Every finding on record at Premier Rehab and Healthcare at Berlin

Based on interview and record review the facility failed to Identify a resident-to-resident altercation as abuse (Resident #1 and Resident #2) and failed to immediately report the incident as required. Finding include: Per record review Resident #1 has a BIMS (Brief Interview of Mental Status) of 0 which indicates significant cognitive impairment. Diagnoses for Resident #1 include major depression disorder, anxiety disorder, restlessness, agitation and history of traumatic brain injury.Per record review Resident #2 has a BIMS of 10 which indicates moderate cognitive impairment. Diagnoses for Resident #2 include cerebral infarction, major depressive disorder, adjustment disorder with anxiety, epilepsy and alcoholic polyneuropathy.Per review of the facility's 5/26/2026 incident report, on 5/23/2026 Resident #1 became angry when s/he thought Resident #2 was wearing a shirt that belonged to him/her. While a staff member was attempting to redirect Resident #1, Resident #1 turned around and willfully hit Resident #2 in the chest with a closed hand. The staff member reported the incident to the shift supervisor who determined the altercation did not signify abuse.Per review of the facility's Compliance with Reporting Allegations of Abuse/Neglect/Exploitation policy (9/2024), it states that administration or designee will be made aware of any report of abuse/neglect/exploitation so that the appropriate agencies could be notified immediately: as soon as possible, but not later than 24 hrs.Per interview with the Director of Nursing (DON) on 6/22/2026 at 11:00 AM, she stated that on 5/26/2026 she read reports from the weekend of 5/23/2026 and became aware of the resident-to-resident altercation. The DON confirmed that the shift supervisor should have called her immediately after the altercation so that the appropriate agencies could be notified within the required timeline. Based on corrective actions completed prior to the onsite survey, this citation is designated as past non-compliance. The following actions were taken by the facility: The incident was reported to [NAME], APS, the family and police on 5/26/2026The week of 5/26/2026 the DON Interviewed all staff members who were present during the incident. An interview with Resident #1 was unable to be conducted by the facility due to significant cognitive impairment.An interview with Resident #2 was conducted by the DON and s/he was not negatively affected by the incident.Social Services is scheduled to complete psycho socials with Resident #2. Supportive care (psych services) and Deer Oaks (talk therapy) have been scheduled to follow up with both residents.Education and competencies on abuse and neglect were completed for all staff by 6/5/2026.The DON reported that audits are to be completed on all units to determine understanding and compliance with abuse and neglect reporting.The supervisor on duty during the incident met with the DON and completed training/competencies on 6/5/2026.The Administrator and DON confirm that the late reporting of this incident will be included in their QAA meetings.

Based on observation and interview, the facility failed to store and prepare in accordance with professional standards for food service safety per observation of stored dirty, greasy, and wet pots and of unclean kitchen equipment.Per observation on 2/2/26 at approximately 10:48 AM, observed numerous pots and pans that were wet on the inside and outside and not dried prior to stacking. Several other pans were noted to be greasy. Per observation on 2/2/26 at approximately 10:58 AM, the meat slicer was observed to have some dry particles on the back of the blade. Per interview on 2/2/26 at approximately 11:02 AM, the Kitchen Manager confirmed the above observations.Per observation on 2/2/26 at approximately 11:03 AM, the floor stand mixer was noted to have a dried, tacky white substance on the underside of the mixer arm, and on the backsplash under the mixer arm. There were some food particles/crumbs noted on the inside of the attached metal mixing bowl. Per interview on 2/2/26 at approximately 11:04 AM, the Kitchen Manager confirmed the above observation.Per observation on 2/2/26 at approximately 11:07 AM, a divided plastic bin containing silverware was noted in the food prep area. The silverware was noted to be dirty with dried particles/debris. Per interview on 2/2/26 at 11:07 AM, the Kitchen Manager confirmed the above observation.Per record review of the facility's Food Procurement policy [revised date 11/2025] revealed: All equipment used in the handling of food shall be cleaned and sanitized, and handled in a manner to prevent contamination. a) Staff shall follow facility procedures for dishwashing and cleaning fixed cooking equipment. b) Clean dishes shall be kept separate from dirty dishes Per observation on 02/04/26 for a follow up kitchen visit at 11:08 AM, It was observed that there were some stacked wet pans that had not been dried prior to stacking. Several pans had some dried thick food debris noted on the inside, and several pans were noted to be greasy on the inside and outside. Per interview on 2/4/26 at approximately 11:09 AM, the Kitchen Manager confirmed the pans were wet, greasy, and dirty.Per observation on 2/4/26 at 11:12 AM, the floor stand mixer was found to have crumbs inside the bowl and some batter splattered close to the attachment. The Kitchen Manager confirmed these findings. Per observation on 2/4/26 at 11:14 AM, the back side of the meat slicer blade was observed to have some crusted dry meat particles. The Kitchen Manager confirmed that the meat slicer was dirty.

Based on record review and interviews, the facility failed to ensure accurate advanced directive choices were indicated in the electronic medical record for 2 of 21 sampled residents (Resident # 10 and Resident #29). Findings include:1.) Per record review of Resident # 10's COLST (Clinicians Orders for Life-Sustaining Treatment) form dated [DATE] revealed the resident wishes to receive CPR (cardiopulmonary resuscitation) and desires full code status. Resident # 10's care plan initiated [DATE] stated Resident #10 is a full code indicating the resident wants CPR. A physician's order dated [DATE] read full code. The EMR (electronic medical record) care profile for Resident #10 has a section for code status that read DNR (do not resuscitate). Per interview with Unit Manager Licensed Practical Nurse (LPN) of B wing on [DATE] at 1:07 PM, she stated her and her staff use the resident care profile to identify a resident's code status. She confirmed Resident #10 is a DNR based on the care profile and that the COLST form indicates the resident is a full code. Per interview with the Director of Nursing (DON) on [DATE] at 1:13 PM, she confirmed the resident's care profile, care plan, physician order, and COLST form in the EMR should all indicate the same code status. The DON confirmed that Resident #10's COLST form code status in the electronic medical records does not match the care profile, care plan, and physician order. 2.) Per review of Resident #29's Care Plan on [DATE], the resident's care plan identifies the resident as having established Advanced Directives which include: Do Not Hospitalize (DNH), Do Not Intubate (DNI), Do Not Resuscitate (DNR). Further review of the Care Plan reveals the resident also identified as having an established advanced directive: Full Code. Review of Physician notes dated [DATE] & [DATE] reads presumed full code although the patient was very dismissive of a discussion of the subject matter. Physician notes dated [DATE] record the patient doesn't have a COLST on file, and physician notes dated [DATE] reveal the resident's code status DNR/DNI/DNH. Per review of the [NAME] DNR/ COLST form [Do Not Resuscitate/Clinician Orders for Life-Sustaining Treatment], Full Code status can include hospitalization, intubation, and cardio-pulmonary resuscitation.Per review of the facility's Residents' Rights Regarding Treatment and Advance Directives policy [Copyright 2025 The Compliance Store, LLC. All rights reserved], the policy includesDecisions regarding advance directives and treatment will be periodically reviewed as part of the comprehensive care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions. An interview was conducted with the Director of Nursing [DON] on [DATE] at 2:23 PM. The DON confirmed Resident #29's Care Plan included contradictory information regarding the resident's Advance Directives. The DON confirmed Resident #29's Care Plan included Advance Directives that direct staff to both withhold specific life sustaining measures and also to initiate the same life sustaining measures. The DON confirmed that contradictory information on the care plan regarding Resident #29's Advance Directives needs to be resolved.

Based on observation and interview the facility failed to provide palatable and appealing food for 10 of 19 sampled Residents (Resident #3, Resident #37, Resident #5, Resident #30, Resident #8, Resident #11, Resident #42, Resident #43, Resident #1, and Resident #27). Findings include:#1: Per interview with Resident #3 on 8/4/2025 at 11:01 AM, she/he reported that s/he has been struggling to eat the food and gags because it’s so bad. Resident #3 also reported that they will heat up his/her food and it will still be cold ninety percent of the time. #2: Per interview with Resident #37 on 8/04/2025 at 11:46 AM, s/he reported that sometimes the food is not hot. #3: Per interview with Resident #5 on 8/04/2025 at 11:56 AM, s/he reported the food is “too often” cold, about 75% of the time. #4: Per interview with Resident #30 on 8/4/2025 at 2:33 PM s/he stated that the food is not always good and not like s/he is used to. #5: Per interview with Resident #8 on 8/4/2025 at 3:14 PM, the Resident reported that s/he does not eat the food provided by the facility and that the food is not healthy, so s/he has friends buy him/her food. #6: Per interview with Resident #11 on 8/4/2025 at 4:13 PM, s/he reports that the food is often cold. #7 Per interview with Resident #42 on 8/05/2025 at 9:22 AM s/he reported that the food is cold and sometimes the food is still cold even after being heated up. #8 Per interview with Resident #43 on 8/6/2025 at 9:10 AM, s/he reported that their breakfast was cold. 9. Per interview with Resident #1 on 8/6/25 at approximately 9:00 AM, s/he stated the food is cold and there not a lot of options. S/he stated by the time it gets to us it is always cold. The meat tastes like rubber and they do not get a lot of beef options. Per Resident #1, We are sick of fish and chicken. I'm diabetic and on dialysis and all they feed us is carbs [carbohydrates]. Snacks at night are all sugar, portions are small. We buy cold food and they throw it out after three days.” 10. Per interview with Resident #27 on 8/6/25 at approximately 9:00 AM, s/he stated the food is almost always cold and there was not much of a variety. S/he discussed there were not a lot of beef options. Resident #27 stated the residents used to get waffles and breakfast sandwiches “And now we don't anymore…They don't give maple syrup, only regular syrup.” 11. Per observation on 8/05/2025 at approximately 12:30 PM, lunch is being served, and the green beans look slimy, mushy, and unappetizing with a thin white sauce over them. Per observation on 8/6/2025 at 2:45 PM, the sampled test tray tasted by a surveyor, had rice that had limited taste and asparagus that was steamed soft.

Based on interview and record review the facility failed to provide adequate supervision to prevent a resident from eloping from a facility for 1 of 3 Residents (Resident #45). Findings include:Per record review of Resident #45's Care Plan, this resident was assessed as an elopement risk upon admission to this facility and has had a Wander Guard on his/her right ankle since admission. The Wander Guard was initiated on 3/7/25. The Care Plan does not indicate interventions related to wandering or for supervision for this resident. This resident has diagnoses of impaired cognitive function, restlessness and agitation and traumatic brain injury.Per review of an Incident Report, Resident #45's eloped on 4/7/25,. The document shows Resident #45 was unable to be located on the facility campus on 4/17/25 at 7:15PM. S/he was located at approximately 7:35PM on the property adjacent to the facility which is located down a hill from the facility. Per record review [SS1] of a 4/18/25 progress note, Resident #45 was transported by Emergency Medical Services from the adjacent property to the hospital where she/he had x-rays done because s/he complained that their head and both knees hurt. Both knees had scrapes on them. The resident said s/he had fallen while walking down the hill between the facility and the adjacent property. Per interview on 8/5/25 at approximately 3:30PM with Resident #45, s/he explained how s/he had excited the building without being noticed. S/he removed the window and the screen in an empty room. S/he then climbed out the window to go for a toddle around with a plan to go to Northfield because s/he wanted to go home. Per interview with Licensed Practical Nurse (LPN) #1 on 8/6/25 at 11:00AM, s/he stated that s/he was part of the search team for Resident #45. S/he and two other staff members found the resident at the Hair Salon down the hill from this facility. S/he stated that the resident was able to tell her/him what had happened and that his/her head and knee hurt. S/he confirmed that Emergency Medical Services was present when s/he arrived and that the resident was taken to the hospital by EMS to be assessed. Per interview on 8/6/25 at 10:50 AM with the Director of Nursing, she stated the last time staff had eyes on him/her was about 6:00 PM. Resident #45 was located at the hair salon which is about 200 yards away. She also confirmed that Resident #45 had the Wander Guard on at the time s/he was found. The DON stated that it did not alarm because the resident went out a window and the windows are not alarmed. She also confirmed that Resident #45 had removed the window and the screen in an empty room that maintenance had been working in.Per observation on 8/6/25 at approximately 3:00PM Resident # 45 exited through an alarmed door while an employee was assisting another resident, in a wheelchair, through the same door, onto the unit. The employee did not stop or redirect Resident #45.

Per observation, interview, and record review, the facility failed to determine whether it is clinically appropriate for residents to self-administer medications for one of one sampled resident (Resident #43). This is a repeat deficiency for this facility, with violations cited during the previous thee recertification surveys, dated 2/6/25, 8/19/24, and 3/01/24. Findings include:Per review of the facility policy titled Medication Administration reviewed on 3/2025, Medication 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. Observe resident consumption of medication.Per record review, Resident #43 has a medical condition called dysphagia, a condition that causes difficulty swallowing. Additionally, the physicians order page in the Electronic Health Record (EHR) revealed Resident #43 does not have orders for self-administration of medications.Per observation on 8/4/2025 at approximately 10:40am, Resident #43 had a pill in a small medicine cup with pudding left on his/her bedside table. There was no nursing staff in the room.Per interview with Licensed Nurse #1 assigned to the medication cart on 8/4/2025 at approximately 10:45am, they confirmed that the medications were left at the bedside and that he/she shouldn't have left them there. The nurse said that in the medication cup there were crushed medications along with a medication that was not crushed, a pill called Protonix (also known as Pantoprazole as stomach acid reducer used to treat acid reflux) that cannot be crushed.

Based on observation, interview, record review, the facility failed to ensure medications were properly stored for 1 of 7 sampled residents (Resident #43). This is a repeat deficiency for this facility, with violations cited during the previous three recertification surveys, dated 2/6/25, 8/19/24, and 3/01/24 Findings include: Per review of the facility policy titled Medication Administration reviewed on 3/2025, Medication 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. Observe resident consumption of medication.Per review of the facility policy titled Medication Storage reviewed on 3/2025, During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.Per record review, Resident #43 has a medical condition called dysphagia, a condition that causes difficulty swallowing. Additionally, the physicians order page in the Electronic Health Record (EHR) revealed Resident #43 does not have orders for self-administration of medications.Per observation on 8/4/2025 at approximately 10:40 AM, Resident #43 had a pill in a small medicine cup with pudding left on his/her bedside table. There was no nursing staff in the room.Per interview with Licensed Nurse #1 assigned to the medication cart on 8/4/2025 at approximately 10:45 AM, they confirmed that the medications were left at the bedside and that he/she shouldn't have left them there. The nurse said that in the medication cup there were crushed medications along with a medication that was not crushed, a pill called Protonix (also known as Pantoprazole as stomach acid reducer used to treat acid reflux) that cannot be crushed.

Based on observation, interview, and record review the facility failed to perform adequate hand hygiene during a dressing change for 1 of 22 sampled Residents (Resident #67). This is a repeat deficiency for this facility, with violations cited during the previous recertification survey dated 2/6/25. Findings include:Record review on 8/5/25 revealed that Resident #67 had an unstageable pressure ulcer on their coccyx (The small bone at the bottom of the spine. It is made up of 3-5 fused bones. It is also called the tailbone) and had an order for daily dressing changes. Observation on 8/5/25 at approximately 2:30 PM, a Physician's Assistant (PA) donned gloves and provided a wound assessment via visual and tactile methods, and they provided wound debridement with a disposable scalpel for Resident #67. After performing the wound assessment and wound debridement, the PA removed the soiled gloves and without sanitizing her/his hands took the disposable scalpel used to debride the residents wound and with her/his bare hand, placed the disposable scalpel inside one of the gloves s/he had removed from their hand. S/he then picked up their pen and made notes on a piece of paper. S/he then touched the inside door knob of the residents room with their bare hand, opened the door and exited the room. Per interview with the PA on 8/5/25 at approximately 2:40 PM, s/he confirmed that s/he had not washed or used hand sanitizer to clean their hands after removing their gloves. Per review of the Hand Hygiene policy it read, 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.

