Every finding on record at Renaissance Care Center

Based on interviews and record reviews, the facility failed to properly maintain the mechanical lift slings for one of three residents (R1) reviewed for falls in a sample of three. This failure resulted in R1 being emergently transferred to the ER (Emergency Room), receiving medical treatment for an acute intertrochanteric right femur fracture. Findings Include:The facility's Hydraulic Lift (Total Body) policy dated 12/10/2025 documents, Purpose: To provide nursing staff with proper guidelines for use of a hydraulic lift. Policy: All nursing staff will be trained on the proper use of the Hydraulic Mechanical Lifts that are used within the facility, to ensure safe transfer for residents. Mechanical Lift will be used as ordered and per nursing judgment. Responsibility: It is the responsibility of the Director of Nurses to ensure that all nursing staff have received proper training on the Mechanical lift prior to using it. It is the responsibility of all nursing staff to ensure that policies and procedures are followed when using a Mechanical lift. Positioning sling for resident in seated position: 16. Prior to lifting an individual, make sure that the straps of the sling are securely placed on the hooks of the carry bar.The facility's Full Body Sling Instruction Manual does not date documents. WARNING: Carefully inspect the sling before each use for wear and damage to seams, fabric, straps, and strap loops. Torn, cut, frayed, or broken slings can fail, resulting in serious personal injury to the user. Use only slings that are in good condition. Discard and destroy old, unusable slings. Washing Instructions: 1. Machine wash warm or cold, a. Maximum washing temperature 185 F (85 C), b. Wash at 160 F (71 C) for 3 minutes, c. Wash at 145 F (63 C) for 10 minutes, d. Air dry, or tumble dry at cool or very low temperature, e. Do not tumble dry at high temperature. 2. Use a non-enzyme detergent. 3. Do not use bleach. 4. Do not wash with other colors. WARNING: After each laundering (in accordance with instructions on the sling), inspect sling(s) for wear, tears, and loose stitching. Bleached, torn, cut, frayed, or broken slings are unsafe and could result in injury. Discard immediately.The facility's Guideline for Identifying Deteriorated Slings not dated documents, Accelerated Deterioration from Bleach, High Temperature Wash or Drying Slings, especially loop straps that have been damaged from being laundered in unsuitable conditions (bleach, high heat wash or dry) may appear to be in good condition but the actual tensile strength of the material may be compromised and pose a safety risk and should not be used for lifting a patient or resident. Proactive Medical slings have been designed and tested for laundry wash conditions of 170F (Fahrenheit) degrees and air dry or dry at low temperature. The slings should never be bleached. Commercial washers and dryers are not recommended. Care instructions on the sling label should always be followed. Laundry equipment should be properly maintained and repaired when necessary. Causes of Deterioration Due to Laundry Conditions: 1. Chemical degradation (bleach, peroxide, chlorine, and other disinfectants). This can occur if bleach was used in high amounts or high-concentration bleach was used during the wash cycle. Washing at higher temperatures will make the fabric more susceptible to attack by the chemical. Insufficient flush, rinse, or neutralizing of the chemicals from fabric, followed by subsequent drying at high temperature will again intensify chemical action and increase the degree of deterioration to the sling fabric. 2. Temperature or high heat damage. This can occur if the slings are left in the dryer for too long or dried at excessive heat. The Slings are made from plastic fibers and do not absorb as much water and require less drying time than other laundry of natural fiber and fabric. 3. Mechanical/Wash Action can contribute to the accelerated deterioration of the slings, especially if they have been subjected to the above conditions. Slings should be washed using a gentle cycle to minimize excessive agitation and internal fiber abrasion.R1's admission Record dated 12/9/2026 documents, Multiple Sclerosis, Nondisplaced Intertrochanteric Fracture of Right Femur.R1's Care Plan dated 12/9/2026 documents, I have an ADL (Activities of Daily Living) Self Care Performance Deficit related to impaired mobility related to MS (Multiple Sclerosis), and muscle weakness. Revision on: 09/21/2020. TRANSFER: R1 requires Mechanical Aid, (Mechanical Lift) for transfers; Assists x 2 (two people must assist with transferring). Date Initiated: 08/02/2022. Revision on: 03/18/2024.R1's MDS (Minimum Data Set) dated 10/4/2025 section GG documents, Functional Limitation in Range of Motion, Upper extremity, 0 (no impairment) and Lower Extremity 2 (impairment on both sides).R1's MDS dated [DATE] section GG documents, Functional Limitation in Range of Motion, Upper extremity 0 (no impairment) and Lower Extremity 1 (impairment on one side).R1's Emergency History of Present Illness dated 12/9/2025 documents, R1 presents to the emergency department by ambulance for right hip and right arm pain. R1 was being transferred via (mechanical lift) at the nursing home when the mechanical lift sling broke causing R1 to fall onto the bed. R1 denies hitting her head or neck pain. X-ray demonstrates an acute intertrochanteric right femur fracture. Normal humerus X-ray. Orthopedic surgery was consulted. R1 admitted to MS (medical surgical floor) for further treatment.The facility's QA (questions and answers) meeting dated 12/2025 documents, Upon investigation, it was identified that the Housekeeping Supervisor had been responsible for managing (mechanical lift) sling rotation and tracking. When the supervisor resigned from the position, this responsibility was not formally transitioned. The incoming supervisor was not made aware of the established sling rotation and monitoring procedure, resulting in a lapse in oversight. Root Cause Analysis: The root cause was identified as a failure to formally assign and communicate responsibility for Mechanical lift sling rotation and expiration tracking during the supervisory transition, resulting in a lack of consistent monitoring.On 2/9/2026 at 9:00 AM, R1 was in the dining room, in her high-back wheelchair, with a mechanical lift sling underneath her. R1 stated she does not remember her fall. R1 stated that when she is transferred with the mechanical lift, there are two people transferring her. R1 stated she feels safe. R1 stated she does not have any concerns. R1 stated she is pretty sure that she has not had any falls. R1 stated she does have pain in her right hip when being moved around a lot.On 2/9/2026 at 11:00 AM, V3 (Environmental Supervisor) stated that before R1's fall in December, the laundry aides would bleach mechanical lift slings and wash them with sheets. V3 stated she also puts the mechanical lift slings in the dryer and is not sure what the temperature was.On 2/9/2026 at 11:30 AM, V4 (Maintenance) stated the washer temperature goes between 105 degrees Fahrenheit to 110 degrees Fahrenheit. V4 also stated the dryer heat is 177 degrees Fahrenheit.On 2/9/2026 at 10:05 AM, V5 (Laundry Aide) stated that when it comes to washing mechanical lift slings, she is supposed to separate them from everything else in the laundry and only wash mechanical lift slings together on the personals setting. V5 was not sure what the temperature was when washing on the personals setting. V5 stated that once the mechanical lift slings are washed, they go into the dryer that has only one setting. V5 was unsure what temperature the dryer setting was on. V5 stated that once the mechanical lift slings are dry, she is to check them for any damage or fraying of thread on the straps and throughout the sling seams before sending them to each hall for use.On 2/9/2026 at 1:52 PM, V8 (Certified Nurse Assistant) stated she was getting R1 up for dinner on 12/9/2025 using the mechanical lift, and when she looked at the mechanical lift sling before using it on R1, the sling did not look frayed. V8 stated once R1 was up in the air in the mechanical lift, V9 (Certified Nurse Assistant) was guiding R1 into her wheelchair. At that point, V8 stated the right bottom strap on the mechanical lift sling broke, and all V8 saw as R1 falling to the ground. V8 stated that once the management staff came in and looked at the mechanical lift sling, the management staff determined that the straps were dry rotted.On 2/9/2026 at 2:00 PM, V9 (Certified Nurse Assistant) stated that on 12/9/2025, she was with V8 (Certified Nurse Assistant) in R1's room, assisting R1 out of bed and into R1's wheelchair with the mechanical lift. V9 stated that once R1 had her mechanical lift sling underneath her, all four straps attached to the mechanical lift, and seemed fine. V8 started to lift R1 using the remote on the mechanical lift from her bed to her wheelchair. V9 stated she was guiding R1 and positioning R1 to be placed in her wheelchair when R1's bottom right mechanical lift strap broke. V9 stated R1 fell out of the mechanical lift sling, hit the side of the bed, and landed on her right side. V9 stated that once the management staff looked at the mechanical lift sling, the management staff determined the broken strap was dry rotted.On 12/9/2026 at 2:22 PM, V10 (Registered Nurse) stated that on 12/9/2025, V9 (Certified Nurse Assistant) came to get her to tell her R1 had fallen out of her mechanical lift during transferring her from the bed to her wheelchair. V10 stated that when she came into R1's room, R1 was lying horizontally on her right side, lying across the mechanical lift legs, and R1's neck was cranked to the side close to the nightstand. V10 stated it was determined that R1's mechanical lift sling strap had broken, and that was why she fell out of the sling and onto the floor.On 12/9/2026 at 3:32 PM, V2 (Director of Nursing) stated that after R1's fall, it was determined that the mechanical lift sling straps were dry-rotted and that the mechanical lift slings were being improperly washed and dried.

