents were seated in the Memory Care Unit dining room. Staff provided their drinks to the residents. On 03/18/25 at 09:00 AM, R 125 stated, Come on, come on, let's go! Certified Nurse Aide (CNA) M stated, Where do you want to go? R125 stated, I want to go get something to eat. R125 repeated this request over and over. On 3/18/25 at 09:05 AM, R124 clapped her hands together, and screamed I want to eat! R124 did this multiple times. On 03/18/25 at 09:15 AM, Resident's in the Memory Care Unit received their food. On 03/18/25 at 09:15 AM, Certified Nurse Aide (CNA) M stated that the meals were late more than they were on time. Upon request, a policy for mealtimes and meal service was not provided by the facility. The facility failed to provide regular times comparable to normal mealtimes for the residents in the Memory Care Unit. This placed the residents at risk of meals by resident needs, preferences, requests, and plans of care for having to wait extended periods before receiving meals.

The facility had a census of 130 residents. The sample included 27 residents. Based on observation., record review, and interview, the facility's Quality Assessment and Assurance (QAA) program failed to provide good faith efforts to identify multiple issues of concern for the 130 residents who resided in the facility. This placed all residents at risk for unidentified and ongoing care issues. Findings included: - The facility failed to provide R2 with the Center for Medicare and Medicaid Services (CMS) Form 10055. Refer to F582. The facility failed to provide a safe, comfortable environment. Refer to F584. The facility failed to address the resident's history of sexually aggressive behavior. Refer to F600. The facility failed to complete comprehensive assessments in a timely manner for R13, R98, and R112. Refer to F636. The facility failed to complete baseline care plans for R13, R78, R98, and R295. Refer to F655. The facility failed to revise care plans for R78 and R117. Refer to F657. The facility failed to provide consistent bathing for R48, R71, R92, R99, R117, R121, and R125. Refer to F677. The facility failed to complete nursing assessments prior to a discharge to the hospital for R35 and R142. The facility failed to complete a nursing assessment following admission for R128. The facility failed to implement intervention to prevent a skin tear for R117, and implement intervention related to R13s back brace. Refer to F684. The facility failed to implement preventative interventions for R78, who had a pressure ulcer. Refer to F686. The facility failed to obtain an order for oxygen therapy and failed to store oxygen tubing in a bag for R346. Refer to F695. The facility failed to obtain orders for R295, who received Dialysis Services. Refer to F698. The facility failed to ensure adequate daily nursing staff were always available to meet the needs of the residents who resided in the facility. Refer to F725. The facility failed to ensure staff possessed the competencies and skill sets necessary to provide nursing and related services for R128 and R142. Refer to F726. The facility failed to ensure physician involvement for R121, who had behaviors. Refer to F742. The facility failed to document signatures in the narcotic count boot. Refer to F755. The facility failed to ensure the Consultant Pharmacist identified and reported to the facility R29's out-of-parameters accu-checks. Refer to F756. The facility failed to notify the physician for Accu-check outside of physician-ordered parameters for R29. The facility failed to document in the Medication Administration Record after administering medication for R295. Refer to F757. The facility failed to prevent medication administration errors for R29, who received the wrong dosage of a medication supplement for six out of six administrations. Refer to F760. The facility failed to store and label biologicals as required in one of seven medication carts when staff failed to place a stop date on R31's Humalog Insulin) Kwik pen. Refer to F761. The facility failed to provide, at regular times comparable to normal mealtimes for two dining room and room meal trays. Refer to F809. The facility failed to provide a plan of care for R112, who was on hospice. Refer to F849. The facility failed to provide a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infections. Refer to F880. On 03/19/25 at 05:00 PM, Administrative Staff A stated the team meets monthly and discussed concerns related to the residents. They had been making a lot of changes for the good of the residents and hope to continue improving the quality of life for all of the residents. The facility's Quality Assurance and Performance Improvement (QAPI) policy, dated 03/19/25, documented the facility, develop, implement, and maintain an effective, comprehensive, data-driven QAPI program. The program focused on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides. The facility's Quality Assessment and Assurance (QAA) program failed to provide good faith efforts to identify multiple issues of concern for the 130 residents who resided in the facility. This placed all residents at risk for unidentified and ongoing care issues.

The facility had a census of 130 residents, with three reviewed for Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on record review and interview, the facility failed to provide form CMS 10055 Advanced Beneficiary Notice (ABN), which included the estimated cost to continue services for skilled services to the resident or their representative for one of three residents, Resident (R) 2. This deficient practice placed R2 at risk for uninformed decisions and unanticipated costs related to skilled services. Findings included: - The Medicare ABN form informed the beneficiaries that Medicare may not pay for future skilled therapy and did not provide an estimated cost to continue their services. The form included an option for the beneficiary to (1) receive specified services listed, and bill Medicare for an official decision on payment, but can appeal to Medicare. (2) receive therapy listed, but do not bill Medicare, I am responsible for payment of services. (3) I do not want the listed services. The facility lacked documentation staff provided R2 (or their representative) the ABN form 10055 when the resident's skilled services ended on 01/10/25. On 03/18/25 at 01:30 PM, Social Service Y stated the facility had not provided R2 the CMS form 10055. Social Service Y stated the previous SS X no longer worked at the facility and had not given him the 10055 form. On 03/19/25 at 02:55 PM, Administrative Nurse D stated that R2 should have received the CMS 1005 form with the estimated cost. The facility's Advance Beneficiary Notices policy, dated 03/19/25, documented the facility would provide timely notices regarding Medicare eligibility and coverage. The facility would provide the resident a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN), Form CMS-10055. The Facility failed to provide R2 with the appropriate non-coverage notice and cost estimate for further services, placing the resident at risk for uninformed decisions regarding skilled services.

The facility had a census of 130 residents. The sample included 27 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 121's sexually aggressive behaviors were addressed. This placed the residents of the facility at risk of sexual abuse. Findings included: The Electronic Medical Recorded (EMR) documented R121 had diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), spastic hemiplegia (paralysis of one side of the body) affecting the nondominant side, dysphagia (swallowing difficulty), cognitive-communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and difficulty in walking. The Admission Minimum Data Set (MDS), dated [DATE], documented R121 had intact cognition, felt down, depressed, and hopeless, and social isolation. The resident had no signs or symptoms of delirium (sudden severe confusion, disorientation, and restlessness), psychosis (any major mental disorder characterized by a gross impairment in reality perception), or exhibited behaviors. R121 had a functional range of motion impairment of one side upper extremity, was dependent on toileting, and lower body dressing, and required substantial/maximal assistance with mobility. The resident had frequent incontinence of urine. The MDS further documented that R121 had occasional mild pain and two non-injury falls since admission. The resident received speech, occupational, and physical therapy. The Functional Abilities Care Area Assessment (CAA), dated 06/29/24, documented R121 had been admitted following hospitalization with a diagnosis of cerebral infarction, requiring assistance of one to two staff members for activities of daily living and transfers, worked with physical and occupational therapies for strengthening and returning to his prior level of function. He used a wheelchair for mobility. The Quarterly MDS, dated [DATE], document R121 had intact cognition, a mood score of 01 with feeling down, depressed, or hopeless, and socially isolated. The resident exhibited no delirium, psychosis, or behaviors. The MDS further documented R121 was dependent with toileting, bathing, and upper and lower body dressing, and required substantial/maximal assistance with mobility. R121 was always incontinent of urine and bowel, had pain frequently which occasionally interfered with day-to-day activities, and had one non-injury fall. R121's Care Plan on 07/03/24, documented R121 had a behavior problem and could be sexually inappropriate to female staff and had allegations of abuse when he was not tended to immediately when requested and of only allowing assistance from certain staff members. The Care Plan directed staff to provide care in pairs only, due to sexually inappropriate behaviors and history of allegations of staff abuse. The Care plan further stated R121 sometimes would touch female staff in inappropriate places and would make sexually inappropriate statements and staff was to encourage him not to do so. On 03/8/25 the care plan documented R121 placed on one-to-one care of staff. The Progress Note dated 07/02/24 at 02:57 PM, documented R121 had exhibited inappropriate behaviors during care in the morning, groping the nurse aide, pulling the aide into bed during the bed bath, calling the aide baby and getting upset when the nurse aide talked to other people, and would make inappropriate comments to the aide. The Progress Note dated 08/09/24 at 05:52 AM, documented when nursing staff went into R121 to give medication R121 was holding his penis and made two sexually inappropriate remarks. The Progress Note dated 08/09/24 at 06:09 AM, documented a nurse aide reported R121 made inappropriate sexual comments. The Progress Note dated 03/08/25 at 06:52 PM, documented R121 had inappropriately touched another R71. R121 was immediately placed on one-to-one care. R121's family member was notified of the situation. The police department spoke to the resident and a family member. Staff explained appropriate touch and the family member told R121 not to be touching any women and inquired about transferring to a facility that only had men and asked that this would be discussed with the physician. The Progress Note dated 03/17/25 at 04:24 PM, documented facility staff spoke with R121's Durable Power of Attorney (DPOA) about new medication order and permission for the resident to receive the medication and to have staff chart any sexual behaviors over the next 48 hours and would reassess the need for one-to-one care. The EMR lacked physician notification of sexual behaviors involving staff. On 03/18/25 at 07:08 AM, Activity Staff Z was seated in the hallway outside of R121 room. Activity Aide stated she was assigned to monitor R121. She stated she was not sure of the reason R121 was being monitored, reporting her supervisor had been also providing one-to-one observation. On 03/18/25 at 12:21 PM, R121 was brought to the dining room by staff. R121 was placed at a meal table which seated several male residents. Staff sat at the table with R121 throughout the meal. On 03/19/25 at 09:37 AM, Certified Nurse Aide (CNA) N reported R121 had been respectful and told the CNA often he appreciated the assistance. On 03/19/25 at 03:15 PM, Administrative Nurse D reported the nursing management went with R121 physician, and the physician was made aware of the behaviors. Administrative Nurse D thought the physician had made note of the sexual behaviors but was not able to find information regarding behaviors in the medical record. The facility's Abuse, Neglect, and Exploitation Policy, dated 03/17/25, documented it is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prevent abuse, neglect, exploitation, and misappropriation of resident property. Identifying, correcting, and intervening in situations in which abuse, neglect, and exploitation were more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents and assure that the staff have knowledge of the individual residents' care needs and behavioral symptoms. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs that might lead to conflict or neglect. The facility failed to ensure R121's sexually aggressive behaviors were addressed. This placed the residents of the facility at risk of sexual abuse.

The facility identified a census of 130 residents. The sample included 27 residents who were reviewed for comprehensive assessments and timing. Based on observation, record review, and interview, the facility failed to ensure the admission comprehensive Minimum Data Set (MDS) was completed for Resident (R) 98, R112, and R13 using the Centers for Medicaid and Medicare (CMS) - specified Resident Assessment Instrument (RAI) guidelines. This deficient practice placed these residents at risk for inaccurate reflections of the resident's status and needed to develop an individualized comprehensive person-centered plan of care. Findings included: - R98 admitted to the facility on [DATE]. R98's Admission MDS had an assessment reference date (ARD) of 02/12/25 and a completion date of 03/02/25. R98's Care Area Assessments were not completed until 03/02/25. R112 readmitted to the facility on [DATE]. R112's Admission MDS had a date of 03/03/25 but had been completed. R13 admitted to the facility on [DATE]. R13's Admission MDS with an ARD of 03/11/25 had not been completed. On 03/19/25 at 12:50 PM, Licensed Nurse (LN) I stated that she completed the MDSs. LN I stated she had been working on the floor to cover for them being short of help. LN I stated she had gotten behind on completing some of the MDS assessments, so she was to blame for that. On 03/19/25 at 03:15 PM, Administrative Nurse D stated she was aware that some of the MDS assessments had not been completed when they should have. Administrative Nurse D stated she was working on getting more facility staff so the MDS coordinator could get back to focusing on only doing the MDS assessments. The Assessment Frequency/Timeliness policy dated 02/01/20 documented the MDS/RAI coordinator would be responsible for tracking due dates for all MDS assessments, whether scheduled or unscheduled. The comprehensive admission assessment would be completed within 14 days after admission, excluding readmissions in which there was no significant change. Medicare PPS assessments, scheduled or unscheduled, would be completed within 14 days of ARD. The type of assessment and ARD would adhere to Medicare guidelines for each assessment. The facility failed to ensure the admission comprehensive MDS was completed for R98, R112, and R13 using the CMS-specified RAI guidelines. This deficient practice placed these residents at risk for inaccurate reflections of the resident's status and needed to develop an individualized comprehensive person-centered plan of care.

The facility had a census of 130 residents. The sample included 27 residents. Based on observation, record review, and interview, the facility failed to revise the care plan for Resident (R) 117 with interventions to prevent skin tears and failed to [NAME] R78's care plan with interventions to prevent pressure ulcers. This placed the residents at risk of further injury and uncommunicative care needs. Findings included: - The Electronic Medical Record (EMR) for R117 documented diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and epilepsy (brain disorder characterized by repeated seizures). The Annual Minimum Data Set (MDS), dated [DATE], documented R117 had severely impaired cognition. R117 was dependent upon staff for all activities of daily living (ADL). R117 had upper one-side functional impairment and had no skin issues. The Quarterly MDS, dated [DATE], documented R117 had severely impaired cognition. R117 was dependent upon staff for all ADLs. R117 had lower functional impairment on both sides and had no skin issues. R117's Care Plan, dated 01/20/25, initiated on 08/05/23, documented R117 was at risk for alterations in skin integrity and directed staff to educate R117 and her family of the causes of skin breakdown. The staff were directed to encourage R117 to report any pain with repositioning, wear pressure relief boots as tolerated, obtain a low air loss mattress, and provide treatment as ordered. The care plan lacked direction to staff on interventions to prevent skin tears and bruises. On 03/18/25 at 09:20 AM, observation revealed R117 had a red, bloody area on her left forearm. The area had a clear bandage on top of it that wrapped around the inner aspect of her forearm. R117's EMR lacked documentation of an assessment of the area or a description of what caused the area. On 03/18/25 at 09:25 AM, Licensed Nurse G stated R117 she was unsure what happened to R117's arm. LN G stated, that R117 often scratched herself and that the area had been there for a couple of days. On 03/18/25 at 09:30 AM, Administrative Staff A stated he was unable to find an assessment or paperwork regarding the skin tear. Administrative Staff A had talked with LN G who was aware of the skin tear and an assessment would be completed and the physician notified. On 03/19/25 at 02:55 PM, Administrative Nurse D stated staff should complete skin assessments when there are skin tears or bruises, and the care plan should be updated with interventions to prevent skin tears. The facility's Care Plan Revisions Upon Status Change policy, dated on 02/01/20, documented the comprehensive care plan would be reviewed and revised as necessary when a resident experienced a status change. The team met and discussed the resident's condition and collaborated on intervention options. The facility failed to revise R117's care plan with interventions to prevent skin tears and bruises. This placed the resident at risk for further injury and uncommunicative care needs. 41713 - R78's Electronic Medical Record (EMR) documented diagnoses of atrial fibrillation (A-Fib rapid, irregular heartbeat), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), embolism (an obstruction in a blood vessel due to a blood clot or other foreign matter that gets stuck while traveling through the bloodstream), and thrombosis (a clot that develops within a blood vessel) of lower extremities. R78's Admission Minimum Data Set (MDS) dated [DATE] documented both short and long-term memory problems. R78 had moderately impaired cognitive skills for daily decision-making. R78 had impairment on both sides of his upper extremity. R78 required a wheelchair for mobility. R78 was dependent on staff for all functional abilities. R78 was always incontinent of bowel and bladder. R78 was at risk of pressure ulcer development. R78 had no pressure ulcers on admission. R78 had a pressure-reducing device for the bed. R78 had application ointments and medications other than to feet. R78's Pressure Ulcer Care Area Assessment (CAA) dated 03/01/25 documented pressure ulcers would be addressed in R78's care plan. Staff were to assist with repositioning per protocol and as needed to help maintain skin integrity. Licensed nursing staff were to monitor skin integrity every week to help monitor for any skin issues. Incontinence creams were to be used as needed to help maintain skin integrity. A pressure redistributing surface was in place to the resident's bed and to the wheelchair to help maintain skin integrity. R78's Care Plan dated 02/08/25 directed staff to educate family and caregivers of causative factors and measures to prevent skin injury. Staff were directed to encourage good nutrition and hydration to promote healthier skin. Staff were directed that R78 preferred to bathe and shower on Wednesday and Saturday evenings. R78's care plan had not been updated and revised to direct staff on his wound care or how much assistance R78 required from staff. R78's Braden Scale Pressure for Predicting Pressure Sore Risk (a tool used to assess the risk of developing a pressure ulcer) admission assessment dated [DATE] documented a score of nine that indicated a high risk of pressure ulcer development. R78's Orders tab of the EMR documented an order dated 02/07/25 for weekly skin assessments by the licensed nurse. Document the findings on the weekly skin UDA every Thursday. R78's 'Weekly Skin Check under the Assessment tab of the EMR revealed skin checks had been completed on 02/12/25, 02/19/25, 02/20/25, 02/27/25, 02/28/25, and 03/06/25. R78's Weekly Skin Check under the Assessments tab dated 02/28/25 documented a new skin issue, pressure related to the right buttock. The skin check lacked any documentation of the skin area characteristics or measurements. R78's Skin/Wound Note under the Progress Notes tab of the EMR dated 02/28/25 at 02:40 PM documented R78 had an open were to the right buttock noted. The area was cleansed and venelex (an ointment used to treat skin wounds) was applied and covered with a border foam dressing. The nurse practitioner and R78's spouse was notified. The Orders tab documented an order dated 02/28/25 for comfort border foam dressing to the right buttock wound. Change twice daily and as needed. R78 had been seen by the Advance Practice Registered Nurse (APRN) on 03/03/25, 03/10/25, 03/13/25, and 03/17/25 but the provider had not addressed R78's pressure wound. A Wound Evaluation completed on 03/19/25 under the Skin and Wound tab of the EMR documented a Stage 3 (a full-thickness pressure injury extending through the skin into the tissue below) pressure ulcer. The wound measured a length of 4.33 centimeters (cm), width of 1.51 cm, depth of 0.1 cm, and total area of 5.01 cm squared. On 03/18/25 at 09:42 AM, R78 laid in bed as nursing staff prepared the resident for care. On 03/19/25 at 10:30 AM, Certified Nurse Aide (CNA) O stated the aides were to look over the resident's skin at each bath given. CNA O stated if any skin changes had been noted it was to be documented on the shower sheet and the nurse was notified immediately. CNA O stated the resident's care plan should list any care for the resident or if cream should be applied. On 03/19/25 at 12:33 PM, Licensed Nurse (LN) J stated a R78's care plan should have staff direction for skin issues and how much assistance was needed for the resident. R78 was dependent on staff for his care. LN J stated the unit manager or the MDS coordinator was who updated orders and the care plan when new issues arose. LN J stated she had not noticed that R78 did not have interventions in place to address his pressure ulcer care. LN J stated she did do the daily dressing changes on R78. LN J stated that R78 did have a wound on his bottom that had just opened a few days ago. LN J stated the wound nurse did see R78 today. On 03/19/25 at 12:50 PM, LN I stated she and the unit manager had gotten behind on getting the care plans and MDSs updated lately. LN I stated a resident's care plan should be updated with any new interventions. R78's care plan should have interventions in place for his wound, but they had not been added yet. On 03/19/25 at 02:53 PM, Administrative Nurse D stated she would expect that a resident would have interventions in place and revised for a resident that had pressure wounds. Administrative Nurse D stated the staff that had updated the care plans had gotten a little behind on getting them updated or completed since those staff had been helping on the floor. Administrative Nurse D would expect that staff had been doing weekly skin assessments and making sure that measurements had been recorded for those wounds. Administrative Nurse D stated she would speak with staff to ensure a resident got the care needed. The Care Plan Revisions Upon Status Change policy implemented on 02/01/20 documented the comprehensive care plan would be reviewed, and revised as necessary when a resident experienced a status change. Upon identification of a change in status, the nurse would notify the MDS Coordinator, the physician, and the resident representative. The care plan would be updated with the new or modified interventions. Care plans would be modified as needed by the MDS Coordinator or other designated staff member. The Unit Manager or other designated staff member would communicate care plan interventions to all staff involved with the resident's care. The facility failed to ensure a care area and interventions were put in place and implemented to care for R78's Stage 3 pressure ulcer on his buttock. This deficient practice placed R78 at risk of complications and possible infection.