Based on interviews and record review, the facility failed to ensure that 3 of 7 residents in the applicable sample (Resident #1, #2, and #3) received necessary treatment and services consistent with professional standards of practice to prevent or promote healing and prevent infection of a pressure injury. As a result, Resident #1 developed an unstageable pressure injury which became necrotic (death of tissue); requiring hospitalization, and resulted in death related to due to osteomyelitis and sepsis of the pressure injury. This citation is at the immediate jeopardy level due to the facility's failure to prevent and treat pressure injury resulting in infection and death of 1 resident. Findings include: 1. Per review of Resident #1's medical record, s/he was admitted to the facility with a diagnosis of failure to thrive and a history of pelvic fracture on [DATE]. On [DATE], a nursing assessment revealed a 12 on the Braden scale for predicting pressure risk, identifying Resident #1 as a high risk for pressure injury. On admission, Resident #1 was assessed to be frequently incontinent of urine and bowel, and dependent for care, including repositioning. Per review of a skin assessment completed by a licensed nurse on [DATE], there is no mention of sacral redness or documentation of the sacral area. Per admission minimum date set (MDS) (a comprehensive assessment of each resident's functional capabilities) submitted on [DATE] by the MDS coordinator, Resident #1 had no unhealed or open pressure injury at time of admission on [DATE]. Facility policy titled Pressure Injury and Prevention Management, last revised 5/2022, reads, After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions . Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have pressure injury present. Per review of Resident #1's care plan, initiated on [DATE], s/he requires assist to complete ADL's [activities of daily living] R/T [related to] impaired mobility, incontinence, and pain. Per the care plan, s/he was dependent for all mobility and identified as at risk for a pressure injury. With interventions that included weekly skin check, and non-specifics including treatments for prevention of skin breakdown. No interventions were added to his/her care plan to turn and reposition. The facility did not follow professional standards of practice or its policy for preventing pressure ulcer development. According to the National Pressure Injury Advisory Panel (NPIAP), identification of a person at risk for pressure injury and implementation of an individualized care plan should include turning and repositioning every two hours and ongoing monitoring to determine if the individual needs more frequent position changes (2024). There is no evidence that turning and repositioning was added to the care plan to prevent pressure injury, or that interventions were revised after pressure injury was identified. An Advanced Practical Registered Nurse (APRN) visit note dated [DATE] revealed [Resident #1] is seen today for noted wounds to the right dorsum, left shin, and self reported pain to the sacrum. Patient is at [his/her] baseline orientation, and assessment of [his/her] skin does not show any wounds or lesions. [His/Her] sacrum is noted to have blanchable redness. [S/he] requires assistance with all ADLs and transfers . Assessment & Plan: Redness of sacrum. Educated staff on proper repositioning for skin integrity. Patient may benefit from an air mattress. Per further review of the APRN progress notes dated [DATE], [DATE], she continued to document pain and sacral redness for Resident #1 and continued to request an air mattress at each visit. There is no documented evidence that the air mattress or turning and repositioning were added to his/her care plan. According to the APRN progress notes, Resident #1 complained of sacral pain on [DATE] and again on [DATE]. Per interview with the APRN by telephone on [DATE] at 2:00 PM, she stated that she was concerned that Resident #1 was a high risk for pressure injury due to lack of fatty tissue and [s/he] was so thin. She reports requesting an air mattress for him/her on [DATE] and multiple times after that. Per record review, there were no interventions added to Resident #1's care plan after this visit. Per interview with the Director of Nursing on [DATE] at approximately 4:30 PM, she confirmed that Resident #1's care plan was not updated to include interventions for turning and repositioning, or the air mattress starting on [DATE], and should have been. She further stated that on [DATE], the facility attempted to use an air mattress from storage; however, per the DON, it would not inflate. Per record review, on [DATE], nursing documented an assessment titled Skin and Wound Evaluation, there is a single photograph of Resident #1's sacrum. The photo revealed the sacrum to be red with a small dark, bruise-like area in the center of the redness. DTPI (Deep tissue pressure injury) start as an inconspicuous bruise that rapidly becomes a full-thickness and often necrotic wound, teaming with potential harm, such as sepsis and osteomyelitis, pain, and suffering (Wound International, 2021). There is no assessment of the area attached to the photo or a progress note in the medical record that provides details of the photo of his/her sacrum on [DATE]. Per interview on [DATE] at approximately 4:30 PM with the Director of Nursing (DON), stated she identified the blanchable redness to Resident #1's sacrum and took a picture of the sacral area on [DATE]. Then she asked the facility's contracted integrated wound care specialist (IWCS) to assess Resident #1's sacrum. Per telephone interview with the IWCS on [DATE] at 3:30 PM, she stated she assessed Resident 1's sacrum on [DATE] but did not write a note. Per the facility policy titled Skin Assessment, last revised 8/2024, A full body, or head-to-toe assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. This assessment may also be performed after a change in condition or after a newly identified pressure injury . Procedure: remove any dressings, using clean technique, unless contraindicated or ordered to remain in place, and note any findings. Note any skin conditions such as redness, bruising, rashes, blisters, skin tears, open areas, ulcers, and lesions. Although record review shows skin assessments were completed on [DATE] and [DATE], there was no evidence that nursing evaluated Resident #1's sacrum or documented any concerns related to the area, even though redness was identified on [DATE]. Per an interview with the DON on [DATE] at 4:00 PM, she stated she was not able to complete all the skin assessments for all residents on her own. She stated she did not have unit managers or the support she needed to complete accurately for all residents. On [DATE] the APRN documented the following note for Resident #1 Chief complaint: Covid-19, pressure ulcer, weakness, pain, depression, constipation . [Section titled skin] Small circular open lesion over the sacrum.[Section titled assessment and plan] Pressure injury of the sacral region, stage 2. Cleanse with wound cleanser. Apply skin prep and cover with sacral dressing. Plan to switch out bed to an air mattress . The APRN entered the following orders on [DATE]: Check under boarder dressing daily. Cleanse with wound cleanser and apply sacrum boarder every 3 days and PRN everyday shift for pressure ulcer prevention. There is no evidence of wound measurements completed at this time for a new pressure injury on Resident #1' sacrum. Per interview with the Director of Nursing on [DATE] at 4:00 PM, she confirmed she verified the above orders for Resident #1 wound care on [DATE]; however, the order was written for pressure prevention, and the APRN did not communicate the findings with her, she did not recognize the order was for an actual wound. She stated she did not review the APRN visit notes associated with the orders written on [DATE]. She stated she didn't become aware of the sacral wound until [DATE]. Per interview with the APRN by telephone on [DATE] at 2:00 PM, she stated that on [DATE], she assessed Resident #1's sacrum and found a small blistered area that appeared to have broken open, and the top layers of skin were missing. She identified the area as a stage 2 pressure injury and entered orders into the electronic medical record to cleanse the area with wound wash and cover with a sacral dressing. Per review of the diagnosis list dated [DATE], the APRN entered the diagnosis of pressure injury stage 2 on [DATE]. Per further interview APRN stated she did not follow her process when she discovered the wound, which would be to review the findings with the nurse attending to the resident on the unit and then review with the DON. APRN also stated during interview she did not measure the area of pressure injury on [DATE]. Per facility skin assessments completed on [DATE] and on [DATE], there was no evidence that nursing evaluated Resident #1's sacrum or documented the stage 2 pressure injury identified on [DATE]. Per further interview with the DON on [DATE] at 4:00 PM she stated she did not have the staff to complete timely skin checks or to verify skin checks were being completed accurately by licensed nursing staff. Per review of Resident #1's Treatment Administration Record (TAR), Resident #1 received a dressing change on 3/16, 3/17, 3/18, 3/20, 3/21, 3/22, 3/23, 3/24, 3/25, 3/26, 3/27, 3/28, 3/29, and [DATE] without documentation of the sacral area. On [DATE], nursing documented the following progress note: Apply protective dressing to sacrum . Pt sore open to air. cleansed wound and placed a dressing over sacrum . There is no documentation of a wound evaluation during any of these dressing changes or that the DON was notified of an opening on Resident #1's sacrum. Per review of Resident #1's treatment administration record, orders dated [DATE], there is a protective sacral border dressing ordered by the APRN, and starting on [DATE], the order is updated to include check under the dressing daily and ensure that it is in place. Several days were signed off in the TAR, however, there is no way to determine when a dressing change had been completed, and there was no wound assessment prior to [DATE] that included measurements or characteristics The medical record revealed no evidence of a wound assessment with measurements until [DATE], 17 days after the pressure injury was first diagnosed by the APRN. Per facility policy, titled Wound Care, last reviewed 5/2022, treatments will be documented on the treatment administration record or in the electronic health record, and will include effectiveness of treatment, healing progression, changes in the characteristics of the wound, including location, pressure injury stage (or level of tissue destruction if not a pressure injury), size-including shape depth and presence of tunneling, undermining and characteristic of exudate, pain, signs of infection and condition of the tissue in the wound bed including assessment of skin around the wound .Treatment decisions will be based on the characteristics of the wound, including the stage, size, exudate, presence of pain, signs of infection, wound bed, wound edge, and surrounding tissue . Interventions will be documented in the care plan and communicated to all relevant staff. The facility did not follow professional standards and policy for treating actual pressure ulcers. Per interview with the DON on [DATE] at 10:30 AM, she stated that Resident #1 should have been referred to the IWCS on [DATE] when the stage 2 pressure injury was identified. She confirmed that there should have been a wound assessment completed weekly and interventions should have been entered into the care plan on [DATE]. She stated resident did not receive a referral to the IWCS or updates to his/her care plan until [DATE] for the actual pressure injury. Per interview on [DATE] at 12:30 PM, the Medical Director explained, she had been the Medical Director at the facility since [DATE]. She was not aware that the facility had any concerns related to skin, including prevention or treatment of pressure injury. She stated that the process as she understood it was that the DON should be notified of any new wounds, and the resident should be placed on a wound tracker immediately. Assessment of a new pressure injury should include measurements and should be completed when the pressure injury is identified, and a referral to IWCS. The Physician, who was also the Medical Director at the time, stated she was not aware of Resident #1's skin issues at the time of her regulatory visit on [DATE]. She further stated she had not reviewed the APRN notes prior to her visit with Resident #1 on [DATE] and should have. An APRN progress note dated [DATE], Chief complaint: Follow-up pain, pressure ulcer, weakness, depression . [S/he] notes [s/he] has been having more generalized pain and is hoping to get [his/her] tylenol increased. [S/he] also has some pain in [his/her] pressure area.[Section titled assessment and plan] Pressure Ulcer of the Sacral Region Stage 2. Ongoing management. Cleanse with wound cleanser, apply skin prep and cover with sacral dressing. Reposition Q2 [every two hours]. Continue to use air mattress . There was no evidence of a wound assessment to include measurements of the pressure injury, on [DATE], or [DATE]. There was no revision to the care plan to include actual pressure injury until [DATE]. An APRN note dated [DATE] revealed Chief complaint: Acute unstageable pressure ulcer, boggy heels .[S/he] is seen today for unstageable pressure ulcer to [his/her] sacrum and new boggy heels. [S/he] originally had a small circular stage 2 to the sacrum .[His/Her] sacrum feels worse and when this writer pulls off the dressing, there is significant drainage as well as dark skin around the wound area. Some odor . Per interview on [DATE] at 7:30 AM, with Resident #1's family representative, s/he stated that s/he was not notified of concerns related to a stage 2 pressure injury on his/her sacrum that was identified on [DATE]. S/he stated that no one at the facility had notified them of a treatment plan for the pressure injury or that the area was deteriorating. S/he stated that s/he visited Resident #1 frequently and s/he complained of pain in his/her sacrum, describing a sore spot on my back. S/he stated that when Resident #1 would complain of pain in his/her sacrum s/he would use the following words, terrible, I can't stand it, my butt is on fire and would occasionally make whimpering sounds. S/he further stated that Resident #1 continued to decline and then on [DATE] noted that Resident #1 had a large amount of swelling of arms and legs and was not eating. S/he stated that s/he was complaining of a lot of pain. Then on [DATE], Resident #1 was transferred to the emergency room. An emergency room Physician's note dated [DATE] when Resident #1 arrives at the emergency department states Primary complaint 11/10 pain to known pressure injury to sacral area. Resident #1 was admitted to the hospital with a necrotic, unstageable pressure injury, which had developed to osteomyelitis (infection of the bone) and sepsis. The resident required treatment that included debridement of his/her sacrum, dressing changes, pain medication, and intravenous antibiotics. Per Resident #1's death certificate dated [DATE], s/he died of complications related to a sacral pressure injury, osteomyelitis, and sepsis. 2. Per record review, Resident #2 had the following care plan focus initiated on [DATE] at high risk for skin breakdown related to limited mobility, frail fragile skin, pruritus [itching], diabetes, and history of skin breakdown . His/her care plan includes the following interventions initiated on [DATE], weekly wound assessment to include measurements and description of the wound status. Per an APRN note dated [DATE], regulatory visit reveals that Resident #2 has a new open area to their left shoulder. The APRN wrote the following orders in his/her note on [DATE], Open wound of left shoulder, initial encounter Acute. Patient inflicted due to itching. Gently cleanse and cover with bandaid until resolved. There is no evidence that the orders were entered into the resident's medical record or a new intervention to his/her care plan. There is no evidence that the left shoulder was monitored or that the care plan was updated to include the actual skin/wound area. Per Resident #2's facility Treatment Administration Record (TAR) for [DATE], there is no evidence that an order was entered to monitor the left shoulder or to treat an open wound starting on [DATE]. According to the TAR, the facility did have the following order: Vit A&D ointment to chest and both shoulders. Per review of the TAR, several days indicate a treatment was not given, and the area where the ointment was applied was not documented. There is no evidence that the facility treated or monitored a new open wound on Resident #2's shoulder. Per facility skin assessments completed on [DATE], [DATE] and [DATE], there was no evidence that nursing evaluated Resident #2's left shoulder or documented the open wound identified on [DATE]. Per further interview with the DON on [DATE] at 4:00 PM, she stated she was not aware of the wound identified on [DATE] by the APRN and did not review the APRN's notes. Per the DON, the APRN attending wound rounds that week on [DATE] and did not report new findings. Per the facility wound care tracker dated [DATE], there is no evidence that Resident #2 was added to the list of new wounds in the facility. 3. Per record review, Resident #3 has diagnoses that include cerebral palsy and limited range of motion. Per observation on [DATE], Resident #3 has minimal use of his/her right arm and has a significant contracture of the right hand. Per review of his/her care plan, there was no evidence of interventions to prevent pressure injury to his/her contracted right hand. Per review of the integrated wound care note dated [DATE], [Resident #3] is seen today a DTI to the right index finger. [S/he] does have CP (Cerebral Palsy) and tends to contract [his/her] fingers in such a way that it places pressure over bony areas, which has resulted in a small DTI [deep tissue injury] . Instructions: Gently clean and pat dry. Apply skin prep over area [and] apply foam dressing for protection. Consider finger separator from PT [physical therapy] if necessary for prevention. Per review, Resident #3's care plan does not address their right hand or any new interventions for the contracure. Per the interview with Resident #3 on [DATE] at approximately 1:00 PM, s/he stated s/he is unable to use their right hand. Resident #3 is observed with his right hand lying flat on the bed; s/he was noted to have significant contracture of the right hand and a small dressing on the second finger. There was no evidence of a finger separator in his/her right hand. Resident #3 stated s/he has pain in the right arm and shoulder and hand at times. Per the Director of Nursing on [DATE] at 12:38 PM in an email stated that Resident #3 has at risk for skin impairment section of the care plan that included 'impaired mobility r/t cerebral palsy' and a section for risk for alterations in functional mobility related to decrease ROM (range of motion), cerebral palsy. Per further interview, the DON stated that even though Resident #3 has limited range of motion in his right arm, s/he does not have a diagnosis of contracture of the right hand and therefore would not have a preventive care plan specific to his/her right hand. Reference: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/ www.woundsinternational.com Ten top tips: mitigation deep tissue pressure injury.

Based on interview, record review, and policy review, the facility failed to ensure the Medical Director assisted the facility with the implementation of resident care policies, specifically related to the total skin program at the facility, and failed to coordinate the medical care in the facility. As a result, one resident died of sepsis related to a pressure injury of the sacrum (Resident #1). This deficient practice has the potential to affect all residents at risk for skin impairment and pressure injury residing in the facility. Findings include: Per review of Resident #1's admission assessment, s/he was admitted to the facility on [DATE] and identified as a high risk for pressure injury with a score of 12. S/he did not have any skin integrity issues with his/her sacrum at the time of admission. Per review of Resident #1's care plan, initiated on [DATE], s/he was identified as at risk for a pressure injury with interventions that included weekly skin checks and nonspecific treatments for prevention of skin breakdown. No interventions were added to his/her care plan to turn and reposition, or any individualized interventions. Revision to Resident #1's care plan did not occur until [DATE]. An Advanced Practical Registered Nurse (APRN) visit note dated [DATE] revealed that Resident #1 was seen for self-reported pain to the sacrum. The note reads, [his/her] skin does not show any wounds or lesions. [His/Her] sacrum is noted to have blanchable redness. [S/he] requires assistance with all ADLs and transfers . Assessment & Plan: Redness of sacrum. Educated staff on proper repositioning for skin integrity. Patient may benefit from an air mattress. Per further review of the APRN progress notes dated [DATE], [DATE], she continued to document pain and sacral redness for Resident #1 and continued to request an air mattress at each visit. There was no evidence of new interventions to the care plan, including an air mattress or turning and repositioning. An APRN progress note dated [DATE] reveals [Section titled skin] Small circular open lesion over the sacrum.[Section titled assessment and plan] Pressure injury of the sacral region, stage 2. Cleanse with wound cleanser. Apply skin prep and cover with sacral dressing. Plan to switch out bed to an air mattress . The following orders were written by the APRN on [DATE]: Check under boarder dressing daily. Cleanse with wound cleanser and apply sacrum boarder every 3 days and PRN every day shift for pressure ulcer prevention. Per interview with the APRN by telephone on [DATE] at 2:00 PM, she stated that she was concerned that Resident #1 was a high risk for pressure injury due to lack of fatty tissue and [s/he] was so thin from time of admission. She reports requesting an air mattress for him/her on [DATE] and multiple times after that. Per interview with the APRN by telephone on [DATE] at 2:00 PM, she stated that on [DATE], she assessed Resident #1's sacrum and found a small blistered area that appeared to have broken open, and the top layers of skin were missing. Per further interview the APRN stated she did not follow her process when she discovered the wound, which would be to review the findings with the nurse attending to the resident on the unit and then review with the DON. Per review of Resident #1's medical record, there was not an actual wound assessment completed of the sacral pressure injury until [DATE] by the IWCS. This was confirmed through interview on [DATE] at 4:00 PM by the Director of Nursing (DON). She explained that she didn't read the APRN's notes and didn't know there was a wound until [DATE] when it worsened to an unstageable pressure injury with necrosis. On [DATE] at 10:30 AM, the DON stated that Resident #1 did not receive a referral to the IWCS (integrated wound care specialist) or updates to his/her care plan until [DATE] for the actual pressure injury. Per interview with Resident #1 POA the resident experienced significant pain and was transferred to the hospital on [DATE]. Per review of hospital records, s/he later died on [DATE] at the hospital related to complications of a sacral pressure injury. See F 686 for more information. A Physician's note dated [DATE] titled regulatory visit, did not address concerns related to pressure injury identified at prior visits by the APRN and the assessment section of the physician's note, titled skin the provider noted that exposed areas are clear with no rashes. During an interview on [DATE] at 12:30 PM, the Physician, who was also the Medical Director at the time, stated she was not aware of Resident #1's skin issues. The Medical Director explained that she had been the medical director at the facility since [DATE]. She was unaware that the facility had any skin-related concerns, including prevention or treatment of pressure injury. She stated that the process as she understood it was that the DON should be notified of any new wounds, and the Resident should be placed on a wound tracker immediately. Assessment of a new pressure injury should include measurements and should be completed when the pressure injury is identified, and a referral to the wound specialist should be made. She was unaware that the facility was not implementing their policy related to pressure ulcer prevention and treatment. During the interview, the Medical Director she stated she had not reviewed the APRN notes or discussed any concerns with her regarding Resident #1's skin or new pressure injury before she completed the regulatory visit on [DATE]. Per facility policy for Medical Director Service, the Medical Director will coordinate medical care, including emergency treatment procedures, maintain effective liaison with attending physicians, and implement methods to keep the quality of care under constant surveillance. Monitor that the residents receive adequate services appropriate to their needs. Monitor that the resident's medical regimen is incorporated into the resident's care plan. There is no documented evidence that the MD was aware of concerns related to pressure injury, for Resident #1, or that she was coordinating the care between the residents' providers and the facility. Per further interview with the Medical Director on [DATE] at 12:30 PM, she stated she was unaware that Resident #1 had died from complications of a sacral pressure injury, sepsis, and osteomyelitis.

Based on interview and record review, the facility failed to ensure that licensed nurses have the specific competencies necessary to care for residents' needs as identified through resident assessments and the plan of care for 4 of 5 sampled nurses. Findings include: Per review of 5 licensed nurses' employee education files, 4 Licensed Practical Nurses (LPN) did not have evidence that they had been assessed for skin or wound assessment competencies. Per facility policy titled Staff Competency Plan, last reviewed on 8/2024, reads, It is the policy of the facility to evaluate each employee to assure they meet appropriate competencies and skills for performing their job .The knowledge and skills required among staff to meet residents' needs are determined through the facility assessment process. Evaluating competency of staff is accomplished through the facility's training program. The Facility Assessment (an assessment that determines what resources are necessary to care for the residents competently during both day-to-day operations and emergencies), dated 1/31/25, section Services and care we offer based on our resident's needs, lists: .skin integrity . [and] pressure injury prevention and care, skin care, wound care, wound care treatments (surgical, other skin wounds). Per review of the competency packet used to evaluate licensed nurses, the packet did not include skin or wound assessment competencies. Per interview on 5/6/25 at 11:35 AM, the Director of Nursing (DON) confirmed that skin and wound assessment competencies are not included in the packet. At 2:45 PM, the DON confirmed that the 4 LPNs did not have competencies related to skin and wound assessments.

Based on interviews and record review, the facility failed to ensure that physicians and other providers (as delegated to per regulation) review the residents' total program of care, including skin, pressure injury risk and prevention and treatment plan at each visit as required for 3 of 7 sampled residents (Resident's #1, #3, and #4). This is a repeat deficiency for this facility, with this violation cited during a previous recertification survey dated 8/19/24. Findings include: 1) Per review of Resident #1's medical record, s/he was admitted to the facility with a diagnosis of failure to thrive and a history of pelvic fracture on 1/27/25. On 1/27/25, a nursing assessment revealed a 12 on the Braden scale for predicting pressure risk, identifying Resident #1 as a high risk for pressure injury. Resident #1 had no pressure injuries at time of admission. A 3/14/25 Advanced Practice Registered Nurse (APRN) progress note dated 3/14/25 reveals that Resdeint #1 has a stage 2 pressure injury on their sacrum. Residnet #1's care plan was not updated to include the stage 2 pressure ulcer or treatment interventions. Per interview with the DON on 5/1/25 at 10:30 AM, she stated that Resident #1 should have been referred to the IWCS on 3/14/25 when the stage 2 pressure injury was identified. She confirmed that there should have been a wound assessment completed weekly and interventions should have been entered into the care plan on 3/14/25. She stated resident did not receive a referral to the IWCS or updates to his/her care plan until 3/31/25 for the actual pressure injury. Per review of the Physician's note for a required regulatory visit dated 3/27/25 in Resident #1's medical record, the note did not address the pressure injury to Resident #1's sacrum, and in the assessment section of the physician's note, titled skin the provider noted that exposed areas are clear with no rashes. There was no evidence that the Physican, who is also the Medical Director, addressed the pressure injury on 3/27/25 by her documentation in the medical record. During an interview on 5/1/25 at 12:30 PM, the Physician, who was also the Medical Director at the time, stated she was not aware of Resident #1's skin issues. During the interview, the Medical Director stated she had not reviewed the APRN's prior notes or discussed any concerns with her regarding Resident #1's skin or new pressure injury before she completed the regulatory visit on 3/27/25. Per interview with the Director of Nursing on 5/6/25 at approximately 2:00 PM, s/he confirmed the provider visit on 3/27/25 was a regulatory visit, and did not reflect skin, wounds, or actual pressure injury for Resident #1and did not accurately review the resident's total program of care, and it should have. 2). Per record review, Resident #3 has diagnoses that include cerebral palsy and limited range of motion. Per observation on 5/6/25, Resident #3 has minimal use of his/her right arm and has a significant contracture of the right hand. A facility skin check dated 2/7/25 identified the following skin areas: right elbow purple and redden area noted R elbow wound is new . Redden area to sacrum wound is new . Resident's skin warm and dry to touch with redness noted to the Sacrum/Groin and pressure area to the right elbow [sic]. A Physician's note dated 2/7/25, titled Recertification, revealed the following assessment by the provider related to Resident #3's skin: Skin exposed areas are clear with no rashes. There is no evidence in the written note that the provider addressed skin, or new pressure areas documented by nursing as new on 4/7/25. 3). Resident #4 was admitted to the facility on [DATE] with diagnoses that included diabetes, history of falls, weakness, and deep tissue pressure injury to his/her left knee. S/he had the following physician orders written on 3/14/25: wound care to pressure ulcer left lateral knee, 1)cleanse with wound cleanser 2) dry skin prep 3) Medi honey to wound bed 4) cover with Opti foam . A facility pressure wound assessment dated [DATE], revealed that Resident #4 was admitted with an unstageable pressure injury to his/her left knee. A Physician's note dated 3/20/25, regulatory visit titled: Admission, does not address the total plan of care for Resident #4 and does not address the actual wound and treatment for a known deep tissue injury to the left knee. The physician documented the following: Skin: exposed areas are clear with no rashes.