Based on interview and record review, the facility failed to prevent misappropriation of controlled substance medications for five of six residents (R1, R2, R3, R4, and R5) reviewed for misappropriation of resident medications in a sample of six. Findings include:The facility's Abuse Prevention Policy, undated, documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Definitions: The following definitions are based on federal and state laws, regulations, and interpretive guidelines. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belongings or money without the resident's consent. Misappropriation of a resident's property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent.On 7/17/25 at 8:45 AM, V1 (Administrator) stated on 6/16/25, R1 requested a pain pill, but no Norco was available. V9 (Registered Nurse) contacted the pharmacy to request a refill. The pharmacy informed her that a card of 30 Norco 5-325 mg tablets had been delivered on 6/13/25. V2 (Director of Nursing) confirmed the presence of the packing slip in the narcotic binder but found no medication card or narcotic count sheet. R1's missing Norco prompted an internal review and launched a broader investigation into potential misappropriation. V1 stated on review of facility video footage V4 (Registered Nurse) was observed taking the medication cart down the hallway and positioning her body to obscure the camera's view of the narcotic box. V4 stood on the side of the cart, leaned over, and appeared to write in the narcotic count book. V4 consistently zipped up her lab coat immediately afterward and positioned her body in a way that made it unclear if she was popping pills from blister cards or placing entire cards into her clothing. V1 noted the behavior and body positioning were unnatural for standard medication administration practices and inconsistent with legitimate narcotic handling procedures. V1 stated V4 is known to be right-handed but was seen moving cards awkwardly with her left hand, further raising concern. V1 further stated after receiving past narcotic slips, the facility identified altered scripts that had been wrote to dispense 60 pills changed to 160 pills, the Drug Enforcement Administration (DEA) number wrote on the scripts appeared to be written in V4's handwriting. V1 stated after comparing schedules to the dates on the scripts, V4 was working on the days that the scripts were altered. On 7/17/25 at 9:30 AM, V2 (Director of Nursing) stated on 6/16/25, around 10:00 AM, V2 was informed by V9 (Registered Nurse) that R1 was out of Norco and V9 had contacted the pharmacy. The pharmacy confirmed a card of 30 Norco tablets was delivered on 6/13/25. V2 confirmed the packing slip for the 6/13 delivery was present but the medication card could not be located. R1's Norco was not found in medication carts on 100 or 200 halls. V2 stated she conducted interviews with staff who had worked on and after the delivery date. V11 (3rd shift Registered Nurse) on 6/13 stated V11 placed the Norco in the narcotic box, signed the narcotic sheet, and filed the packing slip. V4 (Day shift Registered Nurse) on 6/14 and V5 (Assistant Director of Nursing), working 6/14-6/15 both reported R1 did not have Norco available during their shifts. V2 stated on review of security footage, the facility found no evidence the Norco was placed in the cart or signed into the narcotic count sheet, despite packing slips and delivery records confirming receipt. V2 further stated V4 was on vacation from 6/16-6/24. V2 stated V4 was suspended pending investigation and when asked to return on 6/23/25 for an interview, V4 responded that she wouldn't pass a drug test and V4 later resigned via text message and denied taking narcotics. 1.) R1's medical chart includes a prescription dated 3/27/25 for Hydrocodone 5-325 milligrams, one tablet by mouth every six hours as needed for pain, with instructions to dispense 160 tablets and six refills, not to exceed four tablets per day. The facility's final investigation report, documents R1 had an active order for Norco 5/325 milligrams and received the following quantities monthly, as documented on the Pharmacy Delivery List Report compared to what was administered per the electronic Medication Administration Record (MAR): For the month of March 2025, 119 Norco pills were delivered to the facility from the pharmacy, 68 Norco pills were administered to R1, and 51 Norco pills were unaccounted for. April 2025, 90 Norco pills were delivered to the facility from the pharmacy, 55 Norco pills were administered to R1, and 35 Norco pills were unaccounted for. May 2025, 120 Norco pills were delivered to the facility from the pharmacy, 55 Norco pills were administered to R1, and 65 Norco pills were unaccounted for. June 2025, 60 Norco pills were delivered to the facility from the pharmacy, 24 Norco pills were administered to R1, and 36 Norco pills were unaccounted for. These discrepancies total 187 Norco tablets unaccounted for over a four-month period.On 7/17/25 at 10:00 AM, R1 stated There were times I didn't get my pain pills because the staff said they were waiting for delivery. They gave me Tylenol instead.2.) R2's Physician Orders document R2 had an active physician order for Norco 7.5/325 milligrams, one tablet every four hours as needed for pain.The facility's final investigation report document R2 had an active order for Norco 7.5/325 milligrams and received the following quantities monthly, as documented on the Pharmacy Delivery List Report compared to what was administered per the electronic Medication Administration Record (MAR): For the month of March 2025, 210 Norco pills were delivered to the facility from the pharmacy, 13 Norco pills were administered to R2, and 197 Norco pills were unaccounted for. April 2025, 160 Norco pills were delivered to the facility from the pharmacy, 22 Norco pills were administered to R2, and 138 Norco pills were unaccounted for. May 2025, 200 Norco pills were delivered to the facility from the pharmacy, 20 Norco pills were administered to R2, and 180 Norco pills were unaccounted for. June 2025, 70 Norco pills were delivered to the facility from the pharmacy, 11 Norco pills were administered to R2, and 59 Norco pills were unaccounted for. These discrepancies total 574 Norco tablets unaccounted for over a four-month period. On 6/20/25, an additional 30 Norco 5-325 mg were delivered, but never documented or located.On 7/17/25 at 10:40 AM, V2 (Director of Nursing) stated V4 was taking the delivery slips and the narcotic sheet with the medications and that's why nobody noticed. V4 denied all knowledge during her interview.3.) R3's Physician Orders documents an order for Norco 5-325 milligrams, one tablet every four hours as needed for pain.Pharmacy delivery logs and MAR review from March 1 to June 30, 2025, revealed: For the month of March 2025, 150 Norco pills were delivered to the facility from the pharmacy, 0 Norco pills were administered to R3, and 150 Norco pills were unaccounted for. April 2025, 90 Norco pills were delivered to the facility from the pharmacy, 0 Norco pills were administered to R3, and 90 Norco pills were unaccounted for. May 2025, 130 Norco pills were delivered to the facility from the pharmacy, 0 Norco pills were administered to R3, and 130 Norco pills were unaccounted for. June 2025, 90 Norco pills were delivered to the facility from the pharmacy, 0 Norco pills were administered to R3, and 90 Norco pills were unaccounted for. These discrepancies total 460 Norco tablets unaccounted for over a four-month period.On 7/17/25 at 10:50 AM, R3 stated R3 does not have pain that requires taking her Norco.4.) R4's Physician orders document an order for Norco 5-325 milligrams, one tablet every six hours as needed for pain.Pharmacy delivery logs and MAR review from March 1 to June 30, 2025, revealed: For the month of March 2025, 90 Norco pills were delivered to the facility from the pharmacy, 10 Norco pills were administered to R4, and 80 Norco pills were unaccounted for. April 2025, 150 Norco pills were delivered to the facility from the pharmacy, 11 Norco pills were administered to R4, and 139 Norco pills were unaccounted for. May 2025, 120 Norco pills were delivered to the facility from the pharmacy, 4 Norco pills were administered to R4, and 116 Norco pills were unaccounted for. June 2025, 90 Norco pills were delivered to the facility from the pharmacy, 2 Norco pills were administered to R4, and 88 Norco pills were unaccounted for. These discrepancies total 423 Norco tablets unaccounted for over a four-month period.Pharmacy delivery logs and Facility Incident report document a delivery of Norco for R4 on 6/15/25 is missing. Records confirm V4 worked during this delivery. On 7/17/25 at 9:45 AM, R4 stated there have been times Norco wasn't available because pharmacy had not delivered it to the facility. 5.) R5's Physician Orders documents an order for Acetaminophen-Codeine (Tylenol #3) 300-30 milligrams, one tablet by mouth every six hours as needed for severe pain.Pharmacy delivery logs and MAR review from March 1 to June 30, 2025, revealed: For the month of March 2025, 30 Tylenol #3 pills were delivered to the facility from the pharmacy, three Tylenol #3 pills were administered to R5, and 27 Tylenol #3 pills were unaccounted for. April 2025, 0 Tylenol #3 pills were delivered to the facility from the pharmacy, three Tylenol #3 pills were administered to R5, and 0 Tylenol #3 pills were unaccounted for. May 2025, 60 Tylenol #3 pills were delivered to the facility from the pharmacy, five Tylenol #3 pills were administered to R5, and 55 Tylenol #3 pills were unaccounted for. June 2025, 60 Tylenol #3 pills were delivered to the facility from the pharmacy, two Tylenol #3 pills were administered to R5, and 58 Tylenol #3 pills were unaccounted for. These discrepancies total 127 Tylenol #3 pills unaccounted for over a four-month period.On 7/17/25 at 9:30 AM, V2 stated a delivery of Tylenol #3 on 6/15/25 for R5 is missing entirely. V4 was the only nurse on duty at the time.

Based on Observation, Interview, and Record Review the facility failed to ensure refrigerated vaccination units were stored separate from food and beverages. This failure has the potential to affect all 59 residents residing in the facility. Findings include: The facility's Storage of Medications policy, dated 4/2016, documents All medications will be safe and properly stored at all times. Medications requiring refrigeration shall be kept in a separate, securely fastened locked box within a refrigerator or locked refrigerator, at or near the nurse's station, or in a refrigerator within a locked medication room. On 1/9/25 at 11:40 AM, the facility's 100 hall medication storage fridge contained a sign on the outside of the fridge that documents Medications Only. Inside of the fridge was a plastic of container of food from outside of the facility. This dish did not contain a label and was sitting directly on top of two boxes of influenza vaccine. This same fridge contained an open bottle of (flavored hydration drink). V13 (Registered Nurse) and V19 (Licensed Practical Nurse) both confirmed that food and drinks should not be stored in the medication room refrigerator and stated that this fridge is only for medications. V13 stated This looks like chili soup, and it was probably brought in for a resident. We have agency nurses who may not have known where to put it. On 1/9/25 at 11:45 AM V16 (Infection Control Preventionist) confirmed that the influenza vaccines stored in the 100-hall medication room refrigerator can be administered to any resident in the building and stated there should not be any food or open drinks kept in that refrigerator. The facility's Long Term Care Application for Medicare and Medicaid dated 1/7/25 and signed by V1 (Administrator) documents 59 residents reside in the facility.

Based on record review and interview the facility failed to complete Criminal History Background Checks within 24-hour of admission, Illinois Sex Offender Registry checks prior to admission, and Illinois Department of Corrections Sex Registry Checks prior to admission as instructed by the facility's Abuse Policy for five of five residents (R107, R108, R109, R110, R157) reviewed for Abuse Prevention in the sample of 38. Findings include: The Abuse Prevention Program Policy dated 8/11/17 documents Policy It is the policy of this facility to prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property. The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a 3rd (third) party. II. Pre-Admission Screening of Potential Residents: This facility shall check the criminal history background on any resident seeking admission to the facility in order to identify previous criminal convictions. Prior to the admission of a new resident to the facility, this facility will: Check for the resident's name on the Illinois Sex Offender registration. Check for the resident's name on the Illinois Department of Corrections sex registrant search page. Within 24 hours after admission of a new resident to the facility, this facility will: Initiate a Criminal History Background Check according to the Facility Identified Offender Policy and Procedure. 1. R107's Admission Record documents R107 was admitted on [DATE]. R107's Criminal History Background check, Illinois Sex Offender Registry, and Illinois Department of Corrections Registry document being completed on 1-6-25 (three days after R107's admission). 2. R108's Admission Record documents R108 was admitted on [DATE]. R108's Criminal History Background check, Illinois Sex Offender Registry, and Illinois Department of Corrections Registry document being completed on 1-6-25 (three days after R108's admission). 3. R109's Admission Record documents R109 was admitted on [DATE]. R109's Criminal History Background check, Illinois Sex Offender Registry, and Illinois Department of Corrections Registry document being completed on 12-30-24 (three days after R109's admission). 4. R110's Admission Record documents R110 was admitted on [DATE]. R110's Criminal History Background check, Illinois Sex Offender Registry, and Illinois Department of Corrections Registry document being completed on 12-23-24 (three days after R110's admission). 5. R157's Admission Record documents R157 was admitted on [DATE]. R157's Illinois Sex Offender Registry and Illinois Department of Corrections Registry document being completed on 1-7-25 (five days after R157's admission). On 1-8-25 at 11:30 AM V8 (Admission's Coordinator) stated R107-R110's and R157's Criminal History Background Checks, Illinois Sex Offender Registry Checks, and Illinois Department of Corrections Registry Checks were not completed prior to admission or within 24 hours of admission. V8 stated, Me and (V9/Vice President of Operations) are responsible to do the resident background checks, however me and (V9) were off when (R107-R110 and R157) were admitted , so their background checks did not get done within 24 hours of their admission.