The facility identified a census of 130 residents. The sample included 27 residents, with four sampled residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as the result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to ensure interventions were in place and implemented for Resident (R) 78 to prevent skin breakdown which resulted in an avoidable pressure ulcer development. This deficient practice placed R78 at risk for complications and possible infection-associated pressure wounds. Findings included: - R78 ' s Electronic Medical Record (EMR) documented diagnoses of atrial fibrillation (A-Fib rapid, irregular heartbeat), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), embolism (an obstruction in a blood vessel due to a blood clot or other foreign matter that gets stuck while traveling through the bloodstream), and thrombosis (a clot that develops within a blood vessel) of lower extremities. R78 ' s Admission Minimum Data Set (MDS) dated [DATE] documented both short and long-term memory problems. R78 had moderately impaired cognitive skills for daily decision-making. R78 had impairment on both sides of his upper extremity. R78 required a wheelchair for mobility. R78 was dependent on staff for all functional abilities. R78 was always incontinent of bowel and bladder. R78 was at risk of pressure ulcer development. R78 had no pressure ulcers on admission. R78 had a pressure-reducing device for the bed. R78 had application ointments and medications other than to feet. R78 ' s Pressure Ulcer Care Area Assessment (CAA) dated 03/01/25 documented pressure ulcers would be addressed in R78 ' s care plan. Staff were to assist with repositioning per protocol and as needed to help maintain skin integrity. Licensed nursing staff were to monitor skin integrity every week to help monitor for any skin issues. Incontinence creams were to be used as needed to help maintain skin integrity. A pressure redistributing surface was in place to the resident ' s bed and to the wheelchair to help maintain skin integrity. R78 ' s Care Plan dated 02/08/25 directed staff to educate family, and caregivers of causative factors and measures to prevent skin injury. Staff were directed to encourage good nutrition and hydration to promote healthier skin. Staff were directed that R78 preferred to bathe and shower on Wednesday and Saturday evenings. R78 ' s care plan had not been updated and revised to direct staff on his wound care or how much assistance R78 required from staff. R78 ' s Orders tab of the EMR documented an order dated 02/07/25 for weekly skin assessments by the licensed nurse. Document findings on the weekly skin UDA every Thursday. The Orders tab documented an order dated 02/28/25 for comfort border foam dressing to the right buttock wound. Change twice daily and as needed. R78 ' s Braden Scale Pressure for Predicting Pressure Sore Risk (a tool used to assess the risk of developing a pressure ulcer) admission assessment dated [DATE] documented a score of nine that indicated a high risk of pressure ulcer development. R78 ' s ' Weekly Skin Check under the Assessment tab of the EMR revealed skin checks had been completed on 02/12/25, 02/19/25, 02/20/25, 02/27/25, 02/28/25, and 03/06/25. R78 ' s Weekly Skin Check under the Assessments tab dated 02/28/25 documented a new skin issue, pressure related to the right buttock. The skin check lacked any documentation of the skin area characteristics or measurements. R78 ' s Skin/Wound Note under the Progress Notes tab of the EMR dated 02/28/25 at 02:40 PM documented R78 had an open area to the right buttock noted. The area was cleansed and venelex (an ointment used to treat skin wounds) was applied and covered with a border foam dressing. The nurse practitioner and R78 ' s spouse was notified. R78 was seen by the Advance Practice Registered Nurse (APRN) on 03/03/25, 03/10/25, 03/13/25, and 03/17/25, but the provider failed to address R78 ' s pressure wound. A Wound Evaluation completed on 03/19/25 under the Skin and Wound tab of the EMR documented a Stage 3 (a full-thickness pressure injury extending through the skin into the tissue below) pressure ulcer. The wound measured a length of 4.33 centimeters (cm), width of 1.51 cm, depth of 0.1 cm, and total area of 5.01 cm squared. This evaluation was the first time the wound had been measured. On 03/18/25 at 09:42 AM, R78 laid in bed as nursing staff prepared the resident for care. On 03/19/25 at 10:30 AM, Certified Nurse [NAME] (CNA) O stated the aides were to look over the resident ' s skin when each bath was given. CNA O stated if any skin changes were found it was to be noted on the shower sheet, and the nurse notified immediately. CNA O stated the resident's care plan should list any care for the resident or if cream should be applied. On 03/19/25 at 12:33 PM, Licensed Nurse (LN) J stated a R78 ' s care plan should have staff direction for skin issues and how much assistance was needed for the resident. R78 was dependent on staff for his care. LN J stated the unit manager or the MDS coordinator was who updated orders and the care plan when new issues arose. LN J stated she had not known there were no interventions in place to address R78 ' s pressure ulcer care. LN J stated she did do the daily dressing changes on R78. LN J stated that R78 did have a wound on his bottom that had just opened a few days ago. LN J stated the wound nurse had seen R78 today. On 03/19/25 at 12:50 PM, LN I stated she and the unit manager had gotten behind on getting the care plans and MDSs updated lately. LN I stated a resident's care plan should be updated with any new interventions. R78 ' s care plan should have interventions in place for his wound, but they had not been added yet. On 03/19/25 at 02:53 PM, Administrative Nurse D stated she would expect that a resident would have interventions in place and revised for a resident that had pressure wounds. Administrative Nurse D stated the staff that updated the care plans had gotten a little behind on getting them updated, or completed since those staff had been helping on the floor. Administrative Nurse D would expect that staff had been doing weekly skin assessments and making sure that measurements had been recorded for those wounds. Administrative Nurse D stated she would speak with staff to ensure a resident got the care needed. The Pressure Injury Prevention and Management policy implemented 03/19/25 documented the facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce, or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. Licensed nurses would conduct a pressure injury risk assessment on all residents upon admission/re-admission, weekly for four weeks, then quarterly or whenever the resident ' s condition changed significantly. Findings would be documented in the medical record. Assessments of the pressure injuries would be performed by a licensed nurse and documented. The staging of pressure injuries would be clearly identified to ensure correct coding on the MDS. After completing a thorough assessment, the interdisciplinary team (IDT) shall develop a relevant care plan that included measurable goals for the prevention and management of pressure injuries with appropriate interventions. The unit manager would review relevant documentation regarding skin assessments and document a summary of findings in the medical record. The attending physician would be notified of the presence of the new injury, and the progression toward healing weekly. The facility failed to ensure interventions were put in place and implemented to prevent the avoidable development of R78 ' s Stage 3 pressure ulcer on his buttock. This deficient practice placed R78 at risk of complications and possible infection.

The facility identified a census of 130 residents. The sample included 27 residents with two sampled residents reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 346 had a physician's order for supplement oxygen (O2) therapy. The facility failed to ensure staff monitored and documented the effectiveness of R346's supplemental O2. The facility failed to ensure R346's nasal cannula (NC - a thin hollow tube that assists in providing supplemental eO2) was appropriately stored when not used. This deficient practice placed R346 at risk of respiratory complications and possible infection. Findings included: - R346's Electronic Medical Record (EMR) recorded an admitted d 03/01/25 and documented diagnoses of end-stage renal disease (ESRD - when the kidney lose their ability to function and filter waste and excess fluid from the blood), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), and respiratory failure (inadequate gas exchange by the respiratory system). R346's Admission Minimum Date Set (MDS) had not been completed yet due to her admitted d 03/01/25. R346's Care Plan initiated on 03/03/25 lacked a care area for O2 therapy. R346's Orders tab of the EMR reviewed on 03/18/25 lacked a physician's order for supplemental oxygen. R346's Treatment Administration Record (TAR) lacked staff direction to check and monitor R346's O2 saturation level each shift. On 03/17/25 at 12:05 PM, R346 laid in bed resting. R346 had NC in her nose. An O2 concentrator (a machine that provides supplemental oxygen) was in her room and turned on. The wheelchair in her room had an oxygen canister on the back of it. An NC was connected to the canister but was not stored in a bag. On 03/18/25 at 09:15 AM, R346 laid in her bed, had NC in her nose. On 03/19/25 at 10:30 AM Certified Nurse Aide (CNA) O stated the O2 cannula should be stored in a bag when not in use. On 03/19/25 at 12:33, Licensed Nurse (LN) J stated if a resident was on O2 there should be an order for it in the EMR and the saturation levels should be monitored each shift. R346's order might not have been re-entered when she had come back from the hospital. On 03/19/25 at 12:50 PM, Licensed Nurse (LN) I stated she had put in R346's orders when she returned from her hospital visit and she must have overlooked that she omitted getting the O2 order put in. On 03/19/25 at 02:53 PM, Administrative Nurse D stated any resident that received supplemental oxygen needed an order to have it. Administrative Nurse D stated staff should be monitoring the O2 saturation level each shift. Administrative Nurse D could not state why R346 did not have the order for her O2 entered in the EMR. The Medication Orders policy implemented on 01/01/20 documented that medications should be administered only upon the signed order of a person lawfully authorized to prescribe. Elements of the medication order were the date and time the order was written; the resident's full name; the name of the medications; the dosage-strength of the medicated; the time or frequency of administration; type/formulation (if applicable); the hour of administration; and the diagnosis or indication for use. Each medication order should be documented with the date, time, and signature of the person receiving the order. The order should be recorded on the physician's order sheet, and the Medication Administration Record (MAR). The facility that R346 had a physician's order for supplemental O2. The facility failed to ensure staff monitored and documented the effectiveness of R346's supplemental O2. The facility failed to ensure R346's NC was appropriately stored when not used. This deficient practice placed R346 at risk of respiratory complications and possible infection.

The facility had a census of 130 residents. The sample included 27 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 295 who received care and services for dialysis (a procedure where impurities or wastes were removed from the blood), was consistent with professional standards of practice, which included ongoing assessments of residents' condition, communication, and collaboration with the dialysis facility. This placed R295 at risk of complications and unmet care needs related to dialysis treatment. Findings included: - The Electronic Medical Record (EMR) for R295 documented diagnoses of fracture (broken bone)of the left tibia (bone of the lower leg), arteriovenous fistula (AV - a surgically created connection between an artery and a vein), dependence on renal (pertaining to kidneys) dialysis, end-stage renal disease, bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder. The Minimum Data Set (MDS) had not been completed due to recent admission had not met the criteria for completion or submission. R295's Baseline Care Plan, dated 03/12/25, lacked documentation regarding R295 dialysis process or directed staff of care. The Physician Orders lacked orders for dialysis. The Progress Notes lacked documentation of the need or participation in the dialysis process. On 03/18/25 at 07:43 AM, Certified Medication Aide (CMA) S reported that R295 went to dialysis on Mondays and Fridays. On 03/18/25 at 08:29 AM, R295 stated she had been at the facility for over three weeks and went to dialysis on Mondays and Fridays. R295 stated the facility staff had not assessed the AV shunt when returning to the facility following dialysis treatment. R295 also reported the facility had not sent a communication sheet with her to dialysis. On 03/18/25 at 08:39 AM, Licensed Nurse (LN) K reported not working on Mondays and Fridays. LN K stated dialysis residents' vital signs, changes of condition, or medications to be sent were on a communication sheet with a resident who received dialysis treatments. LN K was unable to locate any dialysis communication for R295. On 03/19/25 at 03:15 PM, Administrative Nurse D stated dialysis residents should have assessments before and after dialysis treatments and a communication sheet should accompany the resident at each treatment and verified this had not been completed for R295. Administrative Nurse D stated that R295's care plan should reflect R295's dialysis with directions for care. The facility's Hemodialysis policy, dated 03/19/25, documented the facility will ensure that each resident receiving care and services for the services for the provision of hemodialysis is consistent with professional standards of practice. This would include ongoing assessment and oversight of the resident before, during, and after dialysis treatments, including monitoring of the resident's condition during treatments, monitoring for complications, implementation of appropriate interventions, and using appropriate infection control practices, with ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The facility failed to provide care and services consistent with professional standards of practice which included ongoing assessment of condition, communication, and collaboration with the dialysis treatment center. This placed R295 at risk for complications and unmet care needs related to dialysis treatment.

The facility had a census of 130 residents. The sample included 27 residents. Based on observation, record review, and interview, the facility failed to provide an accurate reconciliation of controlled drugs during the daily work shift. This placed residents at risk for misappropriation of medication by staff. Findings included: - On 03/17/25 at 08:06 AM, observation of the 400-hall treatment cart revealed the count for controlled medication lacked 03/13/25 and 03/14/25 of the going off-shift signatures, and the 03/15/25 coming on shift staff signature. On 03/17/25 at 08:06 AM, Licensed Nurse (LN) G stated staff should sign at the beginning and end of shifts to ensure the accuracy of the controlled medication count. On 03/17/25 at 08:09 AM, observation of the 400-hall medication cart revealed the count for controlled medication lacked 03/15/25 and 03/16/25 both coming on shifts and going off shift staff signatures. On 03/17/25 at 08:09 AM, Certified Medication Aide (CMA) S stated the count for controlled medications should be signed. On 03/19/25 at 03:15 PM, Administrative Nurse D stated she expected staff to sign the controlled medication log with the on-coming and off-shift signatures. The facility's Controlled Substance Administration and Accountability policy dated 01/01/20, documented it was the policy of the facility to promote safe, high-quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place to prevent loss, diversion, or accidental exposure. In an inventory count without automated dispensing systems, two licensed nurses account for all controlled substances and access keys at the end of each shift. The facility failed to provide an accurate reconciliation of controlled medication at the end and beginning of daily work shifts, placing the residents at risk for misappropriation of medications by staff.