Based on interview, observation, and record review, the facility failed to revise the care plan for 3 residents out of 7 sampled (Resident #1, #2, and #3) related to skin, wounds, including pressure prevention interventions and care planning for actual pressure injury. This is a repeat deficiency for this facility, with this violation cited during a previous recertification survey dated 8/19/24. Findings include: 1. Per review of Resident #1's medical record, s/he was admitted to the facility with a diagnosis of failure to thrive and a history of pelvic fracture on 1/27/25. On 1/27/25, a nursing assessment revealed a 12 on the Braden scale for predicting pressure risk, identifying Resident #1 as a high risk for pressure injury. On admission, Resident #1 was assessed to be frequently incontinent of urine and bowel, and dependent for care, including repositioning. Per Resident #1' admission minimum data set (MDS; a comprehensive assessment of each resident's functional capabilities) submitted on 2/10/25 by the MDS coordinator, Resident #1 had no pressure injuries at time of admission on [DATE]. Per review of Resident #1's care plan, initiated on 1/27/25, s/he requires assist to complete ADL's [activities of daily living] R/T [related to] impaired mobility, incontinence, and pain. Per the care plan, s/he was dependent for all mobility and identified as at risk for a pressure injury and had interventions that included weekly skin check, and non-specific interventions including treatments for prevention of skin breakdown. No interventions were added to his/her care plan to turn and reposition. Per record review, a provider note written on 2/17/25 by the Advanced Practical Registered Nurse (APRN) reads [Resident #1] is seen today for noted wounds to the right dorsum, left shin and self reported pain to the sacrum .Assessment & Plan: Redness of sacrum. Educated staff on proper repositioning for skin integrity. Patient may benefit from an air mattress. There was no evidence that the resident's care plan was updated at this time to include repositioning or an air mattress. An APRN progress note dated 3/14/25 reads Chief complaint: Covid-19, pressure ulcer, weakness, pain, depression, constipation . [Section titled skin] Small circular open lesion over the sacrum.[Section titled assessment and plan] Pressure injury of the sacral region, stage 2. Cleanse with wound cleanser. Apply skin prep and cover with sacral dressing. Plan to switch out bed to an air mattress . The following orders were written by the APRN on 3/15/25: Check under boarder dressing daily. Cleanse with wound cleanser and apply sacrum boarder every 3 days and PRN every day shift for pressure ulcer prevention. There was no evidence that the resident's care plan was updated at this time to include the resident's actual wound or treatment. Per interview with the Director of Nursing on 4/29/25 at approximately 4:30 PM, she confirmed that Resident #1's care plan was not updated to include interventions for turning and repositioning, or the air mattress starting on 2/17/25, and should have been. A 3/31/25 APRN note reads Chief complaint: Acute unstageable pressure ulcer, boggy heels .[S/he] is seen today for unstageable pressure ulcer to [his/her] sacrum and new boggy heels. [S/he] originally had a small circular stage 2 to the sacrum and [s/he] was moved to an air mattress to help offload her sacrum. Today when this writer goes to see [him/her], [s/he] notes [his/her] sacrum feels worse and when this writer pulls off the dressing, there is significant drainage as well as dark skin around the wound area. Some odor . The care plan for Resident #1 was not updated until after his/her pressure areas worsened and was found to have signs of deterioration including worsening pressure injury, necrosis and drainage with odor. Facility policy titled Pressure Injury and Prevention Management, last revised 5/2022, reads, After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions . Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have pressure injury present. There is no evidence the facility followed their policy or the professional standards to prevent pressure injury, including not revising Resident #1's care plan after s/he developed a pressure injury on 3/14/25, until 3/31/25. 2. Per record review, Resident #2 had the following care plan initiated on 7/12/2024, at high risk for skin breakdown related to limited mobility, frail fragile skin, purists (itching), diabetes, and history of skin breakdown . His/her care plan includes the following interventions initiated on 8/30/23, weekly wound assessment to include measurements and description of the wound status. An APRN regulatory visit note dated 4/2/25 documented a new open area to Resident #2's left shoulder. The APRN wrote the following orders in his/her note on 4/2/25, Open wound of left shoulder, initial encounter Acute. Patient inflicted due to itching. Gently cleanse and cover with bandaid until resolved. There is no evidence that the orders were entered into the resident's medical record or a new intervention to his/her care plan. There is no evidence that the left shoulder was monitored or that the care plan was updated to include the actual skin/wound area. Per Resident #2's facility Treatment Administration Record (TAR) for April 2025, there is no evidence that an order was entered to monitor the left shoulder or to treat an open wound starting on 4/2/25. According to the TAR, the facility did have the following order: Vit A&D ointment to chest and both shoulders. Per review of the TAR, several days indicate a treatment was not given, and the area where the ointment was applied was not documented. There is no evidence that the facility treated or monitored a new open wound on Resident #2's shoulder or updated his/her care plan to include interventions for actual skin and wound to his/her left shoulder. Per interview with the Director of Nursing on 4/29/25 at approximately 4:30 PM, she confirmed that Resident #2's care plan was not updated to include a wound to the left shoulder and no new orders were entered on 4/2/25, as indicated in APRN's note. 3. Per record review, Resident #3 has diagnoses that include cerebral palsy and limited range of motion. Per observation on 5/6/25, Resident #3 has minimal use of his/her right arm and has a significant contracture of the right hand. Per review of his/her care plan, there was no evidence of interventions to prevent pressure injury to his/her contracted right hand. Per review of the integrated wound care note dated 5/2/25, [Resident #3] is seen today a DTI to the right index finger. [S/he] does have CP (Cerebral Palsy) and tends to contract [his/her] fingers in such a way that it places pressure over bony areas, which has resulted in a small DTI [deep tissue injury] . Instructions: Gently clean and pat dry. Apply skin prep over area [and] apply foam dressing for protection. Consider finger separator from PT [physical therapy] if necessary for prevention. Per review, Resident #3's care plan does not address their right hand and pressure prevention related to contracture. Per the interview with Resident #3 on 5/6/25 at approximately 1:00 PM, s/he stated s/he is unable to use their right hand. Resident #3 is observed with his right hand lying flat on the bed; s/he was noted to have significant contracture of the right hand and a small dressing on the second finger. There was no evidence of a finger separator in his/her right hand. Resident #3 stated s/he has pain in the right arm and shoulder and hand at times. Per the Director of Nursing on 5/8/25 at 12:38 PM she stated in an email that Resident #3 has at risk for skin impairment section of the care plan that included 'impaired mobility r/t cerebral palsy' and a section for risk for alterations in functional mobility related to decrease ROM (range of motion), cerebral palsy. Per further interview, the DON stated that even though Resident #3 has limited range of motion in his right arm, s/he does not have a diagnosis of contracture of the right hand and therefore would not have a preventive care plan specific to his/her right hand.

Based on interviews and record review, the facility failed to notify the resident's power of attorney (POA) of a change in condition on 3/14/25, related to a new pressure ulcer identified on his/her sacrum for 1 resident in the sample of 7 (Resident #1). This is a repeat deficiency for this facility, with violations cited during two previous recertification surveys, dated 2/6/25 and 3/1/24. Findings include: Per review of Resident #1's medical record, s/he was admitted to the facility with a diagnosis of failure to thrive and a history of pelvic fracture on 1/27/25. A nursing assessment dated [DATE] identified Resident #1 as a high risk for pressure injury with a Braden score of 12. Per the admission assessment dated [DATE], s/he was frequently incontinent of urine and bowel, and dependent for care, including repositioning. Per Resident #1's MDS assessment dated [DATE] there was no evidence of a pressure injury upon admission. According to the medical record, Resident #1 developed a stage 2 pressure injury to his/her sacrum. A stage 2 pressure injury is described as a Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister The area was identified on 3/14/25 by the Advanced Practice Registered Nurse (APRN). There is no evidence in the Resident #1's medical record that their POA was notified of the new pressure ulcer. A 3/31/25 APRN visit note reveals that Resident #1 reveals that Resident #1's pressure ulcer worsened to an unstageable pressure ulcer an unstageable pressure injury is described as Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. (NPIAP, 2025) Per the facility policy last revised 8/2024 titled Notification of Change, The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification . Circumstances requiring a notification include . a need to alter treatment including new treatment. Per interview on 5/1/25 at 7:30 AM, with Resident #1's POA, s/he stated that s/he was not notified of concerns related to a stage 2 pressure injury on his/her sacrum that was identified on 3/14/25. S/he stated that no one at the facility had notified them of a treatment plan for the pressure injury or that the area was deteriorating. She stated the first notification of the pressure injury was on 4/1/25. Per an interview with the Director of Nursing (DON) on 4/29/25 at 8:30 AM, the DON confirmed she was not notified or aware that Resident #1 had a stage 2 pressure injury on his/her sacrum and stated she had not completed a change of condition or notification to the family on 3/14/25 when it was found by the APRN. Per the medical record Resident #1's family was not notified of a new pressure injury to Resident #1's sacrum until after 3/31/25 when it deteriorated to an unstageable pressure injury with necrosis. Reference: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/

Based on observation, interview, and review of policies and procedures, it was determined that the facility failed to maintain facility-wide systems for the prevention, identification, and control of infection and communicable disease of residents, staff and visitors through surveillance, staff training and following established policies and procedures related to changing oxygen tubing, hand washing, cleaning and disinfection of reusable equipment, proper use and disposal of PPE (personal protective equipment), and facility cleanliness. Findings include: 1. Per observation on 2/3/25 at approximately 11:30 AM, the Unit Manager was observed in the general milieu without a mask in place. Review of facility policy and procedure titled, Transmission-Based (Isolation) Precautions, date implemented: 5/2022, date reviewed/revised: 07/2024, under subtitle, Policy Explanation and Compliance Guidelines, #11. Droplet Precautions and 12. Airborne Precaution, state,states, a. Intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions (i.e. respiratory droplets that are generated by a resident who is coughing, sneezing, or talking). b. A private room is preferential, but if not available, the resident can be cohorted with a resident with the same infectious agent. c. If a resident who requires droplet precautions has to share a room with a resident who does not have the same infection, the facility will make a decision regarding resident placement on a case-by-case basis after considering infection risks to other residents in the room and available alternatives. d. Draw curtain between beds in multi-bed rooms when one resident is infected with a pathogen that is transmitted by the droplet route. Maintain at least 3 feet of separation between beds. e. Healthcare personnel will wear a facemask for close contact with an infectious resident. f. Based upon the pathogen or clinical syndrome, if there is risk of exposure of mucous membranes or substantial spraying of respiratory secretions is anticipated, gloves and gown as well as goggles (or face shield) should be worn. g. Residents on Droplet Precautions who must be transported outside of the room should wear a facemask if tolerated, and follow respiratory hygiene/cough etiquette as described in the facility's Standard Precautions Infection Control Policy. 2. Airborne Precautions- a. Airborne Precautions prevent transmission of pathogens that remain infectious over long distances when suspended in the air. b. The preferred placement for patients who require Airborne Precautions is in an airborne infection isolation room (AIIR). c. This facility does not have an airborne infection isolation room; therefore, residents who have confirmed infection requiring airborne precautions will be transferred to an acute care hospital that has an available AIIR. d. If unable to transfer resident to an AIIR room, as in the case of COVID-19 infection, the facility will follow CDC guidance as to cohorting, private room accommodation and/or designated units and staff will wear a fit-tested N95 or higher-level respirator and other appropriate PPE while delivering care to the resident. Interview on 2/3/25 at approximately 11:32 AM with the Unit Manager of B wing confirmed there were residents on this unit with active Covid. This Surveyor asked what the direction was for masking this unit, the Unit Manager stated they were not sure as the information about masking had not been made clear. She/he was asked what their expectation was for their staff working on this unit specific to masking and she/he stated they would expect staff to wear masks but she/he wasn't sure if masking was required in the hallways or just in resident rooms and would need to get clarification. Per observation on 2/3/25 at approximately 11:45 AM, a staff member was noted to be carrying 2 clear plastic bags with gloved hands in the hallway. The staff member was observed entering the dirty utility room, where she/he placed each bag in a different bin. She/he removed their gloves and threw them in the trash in the dirty utility room then exited the dirty utility room without performing hand hygiene. The staff member was identified as an LNA (Licensed Nursing Assistant) through interview with her/him on 2/3/25 at approximately 11:47 AM. She/he stated that they always wear gloves to transport dirty linens and trash to the dirty utility but I usually do hand hygiene after I remove my gloves but I must have forgot. Per interview on 2/3/25 with the Unit Manager regarding hand hygiene when donning (putting on) and doffing (taking off) gloves, she/he stated first off staff are not supposed to be wearing gloves in the hallway for any reason but when bringing bags of trash, they could take a clean glove and fold it over and use it to grab the bag. Per observation on 2/3/25 at approximately 12:30 PM, an LNA was observed walking down the B wing hallway with her/his mask under their chin. Per interview on 2/3/25 at approximately 12:31 PM the LNA was asked if there was a masking policy in the building. She/he stated there was but she/he gets hot and I can't breath so I take the mask down for a minute. Per interview on 2/3/25 with the Unit Manager regarding observations of staff not wearing the masks appropriately on the unit, she/he confirmed that this was an issue despite all the reminders and training she/he had provided. She/he asked which staff and then stated she/he has been spoken to numerous times. This same LNA was observed again at approximately 12:48 PM with her/his mask under their nose and upon seeing surveyors moved the mask to the appropriate position over her/his nose. Per observation on 2/3/25 at approximately 1:10 PM a staff, who was later identified as an LNA was observed wearing her/his mask under her/his nose. Interview on 2/3/25 at approximately 1:12 PM with the Unit Manager regarding the above observation, she/he stated and that's the other one that I'm constantly speaking to about their mask. Per observation on 2/4/25 at approximately 9:31 AM. an LNA was observed wearing her/his mask under their nose while on B Unit. Per interview with the LNA on 2/4/25 at approximately 9:33 AM, she/he confirmed she/he was not wearing mask appropriately and at that time put it in proper placement. She/he confirmed receiving instruction on the proper use of PPE. Per observation on 2/4/25 at approximately 9:45 AM, an LNA was observed not wearing her/his mask correctly coming out of room [ROOM NUMBER] with her/his mask under her/his nose. Per observation on 2/4/25 at approximately 10:00 AM, the facility's NP (Nurse Practitioner) was performing an assessment on Resident #12 in room [ROOM NUMBER]. Outside of this room was a precaution cart and precautions sign to the right of the door. It was noted that the NP was using a reusable stethoscope to assess Resident #12. After using the stethoscope on Resident #12, without cleaning it, she/he placed the stethoscope over her/his neck where it hung in place. She/he removed their PPE and exited the room at approximately 10:10 AM, she/he used hand sanitizer from a hall wall dispenser and cleaned her/his hands and stethoscope. She/he put on new PPE and at approximately 10:13 AM she/he re-entered room [ROOM NUMBER] and performed an assessment on Resident #12's roommate. She/he placed their re-usable stethoscope back over her/his neck where it hung. She/he removed all PPE, exited room [ROOM NUMBER], went to precaution cart put on new mask, located the hand sanitizer dispenser on the hall wall and proceeded to clean her/his hands and their re-usable stethoscope. Per interview on 2/4/25 at approximately 10:15 AM, the NP stated she usually cleans her/his stethoscope between residents and after use on a resident with Covid however there was no hand sanitizer in room [ROOM NUMBER] so she/he decided to come out into the hallway to find some. When asked how she/he cleans reusable equipment after use on residents she/he stated that they use alcohol on resident who do not have Covid and bleach wipes on reusable equipment for residents with Covid. When asked what the facility's policy and procedure requires she/he restated the use of alcohol on reusable equipment used on residents who do not have Covid and bleach on reusable equipment used on residents with Covid. When asked if there is a wet contact wait time for hand sanitizer and bleach she/he stated there was but could not state what those times were. Review of the MIFU (Manufacturers Instructions for Use) bleach wipes used in this facility revealed a Wet Contact Time (the amount of time a disinfectant needs to remain wet on a surface to kill germs) of 3 full minutes. Per observation on 2/4/25 at approximately 10:05 AM, an LNA was observed going into a precaution room with just a surgical mask on and no other PPE. Per interview on 2/4/25 at approximately 10:07 AM with the LNA who confirmed she/he had gone into a precaution room with only a surgical mask on and no other PPE, she/he stated they should be wearing full PPE and confirmed that would an N95 mask, face shield, gloves, and a gown. She/he confirmed they were not wearing the correct mask or the other required PPE. Per observation on 2/5/25 at approximately 9:42 AM, an LNA with a badge that read New Staff was observed wearing her/his mask under their nose. Per interview with this staff on 2/5/25 at approximately 9:43 AM, she/he confirmed she/he was an LNA and a new staff member. She /he stated that the mask should be above the nose. This was again observed on 2/5/25 at 9:54 AM, 10:00 AM, 10:30 AM, and again at 10:45 AM. Additional observations were made of staff not wearing masks properly: On 2/03/25 at 11:09 AM, an LNA was in room [ROOM NUMBER]A providing patient care with her mask below her chin. On 2/03/25 at 11:11 AM, an LNA exited room [ROOM NUMBER] A with her mask not covering her nose or mouth. On 2/03/25 at 11:30 AM, an LNA went in and out of room [ROOM NUMBER] A with her mask below her mouth. On 2/3/25 at 12:28 PM, an LNA was in the Unit A hall with her mask pulled off her face and mouth. On 2/3/25 at 12:41 PM, an LPN and an LNA were standing at the medication cart in the hall with their masks on their chin. On 2/3/25 at 1:01 PM, an LNA was in the Unit A hall with her mask not covering her nose or mouth. On 2/3/25 at 3:00 PM, an LNA came out of room [ROOM NUMBER] with her mask below her chin. On 2/3/25 at 3:01 PM, an LNA was in room [ROOM NUMBER] with her mask below her chin. On 2/3/25 at 3:09 PM, an LNA was in the hall with her mask on her chin. On 2/3/25 at 3:10 PM, an LNA was in the hall with her mask below her chin. On 2/3/25 at 3:12 PM, an LNA, mask below her chin in the hall On 2/3/25 at 5:15 PM, an LNA was standing at the Unit A medication cart without her mask covering her nose and mouth. On 2/3/25 at 5:16 PM, an LNA was passing trays in Unit B without her mask covering her nose and mouth. On 2/4/25 at 9:20 AM, an LNA was in the Unit A hall without her mask covering her nose and mouth. On 2/4/25 at 9:28 AM, the Housekeeping Manager was walking down the hallway on Unit B without his/her mask covering their nose and mouth. On 2/4/25 at 9:30 AM, an LNA was in the Unit A hall with her mask below her mouth. On 2/4/25 at 10:35 AM, an LNA was in Resident #22's room providing patent care with her mask pulled below her chin. On 2/4/25 at 10:47 AM, 2 LNAs were walking down the Unit A hall without their masks below their mouths. On 2/4/25 at 12:39 PM, a LNA was providing care in room [ROOM NUMBER] with her mask below her mouth. On 2/4/25 at 12:41 PM, a Dietary Staff was bringing the lunch cart onto Unit B without his mask covering his nose and mouth. On 2/4/25 at 12:42 PM, an LNA was in the Unit B hall without her mask covering her nose and mouth. On 2/4/25 at 3:41 PM, an LNA was in the Unit B hall without her mask covering her nose and mouth. On 2/4/25 at 3:22 PM, an LNA was at the Unit B nurse station with her mask pulled down below her chin. On 2/4/25 at 4:20 PM, an LNA, was in the hall without her mask covering her nose and mouth. On 2/5/25 at 9:44 AM, an LNA was in room [ROOM NUMBER] with her mask below her chin while feeding a resident. On 2/5/25 at 9:45 AM, an LNA is in Resident #464's room with her mask not covering her nose or mouth. On 2/5/25 at 9:52 AM, a Licensed Nurse was in room [ROOM NUMBER] mask with her mask not covering her nose. On 2/6/25 at 11:59 AM, an LNA was not wearing her mask at the Unit A nursing station while residents were in close proximity. 2. Per observation on 2/3/25 at approximately 12:15 PM of Resident #12's room revealed an oxygen concentrator and a nebulizer machine both with attached oxygen tubing that was not dated. Per interview on 2/3/25 at approximately 12:20 PM, the Medication Technician working on the unit where Resident #12 resides stated all oxygen tubing is to be changed and dated every week. She/he accompanied this surveyor to Resident #12's room and confirmed the oxygen tubing was not dated. Review of the facility's Oxygen Administration Policy, date implemented: 5/2022; date reviewed/revised: 9/2024 under subtitle reveals, Policy Explanation and Compliance Guidelines, #5. Staff shall perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measures include: a. Follow manufacturer recommendations for the frequency of cleaning equipment filters. b. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. c. Change humidifier bottle when empty, every 72 hours or per facility policy, or as recommended by the manufacturer. Use only sterile water for humidification. d. If applicable, change nebulizer tubing and delivery devices weekly and as needed if it becomes soiled or contaminated. e. Keep delivery devices covered in plastic bag when not in use. Per observation and interview on 2/3/25 at 11:48 AM, an LPN was changing Resident #6's oxygen tubing. The old tubing did not have a date and the LPN confirmed that it should. Per observation on 2/3/25 at 12:15 PM, Resident #464 did not have a date on their oxygen tubing. Per observation on 2/3/25 at 12:19 PM, Resident #33's oxygen tubing is marked with 1/25. Per facility policy, the tubing should have been replaced within 7 days, which would be 2/1/25. Per observation on 02/03/25 at 2:32 PM, and again on 02/04/25 at 4:30 PM, Resident #8's oxygen tubing was dated 1/22, and the cannula portion was on the floor.Per record review, Resident #8 has an order for oxygen tubing to be changed weekly dated 1/29/25. During an interview on 02/04/25 at 4:30 PM, a Licensed Practical Nurse confirmed Resident #8's oxygen tubing was outdated, and on the floor. Per observation on 2/4/25 at 12:04 PM Resident #33, who is recieving oxygen via nasal canula, had oxygen tubing dated 1/3/25. Per record review Resident #33 had an order stating oxygen tubing must be replaced every 7 days. Per observation and interview on 2/4/25 at 4:27 PM, Resident # 22's oxygen tubing is dated 1/22. Per facility policy, the tubing should have been replaced within 7 days, which would be 1/29/25. An LPN confirmed that Resident #22's oxygen tubing was dated 1/22 and should have been changed after 7 days. 46135 51189 51586

Based on interview and record review the facility failed to conduct and document a facility wide assessment. This has the potential to impact all residents. Findings include: Per the Division of Licensing and Protection, the facility changed ownership on 12/16/2024. During the recertification entrance conference on 2/3/25 at 10:28 AM, the Director of Nursing (DON) was asked to provide a copy of their Facility Assessment. Later, when the DON provided the facility assessment, it had not been documented as reviewed by anyone. The DON explained that it has not been reviewed by the leadership team yet. In an interview on 2/6/25 at 11:00 AM with the Regional Director of Clinical Operations [RDCO], The RDCO stated that the facility assessment was still a work in progress and had not been actually implemented yet. This surveyor questioned the RDCO about a document mentioned in the draft of the facility assessment that was provided to this surveyor titled staff development and training plan and the RDCO stated that the document had not been created yet. In an interview with the Facility Administrator on 2/3/25 at 2:00 PM the Facility Administrator stated that their expectation was that the previous Facility Administrator would have completed the facility assessment. He confirmed that he had not reviewed the facility assessment as of yet andthere was a plan to do so the following week. Record review showed that the facility assessment draft provided for this current survey was not dated or signed by anyone. Record review also showed that the facility assessment referred to a document that did not yet exist and was unfinished.

Based on observation and , it was determined that the facility failed to store food in accordance with professional standards for food service safety and failed to maintain a sanitary kitchen. Findings include: Per observation of the kitchen on [DATE] at 10:34 AM, there were food debris on the steam table. There were cobwebs on the coffee pot and carafe storage rack. There were food debris on the stainless-steel covers located on the steam table. An area on the inside of the microwave door appeared to have been burned off. There were food debris on the inside of the microwave and food debris under the microwave on the counter. Per observation there were water marks and food debris on all the stainless-steel counters. There were food debris under the stove burners and around the grill top. Food debris were on the clean plate holding device. The floor of the kitchen had visible remnants of food under all the stainless-steel working surfaces and in front of the stove and the grill. Per observation of the kitchen's dry storage area, the following items were found to be expired: There is one plastic container of turmeric with an expiration date of [DATE]. There is one plastic container of ground ginger, with an expiration date of [DATE]. There is one plastic container of ground allspice, with an expiration date of [DATE]. There is one plastic container of dried chives, with an expiration date of [DATE]. There are two plastic pitchers of juice on the shelf in the cooler, with an expiration date of [DATE]. An interview was conducted with the Dietary Manager on [DATE] at 10:40 AM. The Dietary Manager confirmed that the turmeric, allspice, ginger, and chives were expired.