Based on observation, interview, and record review the facility failed to assess a resident for the risk of entrapment and medical needs, obtain a physician's order prior to use, and obtain a consent prior to the use of side rails/assist rails for seven of seven residents (R2, R20, R28, R31, R48, R49, R107) reviewed for side rail use in the sample of 38. Findings include: The Side Rails Policy dated 10/9/19 documents Purpose: To provide guidelines assessment and use of side rails. Policy: The use of bed rails as restraints is prohibited unless they are necessary to treat a resident's medical symptoms. All residents who utilize rails will have a side rail screening completed. Responsibility: It is the responsibility of the Care Plan Coordinator/Rehab Nurse to assess the need for side rails, and document and care plan accordingly. Procedure: 1. If a resident requests side rails, a Side Rail Assessment Form must be completed and Side Rail Assessment for Risk of Entrapment. A physician order must be obtained when using side rails. The order must indicate the number of side rails to be used and the medically related reason. If used for mobility, then this must be indicated in the order. (Use) Side Rail Assessment Form. (Use) Side Rail Consent Form. (Use) Side Rail Assessment for Risk of Entrapment. 1.R20's Admission Record documents R20 is a [AGE] year-old that was admitted to the facility on [DATE] with the diagnoses of Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Type II Diabetes Mellitus, Hypotension, and Acquired Absence of the Left and Right Legs Above the Knee. R20's Fall assessment dated [DATE] documents R20 is a moderate risk for falls, is totally incontinent of bowel and bladder, is receiving more than two medications that put R20 at risk for falls and is unable to independently come to a standing position. R20's current Physician's Order Sheets document R20 utilizes 1/2 side rails for mobility and safety. R20's Medical Record does not include a consent or an assessment of R20's 1/2 side rails for appropriate use or risks for entrapment. On 01/07/25 at 9:31 AM R20 was lying in bed with 1/2 side rails in the raised position to both upper sides of R20's bed. 2. R28's Admission Record documents R28 is an [AGE] year-old that was admitted to the facility on [DATE] with the diagnoses of Diabetes Mellitus, Anxiety Disorder, Insomnia, and Chronic Obstructive Pulmonary Disease. R28's current Physician's Order Sheets document R28 utilizes a right-side bed cane (assist rail) for bed mobility. R28's Fall assessment dated [DATE] documents R28 is a high risk for falls, is totally incontinent of bowel and bladder, is confined to a chair and disorientated, is unable to independently come to a standing position, requires hands-on assistance to move from place-to-place, and has decreased in muscle coordination. R28's Medical Record does not include an assessment of R28's 1/8 sized assist rail for appropriate use and risks for entrapment or a consent for the use of R28's assist rail. On 01/08/25 at 9:00 AM R28 was sitting up in bed with an 1/8 sized assist rail in the raised position to the right upper side of R28's bed. 3. R31's Admission Record documents R31 is a [AGE] year-old that was admitted to the facility on [DATE] with the diagnoses of Morbid Obesity, Depression, Anxiety Disorder, and Chronic Obstructive Pulmonary Disease. R31's Fall assessment dated [DATE] documents R31 is a moderate risk for falls, is frequently incontinent of bowel and bladder, and is receiving more than two medications that put R31 at risk for falls. R31's Medical Record does not include an assessment of R31's 1/8 sized assist rail for appropriate use and risks for entrapment, a consent for the use, or a physician's order for the use of R31's assist rail. On 01/08/25 at 9:05 AM R31 was sitting up in bed with an 1/8 sized assist rail in the raised position to the right upper side R31's bed. 4. R107's Admission Record documents R107 is a [AGE] year-old that was admitted to the facility on [DATE] with the diagnoses of Anxiety Disorder, Insomnia, Acute and Chronic Respiratory Failure with Hypoxia, Fibromyalgia, Chronic Obstructive Pulmonary Disease, and Bipolar Disorder. R107's Brief Interview for Mental Status dated 1-8-25 documents R107 is severely cognitively impaired. R107's Fall assessment dated [DATE] documents R107 is a high risk for falls, is frequently incontinent of bowel and bladder, is receiving more than two medications that put R107 at risk for falls, is confined to a chair and disorientated, is unable to independently come to a standing position, exhibits loss of balance while standing, and has decreased muscle coordination. R107's Medical Record does not include an assessment of R107's 1/8 sized assist rail for appropriate use and risks for entrapment, a consent for the use, or a physician's order for the use of R107's assist rail. On 01/08/25 at 09:18 AM R107 was lying in bed with an 1/8 sized assist rail in the raised position to the right upper side of R107's bed. 32875 5. R2's current computerized medical record, documents R2 was admitted to the facility on [DATE] with diagnoses which included Paraplegia, Methicillin Resistant Staphylococcus Aureus Infection as the cause of Diseases Classified Elsewhere, Encounter for Attention to Colostomy, Encounter for Attention to Other Artificial Openings of Urinary Tract. R2's Fall assessment dated [DATE] documents R2 is a low risk for falls, is occasionally incontinent of bowel/bladder, and is confined to a chair and oriented. R2's Medical Record does not include an assessment of R2's 1/8 sized assist rail for appropriate use and risks for entrapment, a consent for use, or a physician's order for the use of R2's assist rail. On 1/9/25 at 9:45 AM, R2 was lying in bed with an 1/8 sized assist rail on the left side of R2's bed. 6. R48's current computerized medical record, documents R48 was admitted to the facility on [DATE] with diagnoses which included Seizures, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Down Syndrome, Retention of Urine, Spondylosis with Myelopathy, Cervical Region, Fusion of Spine, Cervical Region, and Urinary Tract Infection. R48's MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) Score of 2/15, indicating (severe cognitive impairment). R48's Fall assessment dated [DATE] documents R48 is a high risk for falls, has had multiple falls, is totally incontinent of bowel and bladder and is unable to independently come to a standing position. R48's Medical Record does not include an assessment of R48's 1/8 sized assist rail for appropriate use and risks for entrapment, a consent for use, or a physician's order for the use of R48's assist rail. On 1/7/25 at 10:15 AM, R48 was lying in bed with an 1/8 sized assist rail on each side of R48's bed. 7. R49's current computerized medical record, documents R49 was admitted to the facility on [DATE] with diagnoses which included Infarction due to Unspecified Occlusion or Stenosis of Right Middle Cerebral Artery, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Dysphasia, and Metabolic Encephalopathy. R49's MDS assessment dated [DATE] documents a BIMS Score of 13/15, indicating (cognition intact). This MDS also documents that R49 has an impairment on one side of her upper and lower extremity, is dependent on staff for activities of daily living, and requires substantial assistance for bed mobility and transfers. R49's Fall assessment dated [DATE] documents R49 is a high risk for falls, is occasionally incontinent of bowel and bladder, is receiving two medications that put R49 at risk for falls, and is unable to independently come to a standing position. R49's Medical Record does not include an assessment of R49's 1/8 sized assist rail for appropriate use and risks for entrapment, a consent for use, or a physician's order for the use of R49's assist rail. On 1/8/25 at 9:37 AM, R49 was lying in bed with an 1/8 sized assist rail on both sides of R49's bed. On 01/07/25 at 12:15 PM V2 (Director of Nursing) stated, We (the facility) have never completed a side rail or assist rail assessment for any residents that use them. I do not think the facility even has an assessment form to use. (R2, R20, R28, R31, R48, R49, and R107) do not have consents for the use of their side rails and (R2, R20, R31, R48, R49, and R107) do not have physician's orders for the use of their side rails.