The facility had a census of 130 residents. The sample included 27 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's Consultant Pharmacist (CP) failed to identify and report to facility administration the staff had not notified the physician of out-of-parameter accu-checks (blood glucose monitoring test) for one resident, Resident (R) 29. This placed the resident at risk for physical decline and an ineffective medication regimen. Findings included: - The Electronic Medical Record (EMR) for R29 documented diagnoses of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), hypertension (high blood pressure), and epilepsy (epilepsy (brain disorder characterized by repeated seizures). The Annual Minimum Data Set (MDS), dated [DATE], documented R29 had moderately impaired cognition. R29 required supervision of staff with eating, showers, and ambulation. The MDS documented R29 received insulin daily. The Quarterly MDS, dated [DATE], documented R29 had moderately impaired cognition. R29 required set-up assistance with eating, personal hygiene, and showers. R29 was independent with mobility, and transfers, and did not ambulate. The MDS documented R29 received insulin daily. R29's Care Plan dated 01/07/25, initiated on 10/11/23, directed staff to administer medications as ordered and monitor for side effects and effectiveness, fasting blood sugars as ordered, monitor for signs and symptoms of hyperglycemia (high blood sugar), and identify areas of non-compliance. The Physician's Order, dated 10/30/24, directed staff to administer Lantus (a long-acting insulin), inject 12 Units (U), subcutaneously (under the skin), in the morning, and call the physician if the fasting blood sugar was greater than 160 milliliters (ml) per deciliter (dl), for diabetes mellitus type two. The order was discontinued on 03/10/25. Review of the EMR revealed the following times the accu-checks were outside of the physician-ordered parameters and the physician was not notified: January 2025: 25 out of the 31 administrations. February 2025: 17 out of the 28 administrations. March 2025: six out of the 18 administrations. The Medication Regimen Review, for the months of January, and February 2025, lacked documentation the CP identified and notified the facility administration of the outside of the physician-ordered parameters and the physician had not been notified. On 03/1825 at 08:00 AM, Certified Medication Aide (CMA) R administered her medications prior to the breakfast meal. On 03/19/25 at 12:14 PM, Licensed Nurse (LN) H stated she would notify the physician if the blood sugar was below 60 or above 400 and did not know why the order had not been followed. On 03/19/24 at 02:55 PM, Administrative Nurse D stated, that staff needed to follow the physician's orders and stated the CP had not notified her of any concerns. The facility's Pharmacy Services policy, dated 03/19/25, documented the facility would employ or obtain the services of a licensed pharmacist (in accordance with state requirements) who would provide consultation on all aspects of the provision of pharmacy services in the facility. The facility's CP failed to identify and report to facility administration the staff had not notified the physician of out-of-parameter accuchecks for R29. This placed the resident at risk for physical decline and an ineffective medication regimen.

The facility had a census of 130 residents. The sample included 27 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to notify the physician for an Accu-check (blood glucose monitoring test) outside of physician-ordered parameters, for one resident, Resident (R) 29. The facility failed to document in the Medication Administration Record (MAR) after administering medication for R295. This placed the residents at risk for adverse effects related to medications. Findings included: - The Electronic Medical Record (EMR) for R29 documented diagnoses of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), hypertension (high blood pressure), and epilepsy (epilepsy (brain disorder characterized by repeated seizures). The Annual Minimum Data Set (MDS), dated [DATE], documented R29 had moderately impaired cognition. R29 required supervision of staff with eating, showers, and ambulation. The MDS documented R29 received insulin daily. The Quarterly MDS, dated [DATE], documented R29 had moderately impaired cognition. R29 required set-up assistance with eating, personal hygiene, and showers. R29 was independent with mobility, and transfers, and did not ambulate. The MDS documented R29 received insulin daily. R29's Care Plan dated 01/07/25, initiated on 10/11/23, directed staff to administer medications as ordered and monitor for side effects and effectiveness, fasting blood sugars as ordered, monitor for signs and symptoms of hyperglycemia (high blood sugar), and identify areas of non-compliance. The Physician's Order, dated 10/30/24, directed staff to administer Lantus (a long-acting insulin) inject 12 Units (U), subcutaneously (under the skin), in the morning, and call the physician if the fasting blood sugar was greater than 160 milliliters (ml) per deciliter (dl), for diabetes mellitus type two. The order was discontinued on 03/10/25. Review of the EMR revealed the following times the accu-checks were outside of the physician-ordered parameters and the physician was not notified: January 2025: 25 out of the 31 administrations. February 2025: 17 out of the 28 administrations. March 2025: six out of the 18 administrations. On 03/1825 at 08:00 AM, Certified Medication Aide (CMA) R administered her medications prior to the breakfast meal. On 03/19/25 at 12:14 PM, Licensed Nurse (LN) H stated she would notify the physician if the blood sugar was below 60 or above 400 and did not know why the order had not been followed. On 03/19/25 at 02:55 PM, Administrative Nurse D stated, staff should follow physician orders. The facility's Unnecessary Drugs policy, dated 03/19/25, documented that each resident's entire drug/medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, physical, and psychosocial well-being free from unnecessary drugs. The facility failed to notify the physician for Accu-checks outside of the physician-ordered parameters for R29. This placed the resident at risk for physical decline. 37450 - The Electronic Medical Record (EMR) for R295 documented diagnoses of fracture (broken bone) of the left tibia (bone of the lower leg), arteriovenous fistula (AV - a surgically created connection between an artery and a vein), dependence on renal (pertaining to kidneys) dialysis, end-stage renal disease, bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder. The Minimum Data Set (MDS) had not been completed due to recent admission had not met the criteria for completion or submission. R295's Baseline Care Plan dated 03/12/25, had not included medication. The Physician Orders dated 02/28/25 directed staff to administer: Bupropion (a class of medications used to treat mood disorders) 150 milligrams (mg) Extended Release tablet daily in the morning for depression. Levothyroxine (a medication to treat an underactive thyroid- (an organ at the front of the neck that secretes hormones) 200 micrograms (mcg) tablet one time a day for hypothyroidism. Upon review of the 03/2025 MAR, the Bupropion lacked documentation of administration on March 3rd, 4th, 5th, 6th, 8th, and 9th, and Levothyroxine on March 2nd, 3rd, 7th, 11th, 12th, 15th, and 17th without documentation of reason of unsigned administration. The documentation lacked physician notification. On 03/19/25 at 12:01 PM, Certified Medication Aide (CMA) S reported the night shift nurse was scheduled to give the Levothyroxine but did not know why it had not been signed for as administered. The bupropion may not have been available from the pharmacy but was unsure of that also. On 03/19/25 at 03:20 PM, Administrative Nurse D stated medications should be given as ordered and signed in the MAR. The nursing staff were to record why the medication was not administered. The facility's Medication Administration policy, dated 03/19/25, documented that medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. The Medication Administration Record (MAR) is reviewed to identify the medication to be administered, observe the resident's consumption of medication, and sign the MAR after administration. The facility failed to ensure that R295 had documentation of the administration of his medications. This placed the resident at risk of not receiving prescribed medications.

The facility had a census of 130 residents. The sample included 27 residents. Based on observation, record review, and interview, the facility failed to prevent medication administration errors for Resident (R) 29, who received the wrong dosage of a medication supplement for six out of six administrations. This placed the resident at risk for physical decline and other related complications. Findings included: - The Electronic Medical Record (EMR) for R29 documented diagnoses of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), hypertension (high blood pressure), and epilepsy (epilepsy (brain disorder characterized by repeated seizures). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R29 had moderately impaired cognition. R29 required set-up assistance with eating, personal hygiene, and showers. R29 was independent with mobility, and transfers, and did not ambulate. The MDS documented R29 received insulin (a hormone produced by the pancreas, that helps your boy use sugar from food as energy), diuretic (a medication to promote the formation and excretion of urine), hypoglycemia (less than normal amount of sugar in the blood) medication daily. R29's Care Plan, dated 01/07/25, initiated on 10/11/23, directed staff to administer medications as ordered and monitor for potential side effects related to the current medication regimen. The Physician's Order, dated 03/12/25, directed staff to administer Zinc (a supplement), 30 milligrams (mg), by mouth, in the morning for Respiratory Syncytial Virus (RSV), until 03/28/25. The Medication Administration Record (MAR), dated March 2025, documented R29 received six doses of the Zinc supplement at the wrong dose. On 03/18/25 at 8:00 AM, Certified Medication Aide (CMA) R prepared R29's morning medication pass. CMA R looked at the over-the-counter bottle of Zinc and then looked at the physician's order in the EMR and stated, that the Zinc in the bottle was 50 mg, which was higher than what R29 was prescribed. CMA R notified Licensed Nurse (LN) G that there was a discrepancy and LN G stated she would look at the original order. LN G stated she notified the physician of the error and he discontinued the medication. CMA R stated she had given R29 the medication since it had been ordered and should have read the order more carefully. On 03/19/25 at 02:55 PM, Administrative Nurse D stated the CMA had been educated to check the physician's order before she administered the medication. The facility's Medication Errors policy, dated 01/01/20, documented the facility should ensure medications would be administered per physician's orders and in accordance with accepted standards and principles that apply to professionals providing services. Medication errors, once identified, would be evaluated to determine if considered significant or not by utilizing the guidelines of residents' condition, drug category, and frequency of error. The facility failed to prevent medication administration errors for R29, who received the wrong dosage of a medication supplement for six out of six administrations. This placed the resident at risk for physical decline and other related complications.

The facility had a census of 130 residents. The sample included 27 residents. Based on observation, record review, and interview, the facility failed to store and label biologicals as required in one of seven medication carts, when staff failed to place a stop date on R31's Humalog (rapid-acting) Insulin (a hormone that lowers the level of glucose in the blood) Kwik pen (a prefilled, disposable insulin pen). Findings included: - On 03/17/25 at 07:41 AM, on hall 700, 800, and 900 hall treatment cart R31's Humalog insulin Kwik pen lacked an open date. Licensed Nurse (LN) J verified the pen had been opened and stated staff should have placed an open date when they opened it. On 03/19/25 at 03:05 PM, Administrative Nurse D stated she would expect staff to place an open date on an insulin pen when they open it. Upon request, the facility did not provide a policy regarding opening Humalog pens. The facility failed to place an open date on R31's Humalog insulin pen. This placed the residents at risk of receiving an ineffective dose of the medication.