Based on observation, interview, and record review, the facility failed to provide sufficient staffing to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This has the potential to impact all residents. This is a repeat deficiency for this facility, with violations cited during the previous recertification survey, dated 08/19/24. Findings include: 1. In an interview on 2/3/25 at 11:00 AM, Resident #25 stated that when they request as needed medications or personal care, the wait time is often over one hour, or the staff member forgets to return at all. Resident #25 said this sometimes leaves me laying in bed in pain waiting for medication, or just feeling forgotten about. Resident #25 also said that the wait time and staffing issues are noticeably worse on the weekends. Per observation and interview on 2/6/25 at approximately 11:00 AM, a Unit B's medication cart computer showed 8 residents highlighted in red. The LPN working this cart explained that the red indicates that an order is due and is over an hour late. She explained that of the 8 residents marked in red, 1 resident was just administered medications which were over an hour late, and 5 residents are still due for medication administration that was scheduled to be administered an hour or more earlier. She stated that she is late administering medications every day because the unit is short staffed and she has to help with things like passing trays and feeding residents, rather than administering medications. Record review of a document titled [NAME] Health and Rehab Medication Admin Audit Report from the dates 1/23/25-2/6/25 revealed that there were 384 pages of medications given late during that 15 day period (medications were considered late when they were administered over one hour after the time they were ordered by the prescriber). Each page of the report contained about 8-10 late medications, totaling approximently 3,400 late medications in 15 days for 64 residents. The facility had a census of 66 at the start of the recertification survey on 2/3/25. 51189 2. During an interview on 02/04/25 at 10:40 AM, Resident #35 said It is very important to me to be up in my wheelchair in the evening but the staff fights me as s/he requires a Hoyer lift for transfers and staff tell him/her it takes too much time. S/he said staff tell him/her that if s/he wants to lie down in the afternoon, s/he will not be gotten up again in the evening. S/he also said insufficient staffing is worse in the evenings and on weekends. Per record review, Resident #35 has a care plan, dated 01/28/23, that states [Resident #35] requires assistance for ADL care in bathing, grooming, personal hygiene, dressing eating, transfer, locomotion and toileting. Resident #35 also has a Care Plan Intervention that states It is important to me to choose my bedtime. I prefer to go to bed between 8:30 and 9:30 PM. 3. During an interview on 02/03/25 at 10:30 AM, Resident #14 said the Facility is often short staffed and that s/he sometimes has to wait for activities of daily living (ADL) assistance. Per record review, Resident #14 has a care plan dated 11/03/22, that states [Resident #14] requires assistance/is dependent for ADL care related to limited mobility and incontinence. 4. During an interview on 2/3/25 at 11:58 AM, Resident #8 said the Facility is always short staffed on Sundays, and that s/he must wait a long time for someone to answer his/her call light. Per record review, Resident #8 has a care plan, dated 01/03/25, that states [Resident #8] requires assistance for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion and toileting 5. During an interview on 2/3/24 at 2:22 PM, Resident #19 said there is Very low weekend staffing. Per record review, Resident #19 has a care plan, dated 09/17/22, that states [Resident #19] requires assistance/is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting. 6. Per interview on 2/5/25 at approximately 12:40 PM, Resident #563's spouse stated that their spouse was admitted on Friday, 1/31/25 for rehabilitation after a short stay in the hospital. She/he stated they accompanied their spouse to this facility for admission. She/he stated no one took their phone number during the admission process and that later that night she/he called to check-in and see how their spouse was doing and the phone just rang and rang. Their son and daughter also tried to reach someone that night and no one answered. She/he stated that eventually after many attempts and almost calling the police to do a welfare check, she/he was able to reach someone. She/he stated when she/he left after the admission there were no staff to be found to give their phone number to and no one asked during the admission process. She/he stated, there does seem to be a short staffing issue here. 46135

Based on observation, interview, and record review, the facility failed to provide an ongoing activities program to support residents in their choice of group, individual, and independent activities to meet the interests of and support the well-being of each resident as evidenced by a lack of engaging activities both in and out of resident rooms for 6 of 20 sampled residents (Residents #2, #19, #26, #35, #53 and # 563). Findings include: 1. Per observation, no group activities were seen during the four days this survey was conducted, 02/03/25 through 02/06/25. Residents were, however, observed sitting and moving freely in hallways and public spaces. Observations on Unit A included two residents sitting side by side (not social distancing) in the hallway for the majority of the survey. Observation on 2/3/25 of Unit B revealed many residents sitting in the general milieu in wheelchairs, on the couch and in chairs. Some were conversing, others were visiting with family members, some had food and drink and others were sitting alone, There were no activities going on at this time. There was no social distancing occurring on this unit during the entire survey from 2/3/25 through 2/6/25. Per interview on 2/3/25 at approximately 11:00 AM, an LNA stated that activities are on hold because there is active Covid in the building. 2. Per observation on 2/3/25 at 10:45 AM, 11:30 AM, 1:00 PM, and 2:20 PM, Resident #2 was noted to be in bed with no activities occurring at these times. Resident #2 was not interviewable. Per interview on 2/3/25 at 2:25 PM, the Medication Technician stated she/he had not been out of bed all day and because of Covid there were currently no activities scheduled. Review of Resident #2's care plan goal initiated on 08/01/2024 stated, The Recreation Department does a check in daily, delivers a daily chronicle with a schedule of activities for the day attached. (Proper name omitted) is encouraged to attend. There were no activity logs available to review for this resident. Per observation on 2/4/25 at 9:30 AM, 11:00 AM, and 2:50 PM, Resident #2 was noted to be in bed with no activities occurring at these times. Interview on 2/4/25 at 3:00 PM, an LNA who had just begun her/his shift stated due to Covid activities are not taking place. She/he stated they were not aware if this resident had been offered any bedside activity option. She/he stated that the facility only had 1 activities person and she/he had just started. 3. During an interview, on 02/03/25 at 12:22 PM, Resident #19 said there have been no activities for a while but rumor has it a new activities director has been hired. S/he states that s/he just sits in his/her room and watches TV for entertainment. Per record review, Resident #19 has a care plan, dated 04/01/24, that states I like to participate in BINGO and musical events with groups of people. His/her care plan also states that s/he is a risk for distressed/ fluctuating mood with an intervention of Encourage [Resident #19's] participation in activity preferences. 4. During an interview on 02/04/25 at 10:19 AM, Resident #35 said there have been no organized activities recently, only self entertainment such as coloring, puzzles, and TV. S/he has asked staff several times, but has received no answer as to when group activities will restart. Per record review, Resident #35 has a care plan, dated 04/02/24, that states I like to participate in BINGO, arts and crafts and resident council with groups of people. 5. Per interview on 2/4/25 at approximately 11:30 AM, Resident #26 stated the only activities that are offered are BINGO but that hasn't happened in a long time. She/he stated they really like music and other things but nothing is really offered. The residents care plan was updated on 2/3/25 and listed the following information for activities, The Recreation Department provides daily room visit, delivers a daily chronicle to the room, with a schedule of activities for the day attached. Resident is encouraged to attend. Since the start of this survey on 2/3/25, there have been no activities taking place and the Activities Director has not been by to see the resident, and s/he has not been provided with any list of activities. There have been no activities taking place on the B Wing unit during this survey. There were no activity logs available to review for this resident. 6. Per interview on 2/4/25 at approximately 2:15 PM, Resident #53 stated she/he stays in their room all the time. When asked about activities she/he laughed and asked, what activities? There haven't been activities for a long time. The person that use to do the activities was pulled out to be the bus driver. They have no activities. Review of the residents current care plan revealed an activities care plan initiated on 02/05/2025 stated, While in the facility, resident/patient states that it is important that s/he has the opportunity to engage in daily routines that are meaningful relative to their preferences. There were no activity logs available to review for this resident. 7. Per interview on 2/4/25 at approximately 3:00 PM, Resident #563 stated she/he hasn't been at the facility very long and they plan on going home. When asked about what activities are offered that she/he likes, they stated that there have been no activities since she/he was admitted and they are not aware of activities being an option. There were no activity logs available to review for this resident. The Activities Calendars for December 2024, January 2025 and February 2025 state Independent Activities on every Saturday and Sunday, and there were no scheduled activities after 4 PM. Per review of activity logs, there were no December 2024 Daily Activity Logs for Residents #2, #26, #35, #53 and #563. There were no January 2025 or February 2025 Daily Activity Logs for Residents #19, #2, #26, #35, #53 and #563. During an interview with the Activities Director on 02/05/25 at 03:10 PM, s/he stated that group activities were on hold due to a Covid outbreak in the facility, although residents were seen sitting together and moving freely in hallways and common areas. S/he confirmed that there are no planned group activities on evenings or weekends. S/he confirmed that s/he has not reviewed the Activities Assessments of all the residents and that s/he does not know what all the Residents' needs and preferences are. S/he confirmed that s/he is unable to produce Daily Activity Logs for all the residents. S/he confirmed that there are not enough activities for dementia residents. S/he also confirmed that she is the only person on the Activities Staff, and that the Facility needs more Activities Staff. Observation from the start of this recertification survey on 2/3/25 to the exit on 2/6/25 revealed group activities taking place. 43524

Based on interview and record review, the facility failed to develop and implement comprehensive care plans for 2 of 2 sampled residents (Resident #27 and Resident #35) related to palliative care; and failed to implement care plan interventions related to supervision for 1 of 20 sampled residents (Resident #363). This is a repeat deficiency for this facility, with violations cited during the previous two recertification surveys, dated 08/19/24 and 03/01/24. Findings include: 1. Per record review, a Medication Regimen Review (MRR) dated 9/16/24 for Resident #27 stated Currently receiving cyclobenzaprine [used to treat pain and stiffness due to muscle spasms] as a standing order. Long term use not recommended due to high risk of anticholinergic side effects including drowsiness, dizziness, and dry mouth. Please evaluate continued need and consider taper to PRN [as needed] for 1 week then discontinue, if appropriate. The Nurse Practitioner disagreed, writing Palliative care patient as the reason. Per record review, Resident #27's Care Plan does not include any focus or interventions for palliative care. 2. Per record review, two MRRs, dated 4/17/24 and 6/12/24, for Resident #35 stated Currently receiving methocarbamol [used to treat muscle spasms and pain] without a stop date. Long term use not recommended due to high risk of side effects including drowsiness, dizziness and dry mouth. Please evaluate. Consider add [sic] stop date now, if appropriate. The Nurse Practitioner disagreed, writing Palliative care patient as the reason. Per record review, Resident #35's Care Plan does not include any focus or interventions for palliative care. The Facility policy titled Providing End of Life Care, revised on 8/24, defines palliative care as patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. The policy states The facility will complete a comprehensive assessment to provide direction for the development of the resident's care plan to address choices and preferences of the resident. During an interview at 11:18 AM on 2/6/25, the Director of Nursing confirmed that any patient deemed palliative care should be care planned for palliative care. S/he also confirmed that neither Resident #27 nor Resident #35 were care planned for palliative care. During an interview at 11:46 AM on 2/6/25 with the Licensed Practical Nurse assigned to Resident #35 and Resident #27, s/he confirmed that neither resident was care planned for palliative care. During an interview at 1:47 PM on 2/6/25 with the Nurse Practitioner, s/he confirmed that that neither Resident #27 nor Resident #35 were care planned for palliative care. 3. Per record review of the facility's internal investigation report for a resident-to-resident altercation on 1/21/25 states, The nurse on the cart was performing rounds at approx. [approximately] 0118 on 1/21/25, passing by [Resident #48]'s room when [Resident #363] was noted standing over [Resident #48] hitting [him/her] on the upper extremities and pulling [his/her] blanket off while [Resident #48] was sleeping. [Resident #363] was removed from the room and placed on a 1:1 [one to one] .IDT [interdisciplinary team] met and was able to move the resident's roommate to another room. Once this was completed at approx. [approximately] 1500 on 1/21/25 [Resident #363] was changed to Q15 checks [visible checks every fifteen minutes]. Per record review of Resident #363's care plan states, Resident on 1:1 following resident to resident altercation - resolved and placed on Q15min checks when resident's room status became private. Per record review of Resident #363's 15-minute check sheet, there is incomplete documentation on 1/23/25, 1/25/25, 1/26/25, 2/2/25, 2/3/25, and 2/4/25. Per interview on 2/5/25 at 10:20 AM, the LPN assigned to work with Resident #363 confirmed that s/he was unaware Resident #363 was on fifteen minute checks. Per interview on 2/5/25 at 10:26 AM, the LNA assigned to work with Resident #363 confirmed s/he did not know Resident #363 was on fifteen minute checks. S/he stated s/he would know in nursing report hand-off that a resident was on fifteen minute checks.

Based on interview and record review, the facility failed to ensure 1 out of 5 sampled residents (Resident #16) was free from significant medication errors related to the administration of medication by the wrong route, causing pain and requiring medical attention to Resident #16's eyes. Findings include: Per record review, Resident #16 was admitted to the facility with diagnoses that include, dry eyes, Pseudophakia OU (artificial lens in both eyes) and mild retinopathy (damage to the small vessels in the eye as defined by the American Academy of Opthahalmolgy, 2024). During an interview with Resident #16 on 08/06/2024 at 2:00 PM s/he stated that they received drops for his/her ears to both of his/her eyes. Resident #16 stated It hurt like hell and burned. Per review of Resident #16's medication orders written on 07/19/2024, the Advance Practice Registered Nurse (APRN) ordered Debrox Otic (ear) Solution 6.5% (Carbamide Peroxide) Instill 5 drop[s] both ears four times a day for ear wax for 5 Days. Per the Manufacturer, Debrox contains peroxide and oils that help break up the wax in the ear canal. (Drugs.com, 2024) The Advance Practice Registered Nurse telehealth provider, contacted by facility to assess Resident #16, wrote the following note on 07/22/2024 Nurse reports [AGE] year-old [Resident #16] received carbamide peroxide [Debrox] 1 drop into both eyes. Patient reports irritation .Diagnosis ocular pain, bilateral . condition is guarded. The following orders were received: Irrigate eyes and then apply artificial tear drops 2 drop in each eye [follow up] with primary care in the morning. A Follow up note written by the APRN dated 07/23/2024 reads [Resident #16] seen for an acute visit after [s/he] was given incorrect eye drops last night. Per patient [he/she] was given the drops which [he/she] stated burned. Per on call note, patient was given carbamide peroxide 1 drop in both eyes. [S/He] has been getting to [the] ear drops for wax build up. Patient states [his/her] eyes are irritated and itchy . Called the Northern New England Poison Center who recommended patient be sent to the ED [Emergency Department] for urgent follow up on context of extensive discomfort and redness and length of time since event occurred . Bilateral conjunctiva is red and excessively watery . Both eyes red, significant discomfort. Plan to send patient to ED for more urgent follow up. An Emergency Department note written on 07/23/2024 reads the following [Resident #16] seen in the emergency room today for recent chemical exposure to the eye. Thankfully his eye PH (acidity or alkalinity of fluid around the eye) is normal. We have flushed [his/her] eyes and started [him/her] on antibiotic eyedrops to prevent infection. I have placed a referral to the ophthalmology department. A Note written on 07/24/2024 by the APRN reads [Resident #16] seen for follow up eye irritation, [s/he] reports [his/her] eyes are still burning a little. Review of the facility policy Medication Errors, last revised 07/01/2024, reads Medication Error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturer 's specifications (not recommendations) regarding the preparation and administration of the medication or biological . Significant Medication Error means one which causes the patient discomfort or jeopardizes their health and safety . The Center shall ensure medications will be administered as follows: 1.1 According to prescriber's orders . 2.1 Medication administered not in accordance with the prescriber's order. Examples include, but are not limited to: 2.1.1 Incorrect dose, route of administration, dosage form, time of administration safety To prevent medication errors and ensure safe medication administration, nurses should verify the following information: 5.1 Right medication, dose, route, and time of administration; 5.2 Right patient and right documentation. During an Interview with the Advance Practice Registered Nurse on 08/06/2024 at approximately 2:40 PM the APRN confirmed that Resident #16 did receive Debrox to his/her eyes in error. The APRN stated that during his/her assessment of Resident #16 on 07/23/2024 the Resident's eyes were very red, and s/he complained of pain and burning in both eyes. The APRN also stated that s/he was concerned that Resident #16 needed more flushing of his/her eyes, and s/he felt that Resident #16 needed fluoroscopy (imaging of the eye) to determine if there was damage to the eyes. The APRN contacted Poison control, and they recommended sending Resident #16 to the emergency room . Reference List of Cerumenolytics - Drugs.com Diabetic Retinopathy: Causes, Symptoms, Treatment - American Academy of Ophthalmology (aao.org)

Based on interview and record review, the facility failed to obtain laboratory services to meet the needs of its residents for 2 of 2 sampled residents (Residents #1 and #2) related to obtaining urinalyses (UA) and culture and sensitivity [C&S; a test to determine if there is an infection, what germ is causing the infection, and what medication will work best to treat the infection] as requested by medical providers in a timely manner. As a result, Resident #1 and #2 suffered symptoms of urinary tract infections (UTI), a disease that can be diagnosed with a urinalysis and C&S, and were both transferred to the emergency department (ED) with sepsis [a life-threatening complication of an infection] caused by a UTI. Findings include: 1. Per record review, Resident #1 was admitted to the facility on [DATE] with diagnoses that include benign prostatic hyperplasia (BPH; prostate gland enlargement that can cause urination difficulty), morbid obesity, and type 2 diabetes. A 10/2/2023 hospital discharge summary indicates that s/he has chronic colonization (high bacteria levels in urine) and had been treated for multiple catheter-associated urinary tract infections during their hospital stay. Resident #1's care plan, created on 10/2/2023, states that s/he requires a urinary catheter due to BPH and dysuria (pain or burning when urinating). Record review reveals that Resident #1 began having genitourinary (related to genital and urinary organs) pain starting 10/21/23. A 10/21/23 nursing note states that Resident #1 said they were experiencing 'severe urethral' pain that lasted anywhere form 5-10 min [minutes], randomly throughout the day . [S/He] states that [s/he] was previously on pyridium [phenazopyridine HCL; used to relieve the pain, burning, and discomfort caused by infection or irritation of the urinary tract] which helped. Per review of Resident #1's Medication Administration Record (MAR), s/he has the following physician order, phenazopyridine HCL Oral Tablet 100 MG Give 1 tablet by mouth every 8 hours as needed for dysuria start date 10/2/2023. A 10/27/2024 Nurse Practitioner (NP) note states, [S/He] is seen today for an acute visit regarding pain in [his/her] urethra. [S/He] is concerned for a possible UTI. [S/He] does have a chronic foley and the pain is described by [him/her] as 'screaming,' . Plan: Dysuria: At this time will not start any antibiotics due to indwelling catheter and lack of systemic symptoms. Will order a urine screen [urine sample test; UA] with C&S [culture and sensitivity; test to determine if there is an infection, what germ is causing the infection, and what medication will work best to treat the infection] and will follow up on ABX [antibiotic] is needed. Per review of Resident #1's Treatment Administration Record (TAR), s/he has the following physician order, Urine screen, culture and sensitivity one time only for dysuria until 10/29/2023 start date 10/27/2023. The TAR does not show documentation that this was performed but rather to see nurse notes. A 10/28/23 nurse note indicates that the UA was not collected because Resident #1's urine was orange related to his/her medication. There is no evidence that the UA was reattempted at a different time or that the provider was notified that this test was not performed as ordered. Per record review, Resident #1 continued to have genitourinary pain regularly after the initial onset of pain identified on 10/21/23. Resident #1's MAR reveals that Pyridium was administered for dysuria 19 times between 10/22/23 and 11/24/23. A 11/24/2023 NP note states, [Resident #1] is seen today for an acute visit after nursing staff noticed [s/he] was not at [his/her] baseline level of orientation. [S/He] endorses pain but is unable to clarify where [s/he] is feeling it as well as some SOB [shortness of breath]. Of note, a urine screen and culture was drawn 2 weeks ago, but no results ever came from this. Plan: AMS [altered mental status]: Acute, worsening. Plan to send patient to ED for further workup of acutely worsening cognition and orientation. A 12/11/2023 Physician Assistant hospital note reveals that Resident #1 was seen at the ED for a catheter associated UTI resulting in severe sepsis on 11/24/2023. The note indicates that s/he was admitted to the hospital until 12/12/2023 due to complications (some indicated as likely caused by the UTI and sepsis) that include acute metabolic and toxic encephalopathy (brain disease that alters brain function or structure) and acute kidney injury. Per interview on 1/22/2024 at 10:46 AM, Resident #1's Representative explained that Resident #1 was frequently in screaming pain related to his/her urinary tract system. The Representative explained that Resident #1's pain eventually became constant by mid-November and s/he was eventually so sick that s/he needed to be sent to the ED. S/He explained that the provider had ordered a UA at the end of October but it was never done. The Representative expressed concern about Resident #1's pain and the UA not being performed multiple times to both providers and nursing staff at the facility and the issue was not resolved. Per interview on 1/24/2024 at 12:06 PM, the Director of Nursing confirmed that the UA was not obtained as ordered by the provider for Resident #1 and the facility failed to follow their process to follow up with the provider to ensure that the UA was reordered. Per interview on 1/25/2024 at 4:04 PM, the Market Clinical Advisor confirmed that the Director of Nursing did notify the provider that the UA was not preformed and should have. 2. Per record review Resident #2 has diagnoses that include BPH, retention of urine, schizophrenia, bipolar disorder, and major depressive disorder. Resident #2's care plan, created on 9/15/2022, reveals that s/he requires extensive assistance for activities of daily living, has limited mobility, and has episodes of urinary incontinence. A 10/27/2023 NP note states, [S/He] is seen today for increased urinary frequency and nausea. [S/He] reports the nausea occurs randomly throughout the day. Regarding increased urinary frequency, [s/he] reports [s/he] has been going to the bathroom more than usual. [S/He] endorses mild discomfort with urination and the urine is a darker yellow in color. Plan: Dysuria: Plan to order clean catch urine for screen and C&S. Will hold off on ABX until urine results as patient does not have any systemic symptoms. Lab results reveal that at UA and C&S was performed on 10/27/2023 and there was no growth. A 11/2/2023 Psychiatric Advanced Practice Registered Nurse (APRN) note states, Recheck UA, pt [patient] has HX [history] of multiple UTIs with delirium and recent hospitalization with no recheck. UTI will alter the presentation of cognition, mood and psychosis. Per record review, Resident #2 begins to display noticeable changes to his/her baseline in health and behavior, resulting in symptoms that are common in persons with UTIs, and continue to progress in severity until s/he is transferred to the ED on 11/17/2023. A 11/11/23 nurse note indicates that Resident #2 does not feel well. Resident #2's MAR reveals that s/he starts to refuse some of their medications on this day. A 11/14/2023 Psychiatric APRN notes indicates that Resident #2 is being seen for increased confusion and that staff reports that Resident #2 has complained of abd [abdominal] pain, nausea and has been refusing food and medication for past several days. The Psychiatric APRN again requests a UA and C&S to be obtained. The treatment plan indicates the need to rule out a UTI in order to adjust psychiatric mediations to address behaviors. A 11/14/2023 NP note states that Resident #2 is outside his/her baseline, s/he is staying in bed, reports hallucinations, has poor food and drink intake, is nauseous and has abdominal discomfort, is refusing medications, and has a flat affect. The NP indicates that his/her presentation is similar to previous episodes on an UTI and plans to order testing. Per Resident #2's TAR, a UA and C&S is ordered by the NP on 11/14/23 and performed on 11/15/23. A 11/16/2023 NP note reveals that Resident #2 is seen today for continued altered behaviors including refusing medications, not getting up out of bed, incontinence and accused this writer of 'Running experiments on everyone here.' The NP indicates that Resident #2 is presumed to have a UTI and will order antibiotics, adjusting the regimen based on the results of the C&S performed on 11/15/2023. Per 11/16/2023 nurse notes and confirmed by Resident #2's MAR, s/he is continuing to refuse all medications and care. A 11/17/2023 NP note reveals that Resident #2 is continuing to decompensate and refusing to take medication, including the antibiotic to treat his/her UTI requiring a transfer to the emergency room for evaluation. A 11/17/23 transfer form states, reason for transfer Abnormal Urinalysis or urine culture . Resident is refusing care and meds yesterday and today. Won't allow staff to come near [him/her], A 11/18/23 hospital note states that Resident #2 was admitted with a chief complaint of altered mental status and now with a principal diagnosis of sepsis in setting of UTI . Urine with gram neg and positive organisms [different types of bacteria that are sensitive to different medications] suggesting urinary tract [infection] and sepsis [a life-threatening complication of an infection] that were present on admission and drove metabolic encephalopathy and atrial fib [atrial fibrillation; irregular, often rapid heart rate] with RVR [rapid ventricular rate; a complication of atrial fib that disrupts blood supply to the body]. A 11/24/2023 hospital discharge summary indicates that Resident #2 was admitted to the hospital on 11/17/2023 and discharged 8 days later, on 11/24/2023. Per interview on 1/22/2024 at 1:48 PM, the NP stated that s/he was unaware of the recommendation made by the Psychiatric APRN to collect a UA for Resident #2 on 11/2/2023 because s/he was unable to review the Psychiatric APRN's notes. The NP explained that there were a few weeks after the Psychiatric APRN started where notes were not being uploaded into residents' medical records and that would have been how s/he would have known about that request during the time period where communication systems were being established between the Psychiatric APRN and the facility. Per interview on 1/25/2024 at 12:50 PM, the Psychiatric APRN confirmed that s/he had requested a UA to rule out a UTI for Resident #2 on 11/2/2023. S/He explained that this was not completed at his/her next visit with Resident #2 on 11/14/23. S/He explained that the decompensation of his behavioral symptoms (increase in hallucinations) was medical and related to his/her UTI. Per interview on 1/25/2024 at 2:20 PM, the Market Clinical Advisor stated that the Resident #1's provider was responsible for ordering the UA requested by the Psychiatric APRN on 11/2/2024 and confirmed this did not happen.