Based on observation, interview, and record review the facility failed to follow Enhanced Barrier Precautions (EBP) for five residents (R2, R4, R10, R48, and R49) of six residents reviewed for EBP in the sample of 38. Findings include: The Infection Control Policy dated 7/29/24 documents Purpose: Standard Precautions shall be used when caring for residents at all times regardless of their suspected or confirmed infection status. Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have communicable disease or infections that can be transmitted to others. The facility shall make every effort to use the least restrictive approach to managing individual with potentially communicable infections. Transmission-Based Precautions shall only be used when transmission cannot be reasonably prevented by less restrictive measures. F. Enhanced Barrier Precautions: In addition to Standard Precaution, implement Enhanced Barrier Precautions for certain residents during specific high-contact resident care activities associated with MDRO (Multidrug-Resistant Organism) transmission. A. Examples of infection requiring Enhanced Barrier Precautions include but are not limited to: (1) Patients with known MDRO infection. (2) Patients who are colonized with an infectious MDRO organism. (3) Asymptomatic patients who are suspected of/under investigation for colonization or infection with an infectious microorganism. B. Gloves and Handwashing (1) In addition to wearing gloves as outlined under Standard Precautions, wear a gown (clean, non-sterile) when entering the room. C. Gown (1) In addition to wearing a gown as outlined under Standard Precautions, wear a gown (clean, non-sterile) for all interactions that may involve contact with the resident or potentially contaminated items in the resident's environment. Remove the gown and perform hand hygiene before leaving the resident's room. (2) After removing the gown, do not allow clothing to contact potentially contaminated environmental surfaces. 1. R2's current computerized medical record, documents R2 was admitted to the facility on [DATE] with diagnoses which included Paraplegia, Methicillin Resistant Staphylococcus Aureus Infection as the cause of Diseases Classified Elsewhere, Encounter for Attention to Colostomy, Encounter for Attention to Other Artificial Openings of Urinary Tract. R2's MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) Score of 15/15, indicating (cognition intact). R2 has an Ostomy (including urostomy, ileostomy, and colostomy), and has a surgical wound. R2's Physicians Order documents to monitor ostomy site every shift (dated 9/26/24). Treat R2's right thigh wound daily and as needed every shift for wound care (dated 10/2/24). R2's Care Plan documents that R2 has impairment to skin integrity related to Paraplegia. Treat left buttock wound three time a week and as needed until healed (dated 10/9/24). R2 has a urostomy and colostomy due to paraplegia (dated 9/30/24). The revised Enhanced Barrier Precaution/EBP List printed 1/9/24 documents that R2 is in EBP precautions for having a urostomy/colostomy. On 1/7/25 at 3:25 PM, R2 stated that the staff do not wear a gown or gloves when providing care. On 1/9/25 at 9:45 AM R2 was lying in bed on his right side with a wound dressing on R2's left hip. There was no Enhanced Barrier Precaution sign on R2's door and no Personal Protective Equipment/PPE in or by R2's room. R2 stated that a nurse uses PPE when doing wound care, but the staff do not wear a gown or gloves when providing care. 2. R4's current computerized medical record, documents R4 was admitted to the facility on [DATE] with diagnoses which included Atrophy of Kidney (Terminal), Peritoneal Abscess, and Acute Kidney Failure. R4's MDS assessment dated [DATE] documents a BIMS Score of 15/15, indicating (cognition intact). R4 has an Indwelling Urinary Catheter. R4's Physicians Order documents to provide indwelling catheter care daily every shift (dated 12/26/24). The revised EBP List printed 1/9/24 documents that R4 is in EBP precautions for having an indwelling urinary catheter. On 1/7/25 at 3:05 PM, R4 was lying in bed watching television. There was no EBP sign on R4's door and no PPE in or by R4's room. R4 stated that the staff do not wear a gown or gloves when providing care. On 1/09/25 at 9:40 AM, V16 confirmed (R4) is not listed on the facility's EBP resident list and has not been in EBP precautions but should be because (R4) has a urinary catheter. 3. R10's current computerized medical record, documents R10 was admitted to the facility on [DATE] with diagnoses which included Acute Osteomyelitis of Right Ankle and Foot, Type 2 Diabetes Mellitus with Hyperglycemia, Acute Embolism and Thrombosis of Deep Veins of Right Upper Extremity, Cellulitis of Right Upper Limb, and Acute Kidney Failure. R10's MDS assessment dated [DATE] documents a BIMS Score of 15/15, indicating (cognition intact). R10 has a Diabetic Foot Ulcer. R10's Physicians Order documents to treat right heel everyday shift for wound (dated 12/11/24). On 1/7/25 at 3:25 PM R10 was standing at her door talking to another resident. There was no EBP sign on R10's door and no PPE in or by R10's room. R10 stated that the staff do not wear a gown or gloves when providing care. 4. R48's current computerized medical record, documents R48 was admitted to the facility on [DATE] with diagnoses which included Seizures, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Down Syndrome, Retention of Urine, Spondylosis with Myelopathy, Cervical Region, Fusion of Spine, Cervical Region, and Urinary Tract Infection. R48's MDS assessment dated [DATE] documents a BIMS Score of 2/15, indicating (severe cognitive impairment). R48 has a urinary indwelling catheter, has one or more unhealed pressure ulcers/injuries, and three unstageable pressure ulcers. R48's Physicians Order documents to provide catheter care every shift for urinary catheter (dated 11/16/24). Cleanse and treat R48's sacrum wound daily (dated 12/11/24). Treat R48's left medial foot once daily until healed (dated 1/7/25). R48's Care Plan documents that R48 has potential/actual impairment to skin integrity. Treat R48's sacrum every evening shift for wound care (dated 12/12/24). Treat R48's left medial foot everyday shift for wound (dated 1/8/25). R48 has an indwelling urinary catheter related to urinary retention. The revised Enhanced Barrier Precaution List printed 1/9/24 documents that R48 is in EBP precautions for having an indwelling urinary catheter. On 1/8/24 at 9:55 AM, there was no EBP sign on R48's door and no PPE in or by R48's room. 5. R49's current computerized medical record, documents R49 was admitted to the facility on [DATE] with diagnoses which included Infarction due to Unspecified Occlusion or Stenosis of Right Middle Cerebral Artery, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Dysphasia, and Metabolic Encephalopathy. R49's MDS assessment dated [DATE] documents a BIMS Score of 13/15, indicating (cognition intact). R49 has a feeding tube, has an impairment on one side of her upper and lower extremity, R49 is dependent on staff for activities of daily living and requires substantial assistance for bed mobility and transfers. R49's Physicians Order documents that R49 requires an enteral feeding of Jevity 1.2 85 milliliters per hour from 7:00 PM to 7:00 AM and 250-milliliter flush every six hours. R49's Care Plan documents that R49 requires a feeding tube related to a stroke. The revised Enhanced Barrier Precaution List printed 1/9/24 documents that R49 is in EBP precautions for having a G-tube/Gastrostomy tube. On 1/8/25 at 9:40 AM, R49 was lying in bed on her right side with V14/Registered Nurse/RN standing next to the bed with a clear plastic bag that contained R49's soiled disposable brief. V14 stated that incontinent care was just done for R49. V14 was wearing gloves but not a gown. V14 tied the bag closed and put the bag in the trash. V14 was asked why R49 was in EBP precautions and V14 stated that she thought it was because R49 had red areas to her buttock. V14 was asked if PPE needed to be worn and V14 stated No. On 1/8/25 at 9:42 AM, V15/Certified Nursing Assistant/CNA came into R49's room with a mechanical lift to get R49 up. V15 and V14 transferred R49 from the bed to the recliner with the mechanical lift. V14 and V15 were not wearing PPE. V15 stated that once a resident is dressed PPE is not needed. On 1/08/25 at 2:50 PM, V16/Registered Nurse/Infection Control Preventionist stated the facility is implementing EBP for residents who could be at risk for infection. V16 stated When I educated everyone, I told them if anyone has a hole that shouldn't be there, such as a urinary catheter, gastric tube, venous lines or a bad wound that requires a dressing change, they are on automatic EBP because we could potentially give them something. They (staff) must wear a gown and gloves (PPE) for direct contact with the potential infectious area. I didn't realize they need to have the PPE on for transfers or other close contact. We will be implementing that moving forward. They don't have PPE in every room right now. We put the PPE in the more central areas like the linen cart so staff can use it. On 1/09/25 at 9:40 AM, V16 stated During incontinence care on 1/8/25 (for R49) the staff should have been wearing a gown during the close resident contact.

Based on observation, interview, and record review the facility failed to perform maintenance inspections of side rails/assist rails for entrapment zones/risks for seven of seven residents (R2, R20, R28, R31, R48, R49, R107) reviewed for side rail use in the sample of 38. Findings include: 1. On 01/07/25 at 9:31 AM R20 was lying in bed with 1/2 side rails in the raised position to both upper sides of R20's bed. R20's Medical Record does not include a maintenance inspection of R20's 1/2 side rails for entrapment zones/risks. 2. On 01/08/25 at 9:00 AM R28 was sitting up in bed with an 1/8 sized assist rail in the raised position to the right upper side of R28's bed. R28's Medical Record does not include a maintenance inspection of R28's 1/8 assist rails for entrapment zones/risks. 3. On 01/08/25 at 9:05 AM R31 was sitting up in bed with an 1/8 sized assist rail in the raised position to the right upper side of R31's bed. R31's Medical Record does not include a maintenance inspection of R31's 1/8 assit rails for entrapment zones/risks. 4. On 01/08/25 at 09:18 AM R107 was lying in bed with an 1/8 sized assist rail in the raised position to the right upper side of R107's bed. R107's Medical Record does not include a maintenance inspection of R107's 1/8 assist rails for entrapment zones/risks. 32875 5. On 1/9/25 at 9:45 AM, R2 was lying in bed with an 1/8 sized assist rail on the left side of R2's bed. R2's Medical Record does not include a maintenance inspection of R2's 1/8 assist rail for entrapment zones/risks. 6. On 1/7/25 at 10:15 AM, R48 was lying in bed with an 1/8 sized assist rail on each side of R48's bed. R48's Medical Record does not include a maintenance inspection of R48's 1/8 assist rails for entrapment zones/risks. 7. On 1/8/25 at 9:37 AM, R49 was lying in bed with an 1/8 sized assist rail on both sides of R49's bed. R49's Medical Record does not include a maintenance inspection of R49's 1/8 assist rails for entrapment zones/risks. On 01/08/25 at 11:35 AM V18 (Maintenance Assistant) stated, I am not aware of maintenance doing any inspections of side rails or assist rails to check for areas of entrapment with the bed. I just apply the rails and fix them if they break.

Based on observation, interview, and record review the facility failed to cover a urinary drainage catheter bag with a privacy bag for two of 15 residents (R4, R48) reviewed for dignity in the sample of 38. Findings include: The Resident Privacy and Dignity policy dated 1/20/16 documents Purpose: To provide all residents with a home like environment that promotes dignity and respect to the residents of the facility. Policy: To ensure that all residents are provided with dignity and privacy. Responsibility: It is the responsibility of all staff to ensure that all residents have privacy and dignity. The Resident Rights Booklet dated 11/18, documents Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must be safe, clean, comfortable, and homelike. 1. R4's current computerized medical record, documents R4 was admitted to the facility on [DATE] with diagnoses which included Atrophy of Kidney (Terminal), Peritoneal Abscess, and Acute Kidney Failure. R4's MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) Score of 15/15, indicating (cognition intact). R4 has an Indwelling Urinary Catheter. R4's Physicians Order documents to provide indwelling catheter care daily every shift (dated 12/26/24). On 1/7/25 at 3:05 PM, R4's urinary drainage catheter bag was hanging on the side of R4's bed. The urinary drainage catheter bag was visible from the hallway with amber colored urine in the bag. 2. R48's current computerized medical record, documents R48 was admitted to the facility on [DATE] with diagnoses which included Seizures, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Down Syndrome, Retention of Urine, Spondylosis with Myelopathy, Cervical Region, Fusion of Spine, Cervical Region, and Urinary Tract Infection. R48's MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) Score of 2/15, indicating (severe cognitive impairment). R48 has an indwelling urinary catheter. R48's Physicians Order documents to provide catheter care every shift for urinary catheter (dated 11/16/24). On 1/7/25 at 10:15 AM, R48's urinary drainage catheter bag was hanging on the side of R48's bed. The urinary drainage catheter bag was visible from the hallway with yellow colored urine in the bag. On 1/8/25 at 3:06 PM, V2/Director of Nursing verified that the urinary drainage catheter bags should be covered whenever visible to the hallway to promote dignity.

Based on observation, interview, and record review the facility failed to implement a restorative range of motion program and include the restorative program within the resident's care plan for one of one resident (R20) reviewed for limitations in range of motion in the sample of 38. Findings include: The Restorative Program/Range of Motion policy dated 8/3/13 documents Purpose: To provide resident with limited range of motion and appropriate treatment and services to increase or prevent further decrease in range of motion. Policy: All residents will be assessed on admission and quarterly, or more often as a change of condition warrants, for risk factors for development of contractures. A program will be developed based on the resident's unique risk factors and involving formalized therapy and/or restorative nursing, as applicable. This program will be reflected in the interdisciplinary care plan and will be systematically and consistently followed. The facility protocol for ROM (Range of Motion) is ten repetitions daily, seven days a week for prevention of contractures. All residents who have been assessed and found to require range of motion exercises will have services provided by staff. Responsibility: It is the responsibility of the CNA (Certified Nursing Assistant)/Restorative Aide to perform exercises as identified. It is the responsibility of the Care Plan Coordinator for addressing on the care plan. Procedure: 1. Resident to be assessed following to determine need for range of motion. 2. Address ROM on care plan and identify extremities to be exercised. 3 Communicate to CNA's who require ROM. Explain procedure to resident including what areas will be exercised. 5. Perform range of motion including finger and toes of extremities to be exercised. 6. Provide resident with 10 (ten) repetitions as per resident's tolerance. Never continue past the point of resistance or pain. Take caution not to over tire the resident. 8. When possible, encourage the resident to assist with the exercise. R20's MDS (Minimum Data Set) assessment dated [DATE] documents R20 is cognitively intact and has limitations in range of motion to both sides of the lower extremities. R20's Restorative Program dated 12-29-23 documents, Perform active range of motion exercises daily to (R20's) upper bilateral extremities using verbal cues and hand on assistance of one staff as needed. On 01/07/25 at 9:31 AM R20 was sitting up in bed. R20 had two bilateral above the knee amputations and could not lift his arms up above his waist. R20 stated, I do not get range of motion exercises by staff. I cannot raise my arms up. I have really bad arthritis to my left shoulder. I would like for the staff to do exercises. On 01/07/25 at 9:45 AM both V5 (CNA/Certified Nursing Assistant) and V6 (CNA) were transferring R20 from the bed to the wheelchair using a mechanical lift. V5 and V6 both stated they do not do range of motion exercises with R20. On 1-9-24 at 11:10 AM V17 (Restorative Aide) stated, (R20's) restorative program documents (R20) should get hand over assistance of staff to do range of motion exercises every day. I usually try to do (R20's) range of motion once a week with (R20) and the CNAs are supposed to do the other days. I personally have not been able to do range of motion exercises with (R20) in quite a while.