The facility had a census of 117 residents. The sample included 28 residents. Based on observation, record review, and interview, the facility failed to prevent pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) for Resident (R) 84 who developed two stage 3 pressure ulcers (full thickness pressure injury extending through the skin into the tissue below) and one stage 4 pressure ulcers (a deep wound that reaches the muscles, ligaments, or even bone) and R32 who developed a stage 4 pressure ulcer. The facility also failed to promote healing of the pressure injury for R32. These deficient practices placed the resident at risk of further unhealed pressure injuries. Findings included: - The Electronic Medical Record (EMR) document R84 had diagnoses of chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), retention of urine, diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), venous insufficiency, anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), chondrocalcinosis (a condition in which calcium crystals deposit in the joint causing pain), and benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections). The Admission Minimum Data Set (MDS), dated [DATE], documented R84 had moderately impaired cognition, required extensive assistance of two staff for bed mobility, transfers, and dressing. R84 also required physical help of two staff with bathing, and supervision and one-person physical assistance with eating. The MDS further documented R84 was not steady, and only able to stabilize with staff assistance with transition. R84 had an indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag) and was frequently incontinent of bowel. The MDS further documented R84 was at risk for pressure ulcer/injury, had no ulcers, had pressure reducing device for chair and bed, and application of ointment/medication other than to feet. The Quarterly MDS, dated [DATE], documented R84 required extensive assistance of one staff with bed mobility, toileting, and personal hygiene; bathing had not occurred. R84 had an indwelling urinary catheter and was frequently incontinent of bowel. The MDS further documented R84 had two unhealed stage 3 and one stage 4 pressure ulcer/injuries. R84 had pressure relieving devices for bed and chair, but no turning/repositioning program, or nutrition or hydration intervention to manage skin problems. R84 received pressure ulcer care and had applications of ointment/medication other than to feet. The Pressure Ulcer Care Area Assessment (CAA), dated 09/26/23, documented staff to assist the resident with repositioning per protocol and as needed to help maintain skin integrity. The staff were to use incontinence creams as needed on the resident to help maintain skin integrity. The staff placed a pressure redistributing surface to the resident's bed and chair. The Activity of Daily Living (ADL) CAA, dated 09/26/23, documented staff to assist R84 with ADL cares as needed and anticipate cares, so care needs were effectively met. R84's Care Plan initiated on 06/07/23, documented R84 was at risk for skin alteration in skin integrity related to incontinence and decreased mobility. The care plan directed staff to educate the resident, family, and caregivers as to causes of skin breakdown including transfer and positioning requirements, the importance of taking care during ambulation, good nutrition, and frequent repositioning. R84's Care Plan initiated 06/07/23 documented R84 had a self-care performance deficit and required assistance with cares. The care plan directed staff to assist R84 with showers twice a week and as necessary. R84 required moderate assistance with turning and repositioning in bed every two hours and as necessary. R84 could eat with setup and cleanup assistance. R84 required a Hoyer lift (full body mechanical lift) to move between surfaces every two hours and as necessary. On 08/02/23, the care plan was updated to include use of a low air loss mattress, on 09/19/23 an addition also added to wear pressure reducing boots as tolerated. An update dated 09/20/23 again directed R84 required a mechanical lift with two staff assistance for transfers. On 09/19/23, R84's Care Plan was updated to direct he would wear pressure relieving boots as tolerated. The Progress Note, dated 05/28/24 at 02:50 PM, documented R84 admitted to the facility and nursing staff completed a full assessment for ADL needs to formulate a plan of care. The Progress Note, dated 06/09/23 at 12:13 AM, documented R84 had intact skin. The Progress Note, dated 07/31/23 at 08:01 PM, documented new skin concerns were identified. The note did not specify the location of the new skin condition or a description. The Progress Note, dated 08/02/23 at 03:31 PM, documented a new treatment order was received for a right ankle wound. The Wound Progress Note, dated 08/07/23, documented a new patient wound care visit. R84 had a stage three pressure ulcer to the left heel and a stage four pressure ulcer to right lateral malleolus (outer ankle bone) with bone exposure. The Progress Note, dated 08/11/23 at 09:25 AM, documented R84 had tested positive for COVID-19 (highly contagious respiratory virus). The Wound Progress Note, dated 08/14/23, documented R84 received Demacyte (a human amniotic membrane) graft to the left heel and right lateral malleolus. The Wound Progress Note, dated 08/22/23, documented R84 continued with stage three pressure ulcer to left heel, a stage four pressure ulcer to right lateral malleolus, and an unstageable (depth of the wound is unknown due to the wound bed is covered by a thick layer of other tissue and pus) pressure ulcer to the coccyx (area at the base of the spine). The note further documented R84 had moved to a new room related to COVID-19 precautions and the low air loss mattress was not moved with him to the new room. This resulted in increased pressure and ultimately breakdown to the coccyx; R84 now had the low air loss mattress. The Wound Progress Note, dated 08/28/23, documented R84 continued with a stage three pressure ulcer to the left heel, a stage four pressure ulcer to the right malleolus, and an unstageable coccyx wound . The Wound Progress Note, dated 08/28/23, documented R84 continued with a stage 3 pressure ulcer to the left heel, a stage 4 pressure ulcer to the right malleolus, and an unstageable coccyx wound. The note included a new order to obtain a culture for the coccyx wound due to purulent drainage (producing or containing pus) and foul odor. The Progress Note, dated 08/31/23 at 12:43 PM, documented a request for the social service staff to speak with R84 regarding a hospice (end of life care) evaluation due to R84's wound. The Interdisciplinary Team (IDT) Progress Note, dated 09/28/23, documented R84 still with in-house acquired pressure coccyx and right malleolus pressure ulcers which continued to improve. R84 required pressure relief boots to both legs, a low air loss mattress, and a pressure relief cushion for the wheelchair. On 10/03/23 at 12:15 PM observation revealed R84 sat in the dining room in his wheelchair. R84 was not approached by dietary staff for menu selection for midday meal until 12:59 PM, and he did not receive his meal until 01:15 PM. The observation further revealed R84 remained in the dining room until staff took him to the coffee garden at 03:46 PM. This observation period revealed R84 remained in the wheelchair 3.5 hours without a position change. On 10/04/23 at 10:40 AM observation revealed R84 was in the dining room for a group activity. At that time, the breakfast cart arrived at the hall where R84's room was located. Staff placed a breakfast meal on R84's over bed table wrapped in clear plastic wrap; the meal included ground sausage with gravy, pureed waffle, and scrambled eggs topped with cheese. At 11:14 AM staff brought R84 to the coffee garden, where R84 tried to see donuts in the containers there, with the coffee. Staff stopped briefly and the resident asked about the content of the donut boxes and staff informed him there was just coffee, no donuts. R84's breakfast plate remained in the resident's room, uneaten, and covered. At 12:15 PM R84 sat in the dining room. Staff brought food to the table which consisted of pork roast and French fries. R84 was not provided silverware or a clothing protecter. The staff removed R84 from the dining room at 02:31 PM to lay R84 down so the charge nurse could do dressing changes. At 03:49 PM R84 remained up his wheelchair, still awaiting the dressing change. The observation revealed R84 was up to his wheelchair for approximately five hours without a position change. On 10/04/23 at 02:28 PM, Certified Nurse Aide (CNA) M reported R84 required extensive assistance of two staff for ADL cares and stated the resident should be repositioned every two hours. CNA M said R84 had a good appetite. On 10/09/23 at 07:00 AM, Administrative Nurse E verified R82's pressure reducing low air loss mattress was not moved when the resident had a room change due to COVID 19. Administrative Nurse E also verified the resident's need of assistance with meal set up and stated R84 should have received meals. Administrative Nurse E said R84 should have had position changes every two hours but went on to say the resident often refused to lay down during the day. On 10/09/23 at 02:02 PM, Administrative Nurse D verified R84's pressure ulcers to the left heel, right malleolus, and coccyx. Administrative Nurse D said staff should have assisted R84 with eating, and more frequent position changes. On 10/09/23 at 09:50 AM, Consultant GG state the facility did not have enough staff, which contributed to wounds and infections. The facility's Pressure Injury Prevention and Management policy, dated 01/01/20, documented the facility is committed to prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries. The facility shall establish and utilized a systematic approach for pressure ulcer prevention and management including prompt assessment and treatment: intervening to stabilize, reduce or remove underlying risk factors: monitoring the impact of the interventions; and modifying the interventions appropriately. The facility failed to provide care and services including the offloading or pressure reduction for heels to prevent the development of R84's heel and ankle pressure ulcers and further failed to ensure R84 received the required pressure reducing mattress when he changed rooms which resulted in the development of a stage 4 coccyx ulcer. This also placed the resident at risk for continued pressure ulcers. 32360 - The Electronic Medical Record (EMR) for R32 documented diagnoses of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) type 2, congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), chronic kidney disease (kidneys are damaged and cannot filter blood they way they should), mild protein calorie malnutrition (a nutritional status in which reduced availability of nutrition's leads to changes in body composition and function), and vitamin D deficiency (when there is not enough vitamin D in the body). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R32 had intact cognition and was dependent upon two staff for transfers, and toileting. R32 required extensive assistance of one staff for bed mobility, dressing, personal hygiene, and bathing. The assessment further documented R32 as at risk for pressure ulcers, had pressure reducing devices in her bed and chair, required a turning and repositioning program, and had no skin breakdown. The Quarterly MDS, dated [DATE], documented R32 had intact cognition, and was dependent upon two staff for transfers. R32 required extensive assistance of two staff for bed mobility, dressing, toileting, and personal hygiene. The assessment further documented R32 had an unhealed stage 4 (a deep wound that reaches the muscles, ligaments, or even bone) pressure ulcer, had a pressure reducing device in her bed and chair, received pressure ulcer care, and had a nutrition and hydration program. The Braden Scale Assessment, (a formal assessment for predicting pressure ulcer risk) dated 08/22/22, 11/27/22, 01/06/23, 04/03/23, 04/11/23, 04/18/23, and 04/24/23 documented the resident had a moderate risk for pressure ulcers and the 07/22/23 assessment documented a high risk for skin breakdown. The Skin Integrity Care Plan, initiated on 02/13/22 and revised on 04/05/23, documented R32 was at risk for alterations in skin integrity due to impaired mobility and documented R32 had a wound on her coccyx (area at the base of the spine). The plan documented R32 had a low air loss mattress and a wheelchair cushion (02/13/22) and would have skin assessed by a nurse (02/13/222). The plan directed the resident preferred to be positioned on her back, required extensive assistance to turn and reposition at least every two hours or more often as needed, and had a cushion in her wheelchair to help with pressure reduction. The update, dated 03/08/23, directed staff to treat as ordered. The Nurse's Notes, dated 08/31/22 at 11:59 PM, documented resident had red under her armpits and under her breasts with treatment orders in place, lotion applied to bilateral upper extremities, bilateral lower extremities, heels floated, and barrier cream to an irritated area to her bottom. The Physician's Order, dated 10/10/22, directed staff to use wound cleanser on the coccyx wound and apply Chamosyn ointment (moisture barrier cream) with Manuka honey (used as a natural ointment for wounds) every shift and as needed. The order was discontinued on 11/04/22. The Physician's Order, dated 11/04/22, directed staff to cleanse the coccyx wound with wound cleanser, apply Medi-honey (medical grade honey used to aid wound healing) and apply a 4x4 Opti-foam dressing, check every shift and change every three days and as needed. The order was discontinued on 01/19/23. R32's EMR lacked wound assessments and measurements from 08/31/22 when the order was received for the wound until 12/14/22. The Skin and Wound Assessment, dated 12/14/22, documented R32 had an inhouse acquired stage 4 pressure ulcer on her coccyx. The note documented it was unknown how long the resident had the pressure ulcer. The wound measured 0.7 centimeter (cm) squared x 1.1 cm x 0.9 cm x 0.4 cm. The Skin and Wound Assessment, dated 01/17/23, documented R32 had a stage 4 pressure ulcer on her coccyx, which measured 1.5 cm2 x 1.6 cm x 1.3 cm, unsure of depth, and 0.6 cm undermining. The Physician's Order, dated 01/19/23, directed staff to cleanse the wound with wound cleanser, apply calcium alginate (highly absorbent dressing), and place 4 x 4 Opti-foam dressing over the wound (an absorbent foam dressing), change daily and as needed. The order was discontinued on 03/08/23. The Skin and Wound Assessment, dated 03/03/23, documented R32 had a stage 4 pressure ulcer on her coccyx which measured 3.3 cm2 x 3.7 cm x 1.1 cm x 0.5 cm. The Physician's Order, dated 03/09/23, directed staff to cleanse the wound with wound cleanser, pat dry, apply adhesive foam dressing, and change it daily and as needed. The order further directed staff to use skin prep on the peri-wound to help dressing adhere. The order was discontinued on 04/03/23. The Hospital Dietician Assessment, dated 03/31/23, documented R32 received the consult due to a stage 4 pressure injury. The dietician recommended increasing calorie level to 2200 calories to allow for 75 grams of carbohydrate per meal as R32 needed calories and protein to heal her wound. The assessment directed to consider adding a multivitamin, vitamin C, zinc, a probiotic, and vitamin D if a deficiency was suspected. The Hospital Discharge Summary, dated 04/03/23, documented R32 had a non-healing sacral (coccyx) wound, that had been progressively worsening over the past several months. Staff stated that she had been very lethargic and not as interactive as normal plus a worsening smell from the ulcer, so she was brought to the emergency room . The resident had a foul-smelling drainage that was observed by wound care who determined the wound was not actually infected. The Physician's Order, dated 04/03/23, directed staff to apply a normal saline wet to dry dressing, every shift until healed. The order was discontinued on 07/26/23. The Physician's Order, dated 06/08/23, directed staff to administer active liquid protein every day and evening shift for wound care for 90 days. The Physician's Order, dated 06/09/23, directed staff to administer a multiple vitamin, 1 tablet, by mouth for the diagnosis of wound care for 90 days. The order was discontinued on 08/12/23. The Physician's Order, dated 06/15/23, directed staff to administer zinc sulfate (nutritional supplement), 220 milligrams (mg), in the morning, for the diagnosis of wound care. The Physician's Order, dated 06/17/23, directed staff to administer skin, hair, and nails multivitamins with minerals, two gummies, with meals, for the diagnosis of wound care. The Physician's Order, dated 07/29/23, directed staff to cleanse her coccyx with saline, pat dry, apply skin prep to peri wound, apply maxsorb II calcium alginate (dressing that is used for moderate to heavily draining partial and full thickness wounds) to wound bed, fluffed 4 x4 to fill wound, cover with 4x4 and mefix tape on Monday, Wednesday, and Friday The Nurse's Notes, dated 09/04/23 at 03:04 AM, documented to cleanse the coccyx with wound cleanser, apply Medi-honey, a 4x4 Opti-foam Gentle (absorbent foam dressing); check every shift and change every three days and as needed for wound care. The Physician's Order, dated 09/10/23, directed staff to administer active liquid protein, twice per day for wound care for 30 days. The Physician's Order, dated 09/10/23, directed staff to administer Vitamin C, 400 mg, 1 tablet, by mouth, twice daily for 30 days for wound healing. The Nutritional Assessment, dated 09/10/23, documented R32 had a stage 4 pressure ulcer that was improving. R32 received liquid protein twice per day, and her needs were met with diet and supplement. On 10/04/23 at 01:30 PM, observation revealed R32 laid on her left side. Licensed Nurse (LN) G donned clean gloves, cleansed the wound with wound cleanser, removed soiled gloves, donned clean gloves, wiped the peri wound with skin prep, placed a 2x2 gauze with calcium alginate inside the wound, and placed a foam dressing on the wound. LN G placed a wedge cushion behind R32 and a pillow between her legs. On 10/04/23 at 01:30 PM, LN G stated R32 was repositioned hourly, and had liquid protein ordered. LN G stated R32 had the pressure ulcer for a long time. On 10/09/23 at 07:18 AM, Administrative Nurse E stated the wound was from pressure. Administrative Nurse E said R32 received vitamins and supplements and had a low air loss mattress. Administrative Nurse E further stated she had recently taken over wound care and was unsure why R32 was not ordered the vitamins and supplements sooner. On 10/09/23 at 09:30 AM, Certified Nurse Aide (CNA) N stated she repositioned R32 every time she went into the room. CNA N stated R32 liked to face the television. On 10/09/23 at 10:49 AM, Consultant GG stated that there was not enough staff in the building and that contributed to wounds and infections. On 10/09/23 at 02:00 PM, Administrative Nurse D stated she would check into documentation related to R32's pressure ulcer and when R32 first obtained the wound. The facility's Pressure Injury Prevention and Management, dated 01/01/20, documented the facility was committed to the prevention of avoidable pressure injuries and the promotion of healing existing pressure injuries. The facility shall establish and utilize a systematic approach for pressure ulcer prevention and management, including prompt assessment and treatment, intervening to stabilize, reduce, or remove underlying risk factors, monitoring the impact of the interventions and modifying the interventions as appropriated. The facility failed to monitor interventions and revise as needed to prevent the development of a facility acquired stage 4 pressure ulcer. The facility further failed to promote healing of the pressure injury when they failed to implement nutritional interventions for many months after the wound was identified.