Based on interview and record review, the facility failed to obtain an EKG (electrocardiogram; a diagnostic test to evaluate heart function) to meet the needs of its residents for 1 applicable resident (Resident #2). As a result, Resident #2 was transferred to the Emergency Department (ED) and later to the ICU (intensive care unit) to manage the cardiac complications including atrial fibrillation (irregular, often rapid heart rate) with RVR (rapid ventricular response; abnormal rhythm originating in the lower chambers of the heart) and NSTEMI Type II (a heart attack due to mismatched oxygen supply and demand to the heart muscle), both cardiac conditions can potentially be diagnosed with an EKG. Findings include: Per record review Resident #2 has diagnoses that include schizophrenia, hypertension (high blood pressure), and atrial fibrillation. Resident #2's care plan, created on 9/15/2022, states that s/he is at risk for complications related to the use of psychotropic drugs, antipsychotic, anti-manic, anti-depressant. Record review reveals a physician order for risperidone [antipsychotic] oral tablet 2 MG Give 1 tablet by mouth one time a day for Schizophrenia, with a start date 10/13/2023. A 11/2/2023 Psychiatric Advanced Practice Registered Nurse (APRN) note states, Obtain 12 lead EKG to monitor QT [time it takes the heart to contact and refill with blood], [patient] on antipsychotic that causes QT prolongation [a heart rhythm disorder that can potentially cause fast, chaotic heartbeats]. Per interview on 1/24/2024 at 9:35 AM, the Consulting Pharmacist confirmed that Risperidone could potentially cause cardiac side effects. Per record review, an order for an EKG requested on 11/2/2023 was never placed and the test was never performed at the request of the facility. Per interview on 1/22/2024 at 1:48 PM, the Nurse Practitioner (NP) stated that s/he was unaware of the recommendation made by the Psychiatric APRN on 11/2/2023 to perform an EKG for Resident #2 because s/he was unable to review the Psychiatric APRN's notes. S/He confirmed that it was his/her responsibility for putting in an order for the EKG test recommended by the Psychiatric APRN and did not. Per a 11/11/2023 Physician note, Resident #2 had a telemed (virtual) visit with the physician because s/he was tachycardic and hypertensive. The assessment/plan for both the tachycardia and hypertension revealed Stat EKG ordered but cannot be obtained over the weekend. Per record review, an order for an EKG requested on 11/11/2023 was never placed and the test was never performed at the request of the facility. Per a 11/17/2023 progress note, Resident #2 was transferred to the Emergency Department for evaluation and treatment of his/her declining condition and urinary tract infection. A 11/18/2023 hospital progress note states that Resident #2 was admitted to the ICU for altered mental status and atrial fibrillation with RVR initially requiring a dilt drip (diltiazem; medicine to control rapid heartbeats or abnormal heart rhythms) overnight. Multiple cardiac complications occurred requiring Resident #2 to remain in the ICU. In addition to Resident #2's atrial fibrillation, other active problems included NSTEMI Type II. A 11/24/2023 progress note reveals that Resident #2 was readmitted to the facility on [DATE] after an 8 day hospital admission. Per interview on 1/24/2024 at 10:00 AM, the Market Clinical Advisor confirmed that Resident #2 did not have an EKG in November until s/he was transferred to the Emergency Department on 11/17/2023 and confirmed it was the NP's responsibility to place the order for the EKG that was recommended by the Psychiatric APRN on 11/2/2023. Per interview on 1/25/2024 at 12:50 PM, the Psychiatric APRN confirmed that s/he had requested an EKG for Resident #2 on 11/2/2023 and explained that this was not completed at his/her next visit with Resident #2 on 11/14/23. S/He explained that the decompensation of his/her behavioral symptoms (increase in hallucinations) was medical and related to his/her cardiac issues and urinary tract infection.

Based on interview, record review, and review of facility policies, the facility failed to provide pressure ulcer treatment and preventative skin care, consistent with facility policy and professional standards of practice, for 1 of 2 sampled residents (Resident #2) related to not: providing timely and complete wound assessments, providing timely pressure ulcer treatment, creating a baseline care plans for skin, documenting daily diabetic foot checks, or documenting daily monitoring of wounds. Findings include: Facility policy NSG236 Skin Integrity and Wound Management, revised 2/1/23, states, A comprehensive initial and ongoing nursing assessment of intrinsic and extrinsic factors that influences skin health, skin/wound impairment, and the ability of a wound to heal will be performed. The plan of care for the patient will be reflective of assessment findings from the comprehensive patient assessment and wound evaluation. Staff will continually observe and monitor patients for changes and implement revisions to the plan of care as needed. Practice standards include: 4. Identify patient's skin integrity status and need for prevention or treatment interventions through review of all appropriate assessment information. 6.5 The licensed nurse will complete wound evaluation upon admission/readmission, new in-house acquired, weekly, and with unanticipated decline in wounds. 6.6 Perform daily monitoring of wounds or dressings for presence of complications or declines. Document daily monitoring of ulcer/wound site with or without dressing. Monitor: status of dressing (e.g., intact and clean); status of the tissue surrounding the dressing (e.g., Free of new redness or swelling); adequate control of wound associated pain; signs of decline in wound status. The American Diabetes Association Standards of Care in Diabetes-2023 reveals on page S209 the recommendation for diabetics to perform daily examination of the feet to identify early foot problems. Record review reveals that Resident #2 was admitted to the facility on [DATE] for therapy following a hospital stay related to a right hip fracture surgical repair. On admission, his/her diagnoses include venous insufficiency (improper blood flow), anemia (lack of blood), and type 2 diabetes. A transition of care report dated 7/10/23 reveals that Resident #1 had the following wounds: right hip wound, left foot laceration, and moisture associated skin damage to the sacrum. There is no documentation of any compromise to either of Resident #2's heels. A skin check documented in an admission nursing assessment dated [DATE] reveals that Resident #2 had multiple bruises on his/her arms and legs and a right hip incision. There is no documentation of any wounds on either of Resident #2's heels. A wound assessment dated [DATE] indicates that Resident #2 has a stage 2 pressure ulcer (Partial-thickness skin loss) on his/her sacrum. A late entry progress note dated 7/10/23, entered on 7/14/23 reveals a pressure area on Resident #2's right heel. This note does not include any assessment information about the wound. The Attending Physician admission visit note dated 7/13/23 indicates that Resident #2 is concerned about a wound on the bottom of his/her right heel. The note states, There is a DTI [deep tissue injury; a pressure-related injury to subcutaneous tissues under intact skin] on the [right] heel with surrounding erythema [redness], and indicates that Resident #2 has cellulitis (infection) in his/her right heel which requires antibiotic treatment. A Nurse Practitioner (NP) note dated 7/13/23 reveals that Resident #2's Attending Physician requested a wound consult from the NP, who is wound care certified, to assess and put treatment in place for a right heel wound. The NP's note describes the wound as completely filled with blood dark and draining large amount of blood and serosanguineous fluid from a pin hole at the posterior medial section of the wound. Area was surrounded by 0.5 cm of red, hot, tissue, tender to the touch.Some pain of the right heel with palpation. A wound assessment dated [DATE] reveals that Resident #2 has a right heel, middle DTI, present on admission, measuring approximately 26 cm squared, with a moderate amount of sanguineous (bloody) discharge. A NP note dated 7/17/23 indicates Resident #2 has both a right and left heel wound. An incomplete wound assessment dated [DATE] reveals a wound on an unidentified location that was present on admission (8 days old) measuring 1.06 cm x 1.19 cm. Per this surveyor's observation of the photograph attached to this assessment, the area appears to be of a heel with a dark pressure area approximately 1 cm squared surrounded by 1 cm of compromised skin and it is hard to determine if the wound is open or closed. There is no additional assessment information and no additional entries about this wound. A separate wound assessment dated [DATE] reveals that Resident #2's right heel wound is approximately 25 cm squared. There is no evidence in Resident #2's medical record that wound assessments were completed on admission for both Resident #2's right and left heel wounds, which are both documented on later wound assessments as being present on admission (7/10/23). The first wound assessment for the right heel was documented on 7/13/23, three days after admission, and the first wound assessment of the left heel was documented on 7/18/23, eight days after admission. Review of Resident #2's progress notes, medication administration record (MAR) and treatment administration record (TAR) reveal: an order for every other day right heel wound treatment with a start date of 7/17/23 and documented as administered on 7/17/23 and 7/19/23. There are no orders for treatment to the right heel prior to 7/17/23; an order for left heel wound treatment was placed on 7/19/23. A review of Resident #2's TAR reveals an order to monitor wound sites and wound dressings every day shift starting 7/18/23. There is no documentation of daily wound monitoring prior to 7/18/23. There is no evidence in Resident #2's record that wound treatment was provided to Resident #2 right heel prior to 7/13/23, three days after admission, wound treatments were provided to Resident #2's left heel, or that daily foot checks were completed. Resident #2 did not have care plan focuses, goals, or interventions related to skin and diabetes until 7/17/23, 7 days after admission, and there is no evidence of daily diabetic foot checks. See F655 for more information. On 7/25/23 at 12:20 PM, the Market Clinical Lead stated that all wounds are to be monitored daily and should be documented on the TAR. S/He confirmed that this had not been done daily for Resident #2 and confirmed that Resident #2 did not have a baseline care plan within 48 hours of admission. On 7/27/23 at 9:20 AM, the Market Clinical Lead confirmed that there were no wound treatment orders for Resident #2's right heel prior to the wound assessment on 7/13/23.

Based on interview and review of facility policies, the facility failed to ensure that the medical director fulfilled his/her responsibility to coordinate medical care with facility providers and nursing staff related to obtaining and implementing provider orders for necessary care and services for 3 of 3 sampled residents (Residents #1, #2, and #3). Findings include: Facility policy OPS123 Medical Director Responsibilities, last reviewed 1/25/18, states, The Center Medical Director coordinates medical care in the Center and provides clinical guidance and oversight regarding the implementation of patient care policies. He/she helps the Center identify, evaluate, and address/resolve medical and clinical concerns and issues that: Affect patient care, medical care of quality of life; or are related to the provision of services by physicians and other licensed health care practitioners. Record review reveals that, per Resident #1's transfer of care dated 6/20/23 and the 6/20/23 hospital medication administration record (MAR), orders for nystatin (antifungal medication), morphine extended release, and gabapentin (a medication used to treat nerve pain), were not accurately reconciled, transcribed, or checked for accuracy by a second nurse per facility policy. Per Resident #2's transfer of care of care dated 7/10/23, orders for Lovenox [an anticoagulant medication used to treat and prevent deep vein thrombosis (DVT; blood clots in a deep vein) and pulmonary embolism (PE; a blood clot that has traveled to the lungs)] were not accurately transcribed or checked for accuracy by a second nurse. Per Resident #3's discharge summary dated 7/8/23, orders for Budesonide (inhaled steroid to decrease inflammation of the airway), Cephalexin (antibiotic), cefdinir (antibiotic), and doxycycline hyclate (antibiotic) were not accurately reconciled, transcribed, or checked for accuracy by a second nurse per facility policy. As a result, Resident #1 suffered extreme pain for which s/he sought relief for at the emergency room , was not treated for thrush for 5 days, and a wound identified as a small scab, present on admission, significantly deteriorated to become two stage 3 pressure ulcers (full thickness skin loss); Resident #2 was at risk for developing a DVT or PE; and Resident #3 was at risk for breathing complications. On 7/25/23 at 12:20 PM, the Market Clinical Lead confirmed that Resident #1, #2, and #3's transfer of care orders were not effectively reviewed by the Attending Provider/Medical Director or nursing staff, properly transcribed, or checked for accuracy by a second nurse per facility policy. See F635 for more information. Based on interviews conducted on 7/24/23 at 3:29 PM and 7/26/23 at 5:00 PM, the Medical Director confirmed that Resident #1, #2, and #3's admission orders were not accurately reconciled with hospital transfer information. S/He stated that the process of providing comprehensive admission orders should be the responsibility of the transferring hospital, not the facility, and that it is the facility's responsibility to make sure there is a procedure in place to ensure that admission orders are being double checked for accuracy, not hers/his. S/He stated that s/he was not aware that the facility policy titled, OPS424 Medication Reconciliation, effective on 9/1/2022 during his/her time as Medical Director, instructed facility staff to review the hospital MAR while reconciling admission orders and cannot recall if s/he had ever reviewed the policy. S/He indicated that s/he has been aware that there have been widespread problems with the transfer of care and ensuring residents have complete orders to meet all their care needs on admission for a long time. S/He stated that she has brought this problem to past facility leadership but because there have been multiple administrators and nursing directors, no action has been taken to correct the issues by the facility since s/he has been medical director. S/He confirmed that she has not brought the issues with transfer of care to QAPI (quality assurance and performance improvement program) and has not initiated or organized any training with staff about this issue.

Based on staff interview and record review, the facility failed to obtain accurate physician orders to provide necessary care and services on admission for 3 of 3 applicable residents (Residents #1, #2, and #3). Findings include: Facility policy Standards and Procedures for All Licensed Independent Practitioners, revised 9/17/21, states, Upon the admission of a patient, the attending physician or advanced practice provider (APP) is required to: Enter appropriate admission orders on the day of admission. These orders should include comprehensive directions as to diet, vital signs, activity level, rehabilitation services, appropriate testing to rule out active tuberculosis, other laboratory and radio graphic testing, advance care plans and limitations of treatment, medications and other treatments and services. Facility policy OPS424 Medication Reconciliation, effective 9/1/2022, states, The patient's medication orders will be reconciled at each transition of care. Medication reconciliation is the process of comparing a patient's existing medication orders to all the previous medications the patient has been taking. The process involves obtaining and maintaining a complete and accurate list of current medication use across all healthcare settings. Medication reconciliation involves collaboration with the patient representative and multiple disciplines including admission liaisons, physicians/advanced practice providers (APP), licensed nurses, and pharmacy. Medication reconciliation will be performed when patients are admitted /readmitted from hospital. For patients admitted from the hospital: obtain and review copies of Medication Administration Records (MARs), Treatment Administration (TARs), transfer forms, and Physician's Order Sheets (POS). Verify MAR/TAR information with transfer forms and POS, if available. A reconciliation of the patient's admission medication orders to the hospital and/or home care discharge orders will be made. Information to be reconciled includes but is not limited to: prescription medications; PRN [as needed] medications; herbals; vitamins; nutritional supplements; parental nutrition; infusion solutions; over the counter medications; vaccines and date of administration, if known; medication start and discontinue dates. Clarify medication orders with clinical staff from transferring hospital, when necessary. Any discrepancies discovered during reconciliation will be reported to the physician/APP before finalizing the current list of medications. A repeat reconciliation will be performed to compare hospital/home care discharge medication listing to current center medication listing to MAR. Any discrepancy discovered during repeat reconciliation will be reported to the physician/APP. 1. A hospital transition of care report reveals that Resident #1 was transferred to the facility for sub-acute rehabilitation on 6/20/2023 with diagnoses that include: cancer, cancer related pain, severe malnutrition, compression fracture of the spine, and back pain. The note indicates that s/he has 7 wounds on his/her chest and abdomen that resulted from a previous provider leaving on ECG [electrocardiogram; a test that records electrical activity of the heart] leads [metal electrode] on while in an MRI machine [Magnetic resonance imaging machine; a scanner using magnets to create images of the body]. Resident #1 is identified as needing treatment for thrush through 6/22/23. Discharge medications include nystatin (antifungal medication), 100,000 units/ml suspension, 5 mL by mouth 4 times daily for 3 days. The hospital MAR (medication administration record) reveals that Resident #1 received two doses of nystatin prior to discharge from the hospital to the facility and was due for additional doses at 5:00 PM and 9:00 PM. The hospital MAR also reveals Resident #1 has an order for gabapentin (a medication used to treat nerve pain) 100 mg 3 times daily; Resident #1 received one dose of gabapentin prior to discharge from the hospital to the facility and was due for additional doses at 2:00 PM and 9:00 PM. A hospital wound note dated 6/20/23 reveals the following wound care to the blisters and burns on Resident #1's chest and abdomen: Blisters/Bullae - daily wound care Mepitel One [a long staying wound dressing to promote healing and minimize pain at dressing changes]- leave in place for 7 - 14d [days] Clean through Mepitel One with saline [salt water solution] Apply thin layer of Aquaphor [ointment] If leaking noted, cover with Mepilex [foam] border dressing; Burns right chest, left flank, midline abdomen, RLQ [right lower quadrant] - daily wound care Clean with saline Continue use of Silvadene [topical antibiotic] Cover with Mepilex border dressing. Resident #1's facility TAR (treatment administration record) reveals different wound care orders to the blisters and burns on Resident #1's chest and abdomen than what was indicated in the 6/20/23 hospital wound note. The following is a wound care order placed by the facility on 6/20/23: Cleanse areas on chest/trunk with wound spray, pat dry, apply small amount of Vaseline to each area and cover with dry dressing until resolved every day shift every other day. An admission nursing assessment note dated 6/20/23 reveals that Resident #1's tongue is coated and has oral thrush. Review of Resident #1's physician admission orders reveals that an order for nystatin was never entered or placed. A provider note dated 6/24/2023 reveals an acute visit because Resident #1 was experiencing mouth pain. The note states, patient has a burning sensation in the mouth as well as white coating on the inner aspect of the lips and the mouth and throat . [S/he] has mild discomfort with swallowing. A nurse progress note dated 6/21/23 reveals that Resident #1 had used the call bell at 3:10 AM to ask for pain medication and the resident explained to the nurse that a family member called 911 on his/her behalf and an ambulance was on the way. The nurse documented that the resident stated, I am in excruciating pain and you were not doing anything about it. A hospital emergency room Provider note dated 6/21/23 states, Patient [has] not been receiving her 100 mg of gabapentin 3 times daily. Will prescribe the 75 mg of extended release morphine as well as the gabapentin. Hospital discharge orders signed on 6/21/23 at 5:16 AM include discharge orders for 100 mg of gabapentin 3 times daily. Review of Resident #1's Physician orders reveals that an order for gabapentin was never entered or placed on his/her 6/20/23 admission or 6/21/23 readmission. There is no explanation documented in Resident #1's medical record as to why gabapentin was not ordered on admission on 6/20/23 or on return from the emergency department on 6/21/23. Per interview on 7/17/23 at 10:01 AM, the Registered Nurse (RN) that entered in Resident #1's admission orders stated that s/he does not use the hospital MAR to reconcile the medications. S/He said that s/he never looked at the wound care note. Per interview on 7/24/23 at 12:15 PM, the Market Clinical Lead revealed that, per facility policy, the process for obtaining and entering orders for a new admission, would be as such: nursing receives the transfer information from the sending facility. Nursing will review the information, including the transfer of care, discharge summary, MAR, and any other instructions for care with the new admission's facility provider, who will also review the hospital information. Any discrepancies between the information received will be reviewed and reconciled. The provider will give nursing orders for admission, either verbally, when in person, or over the phone. The nurse will enter in the orders into the EHR (electronic health record). A second nurse will review the orders that were entered into the EHR and the hospital transfer information for accuracy; best practice is that the double check of orders will occur before administering medications or providing treatments. The Market Clinical Lead confirmed that Resident #1's admission orders were not reviewed by another nurse before treatment began and that Resident #1's wound orders were not based on the facility's formulary. Per interview on 7/24/23 at 3:29 PM, Resident #1's Attending Physician/Medical Director stated that s/he does not always review the transfer of care information from the sending facility before placing admission orders. S/He stated that nurses are supposed to obtain orders from the facility provider before entering them in but is not sure if that always happen. S/He said that s/he does not use the hospital MAR to reconcile medications, and that it is the responsibility of the sending facility to make sure that all orders are included on the discharge summary. S/He was unaware that Resident #1 was receiving gabapentin at the hospital when s/he gave admission orders. During a follow up interview on 7/26/23 at 5:00 PM, Resident #1's Attending Physician stated that s/he did not discuss Resident #1's wound care treatment orders with the admitting RN and does not know how or why treatment order were changed from what was on the hospital wound note. S/He is unsure why nystatin was not ordered. S/He stated that s/he is aware that there is a very big problem with the process of obtaining admission orders for new residents. See F841 for more information. 2. Record review reveals that Resident #2 was admitted to the facility on [DATE] for therapy following a hospital stay related to a right hip fracture surgical repair. On admission, his/her diagnoses include venous insufficiency, anemia (lack of blood), type 2 diabetes, acute respiratory failure, post-surgical pulmonary embolism [PE; a blood clot that has traveled to the lungs], and heart failure. Resident #2 is at risk for developing a DVT (deep vein thrombosis; blood clots in a deep vein) or PE because s/he is over 60, is post-surgery, and has a history of PE. Per the transition of care note, discharge medications include: enoxaparin [Lovenox; an anticoagulant medication used to treat and prevent DVT and PE] 80 mg/0.8 ml. Inject 80 mg into the skin every 12 hours for 30 days. The hospital MAR reveals that Resident #2 received one dose of Lovenox the morning of transfer to the facility and was due for a second dose that evening. Per interview on 7/17/23 at 11:40 AM, Resident #2 stated that s/he was concerned that s/he was not administered Lovenox the night of admission (7/10/23) or the following morning (7/11/23). Per record review of Resident #2's physicians orders, Resident #2's Lovenox was entered into the EHR [electronic medical record] on 7/10/23 with a start date and time of 7/11/23, 9:00 PM. Review of Resident #2's MAR confirms that s/he did not receive Lovenox until 9:00 PM on 7/11/23. Per interview on 7/20/23 at 10:01 AM, the Market Clinical Lead confirmed that the order for Resident #2's Lovenox should have been started on Resident #2's admitted , 7/10/23 . 3. Record review reveals that Resident #3 was admitted to the facility on [DATE] for physical therapy evaluation and treatment following a hospital stay related to breathing difficulties and pneumonia. On admission, his/her diagnoses include chronic obstructive pulmonary disease (disease that causes obstructed airflow from the lungs), multiple sclerosis (disease of the central nervous system), hypertension, morbid obesity, and s/he is bed bound. A hospital discharge summary, dated 7/7/23, include the following orders: Budesonide [inhaled steroid to decrease inflammation of the airway] 0.5 mg/2 mL suspension for nebulization [changes liquid to a mist for inhalation], 0.5 mg inhalation BID [twice a day]; cefdinir (antibiotic) 300 mg capsule, 300 mg PO [by mouth] BID [twice a day] with instructions to take the last dose tonight to complete the 5 day course; and doxycycline hyclate (antibiotic) 100 mg tablet, 100 mg PO Q12H [every 12 hours] with instructions to take the last dose tonight to complete the 5 day course. The following medication was discontinued: Cephalexin (antibiotic) 250 mg capsule, daily. Record review of Resident #3's physician orders reveal that orders for doxycycline hyclate and cefdinir were never placed; an order for Budesonide was not placed until 7/25/23, 18 days after admission, and cephalexin, despite being discontinued prior to admission to the facility, was ordered by Resident #3's Attending physician from 7/8/23 until 7/10/23 . On 7/26/23 at 5:00 PM, Resident #3's Attending Physician confirmed that orders for doxycycline hyclate, cefdinir, and budesonide should have been placed. S/He stated that s/he did not place the order for cephalexin and confirmed that the order should not have been placed according to the discharge summary. In summary, the facility physician and nursing staff are not accurately reconciling all orders from the transferring facility for new admissions by not effectively reviewing all transfer of care information and accurately transcribing orders resulting in inaccurate admission orders for residents' immediate care.