Based on record review and interview the facility failed to ensure physician ordered daily weights were obtained for a resident with Congestive Heart Failure for one of one resident (R31) reviewed for hydration in the sample of 38. Findings include: The Weights policy dated 9/1/19 documents Purpose: To define the process for obtaining weights on all residents in the facility. It is the responsibility of the C.N.A. (Certified Nursing Assistant)/Designee to obtain weights monthly, and as ordered. The nurse management team is responsible for monitoring to ensure that all weights are obtained in a timely manner. Procedure: 6. D.O.N. (Director of Nursing)/Designee will maintain a log and follow-up to ensure timely completion of weights and proper notification of weight variances. R31's current Physician Order Sheet, dated 1/08/25, document the following order, Daily weight every day due to CHF (Congestive Heart Failure). This order has a start date of 10/24/2024. R31's current Care Plan documents, Focus: I have Congestive Heart Failure. Goal: I will be free of peripheral edema through the next review date. Intervention: 10-24-24 Daily Weight. R31's Weights and Vitals Summary Logs dated 10-24-24 through 1-8-25 document R31 has not been weighed daily as ordered by the physician on ten days within this timeframe. On 01/07/25 at 12:15 PM V2 (Director of Nursing) verified R31 has not been weighed daily as ordered for ten days within the timeframe of 10-24-24 through 1-8-25.

Based on interview and record review the facility failed to ensure that one resident (R1) is free from abuse in a sample of three residents reviewed for abuse. This failure caused R1 to be visibly soiled through outer clothes and to have an odor. Findings Include: The Facility's Abuse Reporting policy dated 8/11/2017 documents This facility will not tolerate resident abuse or mistreatment by anyone, including staff members, other residents, consultants, volunteers, and staff of other agencies, resident representative, legal guardians, friends or other individuals. The Abuse Reporting policy documents For the purposes of this policy, and to assist staff members in recognizing abuse, the following definitions shall pertain: Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish or by deprivation by an individual, including a caretaker, of goods or services that are necessary to attain ore maintain physical, mental psychosocial well-being. Willful Abuse: as used in this definition of abuse, mean the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Mental Abuse: Including, but not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. Neglect/Mistreatment: means the failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness of a resident. A Complaint Form dated 5/22/24 documents that V9 (R1's Health Care Power of Attorney) complained that on the weekend of 5/17/24-5/19/24 she had stopped in and R1 smelled of urine and was not clean. The Follow Up section of the complaint documented Investigation and (State Agency) report completed. See (State Agency) final report. The Final Report for Allegation related to (R1) dated 5/27/24 documents that R1 is alert with confusion and has a BIMS (Brief Interview for Mental Status) score of 2 (out of possible 15/indicating R1 is severely cognitively impaired) She uses a (reclining padded wheelchair) for mobility that is propelled by staff. She is able to utilize her right arm and will often raise it in the air. She is able to utilize her right arm and will often raise it in the air. She is also able to reach and grasp with her right arm/hand. (R1) has a current care plan for crying/being tearful, verbal aggression (yelling and cursing), physical aggression (grabbing and hitting) and pushing herself out of her (reclining padded wheelchair). The Final Report for Allegation related to (R1) dated 5/27/24 documents The following was noted (On 5/19/24) at approximate 5:45 PM V6 (Registered Nurse) came in for her shift and went to check (R1) because she had her arm up in the air. According to staff (R1) sometimes does this to indicate a need, though not consistently due to her confusion. When (V6/RN) checked (R1) she noted her to be wet and soiled, and she was slid down in her wheelchair. (V6/RN) immediately went to get a CNA to assist her in changing (R1) and laying her down. At approximately 6:00 PM (V6/RN) and (V5 Certified Nurse Aide) took (R1) to her room, changed her and laid her down. (V6/RN) asked (V3/RN) why the resident was sliding down in her chair and soiled. (V3/RN)'s response was that (R1) was having behaviors of aggression toward the staff who provided cares. (V6/RN) stated upon interview that (R1) was having no behaviors at the time she interacted with (R1) and was not having behaviors when she and (V5/CNA) provided cares. V3/CNA) was assigned to (R1) on 5/19/24 stated during her interview that (R1) had been having behaviors of yelling and screaming that day and the day before. She states she had been told to make sure (R1) was safe and leave her alone when these behaviors were occurring due to her being physically aggressive and bruising staff when she grabs and holds on.(V4/CNA) sated she noticed (R1) was when she was in the TV area by the nurses' station at approximately 2:20 PM and had asked the nurses if they wanted her to attempt to change (R1) and lay her down. (V3/CNA) was told by (V3/RN) not change her at that time due to the behaviors (R1) was exhibiting. The Final Report for Allegation related to (R1) documents that it was clear that (V3/RN) was not understanding the appropriate response to resident behaviors and ensuring cares are completed even during the occurrence of behaviors. It also became clear that she was not being truthful about her instructions and response to staff in regard to (R1) on 5/19/24. On 6/7/24 at 12:42 V8 (Administrator on call at the time of allegation) stated that she reviewed the video of the areas in question regarding the allegation with R1 on 5/19/24. V8 confirmed that R1 remained in her (reclining padded wheelchair) with no toileting and/or changing of her incontinent brief from the time she got up on 5/19/24 until V6 (Registered Nurse) and V4 (Certified Nurse Aide) took her to her room and changed her around 6:00 PM. On 6/7/24 at 11:30 AM V3 (Registered Nurse) seemed confused when asked about the allegation regarding R1 at the facility on 5/19/24. V3 stated what weekend are you talking about? I wouldn't remember all the details of a busy weekend. When asked why she was terminated from the facility V3 stated Oh, that. I told them that I didn't want the (staff) to have to get beat up just to change (R1)'s pants. (R1) was being very resistive that day and would keep saying no. If (staff working at the time of the incident) thought they should have changed (R1) that is on them, not me. They know how to do their jobs. On 6/7/24 at 11:10 AM V4 (Certified Nurse Aide) stated On that day (5/19/24) (R1) was being a little resistive in the morning after breakfast. So I made sure she was dry and positioned and didn't push it with her. When I went back after lunch I noticed she was slid down in her (reclining padded wheelchair) with foot part over the couch cushions. At about 2:00 PM I asked (V3/RN) about it and she said that she couldn't get (R1) to quit trying to get out of her chair. I told her I would go lay (R1) down and change her and (V3/RN) stated 'No, she can just stay there until she calms down.' V4 stated (R1) can be mean and yell and she does pinch sometimes, but I have never had to leave her wet like that before. V4 stated that at that time, 2:00 PM, R1 was visibly soiled and needed changed. V4 stated that she believed that she could have given cares to (R1) without being physically harmed. V4 stated that at 2:00 PM R1 was not having behaviors that V4 could observe. V6 (Registered Nurse) written statement dated 5/21/24 documents When I had come in for work it was about 5:45 PM and (R1) was positioned against the blue sofa, her feet were kind of over the sofa-she looked like she was sliding out of her chair and there was urine and fecal matter on her. I just, how she was, it wasn't appropriate, and that's why I went to (V8/Administrator on call) about it. I said something to (V3/RN) about it because she was on that side, about her sliding down in her chair and she said she's been having behaviors and I said when I walked over she just grabbed my hand, she wasn't having any behaviors. She (V3/RN) didn't have an answer to that. On 6/7/24 at 2:00 PM V6 (Registered Nurse) confirmed that she came in on 5/19/24 around 5:45 PM and found R1 visibly soiled through her clothes with visible BM (Bowel Movement) and food on her clothes and she smelled. V6 confirmed that V3 (Registered Nurse) told her that R1 had been having behaviors that prevented the staff from giving cares. V6 stated I wasn't comfortable with that, so I reported it. I have never had to leave a confused resident in that state before. If (R1) is having behaviors like the grabbing and pinching if you approach her on her left side she cannot reach you. (R1)'s behaviors usually mean that she needs something. V6 stated that when she and V5 (Certified Nurse Aide) changed R1 that she had no behaviors and was not resistive. On 6/7/24 11:15 AM V5 (Certified Nurse Aide) stated when I came in on that day (5/19/24) (V6/RN) told me to clock in and help her lay (R1) down. At that time (around 6:00 PM) (R1) stunk, and you could see that she was wet and messy. I ended up soaking off some of the BM (Bowel Movement) because it was dried into her skin. On a scale of 0-10 with 10 being the worse, she was a ten plus. It was nasty and I would be upset if my loved one looked like that. We have been trained on how to deal with behaviors, so I don't understand why (R1) would have had to have been left that bad ever. She had no behaviors when we laid her down and she had no behaviors when I did the extensive clean up. On 6/11/24 at 9:15 AM V9 (R1's Health Care Power of Attorney) stated I stopped in on the weekend it was either 5/19 or 5/20 and (R1) looked awful. I had my granddaughter with me, and she usually climbs up in (R1)'s lap and hugs her and she would not even get close to her because she stunk so bad. The smell was awful. I did ask staff and they told me she had been being mean, which I know she does sometimes. But it did bother me enough that I went ahead and reported it because I've never seen her that smelly and gross before.