The facility identified a census of 126 residents. The sample included three residents reviewed for neglect. The facility failed to ensure resident (R) 1 remained free from neglect when staff failed to follow physician orders, prevent medication errors, ensure physician ordered labs were collected, and abnormal results reported to the physician and subsequent orders acted upon. The facility failed to report abnormal vital signs as directed by a defined physician ordered parameter results and failed to provide an ongoing assessment of resident condition after an acute change or abnormal results were identified. On [DATE] resident (R)1's potassium (K) level was high at 5.5 and the staff received an order to discontinue the supplemental K and recheck the K level on [DATE]. The staff did not remove the medication card of potassium from the medication cart and continued to administer it to R1 from [DATE] through [DATE]. The staff did not recheck the K level on [DATE] as ordered, until the morning of [DATE]. The lab result indicated an abnormal high K level of 5.9 and was faxed to the facility at 10:13 AM on [DATE], but nursing staff did not respond and contact the physician until after office hours on [DATE]. The facility further held two doses of sildenafil (medication being used to treat high blood pressure) on the afternoon and evening of [DATE] without notifying the physician. The facility received an order to administer Kayexalate (medication used to reduce potassium levels in the body) and administered around 08:45PM on [DATE], but the staff did not perform a reassessment after doing so. On [DATE], staff again held the morning dose of sildenafil and failed to report R1's pulse 108 bpm as directed by the physician order to report a pulse greater than 100bpm. R1, who also received an antibiotic and oral anti-inflammatory related to pneumonia, was reportedly short of breath on the morning of [DATE] and staff failed to respond to assess and follow up. On [DATE], R1, who had an active Do Not Resuscitate (DNR), was found leaning over in the chair with blue lips. The staff called 911, and the resident expired in the facility at 12:18 PM. The facility failure to ensure R1 remained free from neglect which placed R1 in Immediate Jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented under the Diagnoses tab the following diagnoses: pulmonary hypertension (type of high blood pressure that affects the arteries in the lungs and the right side of the heart), atrial premature depolarization (premature heart beat that arises in the upper chambers of the heart), and nonrheumatic mitral valve insufficiency (mitral valve regurgitation-heart valve disease in which the valve between the left heart chambers does not close completely, allowing blood to leak backwards across the valve). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 required extensive assistance of two staff members for bed mobility, transfers, and toilet use. R1 required extensive assistance of one staff member for dressing. R1 received diuretics (medication to promote the formation and excretion of urine) and opioid (a broad group of pain-relieving drugs that work by interacting with opioid receptors in the cells) medication six out of the seven days during the lookback period. The Activities of Daily Living (ADL) Care Area Assessment (CAA) dated [DATE] documented R1 needed extensive assistance with her daily cares related to her chronic health conditions. The Five Day MDS dated [DATE] documented R1 had a BIMS score of 14, which indicated intact cognition. R1 required extensive assistance of one staff member for bed mobility and dressing. The Black Box Warning Care Plan revised on [DATE] directed staff to administer medications as ordered and monitor labs and report findings to the nurse practitioner or physician as indicated. The Care Plan lacked documentation of R1's heart conditions. The physician orders under the Order tab in the EMR documented: [DATE] potassium chloride extended release (ER) tablet 20 mEq, staff were to administer one tablet by mouth one time a day for hypokalemia (low level of potassium in the blood). This order was discontinued [DATE]. [DATE] Sildenafil citrate tablet 20 milligrams. Staff were to give one tablet by mouth three times a day for hypertension (elevated blood pressure) and hold and notify nurse if systolic blood pressure (blood pressure when the heart is contracting) was under 90 mm/Hg or pulse was less than 60 beats per minute (bpm). Staff were to notify the physician if the systolic blood pressure was over 200 or the pulse was over 100 bpm. [DATE] Opsumit tablet, staff were to give 10 milligrams by mouth one time a say for hypertension, hold and notify nurse if systolic blood pressure was less than 90 mm/Hg or pulse was less than 60 bpm. Staff were to notify the physician if the systolic blood pressure is over 200 mm/Hg, or the pulse is over 100 bpm. [DATE] One time check Basic Metabolic Panel (BMP) for hyponatremia (less than normal amount of sodium in the blood) on [DATE]. Review of the BMP lab collected [DATE] at 07:19 AM, results received to the facility [DATE] at 09:38 AM, noted the resident's potassium level was 5.5 millimoles per liter (mmol/L), which was high (the normal range for potassium levels is 3.6 - 4.9 mmol/L). The physician orders under the Order tab in the EMR documented an order dated [DATE] for a one-time check of the resident's BMP for hyponatremia on [DATE]. Review of the BMP lab collected on [DATE] at 07:05 AM, a day late, and received by the facility at 10:15 AM on [DATE] noted R1's potassium level was high at 5.9 (the normal range for potassium levels is 3.6 - 4.9 mmol/L). Review of the Medication Error Report dated [DATE] at 06:00 PM noted R1's BMP was off, so LN G went through the medication cart and noted R1's potassium and Lasix (diuretic medication) remained in the slot with medications punched out, which indicated it was administered. The Nurses Note dated [DATE] at 06:59 PM documented recent BMP results were reported to the physician's office. Licensed Nurse (LN) L inquired if R1 was still taking any diuretics or potassium supplements. LN G reviewed R1's orders and confirmed R1 had no diuretics or potassium currently ordered. The physician ordered a one-time dose of Kayexalate to be given immediately. After speaking with the physician, LN G went through the medication cart and noted a card of potassium supplements and Lasix in R1's AM medications slot with dates punched out, which indicated the medications were administered. LN G wrote up the medication error and relayed information to Administrative Nurse F. R1's daughter and the physician were made aware of the error. LN G also noted staff failed to administer R1's sildenafil medication on [DATE], this was relayed to the oncoming shift. The physician orders under the Order tab in the EMR documented an order dated [DATE] at 07:52 PM for sodium polystyrene sulfonate oral suspension (Kayexalate) 15 grams (GM)/ 60 milliliter (ml), give 60 ml orally, which staff would administer one time only for hyperkalemia (greater than normal amount of potassium in the blood) for one day. Review of R1's February Medication Administration Record (MAR) 2023 revealed staff administered Kayexalate at 08:46 PM, and sildenafil citrate was not administered two times on [DATE] and one time on [DATE]. R1's Opsumit administration noted R1's pulse of 108 BPM on [DATE] at AM medication pass and the medication was administered. R1's clinical recorded lacked evidence of physician notification of missed medications, elevated pulse outside of physician ordered parameters, and of the lab not being drawn as ordered. R1's clinical record further lacked evidence a physical assessment was completed after the administration of Kayexalate, or further assessment related to increased potassium levels. The Nurses Note draft dated [DATE] at 01:36 PM documented staff reported R1 was in her wheelchair, leaning to the left side, with blue fingertips and lips. Staff called 911, and R1 expired in the facility at 12:18 PM. On [DATE] at 12:25 PM R1's potassium medication card was pulled from the medication cart with all her medication cards and placed in the medication room in the discontinued medication basket. Observation of the potassium medication card revealed it was delivered from the pharmacy on [DATE]. The card was noted to have the following numbers with the tablet punched out: 11, 12, 13, 14, 15, 16, and 17 On [DATE] at 12:26 PM Certified Medication Aide (CMA) R stated when she passed medications for residents, she checked the medication card with the medication administration record to review the order before popping the medication. CMA R verified the numbers with the missing potassium tablet matched the dates the medication would have been given. On [DATE] at 02:03 PM CMA R revealed she was the medication aide that administered R1 the potassium that was not ordered. CMA R further revealed that she had no excuse for giving the potassium that was not on the medication administration order. CMA R stated she messed up. On [DATE] at 02:15 PM Administrative Nurse D stated the lab would have come in on that Friday, [DATE], when the receptionist was not in the facility. Administrative Nurse D further stated she did not know what happened on the days that the receptionist was not at the facility to get the results of labs off the fax machine. Administrative Nurse D stated she did not know why there was a delayed response to the faxed lab. Administrative Nurse D revealed the nurses were the individuals to confirm that a lab was entered into the EMR system to be drawn. Administrative Nurse D further revealed the facility lacked a double check system for the nurses that entered labs, and no one would have reviewed R1's medication administration record after she passed because it would have been out of the system. Administrative Nurse D stated that if a physician ordered a lab on Thursday, it should have been clarified that it was the date needed, due to the lab not coming to the facility on Thursdays. Administrative Nurse D stated if the lab was ordered for that date, it should have been clarified with the physician before drawing the lab a different day. On [DATE] at 02:18 PM Administrative Nurse F stated when a resident passed in the facility it was not reviewed because, there was no reason to. Administrative Nurse F revealed that physicians knew not to order labs on Thursdays because labs were not drawn on Thursday and that service was not available in the facility. On [DATE] at 03:34 PM LN H stated R1 had labs drawn the morning of [DATE] and her potassium was high. LN G went to the medication cart and found the medication that were being held were still in the cart. LN H revealed she administered 60 milliliters of Kayexalate. LN H further revealed R1 started to sound more like herself. LN H reported that the previous night, [DATE], R1 had not sounded like herself and was saying that something was off. LN H stated because R1 had labs ordered, LN H waited for the labs to be drawn and did not call the physician that night when R1 seemed more off than R1 had previously been. LN H reported that R1 was off, and it was passed to the day shift nurse coming on [DATE]. The facility's policy Freedom from Abuse, Neglect, and Exploitation Policy and Procedure revised [DATE] documented to ensure the proper management of conduct between residents and the staff to facility the resident's right to be free from abuse, neglect, misappropriation of resident's property, and exploitation. The facility failed to ensure R1 remained free from neglect when staff failed to provide R1 with the necessary care and services she required. The facility failed to follow physician orders, prevent medication errors, ensure physician ordered labs were collected, and failed to ensure abnormal results were reported to the physician and subsequent orders acted upon. The facility also failed to report abnormal vital signs as directed by a defined physician ordered parameter results and failed to provide an ongoing assessment of resident condition after an acute change or abnormal results were identified. This neglect placed R1 in Immediate Jeopardy. The facility removed the immediacy on [DATE] when the following corrective actions were completed: 1. Administrator/ Designee will train all staff on Neglect 2. DON/ Designee reviewed medication orders from the last 30 days and verified accuracy 3. DON/ Designee reviewed laboratory orders from the last 90 days and verified accuracy 4. DON/ Designee clarified any physician order that needed clarification 5. DON/ Designee notified physician of any physician order that needs to be held because it is unavailable 6. DON/ Designee notified pharmacy of medications that need to be ordered 7. DON/ Designee checked all medication carts for expired and/ or discontinued medications 8. DON/ Designee will educate medication administration professionals a. Medication errors b. Physician notification c. Neglect d. Medication Administration e. Laboratory orders f. Medication destruction/ removal g. 8 Rights of Medication Administration h. Medications unavailable i. Quality of Care 9. DON / Designee will review new medication orders daily at clinical meeting 10. DON/ Designee will review laboratory orders daily at clinical meeting 11. Ad-hoc QAPI at 0800 on [DATE] After the onsite surveyor verified the immediate jeopardy as removed, the scope and severity remained at a G (actual harm).