Based on interview, record review, and review of facility policies, the facility failed to develop and implement a baseline care plan within 48 hours of admission that included the minimum healthcare information necessary to properly care for the resident for 2 of 3 sampled residents (Residents #1 and #2). Findings include: 1. Record review reveals that Resident #2 was admitted to the facility on [DATE] for therapy following a hospital stay related to a right hip fracture surgical repair. On admission, his/her diagnoses include hypertension, venous insufficiency (improper blood flow), anemia, type 2 diabetes, acute respiratory failure, history of falling, post-surgical pulmonary embolism [PE; a blood clot that has traveled to the lungs], and heart failure. A skin check documented in an admission nursing assessment dated [DATE] reveals that Resident #2 had multiple bruises on his/her arms and legs and a right hip incision. There is no documentation of any wounds on either of Resident #2's heels. A wound assessment dated [DATE] indicates that Resident #2 has a stage 2 pressure ulcer (Partial-thickness skin loss) on his/her sacrum. A wound assessment dated [DATE] reveals that Resident #2 has a right heel, middle DTI (deep tissue injury; a pressure-related injury to subcutaneous tissues under intact skin), present on admission, measuring approximately 26 cm squared, with a moderate amount of sanguineous (bloody) discharge. A 7/13/23 Attending Physician admission visit note reveals that Resident #2 has cellulitis (infection) in his/her heel requiring antibiotic treatment. A 7/17/23 Nurse Practitioner note reveals a wound on Resident #2's left heel. Per record review, the facility failed to create and implement a baseline care plan to address Resident #2's skin, wounds, and diabetes. There is no evidence that interventions for wound prevention, wound assessment, wound treatment, wound monitoring, or diabetic foot checks were created or implemented within 48 hours of Resident #2's admission . Additionally, the care plan failed to address initial goals based on admission orders; physician orders; dietary orders; therapy services; and social services as required by the regulations. A care plan related to skin was created on 7/17/23, seven days after Resident #2's admission, and a diabetes care plan was never created. Resident #2 developed cellulitis (infection) in a right heel wound that was not evaluated or treated for three days. See F686 for additional information. Facility policy NSG236 Skin Integrity and Wound Management, revised 2/1/23, indicates that the plan of care for skin integrity and wound management is based on wound evaluation and should include identifying prevention or treatment interventions, comprehensive skin and wound assessments, and daily monitoring of wounds. On 7/25/23 at 12:20 PM, the Market Clinical Lead stated that all wounds are to be monitored daily and should be documented on the TAR. S/He confirmed that this had not been done daily for Resident #2. S/He also confirmed that Resident #2 did not have a complete baseline care plan within 48 hours of admission. On 7/27/23 at 9:20 AM, the Market Clinical Lead confirmed that there were no wound treatment orders for Resident #2's right heel prior to the wound assessment on 7/13/23. 2. A hospital transition of care report reveals that Resident #1 was transferred to the facility for sub-acute rehabilitation on 6/20/2023 with diagnoses that include: cancer, cancer related pain, severe malnutrition, compression fracture of the spine, and back pain. The note indicates that s/he has 7 wounds on his/her chest and abdomen that resulted from a previous provider leaving on ECG [electrocardiogram; a test that records electrical activity of the heart] leads [metal electrode] on while in an MRI machine [magnetic resonance imaging machine; a scanner using magnets to create images of the body]. Resident #1's is identified as needing treatment for thrush through 6/22/23. A goal to follow up with oncology after completing rehab services is identified. Discharge medications include: Morphine 15 mg CR [extended release], 5 tablets every 12 hours for 2 days; morphine 15 mg [immediate release], 1 tablet every 3 hours as needed for pain up to 120 mg a day; gabapentin (a medication used to treat nerve pain) 100 mg 3 times daily; and nystatin (antifungal medication), 100,000 units/ml suspension, 5 mL by mouth 4 times daily for 3 days. A hospital wound note dated 6/20/23 reveals the following wound care to the blisters and burns on Resident #1's chest and abdomen: Blisters/Bullae - daily wound care Mepitel One [a long staying wound dressing to promote healing and minimize pain at dressing changes]- leave in place for 7 - 14d Clean through Mepitel One with saline [salt water solution] Apply thin layer of Aquaphor [ointment] If leaking noted, cover with Mepilex [foam] border dressing; Burns right chest, left flank, midline abdomen, RLQ [right lower quadrant] - daily wound care Clean with saline Continue use of Silvadene [topical antibiotic] Cover with Mepilex border dressing. The note also reveals multiple interventions to prevent pressure injuries, including interventions to consider if Resident #1 is incontinent. An admission nursing assessment note dated 6/20/23 identifies multiple abrasions on Resident #1's chest and an abrasion on the left inner buttock. There are no wound assessments or documentation of daily wound monitoring on the MAR, TAR, or in progress notes Resident #1's medical record. Review of physician orders show the following wound orders placed on 6/20/23: Apply skin prep to scabbed abrasion on left inner buttock as indicated until completely resolved every day shift every other day, and Cleanse areas on chest/trunk with wound spray, pat dry, apply small amount of Vaseline to each area and cover with dry dressing until resolved every day shift every other day. On 7/26/27 at 5:00 PM, Resident #1's Attending Physician stated that s/he does not know why the admitting nurse did not put in wound treatments as what was included on the wound care note. S/He confirmed that even though the wound care orders were put under his/her name on the TAR, s/he did not discuss changing the wound care from what was on the hospital wound note. Resident #1's baseline care plan for skin, initiated on 6/22/23, states s/he is at risk for skin breakdown related to weakness and or has actual skin breakdown Type: scabbed abrasion left inner buttocks, areas on chest and trunk, incontinence, and includes an intervention to provide wound treatment as ordered. However, the facility failed to provide wound treatment as recommended by the 6/20/23 hospital wound note. In addition, per review of Resident #1's baseline care plan and medical record, the facility failed to create and implement interventions for wound assessment and wound monitoring. Resident #1's baseline care plan for activities of daily living, initiated on 6/20/23, reveals a goal to improve the current level of functioning for toileting and includes an intervention to provide extensive assist of 1 for toileting, revealing that Resident #1 was continent of urine on admission. Nursing aide documentation reveals that Resident #1 became incontinent of urine starting 6/22/23 and was incontinent of urine 8 times prior to his/her 6/26/23 transfer, putting him/her at risk for increased skin break down. The baseline care plan was not revised to include interventions related to urinary incontinence. A hospital transfer form dated 6/26/23, reveals that Resident #1 was transferred to the emergency room at 11:00 AM due to an irregular heartbeat. Per review of hospital records, Resident #1 was admitted to the hospital from the emergency on 6/26/23 at 4:05 PM. A hospital nursing note dated 6/26/23 reveals 2 stage 3 pressure ulcers (full thickness skin loss) on Resident #1's buttocks. Per interview on 7/21/2023 at 3:48 PM, a hospital Registered Nurse (RN) that performed Resident #1's skin check on admission to the hospital on 6/26/23 revealed that the skin check took place within 30 minutes of Resident #1 arriving to his/her room. S/He explained that Resident #1's chest and abdomen wounds were dry; some were uncovered and some were covered in paper tape. Resident #1 also had two stage 3 pressure ulcers on her buttock. S/He reviewed the 6/20/23 hospital wound assessments and treatment instructions and concluded that the burn wounds looked much worse than they did on 6/20/23, the wound dressings did not match wound care instructions, and there was no record of a wound on the buttocks area on 6/20/23. The hospital RN reported that Resident #1 had told him/her that the nursing facility staff did not help her out of bed to use the toilet and they double brief him/her so s/he can void in bed . A 6/21/23 nursing note reveals that Resident #1's Representative called for EMS services in the early morning of 6/21/23 because Resident #1 was in extreme pain and was transferred to the emergency room . Per review of Resident #1's MAR, and confirmed by a NP note dated 6/22/23, Resident #1 received morphine at a significantly lower frequency and dose as was previously provided by the hospital and discharged with on the first day and night of his/her admission to the facility. Review of Resident #1's physician orders show that gabapentin was never ordered. A pain assessment interview conducted with Resident #1 on 6/23/23 reveals that Resident #1 reported that s/he has experienced pain almost constantly in the last 5 days which has limited his/her day-to-day activities. S/he reports his/her pain to be a 10. Resident #1's baseline care plan for pain, initiated on 6/20/23, states s/he is at risk for alterations in comfort, and includes the intervention to administer medications as ordered. Per review of the MAR, Resident #1 did not receive medications as ordered prior to the emergency room visit on 6/21/23. In addition, there are no baseline care plan interventions for non-pharmaceutical pain-relieving interventions indicated in Resident #1's baseline care plan. The facility failed to create and implement a baseline care plan to address Resident #1's pain present on admission. An admission nursing assessment note dated 6/20/23 reveals that Resident #1's tongue is coated and has oral thrush. An acute visit physician note dated 6/24/23 reveals that Resident #1 has mouth pain related to thrush and was ordered treatment. Resident #1's MAR reveals that Resident #1 did not receive treatment for thrush until 6/25/23, 5 days after admission. The facility failed to create and implement a baseline care plan addressing Resident #1's thrush present on admission. On 7/25/23 at 12:10 PM, the Market Clinical Lead stated that all wounds are to be monitored daily and should be documented on the TAR and confirmed that there is not documentation of daily wound monitoring or wound assessments for Resident #1, as per indicated in the skin policy. S/He also confirmed that Resident #1 did not have a complete baseline care plan within 48 hours of admission that addressed, non-pharmaceutical pain-relief, thrush, or incontinence and it should have.

Based on interview, record review, and review of facility policies, the facility failed to ensure that a physician reviewed the total program of care during the required admission visits for 2 of 3 sampled residents (Resident #1 and #3), enter signed and dated progress notes per facility policy for 3 of 3 sampled Residents (Residents #1, #2, and #3), and sign and date resident orders for 3 of 3 sampled residents (Resident #1, #2, and #3). Findings include: Facility policy Standards and Procedures for All Licensed Independent Practitioners, last revised 9/17/21, states, Upon the admission of a patient, the attending physician or advanced practice provider (APP) is required to: Enter appropriate admission orders on the day of admission. These orders should include comprehensive directions as to diet, vital signs, activity level, rehabilitation services, appropriate testing to rule out active tuberculosis, other laboratory and radio graphic testing, advance care plans and limitations of treatment, medications and other treatments and services. The practitioner must write a progress note to the patient chart at the time of each visit. The progress note must state the current medical problems and reflect the patients present medical condition, as well as contain a rationale for starting, continuing, and discontinuing of drugs and other treatment. The progress note must be signed and dated, and provided to the medical record within 24 hours of the visit, either manually, through [the electronic health record; EHR]. Practitioners are responsible for maintaining a complete and accurate medical record in accordance with state and federal law. All orders must be signed and dated in accordance with federal or state requirements . Electronic orders must be managed and validated pursuant to the electronic chart document management protocol. Telephone orders must be signed on the physicians next visit to the center. 1. A hospital transition of care report dated 6/20/23 reveals that Resident #1 was transferred to the facility for sub-acute rehabilitation on 6/20/2023 with 7 wounds on his/her chest and abdomen that resulted from a previous provider leaving on ECG [electrocardiogram; a test that records electrical activity of the heart] leads on [metal electrode] while in an MRI machine [magnetic resonance imaging machine; a scanner using magnets to create images of the body]; and is identified as needing treatment for thrush through 6/22/23. Discharge medications include nystatin (antifungal medication), 100,000 units/ml suspension, 5 mL by mouth 4 times daily for 3 days. A hospital wound note dated 6/20/23 reveals the following wound care to the blisters and burns on Resident #1's chest and abdomen: Blisters/Bullae - daily wound care Mepitel One [a long staying wound dressing to promote healing and minimize pain at dressing changes]- leave in place for 7 - 14d [days] Clean through Mepitel One with saline [salt water solution] Apply thin layer of Aquaphor [ointment] If leaking noted, cover with Mepilex [foam] border dressing; Burns right chest, left flank, midline abdomen, RLQ [right lower quadrant] - daily wound care Clean with saline Continue use of Silvadene [topical antibiotic] Cover with Mepilex border dressing. An admission nursing assessment note dated 6/20/23 reveals that Resident #1's tongue is coated and has oral thrush. There are no admission wound evaluations for Resident #1's blisters and burns. A review of Resident #1's admission orders reveals the following wound care order: Cleanse areas on chest/trunk with wound spray, pat dry, apply small amount of Vaseline to each area and cover with dry dressing until resolved every day shift every other day. Record review of Resident #1's physician orders reveals that an order for nystatin was never entered or placed. Resident #1's Attending Physician progress notes for an admission visit on 6/22/23 does not reflect a review of the resident's wounds, wound treatment, thrush, or treatment for thrush. A Physician note dated 6/24/2023 reveals an acute visit because Resident #1 was experiencing mouth pain. The note states, patient has a burning sensation in the mouth as well as white coating on the inner aspect of the lips and the mouth and throat . [S/he] has mild discomfort with swallowing. On 7/26/23 at 5:00 PM, Resident #1's Attending Physician stated that s/he did not discuss Resident #1's wound care treatment orders with the admitting Registered Nurse and does not know how or why treatment orders were changed from what was on the hospital wound note. S/He is unsure why nystatin was not ordered. 2. Record review reveals that Resident #3 was admitted to the facility on [DATE] for physical therapy evaluation and treatment following a hospital stay related to breathing difficulties and pneumonia. On admission, his/her diagnoses include chronic obstructive pulmonary disease (disease that causes obstructed airflow from the lungs), multiple sclerosis (disease of the central nervous system), hypertension, morbid obesity, and s/he is bed bound. A hospital discharge summary dated 7/7/23, includes the following discharge orders: Budesonide [inhaled steroid to decrease inflammation of the airway] 0.5 mg/2 mL suspension for nebulization [changes liquid to a mist for inhalation], 0.5 mg inhalation BID [twice a day]; cefdinir (antibiotic) 300 mg capsule, 300 mg PO [by mouth] BID [twice a day] with instructions to take the last dose tonight to complete the 5 day course; and doxycycline hyclate (antibiotic) 100 mg tablet, 100 mg PO Q12H [every 12 hours] with instructions to take the last dose tonight to complete the 5 day course. The following medication was discontinued: Cephalexin (antibiotic) 250 mg capsule, daily. Record review of Resident #3's physician orders reveal that orders for doxycycline hyclate and cefdinir were never placed; an order for Budesonide was not placed until 7/25/23, 18 days after admission, and cephalexin was ordered by Resident #3's Attending Physician from 7/8/23 until 7/10/23 , even though cephalexin was discontinued at the hospital. Resident #3's MAR reveals that s/he was administered cephalexin on 7/8/23 through 7/10/23. Resident #3's Attending Physician progress note for an admission visit on 7/13/23 states, Continue cefdinir and doxycycline, per hospital discharge. Continue nebulized budesonide twice daily. The note does not indicate that Resident #3's MAR was reviewed at this visit. The note does not address that Resident #3: did not have orders or receive his/her last dose of cefdinir or doxycycline, which should have been completed on the day of admission, did not have orders or receive budesonide since they were admitted , and had orders and received cephalexin between 7/8/23 and 7/10/23, when the hospital discharge summary indicated that the medication was to be discontinued. On 7/25/23 at 1:25 PM, Resident #3's Attending Physician indicated that s/he is to review each resident's MAR on admission visits. On 7/26/23 at 5:00 PM, Resident #3's Attending Physician stated that s/he is unsure why there were not orders for doxycycline hyclate, cefdinir, and budesonide and confirmed that it should have been. S/He stated that s/he did not place the order for cephalexin and confirmed that the order should not have been placed according to the discharge summary. 3. A review of progress notes shows that Resident #1's 6/22/23 Attending Physician admission visit progress note was not entered into the EHR until 7/20/23, 29 days after the visit; Resident #2's 7/13/23 Attending Physician admission visit progress note was not entered into the EHR until 7/23/23, 10 days after the visit; and Resident #3's 7/13/23 Attending Physician admission visit progress note was not entered into the EHR until 7/23/23, 10 days after the visit. On 7/26/23 at 5:00 PM, Resident #1, #2, and #3's Attending Physician stated that s/he was aware that, per facility policy, physician progress notes are to be in residents' charts within 24 hours. 4. Record review of Resident #1, #2, and #3's physician orders on 7/25/23 reveal that Resident #1's admission orders, with the exception of morphine, Resident #2's admission orders, and Resident #3's admission orders were not signed by the ordering provider. On 7/25/23 at 12:20 PM, the Market Clinical Lead confirmed that Residents #1, #2, and #3's orders had not been signed by the ordering provider. On 7/26/23 at 5:00 PM, Resident #1, #2, and #3's Attending Physician stated that orders get sent to her/him for signature in batches and it could be weeks before s/he signs resident orders.