Based on interview the facility failed to ensure that one resident (R1) was free from physical restraint in a sample of three residents reviewed for abuse. Findings Include: The Facility's Physical Restraint policy dated 9/23/15 does not define situations that could be considered a physical restraint. The policy does document that the use of physical restraints shall be limited to situations necessary to maximize a resident's physical, mental and psychosocial wellbeing. Physical restraints shall be considered only after all alternatives to physical restraint usage has been documented as being ineffective in accomplishing a resident's care goals. The [NAME] Webster Dictionary defines a restraint as a device that restricts movement. R1's current care plan dated 12/26/2022 documents I will push myself out of my wheelchair at times. R1's care plan documents, When (R1) is pushing herself out of her wheelchair staff will assist her to her bed. V5(Certified Nurse Aide)'s written statement dated 5/21/24 documents that V5 reported to her shift supervisor that on 5/19/24 R1's wheelchair was pushed up against the couch. On 6/7/24 at 11:15 AM V5 (Certified Nurse Aide) stated when I came in on that day (5/19/24) (R1) was a mess and her chair was reclined back with the footrest over the seat of the couch. She was trying to get out of her chair, but she couldn't because the footrest wouldn't go down. On 6/7/24 at 11:00 AM V4 (Certified Nurse Aide) confirmed that she saw R1 in her reclining wheelchair with her footrest up over the seat of the couch. V4 stated that when she asked V3 (Registered Nurse) about it she was told that R1 had been trying to get out of her chair. V6 (Registered Nurse)'s written statement dated 5/21/24 documents When I had come in for work, it was about 5:45 PM and (R1) was positioned against the blue sofa, her feet were kind of over there on the sofa-she looked like she was sliding out of her chair. On 6/7/24 at 2:00 PM V6 (Registered Nurse) confirmed that on 5/19/24 R1 had been positioned in her reclining wheelchair with the footrest over the couch seat. V6 stated she didn't know how R1 got there. I do know that when she has behaviors she tries to climb out of her chair. V7(Registered Nurse)'s written statement dated 5/21/24 documents On that day (5/19/24) she (R1) kept trying to scoot out of her chair. The written statement documents Do you know anything about her (R1) being pushed up to the couch? I think (V3/Registered Nurse) put her there. On 6/7/24 at 12:42 PM V8 (Administrator on call on 5/19/24) stated that she reviewed video tapes of footage of R1 throughout the day on 5/19/24 related to a complaint voiced by V6 (Registered Nurse) and V9 (R1's Health Care Power of Attorney) related to R1's cares during the 6:00 AM-6:00PM shift on 5/19/24. V8 stated that she observed R1's reclining wheelchair reclined back with R1's footrest over the couch cushions. V8 confirmed that the footrest being in the position would prevent R1 from pushing the foot rest down. V8 stated that she did not know who put R1 in this position. V3 (Registered Nurse) written statement dated 5/20/24 documents We had a complaint related to (R1) being pushed up against the couch in her chair and They said she (R1) was there with her feet propped up on the couch-do you know anything about that? She was in her (padded reclining wheelchair). They said her (padded reclining wheelchair) was propped up on the couch. What? like her feet? that might have been. Have you seen that before? Not typically, but yesterday she kept pulling herself around. On 6/7/24 at 11:15 V3 (Registered Nurse) seemed to be confused when asked about the events that took place on 5/19/24 at the facility. V3 stated I can't remember the details of a busy weekend. When V3 was asked why she was terminated from the facility she stated Oh. That. yes, I know what you are talking about. V3 at first stated that R1 always tries to climb out of the bottom (footrest area) of her (padded reclining wheelchair). Later in the conversation V3 stated that R1 insisted that her footrest be positioned over the couch seats for comfort. V3 confirmed that the couch seat being under the footrest while not touching it does not affect R1's comfort in any way, that the wheelchair itself was supporting her foot area not the couch, The Final Report for Allegation related to (R1) dated 5/27/24 documents that after further discussion with (V3/RN) it was clear she was not understanding the appropriate response to resident behaviors and ensuring cares are completed even during the occurrence of behaviors. It also became clear that she was not being truthful about her instructions and responses to staff regarding (R1) on 5/19/24. V3 was terminated from employment.

Based on interview and record review the facility failed to follow procedures when documenting medication for four residents (R1, R2, R3, and R5) of six residents reviewed for medication in the sample of eleven. Findings include: The Administration of Medication policy dated 8/14/19, documents To provide licensed personnel with guidelines for proper administration of medications. Residents shall receive their medications on a timely basis in accordance with state and federal guidelines, and within established facility policies. It is the responsibility of the Charge Nurse to sign off Medication Administration Record to indicate that medication was given as ordered. 1. Drugs and biological's may be administered only by licensed physicians, licensed registered or practical nursing personnel, and must be administered in accordance with the written orders of the attending physician. 2. Medication must be administered by the same person preparing the doses for administration. 4. Medications must be documented on E-Mar (Electronic Medication Administration Record) immediately follow the administration. The Charge Nurse Job Description (not dated) documents 1. Follows established policies and procedures of the nursing department. 6. Is accountable for administration of medications and treatments as prescribed by the attending physician and recording of such in the health record. The Initial Incident sent to the (State agency) dated 5/7/24 documents On 5/7/2024 day shift nurse called in sick. Because of this situation the night shift nurse (V5/Licensed Practical Nurse) passed some medications to residents on 200 wing. At approximately 7:00 AM a nurse from the 300 wing (V14/Licensed Practical Nurse) came up to the 200 wing and began passing medications. The 100 wing nurse (V19/Registered Nurse) went back to assist (V14) when (V19) was done with her morning medication pass. At 8:30 AM the 300 wing supervisor, (V6) came in and started to assist (V14) with the medication pass. (V6) was signing out (R2's) Lyrica and noted the morning dose had already been signed out by (V5). (V6) stopped passing medication at this time and attempted to call (V5) and left a message. At 9:45 AM (V5) called back and stated that she gave medications to the following residents: (R1), (R2), (R3), (R4), (R5), and (R6). Of these six residents the 8:00 AM medications were given twice to (R1), (R2), and (R5). The Event Report Form (State) Notification (not dated) documents on 5/7/2024 at approximately 7:00 AM, clinical supervisor (V6) was signing out R2's Lyrica and noted the morning dose had already been signed out by the night shift nurse (V5). V6 stopped passing any further medication until she could speak to V5 to clarify what had been given. After speaking with V5 it was found that V5 had also given morning medications to R1, R2, and R5 without signing them out, resulting in those medications being given again by the oncoming nurse (V14). The Final Incident Report sent to the (State agency) dated 5/9/24, documents Background: On Tuesday May 7 the 6:00 AM nurse called in sick. The night shift nurse (V5/LPN) stayed over until another nurse could get there. (V5) passed medications on 6 (six) residents but did not sign them out on the MAR (Medication Administration Record). (V14/LPN) from 300 wing floated up to the 200 wing to start the medication pass. (V19/Registered Nurse), the 100 wing nurse came to help (V14) with her med pass after (V19) finished passing medications on 100 wing. At 8:30 AM the 300 wing supervisor (V6) came in and started to assist (V14) with the medication pass. (V6) was signing out (R2's) Lyrica and noted the morning dose had already been signed out by (V5). (V6) and (V14) stopped passing medications at this time and attempted to call (V5) and left a message to call the facility. Account of incident: At 9:45 AM (V5) called back and stated that she gave medications to the following residents: (R1), (R2), (R3), (R4), (R5), and (R6). Of these six residents (V5) had given the medications to, (V5) did not sign the MARS on (R1), (R2), (R3) and (R5). Of these 4 (four) residents 3 (three) of them were given their medications a second time. V5/Licensed Practical Nurse Interview by V6/Nursing Supervisor dated 5/7/24 at 9:00 AM, documents Informed (V5) she did not sign out the MAR (Medication Administration Record) on (R2) but gave morning meds. I was able to tell (V5) gave morning med's because (V5) signed out the narcotics at 7:50 AM. (V5) confirmed she gave (R2) med's this morning. I educated (V5) that I also gave (R2) his morning med's because (V5) did not sign them out as given. I asked (V5) who else she gave meds to this morning? (V5) states she gave med's to (R1), (R2), (R3), (R4), (R5), and (R6). After talking to (V5), I consulted with (V19/Registered Nurse) who also was assisting with medication pass on 200 wing and (V19) voiced that she also gave med's to (R1) and (R5). On 5/23/24 at 11:10 AM, V1/Administrator stated that a day shift nurse called off and V5/Licensed Practical Nurse stayed over to pass medication until someone else could come in. V6/Nursing Supervisor went to help with the med pass and V5 left. V6 gave medication to R2 and when V6 went to sign it out V6 found it was already signed out of the narcotic book. V5 was contacted and V5 said she had already given medication to R2. V1 also stated (V5) did not have a reason for not signing out the medication, she just didn't. The nurse is supposed to click on the medication, give the medication, then hit save. There is no excuse why this error happened. On 5/23/24 at 11:15 AM, V6/Nursing Supervisor stated that there was a call off and V6 went to help with med pass. V6 went to give R2 his medication and R2 said Didn't I already take those? V6 went back to look at the narcotic book and saw that R2 had been given his Lyrica earlier that morning by V5/LPN. V6 asked R2 if he took those pills and R2 said he did Wasn't I supposed to? V6 stopped the med pass and called V5 to find out what V5 had given. V5 verified who she had given morning medication. There were six residents that V5 had given medication and three of those six had gotten a double dose of medication. On 5/23/24 at 10:20 AM, V4/Director of Resident Services stated that on 5/7/24 a day shift nurse called off. V5/LPN stayed over to help with medication pass. V5 passed medication to six residents but did not record the information on the Medication Administration Record/MAR for four of the residents. On 5/23/24 at 11:32 AM, V3/Assistant Director of Nursing stated The med errors should have never happened. V5 had to use the electronic MAR to issue the medication. I have no idea why she did not click them off. V5 is not new to the system. On 5/23/24 at 3:25 PM, V3/Assistant Director of Nursing stated that the nurse that gets the medication ready is the nurse that should give it to the resident. V3 stated that V6/Nursing Supervisor was the nurse that gave the second dose of medication to R2. V3 was asked why V6 did