The facility identified a census of 126 residents. The sample included seven residents. Based on record review, interview, and observation, the facility failed to ensure staff implemented care and treatment consistent with standards of care when staff failed to follow physician orders, prevent medication errors, ensure physician ordered labs were collected, and abnormal results were reported to the physician, and subsequent orders were acted upon. The facility failed to report abnormal vital signs as directed by a defined physician ordered parameter and failed to provide an ongoing assessment of a resident's condition after an acute change or abnormal results were identified. On [DATE] Resident (R)1's potassium (K) level was high at 5.5 millimoles per liter (mmol/L) and the staff received an order to discontinue the supplemental K and recheck the K level on [DATE]. The staff did not remove the medication card of potassium from the medication cart and continued to administer it to R1 from [DATE] through [DATE]. The staff did not recheck R1's K level on [DATE] as ordered and waited until the morning of [DATE]. The lab result indicated an abnormal high K level of 5.9 mmol/L and was faxed to the facility at 10:13 AM on [DATE], but nursing staff did not respond and waited to contact the physician until after office hours on [DATE]. The facility further held two doses of sildenafil (medication being used to treat high blood pressure) on the afternoon and evening of [DATE] without notifying the physician. The facility received an order to administer Kayexalate (medication used to reduce potassium levels in the body) and administered it around 08:45 PM on [DATE], but the staff did not perform a reassessment after doing so. On [DATE], staff again held the morning dose of sildenafil and failed to report R1's pulse of 108 beats per minute (BPM) as directed by the physician order to report a pulse greater than 100 bpm. On [DATE], staff found R1, who had an active Do Not Resuscitate (DNR), with blue lips and leaned over in the chair. The staff called 911 and the resident expired in the facility at 12:18 PM. The facility's failure to ensure staff provided adequate nursing care for R1 placed R1 in Immediate Jeopardy. Additionally, the facility failed to monitor bowel movements, assess bowel function, respond to the resident's verbalized concerns regarding abdominal discomfort, and provide interventions to prevent constipation for R3. As a result, R3's representatives transported R3 to the emergency room (ER) at R3's request and was diagnosed with a mild fecal impaction (accumulation of hardened feces in the rectum the individual is unable to expel). Findings included: - R1's Electronic Medical Record (EMR) documented under the Diagnoses tab the following diagnoses: pulmonary hypertension (type of high blood pressure that affects the arteries in the lungs and the right side of the heart), atrial premature depolarization (premature heart beat that arises in the upper chambers of the heart), and nonrheumatic mitral valve insufficiency (mitral valve regurgitation-heart valve disease in which the valve between the left heart chambers does not close completely, allowing blood to leak backwards across the valve). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 required extensive assistance of two staff members for bed mobility, transfers, and toilet use. R1 required extensive assistance of one staff member for dressing. R1 received diuretics (medication to promote the formation and excretion of urine) and opioid (a broad group of pain-relieving drugs that work by interacting with opioid receptors in the cells) medication six out of the seven days during the lookback period. The Activities of Daily Living (ADL) Care Area Assessment (CAA) dated [DATE] documented R1 needed extensive assistance with her daily cares related to her chronic health conditions. The Five Day MDS dated [DATE] documented R1 had a BIMS score of 14, which indicated intact cognition. R1 required extensive assistance of one staff member for bed mobility and dressing. The Black Box Warning Care Plan revised on [DATE] directed staff to administer medications as ordered and monitor labs and report findings to the nurse practitioner or physician as indicated. The Care Plan lacked documentation of R1's heart conditions. The physician orders under the Order tab in the EMR documented: [DATE] potassium chloride extended release (ER) tablet 20 mEq, staff were to administer one tablet by mouth one time a day for hypokalemia (low level of potassium in the blood). This order was discontinued [DATE]. [DATE] Sildenafil citrate tablet 20 milligrams. Staff were to give one tablet by mouth three times a day for hypertension (elevated blood pressure) and hold and notify nurse if systolic blood pressure (blood pressure when the heart is contracting) was under 90 mm/Hg or pulse was less than 60 beats per minute (bpm). Staff were to notify the physician if the systolic blood pressure was over 200 or the pulse was over 100 bpm. [DATE] Opsumit tablet, staff were to give 10 milligrams by mouth one time a say for hypertension, hold and notify nurse if systolic blood pressure was less than 90 mm/Hg or pulse was less than 60 bpm. Staff were to notify the physician if the systolic blood pressure is over 200 mm/Hg or the pulse is over 100 bpm. [DATE] One time check Basic Metabolic Panel (BMP) for hyponatremia (less than normal amount of sodium in the blood) on [DATE]. Review of the BMP lab collected [DATE] at 07:19 AM, results received to the facility [DATE] at 09:38 AM, noted the resident's potassium level was 5.5 millimoles per liter (mmol/L), which was high (the normal range for potassium levels is 3.6 - 4.9 mmol/L). The physician orders under the Order tab in the EMR documented an order dated [DATE] for a one-time check of the resident's BMP for hyponatremia on [DATE]. Review of the BMP lab collected on [DATE] at 07:05 AM, a day late, and received by the facility at 10:15 AM on [DATE] noted R1's potassium level was high at 5.9 (the normal range for potassium levels is 3.6 - 4.9 mmol/L). Review of the Medication Error Report dated [DATE] at 06:00 PM noted R1's BMP was off, so LN G went through the medication cart and noted R1's potassium and Lasix (diuretic medication) remained in the slot with medications punched out, which indicated it was administered. The Nurses Note dated [DATE] at 06:59 PM documented recent BMP results were reported to the physician's office. Licensed Nurse (LN) L inquired if R1 was still taking any diuretics or potassium supplements. LN G reviewed R1's orders and confirmed R1 had no diuretics or potassium currently ordered. The physician ordered a one-time dose of Kayexalate to be given immediately. After speaking with the physician, LN G went through the medication cart and noted a card of potassium supplements and Lasix in R1's AM medications slot with dates punched out, which indicated the medications were administered. LN G wrote up the medication error and relayed information to Administrative Nurse F. R1's daughter and the physician were made aware of the error. LN G also noted staff failed to administer R1's sildenafil medication on [DATE], this was relayed to the oncoming shift. The physician orders under the Order tab in the EMR documented an order dated [DATE] at 07:52 PM for sodium polystyrene sulfonate oral suspension (Kayexalate) 15 grams (GM)/ 60 milliliter (ml), give 60 ml orally, which staff would administer one time only for hyperkalemia (greater than normal amount of potassium in the blood) for one day. Review of R1's February Medication Administration Record (MAR) 2023 revealed staff administered Kayexalate at 08:46 PM, and sildenafil citrate was not administered two times on [DATE] and one time on [DATE]. R1's Opsumit administration noted R1's pulse of 108 BPM on [DATE] at AM medication pass and the medication was administered. R1's clinical recorded lacked evidence of physician notification of missed medications, elevated pulse outside of physician ordered parameters, and of the lab not being drawn as ordered. R1's clinical record further lacked evidence a physical assessment was completed after the administration of Kayexalate, or further assessment related to increased potassium levels. The Nurses Note draft dated [DATE] at 01:36 PM documented staff reported R1 was in her wheelchair, leaning to the left side, with blue fingertips and lips. Staff called 911, and R1 expired in the facility at 12:18 PM. On [DATE] at 12:25 PM R1's potassium medication card was pulled from the medication cart with all of her medication cards and placed in the medication room in the discontinued medication basket. Observation of the potassium medication card revealed it was delivered from the pharmacy on [DATE]. The card was noted to have the following numbers with the tablet punched out: 11, 12, 13, 14, 15, 16, and 17. On [DATE] at 12:26 PM Certified Medication Aide (CMA) R stated when she passed medications for residents, she checked the medication card with the medication administration record to review the order before popping the medication. CMA R verified the numbers with the missing potassium tablet matched the dates the medication would have been given. On [DATE] at 02:03 PM CMA R revealed she was the medication aide that administered R1 the potassium that was not ordered. CMA R further revealed that she had no excuse for giving the potassium that was not on the medication administration order. CMA R stated she messed up. On [DATE] at 02:15 PM Administrative Nurse D stated the lab would have come in on that Friday, [DATE], when the receptionist was not in the facility. Administrative Nurse D further stated she did not know what happened on the days that the receptionist was not at the facility to get the results of labs off of the fax machine. Administrative Nurse D stated she did not know why there was a delayed response to the faxed lab. Administrative Nurse D revealed the nurses were the individuals to confirm that a lab was entered into the EMR system to be drawn. Administrative Nurse D further revealed the facility lacked a double check system for the nurses that entered labs, and no one would have reviewed R1's medication administration record after she passed because it would have been out of the system. Administrative Nurse D stated that if a physician ordered a lab on Thursday, it should have been clarified that it was the date needed, due to the lab not coming to the facility on Thursdays. Administrative Nurse D stated if the lab was ordered for that date, it should have been clarified with the physician before drawing the lab a different day. On [DATE] at 02:18 PM Administrative Nurse F stated when a resident passed in the facility it was not reviewed because, there was no reason to. Administrative Nurse F revealed that physicians knew not to order labs on Thursdays because labs were not drawn on Thursday and that service was not available in the facility. On [DATE] at 03:34 PM LN H stated R1 had labs drawn the morning of [DATE] and her potassium was high. LN G went to the medication cart and found the medication that were being held were still in the cart. LN H revealed she administered 60 milliliters of Kayexalate. LN H further revealed R1 started to sound more like herself. LN H reported that the previous night, [DATE], R1 had not sounded like herself and was saying that something was off. LN H stated because R1 had labs ordered, LN H waited for the labs to be drawn and did not call the physician that night when R1 seemed more off than R1 had previously been. LN H reported that R1 was off, and it was passed to the day shift nurse coming on [DATE]. The facility's policy Medication Errors implemented [DATE] directed the facility shall ensure medications would be administered according to the physician's orders. The facility will consider factors indicating errors in medication administration when medications administered not in accordance with the prescriber's order or medication administered not in accordance with professional standards and principles. If a medication error occurs, the following procedure will be initiated: the nurse assesses and examines the resident's condition and notifies the physician or health care practitioner as soon as possible, monitor and document the resident's condition, including response to medical treatment or nursing interventions, and document actions taken in the medical record. The facility's policy Preventing Medication Errors implemented [DATE] directed staff to obtain and record vital signs when applicable or per physician's orders, review the MAR to identify medication to be administered, and compare medication source (bubble pack, vial, etc.) with the MAR to verify resident name, medication name, form, dose, route, and time. It further directed staff that medication would be held for vital signs outside the physician's prescribed parameters. The policy lacked directions for discontinued medications in the medication cart. The facility's policy Diagnostic Testing Services implemented [DATE] directed that the facility would provide the appropriate diagnostic services (laboratory and radiology) required to maintain the overall health of its residents and in accordance with State and Federal guidelines. The facility would maintain a schedule of diagnostic tests (laboratory and radiology) in accordance with the physician's orders. Documentation of diagnostic tests, the results, and date/time of Physicians notification will be maintained in the resident's clinical record. In instances where diagnostic testing is not available to be performed on-site this facility will work with the resident and their family to secure appropriate transportation arrangements for such appointments. The facility's policy Notifications of Changes implemented [DATE] directed staff to ensure the facility promptly informs the resident, consulted the resident's physician; and notify, consistent with his or her authority, resident's representative when there is a change requiring notification. The facility failed to ensure staff implemented care and treatment consistent with standards of care and the physician orders when staff failed to follow physician orders, prevent medication errors, ensure physician ordered labs were collected, and abnormal results reported to the physician and subsequent orders acted upon. The facility failed to report abnormal vital signs as directed by a defined physician-ordered parameter and failed to provide an ongoing assessment of resident condition after an acute change or abnormal results were identified. These failures placed R1 in immediate jeopardy. The facility removed the immediacy on [DATE] when the following corrective actions were completed: 1. DON/ Designee reviewed medication orders from the last 30 days and verified accuracy 2. DON/ Designee reviewed laboratory orders from the last 90 days and verified accuracy 3. DON/ Designee clarified any physician order that needed clarification 4. DON/ Designee notified physician of any physician order that needs to be held because it is unavailable 5. DON/ Designee notified pharmacy of medications that need to be ordered 6. DON/ Designee checked all medication carts for expired and/ or discontinued medications 7. DON/ Designee will educate medication administration professionals a. Medication errors b. Physician notification c. Neglect d. Medication Administration e. Laboratory orders f. Medication destruction/ removal g. 8 Rights of Medication Administration h. Medications unavailable i. Quality of Care 8. DON / Designee will review new medication orders daily at clinical meeting 9. DON/ Designee will review laboratory orders daily at clinical meeting 10. Ad-hoc QAPI at 0800 on [DATE] After the onsite surveyor verified the immediate jeopardy as removed, the scope and severity remained at a G (actual harm). - R3's Electronic Medical Record (EMR) under the Diagnoses tab recorded the following diagnoses: pain, fecal impaction (accumulation of hardened feces in the rectum that the individual was unable to move), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), quadriplegia (paralysis of the arms, legs and trunk of the body below the level of an associated injury to the spinal cord), and need for assistance with personal care. The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R3 required total dependence of two staff members for transfers and toilet use. R3 required extensive assistance of two staff members for personal hygiene, dressing, locomotion on and off the unit, and bed mobility. R3 was frequently incontinent of bowel and had a catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). R3 received opioids (a broad group of pain-relieving drugs that work by interacting with opioid receptors in the cells) one day out of seven day lookback period. The Urinary Care Area Assessment (CAA) dated [DATE] documented R3 was incontinent of bowels and required assistance of two staff members to provide peri cares and to change incontinent brief. The Quarterly MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. R3 had total dependence on two staff members for bed mobility, and transfers. R3 had total dependence on one staff member for locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. R3 was always incontinent of bowels and had a catheter. R3 received opioids seven days out of seven day lookback period. R3's EMR, under the Orders tab, noted the following physician's orders which could cause constipation: [DATE]: oxycodone Hcl (opioid medication used to treat pain) capsule five mg, give one table by mouth two times a day for pain hold if somnolent. [DATE]: oxycodone Hcl capsule five mg give one tablet by mouth every six hours as needed for moderate to severe pain, hold if somnolent (abnormally drowsy). R3's EMR under the Orders tab noted the following physician's orders related to bowel management: [DATE]: docusate sodium (laxative used to treat constipation) capsule 100 milligrams (mg) give one capsule by mouth at bedtime for bowel management. [DATE]: glycolax powder (MiraLAX-laxative used to treat occasional constipation) give 17 grams (gm) by mouth one time a day for constipation in liquid. Review of [DATE] Medication Administration Record (MAR) lacked evidence of administration of any medication on an as needed basis to address R3's constipation Review of [DATE] documentation survey report noted no bowel movement for three days (07:00 AM [DATE] to 07:00 AM [DATE]), and 43 out of 93 opportunities which lacked evidence staff consistently monitored bowel activity: [DATE] missed night opportunity [DATE] missed evening and night opportunities [DATE] missed evening and night opportunities [DATE] missed night opportunity [DATE] missed evening opportunity [DATE] missed all three opportunities [DATE] missed evening opportunity [DATE] missed night opportunity [DATE] missed night opportunity [DATE] missed all three opportunities [DATE] missed all three opportunities [DATE] missed evening and night opportunities [DATE] missed evening opportunity [DATE] missed evening and night opportunities [DATE] missed day and night opportunities [DATE] missed evening and night opportunities [DATE] missed evening and night opportunities [DATE] missed night opportunity [DATE] missed evening opportunity [DATE] missed evening and night opportunities [DATE] missed night opportunity [DATE] missed day and evening opportunity [DATE] missed all three opportunities [DATE] missed day and evening opportunities [DATE] missed evening opportunities Review of [DATE] Medication Administration Record (MAR) lacked evidence of administration of any medication on an as needed basis to address R3's constipation R3's clinical recorded documented R3 had no bowel movement documented for three days at the end of January and the beginning of February, 07:00 AM [DATE] to 07:00 AM [DATE]. Review of February 2023 Documentation Survey Report noted no bowel movement for nine days (03:00 PM [DATE] to 03:00 PM [DATE]), no bowel movement for four days (07:00 AM [DATE] to 07:00 AM [DATE]), and 26 out of 60 opportunities which lacked evidence staff consistently monitored bowel activity: [DATE] missed all three opportunities [DATE] missed all three opportunities [DATE] inaccurately documented evening shift at 11:59 PM; night shift 06:59 AM [DATE] missed evening shift opportunity; night shift inaccurately documented 06:59 AM R3 was out of facility at the ER during this documentation time for bowel movement. [DATE] missed all three opportunities. [DATE] evening opportunity [DATE] missed all three opportunities [DATE] missed all three opportunities [DATE] missed evening and night opportunity [DATE] missed evening opportunity [DATE] missed night opportunity 02//,d+[DATE] missed evening opportunity [DATE] missed evening opportunity [DATE] missed night opportunity [DATE] missed day and evening opportunity Review of the February 2023 MAR lacked evidence of administration of any medication on an as needed basis to address R3's constipation. The Social Service Note dated [DATE] at 11:03 AM documented R3 wanted to go to the hospital. Administrative Nurse D reported R3's catheter was checked, and it was noted to be leaking. An unidentified Licensed Nurse (LN) offered to assist R3 to which R3 declined. R3 further stated that her family was taking her to the hospital. The Progress Notes lacked a nursing assessment prior to R3 leaving for the hospital and upon returning to the facility. The Assessments tab lacked a transfer form related to R3's transfer to theER on [DATE]. Review of the hospital paperwork dated [DATE] documented R3 had been experiencing continued lower abdominal pain with rectal and vaginal pressure. R3 reported that she constantly dealt with constipation. R3 was noted to have a slightly protuberant (protruding; bulging) abdomen and a stool ball in her rectum (end of the digestive tract). R3 was manually dis-impacted (to remove an impaction) of fecal material and was immediately provided a milk and molasses enema (introduction of a solution into the rectum for cleansing or therapeutic purposes). Review of the hospital Discharge Summary documented a computed tomography (CT- scan that used x-ray technology to make multiple cross-sectional views of organs, bone, soft tissue and blood vessels) was completed on [DATE] and documented an impression of fecal impaction in the rectum and mild proctitis (inflammation of the lining of rectum, the lower part of the digestive system) and presacral (situated in front of the sacrum - large triangular bone between the two hip bones) standing. R3 received an enema to clear the impaction and an order to start MiraLAX powder 17 grams by mouth one time a day in liquid for constipation. On [DATE] at 11:04 AM Certified Medication Aide (CMA) S stated that when she first started at the facility a few years ago, she had training on charting in point of care (POC) for documenting activities of daily living for the residents. CMA S further stated in POC there was a part to document bowel movements and continence. CMA S revealed that if a resident had trouble having a bowel movement or there was a concern with the bowel movement she would let the chart nurse know who was working that shift. On [DATE] at 11:40 AM R3 stated that she had not had a bowel movement in a while. R3 revealed that she told the nursing staff, but nothing was done about it. R3 stated she had even asked if her family could come and give her a suppository because she had not had a bowel movement in a while. R3 said she told this to LN J and said LN J told her the facility did R3's medications and offered R3 warm prune juice. R3 revealed that when this happened her bowel sounds were not assessed. On [DATE] at 11:41 AM R3 was observed in her Broda chair (specialized wheelchair with the ability to tilt and recline), leaned back. R3 appeared clean and well groomed, her call light was noted to be tucked behind the headboard of her bed and out of reach. On [DATE] at 02:40 PM Administrative Nurse D stated that when a resident has not had a bowel movement in more then 72 hours it triggered, this 72 hours triggered as well if a bowel movement had not been documented in more then 72 hours. The triggered bowel movements were reviewed in the morning. Administrative Nurse D stated that the nurse administration team was getting more detailed on how to drill down on the lack of bowel movements and making sure residents had a bowel movement. On [DATE] at 11:48 AM LN G reported that residents who had not had a bowel management triggered on the message board. LN G revealed the message board needed to be checked every shift to see what residents would need an assessment and intervention related to a lack of bowel movements. On [DATE] at 12:32 PM LN J stated upon arriving to work on [DATE] R3 had already called her family and requested the family call R3 an ambulance for her to get evaluated and treated at the ER. LN J revealed that he spoke to the off-going nurse and was told that R3 was going out. LN J further revealed that he did assess R3 prior to her leaving to go to the ER and recalled listening to bowel sounds and they were positive in all four quadrants but were noted to be sluggish in the in the lower left quadrant. LN J stated he was called to enter the charting in a few days later by Administrative Staff A. LN J received a report from the ER staff that R3 had a mild fecal impaction, and received a fleet enema. R3 had a new order for MiraLAX daily. LN J stated that upon R3's return he assessed R3 and looked R3 over. LN J said R3 was always incontinent of bowels. On [DATE] at 01:05 PM Certified Nurse Aide (CNA) N stated she documented cares and bowel movements in the kiosk and there were times that she was unable to complete her charting. On [DATE] at 02:05 PM LN K stated that activities of daily living (ADL) were reviewed, and bowel and bladder elimination were reviewed when doing the MDS. LN K revealed that she occasionally found inaccuracies with point of care (POC) documentation. LN K further revealed that R3 was incontinent of bowels and had a catheter. LN K explained that there were a lot of missing documentation in the charting for POC. On [DATE] at 02:13 PM Administrative Nurse D stated that the administrative nurses checked each morning to see what documentation had been completed. Administrative Nurse D revealed that the administrative nurses walked the hallways to make sure documentation got completed. Administrative Nurse D further revealed that usually accuracy for POC documentation was completed through the MDS documentation. Administrative Nurse D reported that the documentation on R3 did not reflect R3 completely. Administrative Nurse D stated that a one at the beginning of the POC bowel charting indicated that the resident was continent. Administrative Nurse D stated that R3 was not placed on the toilet and that R3 had her brief changed when she had a bowel movement. Administrative Nurse D revealed that the documentation in POC was missing was reported to the staff that was working to be completed. Administrative Nurse D further revealed that follow up was not effective to assure that documentation was completed. The facility's policy Bladder and Bowel Management dated [DATE] documented that bowel management involved promoting regular , voluntary, controlled bowel evacuations of normal consistency. The policy documented protocol standing orders for constipation: Protocol 1. Milk of Magnesium (MOM) 30 cc by mouth daily as needed for no stool for three days. Protocol 2. Bisacodyl suppository one rectally as needed in no stool for three days and MOM is ineffective then move to protocol 3. Protocol 3. Fleets enema rectally as needed if MOM or suppository was not effective. Notify physician if constipation persists. The facility failed to consistently and accurately monitor R3's bowel elimination and assess her when she reported abdominal pain. R3 subsequently developed a mild fecal impaction, which required treated at the emergency room .

The facility identified a census of 126 residents. The sample included seven residents. The facility failed to prevent a significant medication error when facility staff wrongly administered potassium to Resident (R) 1, who had a high potassium level. On [DATE] R1's potassium level was abnormally high at 5.5 millimoles per liter (mmol/L). The physician ordered to discontinue the potassium 20 milliequivalents (meq) daily. The facility staff failed to remove the medication card from the medication cart and staff continued to administer the medication from the card without checking the actual orders. As a result, R1 received potassium, despite her already elevated levels, for four additional days from [DATE] through [DATE]. On [DATE], R1's potassium level was even more elevated at 5.9 mmol/L. The facility additionally failed to administer R1's sildenafil, a medication used to treat R1's cardiac condition, the afternoon and evening of [DATE], and the morning of [DATE]. The following day, staff found R1 in her room, leaned over in her chair, with blue lips. R1 expired in the facility on [DATE] at 12:20 PM. These significant medication errors placed R1 in Immediate Jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented under the Diagnoses tab the following diagnoses: pulmonary hypertension (type of high blood pressure that affects the arteries in the lungs and the right side of the heart), atrial premature depolarization ( premature heart beat that arises in the upper chambers of the heart), and nonrheumatic mitral valve insufficiency (mitral valve regurgitation-heart valve disease in which the valve between the left heart chambers does not close completely, allowing blood to leak backwards across the valve). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R1 required extensive assistance of two staff members for bed mobility, transfers, and toilet use. R1 required extensive assistance of one staff member for dressing. R1 received diuretics (medication to promote the formation and excretion of urine) and opioid (a broad group of pain-relieving drugs that work by interacting with opioid receptors in the cells) medication six out of the seven days during the lookback period. The Activities for Daily Living (ADL) Care Area Assessment (CAA) dated [DATE] documented R1 needed extensive assistance with her daily cares related to her chronic health conditions. The Five Day MDS dated [DATE] documented R1 had a BIMS score of 14 which indicated intact cognition. R1 required extensive assistance of one staff member for bed mobility and dressing. The Black Box Warning Care Plan revised on [DATE] directed staff to administer medications as ordered and monitor labs and report findings to the nurse practitioner or physician as indicated. The Care Plan lacked documentation of R1's heart conditions. The physician orders under the Order tab in R1's EMR documented: [DATE] potassium chloride extended release (ER) tablet 20 milliequivalent (mEq), one tablet by mouth one time a day for hypokalemia (low level of potassium in the blood). This order was discontinued [DATE]. [DATE] Sildenafil citrate tablet 20 milligrams, one tablet by mouth three times a day for hypertension (elevated blood pressure). Hold and notify nurse if systolic blood pressure (blood pressure when the heart is contracting) was under 90 or pulse is less then 60 beats per minute (bpm). Staff were to notify the physician if the systolic blood pressure was over 200 or the pulse is over 100 bpm. [DATE] One time check Basic Metabolic Panel (BMP) for hyponatremia (less than normal amount of sodium in the blood) on [DATE]. Review of the BMP lab collected [DATE] at 07:19 AM, results received to the facility [DATE] at 09:38 AM, noted the resident's potassium level was 5.5 millimoles per liter (mmol/L), which was high (the normal range for potassium levels is 3.6 - 4.9 mmol/L). The physician orders under the Order tab in the EMR documented an order dated [DATE] for a one-time check of the resident's BMP for hyponatremia on [DATE]. Review of the BMP lab collected on [DATE] at 07:05 AM, a day late, and received by the facility at 10:15 AM on [DATE] noted R1's potassium level was high at 5.9 (the normal range for potassium levels is 3.6 - 4.9 mmol/L). Review of the Medication Error Report dated [DATE] at 06:00 PM noted R1's BMP was off, so LN G went through the medication cart and noted R1's potassium and Lasix (diuretic medication) remained in the slot with medications punched out, which indicated it was administered. The Nurses Note dated [DATE] at 06:59 PM documented recent BMP results were reported to the physician's office. Licensed Nurse (LN) L inquired if R1 was still taking any diuretics or potassium supplements. LN G reviewed R1's orders and confirmed R1 had no diuretics or potassium currently ordered. The physician ordered a one-time dose of Kayexalate to be given immediately. After speaking with the physician, LN G went through the medication cart and noted a card of potassium supplements and Lasix in R1's AM medications slot with dates punched out, which indicated the medications were administered. LN G wrote up the medication error and relayed information to Administrative Nurse F. R1's daughter and the physician were made aware of the error. LN G also noted staff failed to administer R1's sildenafil medication on [DATE], this was relayed to the oncoming shift. The physician orders under the Order tab in the EMR documented an order dated [DATE] at 07:52 PM for sodium polystyrene sulfonate oral suspension (Kayexalate) 15 grams (GM)/ 60 milliliter (ml), give 60 ml orally, which staff would administer one time only for hyperkalemia (greater than normal amount of potassium in the blood) for one day. Review of R1's February Medication Administration Record (MAR) 2023 revealed staff administered Kayexalate at 08:46 PM, and sildenafil citrate was not administered two times on [DATE] and one time on [DATE]. The Nurses Note draft dated [DATE] at 01:36 PM documented staff reported R1 was in her wheelchair, leaning to the left side, with blue fingertips and lips. Staff called 911, and R1 expired in the facility at 12:18 PM. On [DATE] at 12:25 PM R1's potassium medication card was pulled from the medication cart with all her medication cards and placed in the medication room in the discontinued medication basket. Observation of the potassium medication card revealed it was delivered from the pharmacy on [DATE]. The card was noted to have the following numbers with the tablet punched out: 11, 12, 13, 14, 15, 16, and 17. On [DATE] at 12:26 PM Certified Medication Aide (CMA) R stated when she passed medications for residents, she checked the medication card with the medication administration record to review the order before popping the medication. CMA R verified the numbers with the missing potassium tablet matched the dates the medication would have been given. On [DATE] at 02:03 PM CMA R revealed she was the medication aide that administered R1 the potassium that was not ordered. CMA R further revealed that she had no excuse for giving the potassium that was not on the medication administration order. CMA R stated she messed up. On [DATE] at 02:15 PM Administrative Nurse D reported that the missed medications were reviewed the following day at morning stand up and followed up accordingly. Administrative Nurse D revealed that R1's medications would probably not have been reviewed if the medication error had not been caught. On [DATE] at 03:34 PM LN H stated R1 had labs drawn the morning of [DATE] and her potassium was high. LN G went to the medication cart and found the medication that were being held were still in the cart. LN H revealed she administered 60 milliliters of Kayexalate. LN H further revealed R1 started to sound more like herself. LN H reported that the previous night, [DATE], R1 had not sounded like herself and was saying that something was off. LN H stated because R1 had labs ordered, LN H waited for the labs to be drawn and did not call the physician that night when R1 seemed more off than R1 had previously been. LN H reported that R1 was off, and it was passed to the day shift nurse coming on [DATE]. The facility's policy Medication Errors implemented [DATE] directed the facility shall ensure medications would be administered according to the physician's orders. The facility will consider factors indicating errors in medication administration when medications administered not in accordance with the prescriber's order or medication administered not in accordance with professional standards and principles. If a medication error occurs, the following procedure will be initiated: the nurse assesses and examines the resident's condition and notifies the physician or health care practitioner as soon as possible, monitor and document the resident's condition, including response to medical treatment or nursing interventions, and document actions taken in the medical record. The facility's policy Preventing Medication Errors implemented [DATE] directed staff to obtain and record vital signs when applicable or per physician's orders, review the MAR to identify medication to be administered, and compare medication source (bubble pack, vial, etc.) with the MAR to verify resident name, medication name, form, dose, route, and time. It further directed staff that medication would be held for vital signs outside the physician's prescribed parameters. The policy lacked directions for discontinued medications in the medication cart. The facility failed to prevent a significant medication error when facility staff wrongly administered potassium to R1, who had a high potassium level. The facility further failed to administer three doses of R1's cardiac medication as ordered. These deficient practices placed R1 in Immediate Jeopardy. The facility removed the immediacy on [DATE] when the following corrective actions were completed: 1. DON/ Designee reviewed medication orders from the last 30 days and verified accuracy 2. DON/ Designee reviewed laboratory orders from the last 90 days and verified accuracy 3. DON/ Designee clarified any physician order that needed clarification 4. DON/ Designee notified physician of any physician order that needs to be held because it is unavailable 5. DON/ Designee notified pharmacy of medications that need to be ordered 6. DON/ Designee checked all medication carts for expired and/ or discontinued medications 7. DON/ Designee will educate medication administration professionals a. Medication errors b. Physician notification c. Neglect d. Medication Administration e. Laboratory orders f. Medication destruction/ removal g. 8 Rights of Medication Administration h. Medications unavailable i. Quality of Care 8. DON / Designee will review new medication orders daily at clinical meeting 9. DON/ Designee will review laboratory orders daily at clinical meeting 10. Ad-hoc QAPI at 0800 on [DATE] After the onsite surveyor verified the immediate jeopardy as removed, the scope and severity remained at a G (actual harm).