Based on interview and record review, the facility failed to ensure 3 of 3 sampled resident (Residents #1, #2, and #3) are free from significant medication errors. Findings include: 1. A hospital transition of care report reveals that Resident #1 was transferred to the facility for sub-acute rehabilitation on 6/20/2023 with diagnoses that include: cancer, cancer related pain, severe malnutrition, compression fracture of the spine, and back pain. The note indicates that s/he has 7 wounds on his/her chest and abdomen that resulted from a previous provider leaving on ECG [electrocardiogram; a test that records electrical activity of the heart] leads [metal electrode] on while in an MRI machine [magnetic resonance imaging machine; a scanner using magnets to create images of the body]. His/Her pain was controlled with extended release and immediate release morphine. The report reveals the following as discharge medications orders: Morphine 15 mg CR [extended release], 5 tablets every 12 hours for 2 days; and morphine 15 mg [immediate release], 1 tablet every 3 hours as needed for pain up to 120 mg a day. The hospital medication administration record (MAR) for 6/20/23 reveals that prior to her transfer to the nursing facility she received 75 mg of extended release morphine at 8:04 AM and was due for his/her next dose at 9:00 PM, and 15-30 mg of instant release morphine at 12:20 AM, 4:29 AM, 6:07 AM, 8:11 AM, and 11:41 AM. Review of Resident #1's vitals reveal that his/her pain (on a scale of 0-10, 10 being the worst) on 6/20/23 was documented as a 3 at 2:25 PM, a 10 at 4:11 PM, a 10 at 6:30 PM, a 5 at 6:51 PM, and a 6 at 10:45 PM. On 6/21/23, his/her pain was documented as an 8 at 12:10 AM and a 5 at 3:10 AM. Review of Resident #1's facility MAR reveals that Resident #1 received the following pain-relieving medications on the afternoon and evening of admission, 6/20/23, and early morning 6/21/23: 15 mg of immediate release morphine at 4:11 PM, 15 mg of immediate release morphine at 10:45 PM, and 15 mg of immediate release morphine at 12:10 AM. A telehealth evaluation note dated 6/20/2023 at 7:14 PM indicates that the on-call provider was notified of Resident #1's pain and was requesting additional pain-relieving medication because they did not have pain medication ordered. The note states that Resident #1's pain rating is at a 9. This provider orders Tylenol 1000 every 6 hours as needed. A nurse progress note dated 6/21/23 reveals that Resident #1 had used the call bell at 3:10 AM to ask for her morphine. The resident explained to the nurse that a family member called 911 on his/her behalf and an ambulance was on the way. The nurse documented that the resident stated, I am in excruciating pain and you were not doing anything about it. An EMS (Emergency Medical Services) report indicates the reason for their dispatch to the facility was that Resident #1 was in extreme pain and did not have access to pain meds. The note states, Patient state getting to rehab today and is not getting [his/her] pain medications, not as ordered and in time to manage [his/her] pain and is taking [his/her] medications. patient states [s/he] is in excruciating pain all over especially in [his/her] chest and back, which is the way it was before her pain was managed in hospital. When asked states [s/he] did get [his/her] morphine dose but does not believe that [s/he] got [his/her] full dose. Record review of Resident #2's physician orders reveal that orders for Resident #1's morphine were put in correctly on admission by a registered nurse. These correct orders were subsequently struck out by the Nurse Practitioner and incorrectly reentered into the system. The order for the extended release morphine was put in for one 15 mg tab every 12 hours instead of five 15 mg tabs every 12 hours. On 7/24/23 at 12:15 PM the Market Clinical Lead Stated that s/he had an interview with the Nurse Practitioner who revealed that NP confirmed that s/he entered the order into the system incorrectly. The Market Clinical Lead explained that the facility had not received Resident #1's medications from the pharmacy until approximately midnight on the night of Resident #1's admission, and they should have been received much earlier. In this case, the nurse is expected to get medications from the Pyxis [medication dispensing machine] until the medication is received. The only available morphine in the Pyxis was extended release morphine and the dose of immediate release morphine that was documented on the MAR as administered on 6/20/23 at 4:11 PM was actually extended release morphine. She confirmed that resident did not receive the correct dose of morphine at the facility until the following day. A pharmacy packing slip, dated 6/21/23 and signed as received by the facility on 6/21/23, reveals that Resident #1's morphine IR and morphine ER were not delivered to the facility until the day after s/he was admitted . Resident #1's hospital transition of care note, dated 6/20/23, reveals that Resident #1 is being treated for thrush and has the following discharge medications orders: nystatin (antifungal) 100,000 units/ml suspension, 5 mL by mouth 4 times daily for 3 days. On review of Resident #1's MAR, there is not an order for nystatin. A telehealth evaluation note dated 6/24/2023 indicates that the on-call provider was notified that Resident #1 was experiencing mouth pain. The note states, patient has a burning sensation in the mouth as well as white coating on the inner aspect of the lips and the mouth and throat . [S/he] has mild discomfort with swallowing. On 7/24/23 at 3:29 PM, Resident #1's Attending Physician stated that s/he was not sure why the nystatin was not ordered on admission and confirmed that it should have been. 2. Record review reveals that Resident #2 was admitted to the facility on [DATE] for therapy following a hospital stay related to a right hip fracture surgical repair. On admission, his/her diagnoses include venous insufficiency, anemia, type 2 diabetes, acute respiratory failure, post-surgical pulmonary embolism [PE; a blood clot that has traveled to the lungs], and heart failure. Per the transition of care note discharge medications include enoxaparin [Lovenox;] 80 mg/0.8 ml. Inject 80 mg into the skin every 12 hours for 30 days. Lovenox is an anticoagulant medication. It is used to treat and prevent deep vein thrombosis [DVT; blood clots in a deep vein] and pulmonary embolism. Resident #2 is at risk for developing a DVT or PE because s/he is over 60, is post-surgery, and has a history of PE. Per interview on 7/17/23 at 11:40 AM, Resident #2 stated that s/he was concerned that s/he was not administered Lovenox the night of admission or the following morning. Per record review of Resident #2's physician orders, the order for Resident #2's Lovenox was entered into the EHR [electronic medical record] on 7/10/23 with an incorrect start date and time of 7/11/23, 9:00 PM. Review of Resident #2's MAR confirms that s/he did not receive Lovenox until 9:00 PM on 7/11/23. Per interview on 7/20/23 at 10:01 AM, the Market Clinical Lead stated that it looks like there was a transcription error in entering in Resident #2's admission orders for Lovenox and confirmed that the order should have been started on 7/10/23. 3. Record review reveals that Resident #3 was admitted to the facility on [DATE] for physical therapy evaluation and treatment following a hospital stay related to breathing difficulties and pneumonia. On admission, his/her diagnoses include chronic obstructive pulmonary disease (disease that causes obstructed airflow from the lungs), multiple sclerosis (disease of the central nervous system), urge incontinence (urinary incontinence), hypertension, morbid obesity, and s/he is bed bound. Per a hospital discharge summary dated 7/7/23, Resident #3 was discharged with the following order: Budesonide [inhaled steroid to decrease inflammation of the airway] 0.5 mg/2 mL suspension for nebulization [changes liquid to a mist for inhalation], 0.5 mg inhalation BID [twice a day]. The following medication was discontinued: Cephalexin (antibiotic) 250 mg capsule, daily. Review of Resident #3's MAR reveals that there are no orders for Budesonide treatment from 7/7/23 through 7/25/23, totaling 18 days, and Cephalexin was documented as administered on 7/8/23, 7/9/23, and 7/10/23. Per review of Resident #3's physician orders, an order for Cephalexin Oral Capsule 250 MG (Cephalexin) Give 1 capsule by mouth one time a day for infection for 5 Days, reveals that this was a prescriber written order from Resident #1's Attending Physician given at 7/7/23 at 12:09 PM and entered into the EHR on 7/7/23 at 12:13 PM by a licensed nurse. On 7/26/23 at 5:00 PM, Resident #3's Attending Physician confirmed that Budesonide should have been ordered on admission. S/He stated that s/he did not place the order for cephalexin and confirmed that the order should not have been placed according to the discharge summary. In summary, the facility failed to administer the correct dose and frequency of morphine on the day of admission and nystatin for Resident #1 per the transfer of care; resulting in Resident #1 to suffer extreme pain on the night of admission, and mouth pain related to untreated thrush. The facility failed to administer two doses of Lovenox for Resident #2, putting Resident #2 at risk for developing a DVT or PE. The facility failed to provide orders for and administer budesonide for Resident #3, putting them at risk for breathing complications, and administered cephalexin, which was not ordered by the provider.

Based upon interview and record review, the facility failed to implement a comprehensive person-centered care plan to meet a resident's medical, nursing, and mental and psychosocial needs for 1 resident [Res. #10] of 12 sampled residents. Findings include: Review of Res. #10's medical record reveals the resident's extensive diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Per review of Res. #10's Care Plan, the resident is identified as 'at risk for Pain related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .' The pain medication administration was ordered to begin on 12/22/21 at 9:00 PM. For the next 9 days, the pain medication was to be administered 17 times: per record review, the [MEDICATION(S)] was administered as ordered only twice. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Nurses Notes for the 15 times the [MEDICATION(S)] was not given reveal either no note, notes that simply repeat the order, or entries including ordered, on order, not available, not sent by pharmacy, and not received from pharmacy- there is no documentation that the physician was notified that the medication for Chronic Pain was not received and not administered as ordered. On 12/27/21, 6 days after the medication was to have been started, a Nurses Note reads not available from pharmacy, will contact doctor today for new RX. The next time the [MEDICATION(S)] is due, the medication is again not given and is noted as ordered with no further explanation. Further review of Res. #10's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] =no pain, and 10=worst pain. During the time the resident was ordered to be receiving [MEDICATION(S)] for pain but received none, the resident's pain level on 12/23 was measured as '9 out of 10', on 12/24 a '6' two times, and on 12/25 '7 out of 10'. Per review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Per review of the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Per review of the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Per review of Res. #10's Care Plan, the resident is identified as 'requires indwelling catheter related to: [CONDITION(S)] bladder', with interventions that include 'Provide Catheter care as per physician order'. Per review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Per review of the resident's Treatment Administration Record [TAR] for December 2021, there are spaces on 12/3, 12/6, 12/10, 12/12, 12/14, 12/15, 12/19, 12/24, 12/25, 12/26, 12/27, 12/28, 12/29, 12/30, 12/31/21 where nursing would initial that the treatment was completed as ordered but are left blank. Per review of Res. #10's Care Plan, the resident is identified as 'at risk for altered cardiovascular status related to Hypertension, [CONDITION(S)] vascular disease' with interventions that include 'Administer oxygen as ordered by the physician.' Per review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] @ 2 Liters continuous per nasal cannula every shift related to Acute and Chronic [CONDITION(S)] with [CONDITION(S)].' Per review of the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Per review of Res. #10's Care Plan, the resident is identified as having 'a Stage 3 pressure ulcer on Left ischial tuberosity [hip] related to Immobility related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Per review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . skin prep outside skin around the wound. Pack wound with collagen rope with silver (Ag) and cover with a bordered adhesive foam daily.' Per review of the resident's Treatment Administration Record [TAR] for December 2021, there are spaces on 12/1, 12/4, 12/5, 12/6, 12/7/21 where nursing would initial that the treatment was completed as ordered but are left blank. Further review reveals the wound care was advanced to two times a day, with spaces on the TAR for 12/10, 12/14, 12/15, 12/23, 12/24, 12/25, 12/26, 12/27, 12/28, 12/29, 12/30, 12/31/21 where nursing would initial that the treatment was completed as ordered but are left blank. Additionally, Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . every shift'. Per review of the resident's Treatment Administration Record [TAR] for December 2021, there are spaces on 12/3, 12/6, 12/10, 12/12, 12/14, 12/15, 12/19, 12/24, 12/25, 12/26, 12/27, 12/28, 12/29, 12/30, 12/31/21 where nursing would initial that the treatment was completed as ordered but are left blank. Further record review reveals no documentation regarding why any of the medications and/or treatments listed above were not administered as ordered and per the resident's plan of care. An interview was conducted with the Staff Nurse on Res. #10's unit on 1/4/22 at 1:37 PM. The Staff Nurse confirmed the blank spaces in Res. #10's treatment record and the absence of documentation regarding completion of treatment and implementation of physician orders. The Staff Nurse confirmed there should be no blanks spaces on any resident's TAR. The Staff Nurse confirmed the TAR should be initialed if the treatment or assessment was completed, or there should be documentation as to whether the treatment and assessments were not completed as ordered, but there was none.

Based on resident, family, and staff interviews and record review, the facility failed to ensure that three of four resident in the applicable sample were free from significant medication errors. Findings include: Per interview with the Licensed Practical Nurse (LPN) on duty on 1/3/2022 at 9:15 PM It is impossible to get everything done when it is supposed to get done, the residents complain that their meds are late and that they have to wait for care. One nurse can't do all the meds and treatments and take care of issues when they happen. Per interview with the Unit Manager (UM) on 1/3/2022 at 9:30 PM due to staff shortages s/he has been filling in on the medication cart over the past few weeks. The nurse who is responsible for administering medications is also responsible to do treatments including wound care. When asked if it is difficult getting the medications to the residents timely s/he stated the medication pass is challenging. Sometimes they are late. The UM also stated that there needs to be medication reviews done for medication reduction and changes in administration times. Because there have been so many changes in managers and staffing issues it has made it hard to find time to review the meds. 1. During interview on 1/3/2022 at 11:30 PM Resident #1 stated Medication errors are a big thing. Last weekend the nurse almost gave me too much [MEDICATION(S)]. I watch what they are giving me, like not the right pills. I don't always get my morning pills till afternoon because they are just too busy. This is not good because I take [MEDICATION(S)] (a drug used to treat symptoms of [CONDITION(S)], such as slowness, stiffness, shakiness, and imbalance) five times a day for my [CONDITION(S)] and when I miss a dose or get it late, I have trouble moving. Then I'm taking it so close together. Per record review Resident #1 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physicians order for [MEDICATION(S)]-[MEDICATION(S)] ([MEDICATION(S)]) 25-100 give 2 tablets orally five times a day related to [CONDITION(S)] that is scheduled to be administered at 6:00 AM, 10:00 AM, 2:00 PM, 6:00 PM, and 8:00 PM. Review of Resident #1's time stamped Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The dose scheduled for 2:00 PM was administered at 2:15 PM one hour after the 10:00 AM dose was administered. The December MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Per record review Resident #2 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The doses are scheduled for 9:00 AM and 9:00 PM. Medications scheduled and administered at the same time as the 9:00 AM and 9:00 PM [MEDICATION(S)] include; [MEDICATION(S)] Tablet 3.125 MG Give 1 tablet by mouth two times a day related to Hypertension [MEDICATION(S)] Tablet 600 MG Give 1 tablet by mouth three times a day for pain [MEDICATION(S)] Tablet 500 MG Give 2 tablet by mouth two times a day for muscle spasms [MEDICATION(S)] 20 GM/30 ML Give 67.5 ml by mouth four times a day related to Alcoholic [CONDITION(S)] of the Liver Potassium Chloride ER Tablet Extended Release 20 MEQ Give 2 tablet by mouth one time a day for supplement [MEDICATION(S)] Capsule Delayed Release Particles 60 MG ([MEDICATION(S)]) Give 1 capsule by mouth one time a day related to Major Depressive Disorder [MEDICATION(S)] Tablet 400 MG Give 2 tablet by mouth three times a day for supplement [MEDICATION(S)] Tablet 650 MG Give 1 tablet by mouth three times a day for supplement Administration of [MEDICATION(S)] with other medications can interfere with their absorption. It is recommended that Cholestryramine be administered 1 hour prior to or 4 hours after other medications. Resident #2 also has Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the December 2021 time stamped MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/22/2021 at 8:03 AM Resident #2 received both 8:00 AM and 12:00 PM doses of [MEDICATION(S)], and both 8:00 AM and 2:00 PM doses of [MEDICATION(S)] and Magnesium. 3. Per interview with Resident #3's family member on 1/6/2022 at 1:00 PM s/he stated that on 12/26/2021 at 10:00 AM during a visit, s/he noticed that Resident #3 appeared anxious. S/he was told by staff that the resident had been up since 8:00 AM and had not received the scheduled 8:00 AM medications including a scheduled [MEDICATION(S)]. The medications were not administered until 11:00AM and the resident received the 1:00 PM dose. The family member also reports that the resident was very agitated and took some time to calm down then became zombie like in the afternoon. Per record review Resident # 3 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The December 26, 2021, time stamped MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . S/he then recieved the 12:00 PM dose at 1:06 PM, with only two hours and 26 minutes between doses. Per the December 2021 time stamped MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] 12/6 the dose scheduled for 12:00 PM was administered at 2:12 PM 12/7 the dose scheduled for 12:00 PM was administered at 1:35 PM 12/8 the dose scheduled for 8:00 AM was administered at 10:24 PM 12/11 the dose scheduled for 8:00 AM was administered at 10:10 AM and the 12:00 PM dose was administered at 1:44 PM 12/16 the dose scheduled for 8:00 AM was administered at 10:38 AM and the 12:00 PM dose was administered at 2:08 PM 12/17 the dose scheduled for 8:00 AM was administered at 12:16 PM and the 12:00 PM dose was administered at 2:35 PM 12/21 the dose scheduled for 12:00 PM was administered at 2:30 PM 12/22 the dose scheduled for 8:00 AM was administered at 11:19 AM and the 12:00 PM dose was administered at 2:40 PM 12/23 the dose scheduled for 12:00 PM was administered at 2:00 PM 12/24 the dose scheduled for 12:00 PM was administered at 3:28 PM 12/25 the dose scheduled for 8:00 AM was administered at 10:29 AM and the 12:00 dose was administered at 2:06 PM Review of the facility Medication Administration policy and procedure, titled, NSG305 Medication Administration: General revealed the following: Page 1 Purpose To provide a safe, effective medication administration process. Under PRACTICE STANDARDS, #5. Doses will be administered within one hour of the prescribed time unless otherwise indicated by the prescriber. 5.1.4 If unable to provide the medication9s0 or substitution(s) within one hour of prescribed time, refer to Medication Errors ploicy. Per interview with the Interim Director of Nursing and Regional Nurse Consultant the on 1/4/2022 at Medication Administration policy provided by the facility reflects that medications are to be administered between one hour prior to and one hour after the prescribed scheduled times. Confirmation that medications given outside the hour parameters are considered medication errors was made.

Based upon observation, interview, and record review, the facility failed to ensure services provided met professional standards of quality regarding resident medications administered as ordered, treatments administered as ordered, and assessments completed as ordered for 1 resident [Res.# 10] of 12 sampled residents. Findings include: Review of the American Nurses Association's Standards of Professional Nursing Practice (Nursing: Scope and Standards of Practice (wordpress.com)) reveals: The Standards of Professional Nursing Practice are authoritative statements of the duties that all registered nurses, regardless of role, population, or specialty, are expected to perform competently. Under 'Standard 5. Implementation: -The registered nurse implements the identified plan. - Implements the plan in a timely manner in accordance with patient safety goals. -Documents implementation and any modifications, including changes or omissions, of the identified plan'. Review of Res. #10's medical record reveals the resident's extensive diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Per review of Res. #10's Care Plan, the resident is identified as 'at risk for Pain related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .' The pain medication administration was ordered to begin on 12/22/21 at 9:00 PM. For the next 9 days, the pain medication was to be administered 17 times: per record review, the [MEDICATION(S)] was administered as ordered only twice. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Nurses Notes for the 15 times the [MEDICATION(S)] was not given reveal either no note, notes that simply repeat the order, or entries including ordered, on order, not available, not sent by pharmacy, and not received from pharmacy- there is no documentation that the physician was notified that the medication for Chronic Pain was not received and not administered as ordered. On 12/27/21, 6 days after the medication was to have been started, a Nurses Note reads not available from pharmacy, will contact doctor today for new RX. The next time the [MEDICATION(S)] is due, the medication is again not given and is noted as ordered with no further explanation. Further review of Res. #10's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] =no pain, and 10=worst pain. During the time the resident was ordered to be receiving [MEDICATION(S)] for pain but received none, the resident's pain level on 12/23 was measured as '9 out of 10', on 12/24 a '6' two times, and on 12/25 '7 out of 10'. Per review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Per review of the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Per review of the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Per review of Res. #10's Care Plan, the resident is identified as 'requires indwelling catheter related to: [CONDITION(S)] bladder', with interventions that include 'Provide Catheter care as per physician order'. Per review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Per review of the resident's Treatment Administration Record [TAR] for December 2021, there are spaces on 12/3, 12/6, 12/10, 12/12, 12/14, 12/15, 12/19, 12/24, 12/25, 12/26, 12/27, 12/28, 12/29, 12/30, 12/31/21 where nursing would initial that the treatment was completed as ordered but are left blank. Per review of Res. #10's Care Plan, the resident is identified as 'at risk for altered cardiovascular status related to Hypertension, [CONDITION(S)] vascular disease' with interventions that include 'Administer oxygen as ordered by the physician.' Per review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] @ 2 Liters continuous per nasal cannula every shift related to Acute and Chronic [CONDITION(S)] with [CONDITION(S)].' Per review of the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Per review of Res. #10's Care Plan, the resident is identified as having 'a Stage 3 pressure ulcer on Left ischial tuberosity [hip] related to Immobility related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Per review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . skin prep outside skin around the wound. Pack wound with collagen rope with silver (Ag) and cover with a bordered adhesive foam daily.' Per review of the resident's Treatment Administration Record [TAR] for December 2021, there are spaces on 12/1, 12/4, 12/5, 12/6, 12/7/21 where nursing would initial that the treatment was completed as ordered but are left blank. Further review reveals the wound care was advanced to two times a day, with spaces on the TAR for 12/10, 12/14, 12/15, 12/23, 12/24, 12/25, 12/26, 12/27, 12/28, 12/29, 12/30, 12/31/21 where nursing would initial that the treatment was completed as ordered but are left blank. Additionally, Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . every shift'. Per review of the resident's Treatment Administration Record [TAR] for December 2021, there are spaces on 12/3, 12/6, 12/10, 12/12, 12/14, 12/15, 12/19, 12/24, 12/25, 12/26, 12/27, 12/28, 12/29, 12/30, 12/31/21 where nursing would initial that the treatment was completed as ordered but are left blank. Per record review, Nurses Notes include only sporadic references to treatments e.g. 12/25/21 Did not occur. Further record review reveals no explanation regarding why any of the medications and/or treatments listed above were not administered as ordered and per the resident's plan of care, or of the physician being notified that medications and treatments were never received.

Based on record review and staff interview, the facility failed to provide the necessary care and services consistent with professional services to one resident with venous stasis ulcers. (Resident # 1) Findings include: 1. Resident # 1, who had a significant vascular condition resulting in impaired blood flow to the left leg, developed two venous stasis ulcers on the left lower leg on 8/8/17 and 2/6/18. The assessment tool Skin-Venous (stasis) Ulcer v4 sheet last completed on 2/15/18 described the new stasis ulcer as being 6.5 centimeters long x 2.3 centimeters wide, and the older ulcer as being 3 centimeters long x 2.3 centimeters wide. One stasis ulcer had improved, but the new stasis ulcer had deteriorated. The DNS reported that skin assessments are conducted weekly on residents with pressure ulcers, venous stasis ulcers and for other skin issues such as skin tears and lacerations. Following the assessment completed on 2/15/18, no other venous stasis assessments were completed monitoring the size, appearance, pain, palpable pulses, drainage or if the ulcers had improved or deteriorated. The nursing notes did not include any description of the stasis ulcers following the 2/15/18 assessment. A separate document, Skin Check dated 2/22/18, used to assess Resident #1's skin tears, documented the presence of left lower leg. Vascular ulcers. No assessment was done related to the size, appearance, palpable pulses, pain, drainage or if the stasis ulcers had improved or deteriorated. A Wound Management Tracking Tool used by the DNS during wound rounds on 2/22/18 included the size of the two stasis ulcers, but the 2/28/18 assessment did not include any measurements. The wound measurements obtained on 2/22/18 were not incorporated into Resident # 1's medical record monitoring the condition of the ulcers. In addition to the lack of weekly assessments for the stasis ulcers after 2/15/18, there were no nursing notes monitoring Resident # 1's stasis ulcers or h/her general condition. The last nursing note was an eMAR note dated 2/24/18 concerning the application of hydraguard lotion to both heels and a Una boot to the left heel. Upon interview on 3/13/18 at 11:30 AM, the DNS confirmed the lack of monitoring and assessment of the ulcers stating the 'populated files' that would have prompted follow up assessments and documentation in the electronic medical record had been accidentally deleted. Per review of physician orders, on 2/28/18 at 11:35 AM, the physician ordered a referral to the wound clinic. The DNS reported that staff was very concerned about Resident # 1's leg, however, there was no documentation in the nursing notes describing Resident # 1's leg or h/her condition. Later that evening, Resident # 1's left lower leg was described as ice cold, deep purple in color with a foul odor emanating from the ulcer, Resident # 1 also had a fever of 101.3 degrees. Resident # 1 was admitted to a local hospital with an ischemic limb, which is a decreased supply of [MEDICATION NAME] blood to a body part. Hospital records noted Resident #1's anterior left leg stasis ulcer measured 10 cm x 8 cm which was covered with eschar (scab or dry crust). In addition eschar, was present on the dorsal surfaces of the 3rd, 4th and 5th toes. During interview with the Unit Manager on 3/15/18 @ 2:24 PM, Resident #1 had small dry scabbed on the toes of the left foot prior to her transfer to the hospital, but h/she hadn't seen them in a couple of weeks.