not sign the Medication Administration Record/MAR for R2. (V14/LPN had signed the MAR for R2.) V3 stated that did not make sense. Maybe one signed for the medication and the other gave it. On 5/24/24 at 3:58 AM, V5/Licensed Practical Nurse stated that she was told she did not sign the MAR for at least three residents and R1, R2, and R5 were given their medication twice. V5 also stated I wish I had a better explanation of why I didn't sign the MAR, but I don't. Policies and Procedures are in place for a reason, and I know it. I've been a nurse for [AGE] years and have never made a mistake like this. That is not how I do a med pass. I was so upset. I have gone over the scenario a thousand times and don't know how I made this mistake. All I can figure was I was tired and hurrying too fast. I had worked 14 hours and was trying to get as much done as I could to help whoever was coming in to take over. On 5/24/24 at 11:55 AM, V14/LPN stated that she did not know R1, R2, and R5 and did not give any medication to them. V14 was asked why her initials were on the MAR as giving their medication. V14 stated I might have signed it. V14 also stated that she was Shadowing V6/Nursing Supervisor and V6 gave the medication to R2. On 5/25/24 at 10:17 AM, V19/Registered Nurse stated that she was helping V14 with the med pass because V14 was not familiar with the residents on the 100-200 Hall. V19 named five residents she helped V14 with. They were R1, R7, R8, R9, and R10. V19 was told that V14 stated V14 did not give any medication to the residents because V14 did not know the residents. V14 specifically said she did not give med's to R1, R2, and R5. V19 stated I might have given (R1) hers. Later V6/Nursing Supervisor was helping V14 with med pass. 1. R1's current computerized medical record, documents R1 was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus without Complications, Essential (Primary) Hypertension, Hyperlipidemia, Major Depressive Disorder, Polyneuropathy, Chronic Obstructive Pulmonary Disease, Dementia, Psychotic Disturbance, Mood Disturbance, Anxiety, Acute and Chronic Respiratory Failure, and Acute Kidney Failure. R1's Medication Administration Record/MAR dated 5/1/24 - 5/31/24 documents that on 5/7/24, twelve 8:00 AM medications were signed as given by V14/Licensed Practical Nurse. (These meds were already given by V5 but V5 did not sign the MAR.) The medications were as follows: Amlodipine 10 mg, Aspirin 81 mg, Doxepin 10 mg, Flonase Suspension 50 mcg 2 sprays each nostril, Loratadine 10 mg, Protonix 40 mg, Vitamin B Complex, Gabapentin 600 mg, Oxybutynin 5 mg, Polysaccharide Iron 150 mg, Tizanidine 2 mg, and Tylenol 325 mg (2 tabs). R1's Nursing Note dated 5/7/24 at 2:58 PM, documents that it was found that R1 received a second dose of morning medications. R1's Medication Error Form dated 5/7/24 at 8:30 AM, documents that V5/LPN did not sign out the 8:00 AM medications and they were given twice. 2. R2's current computerized medical record, documents R2 was admitted to the facility on [DATE] with a diagnosis of Chronic Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure, Type 2 Diabetes Mellitus without Complications, Long Standing Persistent Atrial Fibrillation, Acute Kidney Failure, Hypotension, Chronic Kidney Disease Stage 3, Peripheral Vascular Disease, Essential (Primary) Hypertension, Hyperlipidemia, Acute Embolism and Thrombosis of Deep Veins of Left Upper Extremity, Depression, Acute and Chronic Respiratory Failure with Hypercapnia. R2's Medication Administration Record/MAR dated 5/1/24 - 5/31/24 documents that on 5/7/24, nine 8:00 AM medications were signed as given by V14/Licensed Practical Nurse. (These meds were already given by V5 but V5 did not sign the MAR.) The medications were as follows: Fluoxetine 10 mg, Furosemide 40 mg, Omeprazole 40 mg, Apixaban 5 mg, Carvedilol 25 mg, Polysaccharide Iron Complex 150 mg, Potassium Chloride Extended Release 10 milliequivalents/MEQ, Pregabalin 75 mg, and Umeclidinium-Vilanterol Inhalation 1 puff. R2's Nursing Note dated 5/7/24 at 3:01 PM, documents that it was found that R2 received a second dose of morning medications. R2's Medication Error Form dated 5/7/24 at 8:30 AM, documents that V5/LPN did not sign out the 8:00 AM medications and they were given twice. 3. R3's current computerized medical record, documents R3 was admitted to the facility on [DATE] with a diagnosis of Depression, Chronic Obstructive Pulmonary Disease, Respiratory Failure, Unspecified with Hypoxia, and Hyperlipidemia. R3's Medication Administration Record/MAR dated 5/1/24 - 5/31/24 documents that on 5/7/24, four 8:00 AM medications were signed as given by V6/Nursing Supervisor. (These meds were already given by V5 but V5 did not sign the MAR.) The medications were as follows: Duloxetine 20 mg, Prednisone 10 mg, Buspirone 15 mg, and Symbicort Inhalation 160-4.5 mcg 2 puffs. On 5/23/24 at 3:25 PM, V3/Assistant Director of Nursing was asked why V6 had signed off giving R3's med's if V6 did not give them. V3 stated that V6 probably did because V6 knew that V5 had already given the medication to R3 and wanted to show that it had been given. V3 was asked if the MAR should have been coded to read the progress note? V3 replied Yes. On 5/24/24 at 7:25 AM, V3/Assistant Director of Nursing stated that V6 signed R3's med's as being given on the MAR after V6 had talked to V5. V6 should have coded the MAR as a 9 for each medication and entered a Progress Note. The Medication Administration Record Chart Codes document 9=Other/See Nurses Notes (None of R3's 8:00 AM medications were coded as 9) 4. R5's current computerized medical record, documents R5 was admitted to the facility on [DATE] with a diagnosis of Seizures, Crohn's disease, Chronic Kidney Disease Stage 4, Polyosteoarthritis, Essential (Primary) Hypertension, Rheumatoid Arthritis, Vitamin D Deficiency, Hyperlipidemia, Dependence on Renal Dialysis, and End Stage Renal Disease. R5's Medication Administration Record/MAR dated 5/1/24 - 5/31/24 documents that on 5/7/24, fifteen 8:00 AM medications were signed as given by V14/Licensed Practical Nurse. (These meds were already given by V5 but V5 did not sign the MAR.) The medications were as follows: Fluticasone Furoate Vilanterol 1 puff, Fish Oil 1200 mg, Folic Acid 1 mg, Furosemide 10 mg, Lasix 20 mg, Levothyroxine 50 Micrograms/MCG, Loratadine 10 mg, Myrbetriq Extended Release 25 mg, Omeprazole 20 mg, Primidone 150 mg, Multivitamin with Mineral, Amino Acids Protein Hydrolysate 30 milliliters/ml, Tamsulosin 0.4 mg, Colace 100 mg, Sodium Bicarbonate 650 mg. R5's Nursing Note dated 5/7/24 at 3:15 PM, documents that it was found that R5 received a second dose of morning medications. R5's Medication Error Form dated 5/7/24 at 8:30 AM, documents that V5/LPN did not sign out the 8:00 AM medications and they were given twice.

Based on interview and record review the facility failed to prevent significant medication administration errors for 3 residents (R1, R2, and R5) of 6 residents reviewed for medication administration in the sample of 11. Findings include: The Administration of Medication policy dated 8/14/19, documents To provide licensed personnel with guidelines for proper administration of medications. Residents shall receive their medications on a timely basis in accordance with state and federal guidelines, and within established facility policies. It is the responsibility of the Charge Nurse to sign off Medication Administration Record to indicate that medication was given as ordered. 1. Drugs and biologicals may be administered only by licensed physicians, licensed registered or practical nursing personnel, and must be administered in accordance with the written orders of the attending physician. 2. Medication must be administered by the same person preparing the doses for administration. 4. Medications must be documented on E-Mar immediately follow the administration. The Charge Nurse Job Description (not dated) documents 1. Follows established policies and procedures of the nursing department. 6. Is accountable for administration of medications and treatments as prescribed by the attending physician and recording of such in the health record. The Initial Incident sent to the (State agency) dated 5/7/24 documents On 5/7/2024 day shift nurse called in sick. Because of this situation the night shift nurse (V5/Licensed Practical Nurse) passed some medications to residents on 200 wing. At approximately 7:00 AM a nurse from the 300 wing (V14/Licensed Practical Nurse) came up to the 200 wing and began passing medications. The 100 wing nurse (V19/Registered Nurse) went back to assist (V14) when (V19) was done with her morning medication pass. At 8:30 AM the 300 wing supervisor, (V6) came in and started to assist (V14) with the medication pass. (V6) was signing out (R2's) Lyrica and noted the morning dose had already been signed out by (V5). (V6) stopped passing medication at this time and attempted to call (V5) and left a message. At 9:45 AM (V5) called back and stated that she gave medications to the following residents: (R1), (R2), (R3), (R4), (R5), and (R6). Of these six residents the 8:00 AM medications were given twice to (R1), (R2), and (R5). The Event Report Form (State) Notification (not dated) documents on 5/7/2024 at approximately 7:00 AM, clinical supervisor (V6) was signing out R1's Lyrica and noted the morning dose had already been signed out by the night shift nurse (V5). V6 stopped passing any further medication until she could speak to V5 to clarify what had been given. After speaking with V5 it was found that V5 had also given morning medications to R1, R2, and R5 without signing them out, resulting in those medications being given again by the oncoming nurse (V14). All residents were immediately assessed with no adverse reaction noted. All physicians and Power of Attorneys were also notified. Orders were given to monitor residents for adverse reactions. Vitals for all three residents were taken at discovery, two hours later, then they will be taken every four hours the first day, than every shift for three days. The pharmacist (V16) was consulted and gave instructions for monitoring for specific adverse reactions, and the advanced practical nurse (V15) completed face to face assessments with each resident. There were no negative outcomes to any resident. Investigation initiated. A full report to follow. The Final Incident Report sent to the (State agency) dated 5/9/24, documents Background: On Tuesday May 7 the 6:00 AM nurse called in sick. The night shift nurse (V5/LPN) stayed over until another nurse could get there. (V5) passed medications on 6 (six) residents but did not sign them out on the MAR (Medication Administration Record). (V14/LPN) from 300 wing floated up to the 200 wing to start the medication pass. (V19/Registered Nurse), the 100 wing nurse came to help (V14) with her med pass after (V19) finished passing medications on 100 wing. At 8:30 AM the 300 wing supervisor (V6) came in and started to assist (V14) with the medication pass. (V6) was signing out (R2's) Lyrica and noted the morning dose had already been signed out by (V5). (V6) and (V14) stopped passing medications at this time and attempted to call (V5) and left a message to call the facility. Account of incident: At 9:45 AM (V5) called back and stated that she gave medications to the following residents: (R1), (R2), (R3), (R4), (R5), and (R6). Of these six residents (V5) had given the medications to, (V5) did not sign the MARS on (R1), (R2), (R5) and (R3). Of these 4 (four) residents 3 (three) of them were given their medications a second time. V5/Licensed Practical Nurse Interview by V6/Nursing Supervisor dated 5/7/24 at 9:00 AM, documents Informed (V5) she did