The facility identified a census of 126 residents. The sample included three residents reviewed for accidents. Based on record review, interview, and observation the facility failed to ensure one resident was free from accidents and injury when staff failed to provide the necessary services as directed by Resident (R) 2's plan of care. R2 required physical assistance from two staff members with the use of a sit to stand lift to safely transfer R2. On 02/07/23, Certified Nurse Aide (CNA) M operated the sit to stand lift without use of a second staff member to transfer R2 between the wheelchair to her bed. Subsequently, R2 began to lose her ability to stand when the sit to stand lift pivoted between locations, which resulted in R2 receiving bruises to her right shoulder, left knee, and swelling to her left knee. R2 was further noted to have a left leg fracture (broken bone) that required surgical intervention. Findings included: - R2's Electronic Medical Record (EMR) documented under the Diagnoses tab the following diagnoses: repeated falls, cognitive communication deficit, impulsiveness, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), muscle weakness, unsteadiness on feet, and presence of left artificial knee joint. The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. R2 was totally dependent of two staff members for bed mobility, and transfers. R2 was totally dependent of one staff member for dressing and personal hygiene. The Falls Care Area Assessment (CAA) dated 05/13/22 documented R2 required assistance of a full body lift and assistance of two staff members for all transfers. The Quarterly MDS dated [DATE] documented a BIMS score of three, which indicated severely impaired cognition. R2 required extensive assistance of two staff members with transfers. R2 required total dependence of one staff member with dressing, and locomotion on and off the unit. R2 required extensive assistance of one staff member for personal hygiene, toilet use, and bed mobility. The Rehab and Mobility Care Plan initiated on 05/12/22 directed R2 transferred with two staff members max assistance to move between surfaces, with use of sit to stand lift. The Skin Integrity Care Plan revised on 02/08/23 revealed nursing assessed redness and swelling to R2's left knee and the physician ordered an x-ray and to send to emergency room (ER) for evaluation. The Weekly Skin Check dated 02/01/23 at 06:18 PM documented R2 had a previously identified area, staff were monitoring a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) on the posterior knee, and no new skin concerns were noted. The Incident Note dated 02/08/23 at 05:47 PM documented an unidentified staff member notified Licensed Nurse (LN) G that R2's leg was swollen and bruised. R2's left leg was red and yellow in color, swollen, and warm to touch. The whole left knee was bruised. Upon further examination staff noted R2 had a golf ball size yellow bruise on her left shoulder and two dime size yellow bruises to her right arm (one close to the elbow and the other in the middle of the right upper arm). Range of Motion (ROM) was attempted, R2 showed signs of pain with facial expressions. The physician was notified, ordered received for two view x-rays of R2's left knee, keep R2 non-weight bearing and perform a return call with the results. R2 received the x-rays and was noted to have a fracture of the distal end of the left femur. The physician was notified, orders received to send to the ER to have the fracture evaluated and treated. The Progress Notes lacked an incident entry to indicate injury or accident event regarding R2. The Weekly Skin Check assessment dated [DATE] at 10:52 AM documented new skin concerns identified: right antecubital (bend of the elbow) had bruising, right elbow had bruising, left knee (front) had bruising, and left shoulder (front) had bruising. Review of the Left Knee, 1/2 view X-Ray dated 02/08/23 documented displaced fracture of the distal femur. The impressions of acute fracture, fracture deformity is new compared to 05/25/22. Review of the facility reported incident, emailed on 02/09/23 intake number 8069, noted that R2 had a near fall in an unsafe transfer of the sit to stand mechanical lift and one staff member. The unnotarized Witness Statement by LN I, lacked a date, documented on 02/06/23 R2 received treatment to R2's knees as ordered with only old bruise and hematoma noted to the back of R2's left knee. LN I noted no bruise to the top of either knee in the morning or at lunch. The unnotarized Witness Statement by Certified Nurse Aide (CNA) M, dated 02/09/23, documented R2 almost had a fall on 02/07/23 during a transfer. CNA M reported R2 started to fall during a transfer, twisting to the right. CNA M stated R2 was quickly transferred to the bed. Another unnotarized Witness Statement by CNA M, lacked a date, documented R2 was being transferred with the sit to stand lift when R2 started to go down while in the lift. CNA M hurried up and pushed R2 and the lift to the bed. CNA M stated the lift would not come down and R2 continued to fall out of the lift onto the bed at the same time. After a couple of seconds CNA M stated the lift went down. Review of Individual Performance Improvement Plan dated 02/09/23 documented CNA M used a mechanical lift without a second person resulting in an unsafe transfer. On 02/23/23 at 11:04 AM Certified Medication Aide (CMA) S stated mechanical transfers required two staff members. CMA S revealed if during a mechanical lift transfer a resident should start to fall CMA S and the other staff member that was with her would try to get the resident over a safe place to lower the resident like the bed, toilet, or wheelchair. CMA S further revealed that if that was not able to happen, she would safely lower the resident to the floor. On 02/23/23 at 11:29 AM CNA M attempted contact, unavailable for interview. On 02/23/23 at 11:48 AM LN G stated that prior to R2 getting the most recent fracture R2 used the sit to stand mechanical lift for transfers. LN G stated she located R2's bruising and swelling and contacted the physician, family and Administrative Nurse D. LN G revealed that she was nervous to contact R2's family due to not knowing how R2 initially got hurt. LN G revealed to the family the injury was being investigated and theand the facility would follow up and let the family know the findings of the investigation. On 02/23/23 at 02:13 PM Administrative Nurse D stated she believed R2's family had been notified about R2's injury and how it was suspected to have occurred. Administrative Nurse D further stated she knew that R2's family was notified about the bruise, butbruise but could not confirm R2's family was notified of the end results of the facility investigation. On 02/23/23 at 02:38 PM R2's representative stated the facility did not notify the family about any completion of the investigation related to R2's fractured left leg. R2's representative revealed the facility only informed them about the bruising and R2 going out to the ER. The facility's policy Accidents and Supervision, lacking a date, documented the resident environment would remain as free of accident hazards as is possible; and each resident received adequate supervision and assistive devices to prevent accidents. The facility should make a reasonable effort to identify the hazards and risk factors for each resident. The facility failed to ensure R2 was free from accidents and safety hazards when facility staff failed to transfer R2 with two staff members, while utilizing the sit to stand mechanical lift. This deficient practice caused actual harm to R2 when she sustained a fractured left distal femur that required surgical intervention. The facility completed an all nursing staff in-service on education for proper use of sit to stand mechanical lifts on 02/09/22, which included ensuring the appropriate number of staff were available for the transfer Due to the facility's corrective actions implemented on 02/09/22 this deficient practice was cited as past non-compliance and existed at a G (isolated, actual harm) scope and severity.

The facility reported a census of 133 residents. The sample included six residents reviewed for elopement risk. Based on observation, interview, and record review, the facility failed to provide adequate supervision for one resident (#1). The resident eloped from the facility on 2/24/18, and staff found the resident approximately 250 feet from the facility on a suburban street with fewer than 4 cars passing by, and a speed limit of 30 miles per hour (mph). The resident walked south towards a busier street, with more than 20 cars passing by, and a speed limit of 30 mph over approximately 3 minutes. Facility staff observed the resident outside of the facility, and failed to immediately stop and bring the resident back inside the facility. This deficient practice placed this resident in immediate jeopardy. Findings included: - The electronic medical record documented the facility admitted resident #1 on 1/30/18 with a [DIAGNOSES REDACTED]. The 5-day Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 8, indicative of moderate cognitive impairment. The resident did not exhibit wandering or exit-seeking behaviors during the assessment period. He/she ambulated with limited staff assistance and used a walker and wheelchair for mobility. The Care Area Assessment (CAA), dated 2/5/18, for Cognitive Loss and Dementia documented the resident had dementia and impulsive behavior. The CAA for Activities of Daily Living (ADLs) documented the resident required limited staff assistance with his/her care. The clinical record lacked documentation of an elopement assessment prior to 2/16/18. The elopement risk assessment, dated 2/16/18, documented the resident was a high risk for elopement, after he/she attempted to exit the facility several times. The care plan, dated 1/30/18, documented the resident alarmed several exit doors, but did not exit. Staff revised the care plan on 1/31/18 to include increased supervision of this resident. Staff revised the care plan again on 2/16/18 when staff placed his/her photo on the photo board at the nursing station. A progress note, dated 2/16/18 at 11:00 AM documented staff found the resident at an exit door when it alarmed, but he/she did not exit the facility. Staff redirected the resident to his/her room. A progress note, dated 2/16/18 and untimed, documented staff placed the resident on frequent checks and placed his/her picture on the photo board at all nursing stations and at the reception desk. A progress note, dated 2/16/18 at 1:30 PM (2 and 1/2 hours after the first elopement attempt), the resident set off the door alarm in another hall. A progress note, dated 2/17/18 during the evening, documented the resident continued to wander about the facility. A progress note, dated 2/19/18 at 3:48 PM, documented staff observed the resident to pack his/her belongings, and he/she stated he/she was going home. A progress note, dated 2/19/18 at 7:48 PM, documented the resident stated he/she was looking for his/her car keys to go home. Staff explained to him/her that it would be unsafe to drive due to sleet conditions, and he/she agreed to remain inside. A progress note, dated 2/24/18 and untimed, documented the resident triggered the door alarm on hall #7 at 1:40 PM, but staff redirected him/her away from the door. The facility's investigation, dated 2/24/18, documented the resident eloped from the facility at approximately 1:50 PM. Direct care staff Z drove in to the facility's parking lot at 1:50 PM, and thought he/she saw the resident in his/her rear-view mirror. Staff Z parked his/her car and ran through the facility to notify the nursing staff the resident was outside. He/she encountered the resident near the hotel south of the facility, where another staff saw the resident and waited with him/her until they escorted the resident back into the facility. The investigation documented the resident wore sweat pants and a short-sleeved shirt. According to www.Wunderground.com, the temperature on 2/24/18 was 38 degrees Fahrenheit, wind speed was approximately 9 miles per hour, and there was no precipitation. The weekly door alarm logbook documented maintenance staff checked the function of all door alarms on 2/13/18. On 3/1/18 at 12:00 PM, the main exit door revealed a sign near the keypad, which warned visitors to not allow anyone out of the building without checking with the nursing staff. On 3/1/18 at 12:05 PM, the exit door at the end of hall #7 revealed a metal sign on the door documenting it was an emergency exit On 3/1/18 at 8:07 AM, administrative nursing staff D stated staff assessed the resident as a high risk for elopement. He/she stated staff increased monitoring of the resident, and observed the resident every 30 minutes. Staff D further stated staff thought the resident followed someone out of the door on 2/24/18 since it did not alarm. On 3/1/18 at 9:45 AM, direct care staff N stated the facility maintained a board of pictures of the residents who staff assessed to be a high risk for elopement at the nursing stations, the reception desk, and the break room. Staff N stated if staff heard a door alarm, they immediately checked the door and outside of the door. He/she stated when this resident exited on 2/24/18, staff did not hear an alarm. On 3/1/18 at 12:50 PM, direct care staff Z read over his/her notarized witness statement and affirmed it was complete. He/she stated he/she did not stop his/her car to immediately retrieve the resident, because the car would have been in the middle of the street. He/she further stated initially he/she was not sure that it was a resident. He/she parked his/her car in the rear parking lot, ran through the facility, past the nursing station, and told the nursing staff there was a resident outside as he ran through the front door. He/she stated the resident returned to the building at approximately 1:55 PM. On 3/1/18 at 2:05 PM, reception staff AA stated the door at the end of hall #7 was not used by visitors or staff. He/she stated the door would alarm if opened and would continue to alarm if it was not latched properly. The facility's Elopement Assessment Protocols policy, revised (MONTH) (YEAR), documented all residents would be assessed for risk of elopement on admission, quarterly, annually, and with any significant change in condition. Further, the policy documented the staff would alert the unit manager, director of nursing, and the facility administrator, should they observe a resident with wandering or exit-seeking behaviors, such as alarming doors or attempting to leave the facility. Any cognitively impaired resident with exit seeking behaviors as described above would be placed on one-on-one staff monitoring status for strict observation. The facility failed to assess in a timely manner, implement effective interventions, and provide supervision to this cognitively impaired resident who eloped from the facility on 2/24/18.This deficient practice placed resident #1 in immediate jeopardy. The facility abated the immediate jeopardy on 3/5/18 at 10:00 AM by initiating the following: 1. Placed the resident on one-on-one staff supervision when he/she returned to the facility on [DATE] at approximately 1:50 PM. 2. Staff checked the doors on the unit the resident resided to ensure they alarmed as expected. 3. Nursing staff trained on 2/24/18 regarding elopement procedures and one-on-one supervision. 4. Staff reviewed and updated the resident's care plan on 2/24/18. 5. The maintenance staff checked all door alarms on 2/26/18 to ensure they operated correctly. 6. The Interdisciplinary Team discussed the elopement on 2/26/18. 7. Staff continued one-on-one observation until the resident's discharge on 2/27/18. 8. The facility would provide training to staff regarding the facility elopement policy and procedures. This training would begin 3/1/18 at approximately 3:00 PM and would be completed on 3/5/18 at 10:00 AM. 9. The facility obtained quotes for the installation of a Wander Guard system (a bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort), to be installed on public entrance doors. Quotes for the system were requested on 3/1/18. The system would be installed as soon as it could be obtained from the manufacturer. Until the Wander Guard system could be installed, residents with exit-seeking behaviors would be placed on one-on-one staff supervision until they could be placed in a safer environment. After the installation of the Wander Guard system, staff would place a Wander Guard bracelet on residents who staff identified as elopement risks. The facility's policy and procedure regarding elopements would be updated to include any changes needed for the Wander Guard system. 10. The director of nursing or his/her designee would continue to monitor incidents of elopement attempts with the interdisciplinary team and with the Quality Assurance and Process Improvement (QAPI) Committee routinely. This elopement would be reviewed with the QAPI committee on 3/15/18. The deficient practice remained at a scope and severity of a D.