Based on staff interview and medical record review, the facility failed to ensure that each resident receives the necessary care and services to maintain the highest practicable physical well-being for 2 of 3 sampled residents (Resident #1 and #2) regarding proper assessment and monitoring after falls. The findings include the following: 1. Per record review, Resident #1, who is [AGE] years of age, was admitted with [DIAGNOSES REDACTED]. Resident #1 has had documented falls as follows: [DATE] at 11:36 AM Resident witnessed falling backwards into the medication cart located in the hallway; [DATE] Resident sat on the floor after feeling dizzy; [DATE] at 7:30 PM Resident backing out of his/her room attempting to close the stop sign on the door, lost his/her balance and fell to the floor. This incident was not witnessed; [DATE] Resident was witnessed lowering self to the floor twice on the evening shift. Nurses notes identify that the resident was ambulating with an unsteady gait; [DATE] at 12 noon staff heard a large crash and found resident on the floor. Family was present during the fall; [DATE] at 10:45 AM Resident was found lying on his/her left side in front of the closet. Sustained a small laceration on right temple by the eyebrow. Resident was also witnessed placing him/her self on the floor and getting up independently on 4 different times during the shift; [DATE] at 8:30 AM Resident was witnessed standing up and sitting/falling in the dining room; [DATE] at 11:15 AM Resident found on his/her hands and knees at the foot of the bed; [DATE] staff witnessed resident crawl out of bed on to the floor next to the bed. Registered Nurse identifies that the resident will be monitored. After each of the above falls, Resident #1 was assessed for injury by the Licensed Practical Nurse (LPN) on duty. Per the Vermont Board of Nursing Position Statement, "LPNs may not independently assess the health status of an individual or group and may not independently develop or modify the plan of care. LPNs may contribute to the assessment and nursing care planning processes; however, patient assessment and care plan development or revision remain the responsibility of the RN, APRN, or other authorized health care practitioner." Only two of the 9 listed incidents were reported to the Director of Nurses (DNS). Progress notes dated [DATE] evidence that the resident requested, his/her back x-rayed. The nurse documented that the resident was difficult to follow. Family notified of rib complaint and family voiced that the ("resident was favoring that side yesterday. It is new.") Family told the nurse that it has been going on a couple of weeks. On [DATE], a Physician order [REDACTED]." Nurses note [DATE] identifies that physician informed nurse he would not do the x-ray unless Resident #1 was having breathing issues. Progress notes from [DATE] to [DATE] do not evidence that any professional staff conducted a respiratory/lung assessment, nor is there any evidence identifying that the X-Ray was ever considered. An [DATE] LPN progress note identifies that Resident #1 was "moaning loudly, (s/he) could be heard all the way down the hallway." On [DATE] the Attending Physician was notified that the resident has been talking about wanting to kill himself, spit out medication and staff advised to transport to the Emergency Department (ED) for evaluation. There is no evidence in the medical record that the resident had any bruises or abrasions throughout his/her stay at the facility. On exam in the ED on [DATE], documentation evidences that Resident #1 had multiple bruises of his/her arms and diagnostic imaging showed a [MEDICAL CONDITION]. The Resident was then transferred to the VA Hospital for the management of pneumonia and a closed [MEDICAL CONDITION]. Resident #1 died on [DATE] after attempted Cardiac [MEDICAL CONDITION] Resuscitation failed. Per interview with the DNS on [DATE] confirmation was made at 9:15 AM that a Registered Nurse (RN) assessment was not conducted for the above listed incidents. 2. Per medical record review, Resident #2 fell on [DATE] at approximately 1145. Resident was found on the floor in the bathroom after attempting to transfer independently. Resident was assessed by the Registered Nurse (RN) and neurological vital signs were begun. Neurological Evaluation Flow Sheet identifies that neurological evaluation was not conducted on [DATE] for the ,[DATE] shift. On [DATE] Resident was found sitting on the floor next to his/her bed. Resident was assessed by the Licensed Practical Nurse (LPN) on duty and neurological signs were begun. Neurological Evaluation Flow Sheet identifies that neurological evaluation was not conducted as per policy for the first hour, nor was evaluation conducted on day 3 during the ,[DATE] shift. Per facility policy for Neurological assessment dated [DATE] evidences that neurological assessments are to be completed on unwitnessed falls and completed every 15 minutes for 1 hour, every 30 minutes for 4 hours, every hour for 2 hours and every shift for 72 hours unless specified by MD. Per interview with the Director of Nurses on [DATE] at 9:04 AM confirmation is made that the neurological assessments were not completed as per policy, nor was the resident assessed after the fall of [DATE] by an RN. (See also F281) References: 1. Lippincott Manual of Nursing Practice (9th ed.). Wolters Kluwer Health/Lippincott Williams & Wilkins. 2. Vermont State Board of Nursing - The Role of the Licensed Practical Nurse in Patient Assessment and Triage - Position Statement. https://www.sec.state.vt.us/media/ 5/PS-Role-of-LPNs-in-Triage.pdf (accessed [DATE]).

Based on staff interview and medical record review, the facility failed to ensure services provided met professional standards of quality for 2 of 3 residents in the sample. Resident #1 was not assessed by a Registered Nurse (RN) after numerous falls, nor was the resident's change in condition acted upon. For Resident #2, an RN assessment was not completed after a fall nor was the resident closely monitored for a possible head injury. The findings include the following: 1. Per record review, Resident #1, who is [AGE] years of age, was admitted with [DIAGNOSES REDACTED]. Resident #1 has had documented falls as follows: [DATE] at 11:36 AM Resident witnessed falling backwards into the medication cart located in the hallway; [DATE] Resident sat on the floor after feeling dizzy; [DATE] at 7:30 PM Resident backing out of his/her room attempting to close the stop sign on the door, lost his/her balance and fell to the floor. This incident was not witnessed; [DATE] Resident was witnessed lowering self to the floor twice on the evening shift. Nurses notes identify that the resident was ambulating with an unsteady gait; [DATE] at 12 noon staff heard a large crash and found resident on the floor. Family was present during the fall; [DATE] at 10:45 AM Resident was found lying on his/her left side in front of the closet. Sustained a small laceration on right temple by the eyebrow. Resident was also witnessed placing him/her self on the floor and getting up independently on 4 different times during the shift; [DATE] at 8:30 AM Resident was witnessed standing up and sitting/falling in the dining room; [DATE] at 11:15 AM Resident found on his/her hands and knees at the foot of the bed; [DATE] staff witnessed resident crawl out of bed on to the floor next to the bed. Registered Nurse identifies that the resident will be monitored. After each of the above falls, Resident #1 was assessed for injury by the Licensed Practical Nurse (LPN) on duty. Per the Vermont Board of Nursing Position Statement, "LPNs may not independently assess the health status of an individual or group and may not independently develop or modify the plan of care. LPNs may contribute to the assessment and nursing care planning processes; however, patient assessment and care plan development or revision remain the responsibility of the RN, APRN, or other authorized health care practitioner." Only two of the 9 listed incidents were reported to the Director of Nurses (DNS). Progress notes dated [DATE] evidence that the resident requested, his/her back x-rayed. The nurse documented that the resident was difficult to follow. Family notified of rib complaint and family voiced that the ("resident was favoring that side yesterday. It is new.") Family told the nurse that it has been going on a couple of weeks. On [DATE], a Physician order [REDACTED]." Nurses note [DATE] identifies that physician informed nurse he would not do the x-ray unless Resident #1 was having breathing issues. Progress notes from [DATE] to [DATE] do not evidence that any professional staff conducted a respiratory/lung assessment, nor is there any evidence identifying that the X-Ray was ever considered. An [DATE] LPN progress note identifies that Resident #1 was "moaning loudly, (s/he) could be heard all the way down the hallway." On [DATE] the Attending Physician was notified that the resident has been talking about wanting to kill himself, spit out medication and staff advised to transport to the Emergency Department (ED) for evaluation. There is no evidence in the medical record that the resident had any bruises or abrasions throughout his/her stay at the facility. On exam in the ED on [DATE], documentation evidences that Resident #1 had multiple bruises of his/her arms and diagnostic imaging showed a [MEDICAL CONDITION]. The Resident was then transferred to the VA Hospital for the management of pneumonia and a closed [MEDICAL CONDITION]. Resident #1 died on [DATE] after attempted Cardiac [MEDICAL CONDITION] Resuscitation failed. Per interview with the DNS on [DATE] confirmation was made at 9:15 AM that a Registered Nurse (RN) assessment was not conducted for the above listed incidents. 2. Per medical record review, Resident #2 fell on [DATE] at approximately 1145. Resident was found on the floor in the bathroom after attempting to transfer independently. Resident was assessed by the Registered Nurse (RN) and neurological vital signs were begun. Neurological Evaluation Flow Sheet identifies that neurological evaluation was not conducted on [DATE] for the ,[DATE] shift. On [DATE] Resident was found sitting on the floor next to his/her bed. Resident was assessed by the Licensed Practical Nurse (LPN) on duty and neurological signs were begun. Neurological Evaluation Flow Sheet identifies that neurological evaluation was not conducted as per policy for the first hour, nor was evaluation conducted on day 3 during the ,[DATE] shift. Per facility policy for Neurological assessment dated [DATE] evidences that neurological assessments are to be completed on unwitnessed falls and completed every 15 minutes for 1 hour, every 30 minutes for 4 hours, every hour for 2 hours and every shift for 72 hours unless specified by MD. Per interview with the Director of Nurses on [DATE] at 9:04 AM confirmation is made that the neurological assessments were not completed as per policy, nor was the resident assessed after the fall of [DATE] by an RN. (See also F309) References: 1. Lippincott Manual of Nursing Practice (9th ed.). Wolters Kluwer Health/Lippincott Williams & Wilkins. 2. Vermont State Board of Nursing - The Role of the Licensed Practical Nurse in Patient Assessment and Triage - Position Statement. https://www.sec.state.vt.us/media/ 5/PS-Role-of-LPNs-in-Triage.pdf (accessed [DATE]).

Based on record review and interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of two residents sampled. (Resident #1). Findings include: Per record review on 4/17/13, Resident #1 was found by the staff on the morning of 4/6/13 to be sitting on the edge of the bed with a bedpan under his/her buttocks. According to staff staements, the LNAs laid the resident back down, removed the bedpan, and discovered that there were open areas on the resident ' s buttocks. The nurse was informed, and assessed the wounds as a horseshoe shaped series of skin tears on the right and left buttocks. Per interview on 4/17/13 at 11:30 AM, Resident #1 was not clear about who placed them on the bedpan or when, stating that they did not want to say, however stated that they had been sitting on the bedpan since the previous day. The facility investigation into the incident was conducted, and no definite conclusion was drawn as to the actual time or person that placed the bedpan under the resident. Per review of the plan of care, there was an update made on 4/12/13, which stated that the VA hospital assessed this as a pressure wound caused by the bedpan There was no update to the care plan to identify the new wound identified on 4/6/13, until the resident returned to the facility after hospitalization on [DATE]. Although there was some discrepancy regarding the categorization of the wound as a skin tears or a Stage 2 pressure ulcer, there was no question as to the source of the wound being from sitting on the bedpan. Per interview on 4/17/13 at 4:10 PM, the Director of Nursing stated that the LNAs had been educated to have outgoing and incoming LNAs check all residents at change of shift rounds for incontinence, if a bedpan was in place, if call bell was in reach, and check for any resident needs at that time. Per this same interview, the DNS also confirmed that despite the unclear series of events leading up to the bedpan being discovered under the resident, and the discrepancy of what type of wound to call this, there was no doubt that the open areas were caused by the resident sitting on the bedpan for some extended period of time.

Based upon interview and record review, the facility failed to assure that 1 applicable resident received sufficient amount of fluids based upon individual needs, who then required admission to an Intensive Care Unit at a local hospital the same day as discharge from the facility for dehydration. (Resident #1). Findings include: Per Policy Review "Resident Hydration and Prevention of Dehydration" and confirmed during interview with the Director of Nursing (DNS) on 2/29/12 at 1:10 PM, the policy states the dietician will assess all residents for hydration adequacy at least quarterly and more often as necessary per resident need. Minimum fluid needs will be calculated and documented on initial assessment, nursing will assess for signs and symptoms of dehydration during physical care, and if potential inadequate intake and/or signs of symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the care plan, the dietician, nursing staff and the physician will assess factors that may be contributing to inadequate fluid intake. Per record review of the Registered Dieticians Nutritional assessment dated [DATE] and confirmed with the Registered Dietician (RD) on 2/29/12 at 11:38 AM, Resident #1's nutritional assessment was incomplete and did not include the estimated nutrient needs for calories or fluids. During the interview, the RD stated s/he did not update the nutritional assessment upon admission and prior to discharge. The RD stated that Resident #1's food and fluid requirements were not calculated during the resident's stay. Per interview on 2/29/12 at 12:05 PM the RD calculated, per request of the surveyor, that Resident #1's daily fluid requirement is 1648 cc fluid per day based upon a height of 69 inches and recorded weight of 145 pounds. Per record review of the nursing notes and confirmed with the DNS on 2/29/12, Resident #1 had 3 loose stools on 2/14/12 and Norovirus (gastrointestinal illness) was present in the facility on this date. Per record review and confirmed with the Registered Dietician (RD) on 2/29/12 at 11:38 AM, the 'Follow Up Question Report: What percentage of the meal was eaten', Resident #1 consumed 19 meals from 2/3/12 to 2/19/12 (ending at 1:39 PM). At 12 of those 19 meals, the resident consumed less than 50% of the meal. From 2/10/12 (starting at 2:40 PM) to 2/21/12, the resident consumed 33 meals. The resident refused 7 of 33 meals, and for 23 of 33 meals, the resident consumed less than 50% of the meal. In addition, the 2/9/12 RD Progress Note for Resident #1 states "Nutrition assessment: PO (oral) intake overall fair with approximately 2/3 of meals at 25%; Decreased appetite prior to admission noted, expected to improve as as resident adjusts/recovers". Also, the RD stated that at the 2/16/12 Weight Meeting, food refusal for all residents was noted and discussed at the interdisciplinary meeting and no dietary supplements were ordered for Resident #1. Per record review of documents obtained from Central Vermont Medical Center, the 2/21/12 Emergency Department Physician Summary states: "Diagnosis Primary: Dehydration; Patient Status: Patient status is critical; Chief Complaint: The caregiver found (Resident #1) half off the chair and unresponsive so called EMS (Emergency Medical Services); Severity: Maximum severity is severe, currently symptoms are severe". Per record review of the 2/21/12 Emergency Department Physician Summary History and Physical, Resident #1's, "Chief Complaint: unresponsive"; Clinical Impression: significant volume depletion and sodium is markedly elevated at 156"; Disposition: (Resident #1) will be admitted to the ICU (Intensive Care Unit) as a full admission". ;

Based upon interview and record review, staff failed to meet professional standards of quality for 1 applicable resident by: 1) Failing to notify the Physician concerning a low blood pressure reading; 2) Failing to notify the Physician that the Resident was very drowsy and unresponsive at the time of discharge; and 3) Not monitoring the Resident's intake and output when indicated. (Resident #1) In addition, Resident #1 required an admission to an Intensive Care Unit at a local hospital the same day as discharge from the facility for dehydration. Findings include: Per record review of the Physician Orders, Nursing Notes and documentation of blood pressure readings for Resident #1, and confirmed with the Director of Nursing (DNS) on 2/29/12 at 1:27 PM, the Resident's Blood Pressure (BP) was documented as 88/48 on 2/18/12. Staff did not report the low BP to the Physician (MD) and did not assess Resident #1 per Facility policy "Blood Pressure, Measuring" for low blood pressure readings. Per review of the Facility policy, "Blood Pressure, Measuring": [MEDICAL CONDITION] is defined as blood pressure less than 100/60 mm/hg. The policy states that [MEDICAL CONDITION] should be reported to the physician and that staff should record several readings throughout the day, including before and after meals. Per record review and confirmed with the DNS on 2/29/12 at 1:27 PM, there is no documentation of additional BP readings per Facility Policy for Resident #1 and the 2/18/12 nursing note states Resident #1 is oriented to name and unable to follow simple commands. Per record review and confirmed with the Director of Nursing (DNS) on 2/29/12 at 2:03 PM, the 2/3/12 the Admission Nursing Evaluation for Resident #1 states: "Mobility: Ambulates with assist of one; Comments: Ambulates with a walker device and one assist". The 2/21/12 Nursing Discharge Note states, "discharged today home with his son and home health services. Resident did not participate in transfers from bed to wheelchair or wheelchair to car. Very drowsy, non responsive. PT (Physical Therapy) informed." In addition, the DNS confirmed that the MD (physician) was not informed of the resident's condition at time of discharge. Per staff interview with a Licensed Practical Nurse (LPN) on 2/29/12 2:45 PM (with Director of Nursing present during the interview), the resident was discharged on [DATE] at 11:00 AM. Prior to exiting the building, s/he stated the resident was very drowsy. The LPN and LNA (Licensed Nursing Assistant) had to "pick him up to move him from the bed to the wheelchair". The LPN stated s/he informed the Unit Manager that the resident was very drowsy and not responding to commands. The LPN was directed to proceed with the discharge. The LPN and LNA transported the resident to the car via wheelchair and the resident was unable to assist them in transferring from the wheelchair to the car. The LPN notified the Unit Manager a second time and was told to contact Physical Therapy concerning how they transfer the resident. The LNA picked up the resident and pivoted him/her in the car. The resident's son stated he did not know how he was going to transfer the resident from the car to the house. When the LPN returned to the facility, s/he told the Unit Manager that s/he did not think the resident should have been discharged . Per record review and confirmed during interview with the Director of Nursing (DNS) on 2/29/12 at 1:10 PM, Resident #1 was not on Intake and Output monitoring. Per facility policy "Resident Hydration and Prevention of Dehydration, "The dietician will assess all residents for hydration adequacy at least quarterly and more often as necessary per resident need. Minimum fluid needs will be calculated and documented on initial assessment, nursing will assess for signs and symptoms of dehydration during physical care, and if potential inadequate intake and/or signs of symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the care plan, the dietician, nursing staff and the physician will assess factors that may be contributing to inadequate fluid intake. Per record review of the 2/14/12 nursing notes and confirmed with the DNS on 2/29/12, the resident had 3 loose stools on 2/14/12 and Norovirus (gastrointestinal illness) was present in the facility on this date. Per record review of the 'Follow Up Question Report: What percentage of the meal was eaten' for Resident #1 and confirmed with the Registered Dietician on 2/29/12 at 11:38 AM, from 2/3/12 to 2/10/12 (ending at 1:39 PM), Resident #1 consumed 19 meals. At 12 of those 19 meals, the resident consumed less than 50% of the meal. From 2/10/12 (starting at 2:40 PM) to 2/21/12, the resident consumed 33 meals. The resident refused 7 of 33 meals, and for 23 of 33 meals, the resident consumed less than 50% of the meal. Per record review of documents obtained from Central Vermont Medical Center, the 2/21/12 Emergency Department Physician Summary states: "Diagnosis Primary: Dehydration, Patient Status: Patient status is critical; Chief Complaint: The caregiver found (Resident #1) half off the chair and unresponsive so called EMS (Emergency Medical Services); Severity: Maximum severity is severe, currently symptoms are severe". Per record review of the 2/21/12 Emergency Department Physician Summary History and Physical, Resident #1's, "Chief Complaint: unresponsive"; Clinical Impression: significant volume depletion and sodium is markedly elevated at 156"; Disposition: (Resident #1) will be admitted to the ICU (Intensive Care Unit) as a full admission". Also see F201 and 327.

Based upon interview and record review, the facility failed to ensure that a discharge was appropriate because the resident's health improved sufficiently so the resident no longer needed services provided by the facility for one applicable resident. (Resident #1). Findings include: Per record review and confirmed with the Director of Nursing (DNS) on 2/29/12 at 2:03 PM, the 2/3/12 the Admission Nursing Evaluation for Resident #1 states: "Mobility: Ambulates with assist of one, Comments: Ambulates with a walker device and one assist". The 2/21/12 Nursing Discharge Note states, "discharged today home with his son and home health services. Resident did not participate in transfers from bed to wheelchair or wheelchair to car. Very drowsy, non responsive. PT (Physical Therapy) informed." In addition, the DNS confirmed that the MD (physician) was not informed of the resident's condition at time of discharge. Per staff interview with a Licensed Practical Nurse (LPN) on 2/29/12 at 2:45 PM (with the DNS present during the interview), Resident #1 was discharged on [DATE] at 11:00 AM. Prior to exiting the building, s/he stated that Resident #1 was very drowsy. The LPN and LNA (Licensed Nursing Assistant) had to "pick him up to move him from the bed to the wheelchair ". The LPN stated s/he informed the Unit Manager that the resident was very drowsy and not responding to commands. The LPN was directed to proceed with the discharge. The LPN and LNA transported the resident to the car via wheelchair and the resident was unable to assist them in transferring from the wheelchair to the car. The LPN notified the Unit Manager a second time and was told to contact Physical Therapy concerning how they transfer the resident. The LNA picked up the resident and pivoted him/her into the car. The resident's son stated he did not know how he was going to transfer the resident from the car to the house. After returning to the facility, the LPN informed the Unit Manager that s/he did not think that Resident #1 should have been discharged . Per record review of documents obtained from Central Vermont Medical Center, the 2/21/12 Emergency Department Physician Summary states: "Diagnosis Primary: Dehydration; Patient Status: Patient status is critical; Chief Complaint: The caregiver found (Resident #1) half off the chair and unresponsive so called EMS (Emergency Medical Services); Severity: Maximum severity is severe, currently symptoms are severe". Per record review of the 2/21/12 Emergency Department Physician Summary History and Physical, Resident #1's, "Chief Complaint: unresponsive"; Clinical Impression: significant volume depletion and sodium is markedly elevated at 156"; Disposition: (Resident #1) will be admitted to the ICU (Intensive Care Unit) as a full admission". Also see F281