The facility had a census of 132 residents. The sample included 20 residents. Based upon observation, record review and interviews, the facility failed to develop and implement effective interventions to prevent the development of pressure ulcers for 2 (#3, #91) of 3 residents sampled for pressure ulcers, who developed avoidable facility acquired unstagable pressure ulcers. Findings included: - Resident #3's admission Minimum Data Set (MDS) 3.0 MDS dated [DATE] identified the resident scored 3 (severely impaired cognition) on the Brief Interview for Mental Status and displayed physical and verbal behaviors for 1 to 3 days during the 7 day assessment period. The MDS coded the resident required extensive staff assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. The MDS recorded the resident was totally dependent upon staff for transfers, locomotion on/off unit, and the activity of walking in the corridor/room occurred only once or twice during the 7 day assessment period. The MDS identified the resident was always incontinent of urine, weighed 163 pounds, had no weight loss, and was at risk for the development of pressure ulcers. The MDS coded the resident had no unhealed pressure ulcers, had a pressure relieving device for his/her bed and chair, was not on a turning/repositioning program, and had no nutrition or hydration interventions to manage skin problems. The resident's Pressure Ulcer Care Area Assessment (CAA) dated 8/4/13 identified the resident was at risk for pressure ulcers related to his/her mobility and incontinence, and the resident did not have unhealed pressure ulcers. The CAA documented the resident had a cushion in his/her wheelchair, staff monitored the resident's skin daily during activities of daily living, and staff performed skin assessments on a weekly basis when staff showered the resident. The resident's Nutritional CAA dated 8/5/13 included the resident received a mechanical soft diet with honey thickened liquids. A Braden Scale (scale used to predict the development of pressure ulcers) dated 7/18/13 identified the resident scored 12 (high risk for the development of pressure ulcers). The resident's care plan dated 8/15/13 addressed the resident had a low air loss mattress, a pressure relieving device in his/her wheelchair, the resident required extensive staff assistance with bed mobility, and staff repositioned the resident hourly. The care plan included the resident had a history of [REDACTED]. The above interventions were in place effective 7/19/13. The care plan included staff performed the treatment to the resident's sacrum as ordered, and staff offered to toilet the resident every 2 hours. On 9/9/13 the facility placed the resident on the Foods First Program (fortified supplemental meal plan which may include foods that contain higher calories and protein). A physician's orders [REDACTED].M. included the resident to receive a Magic Cup (supplement to meet calorie needs) at noon and at night (HS) and to receive 120 cubic centimeters of Resource 2.0 (high calorie, high protein drink) twice a day. A skin assessment dated [DATE] (date resident admitted to the facility) documented the resident had a red blanchable (blood returned and pressure removed from an area) area on his/her coccyx. A wound assessment dated [DATE] documented the resident had an unstagable facility acquired pressure ulcer on his/her coccyx that measured 2.5 centimeters (cm) by 1.5 cm. The center of the pressure ulcer was dark and appeared to be necrotic (dead) tissue, and fluid filled intact blister like areas surrounded the pressure ulcer. A wound assessment dated [DATE] documented, the unstagable pressure ulcer was technically in the resident's sacral area and the pressure ulcer measured 2.3 cm by 1.2 cm. The assessment included the pressure ulcer was in a place of scar tissue and the resident's guardian reported the resident had a history of [REDACTED]. A wound assessment dated [DATE] documented the unstageable pressure ulcer measured 2.0 cm by 1.0 cm with 90 % yellow adherent slough and 10 % granulation. A wound assessment dated [DATE] documented the unstagable pressure ulcer on the resident's sacrum was facility acquired, measured 1.3 cm by 0.5 cm with moderate amount of seroserous (wound drainage of a semi-thick reddish fluid). The assessment included the resident needed to sit up after meals due to the resident's risk of aspiration which conflicted at times with his/her adequate hourly repositioning after meals, the head of the resident's bed was at 30 degrees at all times which increased the resident's risk of shear, staff would continue to reposition the resident on a hourly basis but recognized that after meals, it may be closer to 2 hours before staff repositioned the resident again. A wound assessment dated [DATE] documented the facility acquired unstagable pressure ulcer on the resident's sacrum measured 1.0 cm by 0.4 cm and contained 90 percent (%) slough (non-viable tissue). A wound assessment dated [DATE] included, the facility acquired unstagable pressure ulcer on the resident's sacrum measured 0.7 cm by 0.3 cm, and had 5% yellow slough. The clinical record lacked evidence to support a wound assessment was performed from 9/3/13 to 9/13/13 (duration of 10 days). A laboratory report dated 7/19/13 recorded the resident's serum [MEDICATION NAME] (indicators of protein storage in the blood) level at 3.4 grams/deciliter gm/dL (normal reference range 3.5 gm/dL to 5.7 gm/dL). Review of the resident's weights were as follows: 7/24/13: 164 pounds 7/31/13: 152 pounds 8/10/13: 152 pounds (weight loss of 12 pounds in less than 1 month, a significant weight loss of 7.31%) During the above time frame the resident developed the facility acquired unstagable pressure ulcer on his/her sacral area. A Registered Dietician (RD) note dated 7/27/13 and timed 2:14 P.M. included the resident's weight was recorded as 223 pounds (#) and the RD requested a re-weigh for the 163-164# weight range recording. The note documented the resident did not have pressure ulcers and/or wounds, the resident's [MEDICATION NAME] level was low, and the resident consumed 50-75% at meals. The resident's nutritional needs were Energy: 2045 calories, Protein: 68-102 grams, and fluid: 2511 cubic centimeters (cc's) per day. The note included the resident required increased protein needs related to the resident's low [MEDICATION NAME] and the resident intake at 50% was less than required. Interventions included Prostat supplement (supplement to increase protein), and 2.0 supplement 120 cc QID (four times a day), and to maintain the resident's weight at 160# plus. The facility started the resident on the 2.0 supplement on 7/22/13. A RD note dated 8/11/13 and timed 3:28 PM included the resident had experienced a weight loss, and had a wound (unstagable pressure ulcer), and the resident's [MEDICATION NAME] was low on 7/18/13. The note included the resident consumed 50-75%, the resident's nutritional needs were Energy: 2045-2555 calories, Protein: 68-102 grams and fluid: 2511 cc's per day. The note included the resident had increased protein needs related to low [MEDICATION NAME], wound healing and weight loss. The note included the RD recommended Food 1st with meals. Review of the resident's consumption for the Resource 2.0 from 9/1/13 to 9/9/13 recorded the resident consumed an average of 46% of the supplement during the above time frame. (75% during the AM, 8% at 12:00 P.M., 80% in the PM and 19% at night). The resident's clinical record lacked evidence to support the facility consistently offered the resident the supplement at a different time or provided an alternate when the resident did not consume the supplement. On 9/10/13 the resident sat in his/her wheelchair in his/her room at 7:50 A.M., 8:00 A.M., and 8:05 A.M. At 8:25 A.M. staff pushed the resident from his/her room to the dining room. The resident sat in the wheelchair in the dining room until 8:50 A.M. At 8:50 A.M. a nurse aide assistant student pushed the resident to his/her room. The resident continued to sit in the wheelchair in his/her room at 9:00 A.M., 9:08 A.M., 9:15 A.M., 9:20 A.M., 9:27 A.M. and 9:31 A.M. (duration of 1 hour and 41 minutes). ., On 9/10/13 at 12:00 PM, 12:10 P.M., 12:20 P.M., 12:30 P.M. and 12:45 P.M. the resident sat in his/her wheelchair in the television room on the unit where he/she resided. At 1:00 P.M. the resident sat in the dining room in his/her wheelchair at a dining room table. Observation revealed the resident did not eat the pureed potatoes, vegetables or meat offered. At that time staff prepared a chocolate shake for the resident. The resident sat in the dining room in the wheelchair at 1:10 P.M. (duration of 1 hour and 10 minutes). On 9/10/13 at 2:00 P.M., 2:15 P.M., 2:30 P.M., 2:45 P.M. 3:00 P.M., 3:15 P.M., 4:00 P.M., and 4:15 P.M. the resident laid in bed on his/her back (duration of 2 hours and 15 minutes). On 9/12/12 the resident laid in bed on his/her left side at 9:40 A.M.. 9:50 A.M., 10:00 A.M., 10:10 A.M., 10:20 A.M., 10:30 A.M., 10:35 A.M., 10:40 A.M., 10:50 A.M., and 11:04 A.M. (duration of 1 hour and 24 minutes). On 9/12/12 at 12:45 P.M. the resident had consumed all of the pureed ham and beans, pureed broccoli, and applesauce. Observation of the resident's diet card did not included the resident was on the Foods First Program. During interview with dietary staff DD (staff that prepared the resident's lunch tray) at that time, he/she stated he/she did not know of the Foods First Program, and/or residents that received fortified foods. Dietary staff DD stated staff told him what residents wanted and he/she prepared the tray accordingly. During interview with direct care staff O who assisted the resident with the lunch meal, he/she stated he/she was not aware of the Foods First Program and/or fortified food plan. Direct care staff P also stated he/she was unaware of the Foods First Program. On 9/16/13 at 7:25 A.M. the resident laid in bed on his/her left side and stated he/she was wet and soiled. Observation revealed the resident had a dressing in place over his/her sacrum. Observation also revealed feces in the resident's rectum. Licensed nurse I removed the dressing and stated the dressing was wet with urine. Observation revealed the resident had a Stage 2 pressure ulcer on his/her her sacrum area that measured approximately 0.5 cm by .05 cm. Direct care staff entered the resident's room to perform the resident's incontinent care. On 9/16/13 the resident laid in bed on his/her left side at 7:45 A.M., 8:00 A.M., 8:15 A.M., 8:30 A.M., 8:40 A.M., 8:54 A.M., 9:00 A.M. and 9:10 A.M. (duration of 1 hour and 25 minutes). On 9/16/13 at 1:43 P.M. direct care staff R stated staff repositioned the resident at least hourly. Direct care staff R stated when the resident sat in the wheelchair staff scooted the resident over a little which was all staff could do when the resident sat in the wheelchair. Direct care staff R stated the resident did not always consume the Resource 2.0. On 9/16/13 at 1:50 P.M. direct care staff S stated sometimes the resident drank 100% of the Resource 2.0 and other times the resident did not consume any of the supplement. On 9/16/13 at 3:07 P.M. administrative nursing staff G stated upon admission the resident had a red blanchable area on his/her coccyx and it progressed to an unstagable facility acquired pressure ulcer. Administrative nursing staff G stated staff repositioned the resident every hour when in bed, after meals it might be longer than an hour before staff repositioned the resident due to the resident's risk of aspiration. Administrative nursing staff G stated the facility changed the supplement order on 9/12/13, the resident now received a Magic Cup at noon and at night because at those times the resident consumed less of the Resource 2.0 and the Magic Cup provided more calories for the resident. Nursing administrative staff G stated if the resident refused the supplement staff should ask the resident at a later time or provide a snack to the resident. Administrative nursing staff G stated the resident's snack consisted of lollipops or chocolate shakes. The facility undated policy and procedure on Wounds/Skin Protocol included the wound nurse would complete a comprehensive review of the resident's nutrition/hydration, review with direct care staff residents with wounds, would be checked every hour to ensure the resident was clean and dry, and staff would reposition the resident every 2 hours. Staff performed a wound assessment weekly and documented the description and measurements each week. The facility failed to reposition this resident every hour as care planned, failed to ensure all staff were aware the resident was on the Foods First Program, failed to consistently offer an alternate supplement of equal nutritional value when the resident did not consume the Resource 2.0, and failed to perform weekly wound assessments for this resident that was at high risk for the development of pressure ulcers upon admission and developed an avoidable unstagable pressure ulcer on his/her sacrum. - The admission Minimum Data Set 3.0 ((MDS) dated [DATE] for the closed record of resident #91 revealed a brief interview for mental status (BIMS) score of 13, indicating the resident was cognitively intact. The resident required extensive assistance of 2 or more staff members for bed mobility, transfers, dressing, and toilet use. The resident was identified at risk for development of pressure ulcers but did not have one upon admission. The staff provided a pressure reducing device for the resident's bed and chair. The 6/7/13 Care Area Assessment (CAA) for activities of daily living (ADLs) revealed the resident required extensive assistance from staff for most ADLs related to him/her being non-weight bearing at the time of admission. The CAAs for pressure ulcers and nutrition did not trigger. The temporary care plan dated 6/1/13 lacked interventions to prevent pressure ulcer development. The Braden scale (a numerical tool used to assess resident's potential for developing pressure ulcers) dated 6/1/13 revealed a score of 14, indicating moderate risk for development of a pressure ulcer. The comprehensive care plan initiated 6/2/13 revealed the nurse checked the resident's skin under his/her brace daily for breakdown. Staff revised the care plan on 6/17/13 to include the intervention of floating the resident's heels on a pillow while in bed and for staff to encourage the resident to change positions frequently. Laboratory test results dated 6/3/13 documented a low [MEDICATION NAME] level of 2.5 grams per deciliter (g/dl), with the normal range 3.5-5.7 g/dl and low total protein level of 4.3 g/dl with the normal range of 6.4-8.9 g/dl. The dietary note dated 6/8/13 at 4:10 P.M. revealed the resident had low [MEDICATION NAME] levels and recommended the resident received a nutritional supplement to increase protein intake. The wound assessment dated [DATE] revealed the resident had an unstagable pressure ulcer noted on his/her right heel which was acquired while in the facility. The wound dimensions were documented as 4.0 centimeters (cm) by (x) 5.6 cm, a small amount of serosanguineous (wound drainage of a semi-thick reddish fluid), drainage was noted, and the wound edges were undefined. Interview on 9/16/13 at 10:44 A.M. with administrative nursing staff E revealed he/she performed wound assessments at the facility. Staff E acknowledged repositioning with the use of pillows under the resident's legs to reduce pressure was not initiated until 6/17/13 per the care plan. He/she expected if a resident was identified at risk for pressure ulcers staff would initiate interventions on the care plan prior to the development of a pressure ulcer. Interview on 9/16/13 at 12:15 P.M. with administrative nursing staff D revealed if a resident was identified on the MDS at risk for pressure ulcers staff would develop a care plan for the resident to reduce the risk of developing a pressure ulcer. The policy regarding wound/skin protocols, pressure ulcers stage and definitions dated 01/13, revealed the best treatment was proactive prevention which included the following: Braden score assessment and/or nursing judgment to determine initiation of interventions, repositioning frequently, pressure reduction, ensuring skin was kept clean and dry, and for staff to pay special attention to nutrition and hydration including evaluation of protein and [MEDICATION NAME] if indicated. The procedure also stated every resident on admission and monthly would be assessed by a licensed nurse for skin impairment. The facility failed to provide interventions for the prevention of pressure ulcers for this resident identified at risk for the development of pressure ulcers who developed an avoidable unstagable pressure ulcer at the facility.