not sign out the MAR (Medication Administration Record) on (R2) but gave morning meds. I was able to tell (V5) gave morning med's because (V5) signed out the narcotics at 7:50 AM. (V5) confirmed she gave (R2) med's this morning. I educated (V5) that I also gave (R2) his morning med's because (V5) did not sign them out as given. I asked (V5) why she did not sign these med's out? (V5) replied she does not know why, that's not her normal behavior. I asked (V5) who else she gave meds to this morning? (V5) states she gave med's to (R1), (R2), (R3), (R4), (R5), and (R6). After talking to (V5), I consulted with (V19/Registered Nurse) who also was assisting with medication pass on 200 wing and (V19) voiced that she also gave med's to (R1) and (R5). The Employee Progressive Disciplinary Form dated 5/22/24 documents that V5/Licensed Practical Nurse was given a written warning for failing to sign out administered medication. On 5/7/24 a call off occurred on day shift. (V5) (night shift nurse) began passing morning medications and failed to sign out medications in the EMAR (Electronic Medication Administration Record) after administering to residents, which then resulted in 3 (three) residents inadvertently receiving a double dose of their 8:00 AM medications. On 5/23/24 at 11:10 AM, V1/Administrator stated that a day shift nurse called off and V5/Licensed Practical Nurse stayed over to pass medication until someone else could come in. V6/Nursing Supervisor went to help with the med pass and V5 left. V6 gave medication to R2 and when V6 went to sign it out V6 found it was already signed out of the narcotic book. V5 was contacted and V5 said she had already given medication to R2. V1 also stated (V5) did not have a reason for not signing out the medication, she just didn't. The nurse is supposed to click on the medication, give the medication, then hit save. There is no excuse why this error happened. On 5/23/24 at 11:32 AM, V3/Assistant Director of Nursing stated The med errors should have never happened. V5 had to use the electronic MAR to issue the medication. I have no idea why she did not click them off. V5 is not new to the system. I believe there were three residents that got their medication twice that morning. On 5/23/24 at 10:20 AM, V4/Director of Resident Services stated that on 5/7/24 a day shift nurse called off. V5/LPN stayed over to help with medication pass. V5 passed medication to six residents but did not record the information on the Medication Administration Record/MAR for four of the residents. V6/Nursing Supervisor took over the med pass. While passing medication when V6 was going to give R2 his narcotic it was already signed out that R6 had gotten the medication that morning. V6 stopped the med pass and called V5. Three of the four residents got duplicate medication. On 5/24/24 at 3:58 AM, V5/Licensed Practical Nurse stated that she works 6:00 PM to 6:00 AM. On 5/7/24 a day shift nurse called in and V5 was asked to stay over to help pass medication. V5 does not usually pass medication on the day shift. There are a lot of meds in the morning, and it is a busy time. V5 started passing the day shift medication. V5 passed medication to several residents before going home. V5 was home and got a call from V6/Nursing Supervisor asking V5 who V5 had passed medication to that morning. V6 told V5 that R2 said he had already got his medicine, but it was not signed off the MAR/Medication Administration Record. V5 went over each resident with V6 that V5 had given med's to and there were at least three that V5 had not signed the meds off the MAR. Of the residents that V5 had not signed the MAR, V6 stated that R1, R2, and R5 were given medication again. V5 also stated I wish I had a better explanation of why I didn't sign the MAR, but I don't. Policies and Procedures are in place for a reason, and I know it. I've been a nurse for [AGE] years and have never made a mistake like this. That is not how I do a med pass. I was so upset. I have gone over the scenario a thousand times and don't know how I made this mistake. All I can figure was I was tired and hurrying too fast. I had worked 14 hours and was trying to get as much done as I could to help whoever was coming in to take over. On 5/23/24 at 11:15 AM, V6/Nursing Supervisor stated that there was a call off and V6 went to help with med pass. V6 went to give R2 his medication and R2 said Didn't I already take those? V6 went back to look at the narcotic book and saw that R2 had been given his Lyrica earlier that morning by V5/LPN. V6 asked R2 if he took those pills and R2 said he did Wasn't I supposed to? V6 stopped the med pass and called V5 to find out what V5 had given. V5 verified who she had given morning medication. There were six residents that V5 had given medication and three of those six had gotten a double dose of medication. V5 was asked why she did not sign the medication as given and V5 stated It was a crazy morning. 1. R1's current computerized medical record, documents R1 was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus without Complications, Essential (Primary) Hypertension, Hyperlipidemia, Major Depressive Disorder, Polyneuropathy, Chronic Obstructive Pulmonary Disease, Dementia, Psychotic Disturbance, Mood Disturbance, Anxiety, Acute and Chronic Respiratory Failure, and Acute Kidney Failure. R1's Physician Orders documents Amlodipine 10 mg one time a day at 8:00 AM, Aspirin 81 mg one time a day at 8:00 AM , Doxepin 10 mg one time a day at 8:00 AM, Flonase Suspension 50 micrograms/mcg 2 sprays each nostril one time a day at 8:00 AM, Loratadine 10 mg one time a day at 8:00 AM, Protonix 40 mg one time a day at 8:00 AM, Vitamin B Complex one time a day at 8:00 AM, Gabapentin 600 mg twice a day at 8:00 AM and 4:00 PM, Oxybutynin 5 mg twice a day at 8:00 AM and 4:00 PM, Polysaccharide Iron 150 mg twice a day at 8:00 AM and 4:00 PM, Tizanidine 2 mg twice a day at 8:00 AM and 5:00 PM, and Tylenol 325 mg (2 tabs) twice a day at 8:00 AM and 6:00 PM. R1's Medication Administration Record/MAR dated 5/1/24 - 5/31/24 documents that on 5/7/24, twelve 8:00 AM medications were signed as given by V14/Licensed Practical Nurse. (These meds were already given by V5 but V5 did not sign the MAR.) The medications were as follows: Amlodipine 10 mg, Aspirin 81 mg, Doxepin 10 mg, Flonase Suspension 50 mcg 2 sprays each nostril, Loratadine 10 mg, Protonix 40 mg, Vitamin B Complex, Gabapentin 600 mg, Oxybutynin 5 mg, Polysaccharide Iron 150 mg, Tizanidine 2 mg, and Tylenol 325 mg (2 tabs). R1's Nursing Note dated 5/7/24 at 2:58 PM, documents that it was found that R1 received a second dose of morning medication. R1's Medication Error Form dated 5/7/24 at 8:30 AM, documents that V5/LPN did not sign out the medication and it was given twice. V6 discovered the med error. The following medications were given twice: Amlodipine 10 milligrams/mg, Aspirin 81 mg, Doxepin 10 mg, Loratadine 10 mg, Protonix 40 mg, Vitamin B Complex, Gabapentin 600 mg, Oxybutynin 5 mg, Polysaccharide Iron 150 mg, Tizanidine 2 mg, Tylenol 325 mg, and Flonase Suspension 50 microgram/mcg 2 sprays each nostril. The medications were given around 7:00 AM and repeated around 8:00 AM. It was noted on a different resident that a narcotic had already been given and after an interview with the night shift nurse (V5) it was decided (R1) had also received her medications. V5 gave medications and did not sign them out. 2. R2's current computerized medical record, documents R2 was admitted to the facility on [DATE] with a diagnosis of Chronic Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure, Type 2 Diabetes Mellitus without Complications, Long Standing Persistent Atrial Fibrillation, Acute Kidney Failure, Hypotension, Chronic Kidney Disease Stage 3, Peripheral Vascular Disease, Essential (Primary) Hypertension, Hyperlipidemia, Acute Embolism and Thrombosis of Deep Veins of Left Upper Extremity, Depression, and Acute and Chronic Respiratory Failure with Hypercapnia. R2's MDS (Minimum Data Set) dated 3/21/24 documents a BIMS (Brief Interview for Mental Status) Score of 13/15, indicating (cognition intact). R2's Physician Orders documents Fluoxetine 10 mg one time a day at 8:00 AM, Furosemide 40 mg one time a day at 8:00 AM, Omeprazole 40 mg one time a day at 8:00 AM , Apixaban 5 mg twice a day at 8:00 AM and 6:00 PM, Carvedilol 25 mg twice a day at 8:00 AM and 6:00 PM, Polysaccharide iron complex 150 mg twice a day at 8:00 AM and 6:00 PM, Potassium Chloride extended release 10 milliequivalents/MEQ twice a day at 8:00 AM and 5:00 PM, Pregabalin 75 mg twice a day at 8:00 AM and 6:00 PM, and Umeclidinium-Vilanterol Inhalation 1 puff one time a day at 8:00 AM. R2's Medication Administration Record/MAR dated 5/1/24 - 5/31/24 documents that on 5/7/24, nine 8:00 AM medications were signed as given by V14/Licensed Practical Nurse. (These meds were already given by V5 but V5 did not sign the MAR.) The medications were as follows: Fluoxetine 10 mg, Furosemide 40 mg, Omeprazole 40 mg, Apixaban 5 mg, Carvedilol 25 mg, Polysaccharide iron complex 150 mg, Potassium Chloride extended release 10 milliequivalents MEQ, Pregabalin 75 mg, and Umeclidinium-Vilanterol Inhalation 1 puff. R2's Controlled Substance sheet for Pregabalin 75 mg capsule documents Take 1 (one) capsule by mouth twice daily for nerve pain. V5 gave the medication at 7:50 AM on 5/7/24 and V6 gave it again at 9:00 AM on 5/7/24. R2's Nursing Note dated 5/7/24 at 3:01 PM, documents that it was found that R2 received a second dose of morning medication. R2's Medication Error Form dated 5/7/24 at 8:30 AM, documents that V5/LPN did not sign out the medication and it was given twice. V6 discovered the med error. The following medications were given twice: Fluoxetine 10 milligrams/mg, Furosemide 40 mg, Omeprazole 40 mg, Apixaban 5 mg, Carvedilol 25 mg, Polysaccharide Iron Complex, Potassium Chloride 10 MEQ, and Pregabalin 75 mg. The error was noted when (V6) was signing out Pregabalin in the narcotic book. Previous Nurse (V5) did not sign out drugs on the MAR after administering them. On 5/24/24 at 7:56 AM, R2 was asked if he ever got medication he should not have got. R2 stated Yes, once. 3. R5's current computerized medical record, documents R5 was admitted to the facility on [DATE] with a diagnosis of Seizures, Crohn's Disease, Chronic Kidney Disease Stage 4, Poly Osteoarthritis, Essential (Primary) Hypertension, Rheumatoid Arthritis, Vitamin D Deficiency, Hyperlipidemia, Dependence on Renal Dialysis, and End Stage Renal Disease. R5's Physician Orders documents Fluticasone Furoate Vilanterol 1 puff one time a day at 8:00 AM, Fish Oil 1200 mg one time a day at 8:00 AM, Folic Acid 1 mg one time a day at 8:00 AM, Furosemide 10 mg one time a day at 8:00 AM, Lasix 20 mg one time a day every Tuesday, Thursday, Saturday, and Sunday at 8:00 AM, Levothyroxine 50 Micrograms/MCG one time a day at 8:00 AM, Loratadine 10 mg one time a day at 8:00 AM, Myrbetriq Extended Release 25 mg one time a day at 8:00 AM, Omeprazole 20 mg one time a day at 7:30 AM, Primidone 150 mg one time a day at 7:00 AM, Multivitamin with Mineral one time a day at 8:00 AM, Amino Acids Protein Hydrolysate 30 milliliters/ml one time a day at 8:00 AM, Tamsulosin 0.4 mg one time a day at 7:00 AM, Colace 100 mg one time a day at 8:00 AM, Sodium Bicarbonate 650 mg one time a day at 8:00 AM. R5's Medication Administration Record/MAR dated 5/1/24 - 5/31/24 documents that on 5/7/24, fifteen 8:00 AM medications were signed as given by V14/Licensed Practical Nurse. (These meds were already given by V5 but V5 did not sign the MAR.) The medications were as follows: Fluticasone Furoate Vilanterol 1 puff, Fish Oil 1200 mg, Folic Acid 1 mg, Furosemide 10 mg, Lasix 20 mg, Levothyroxine 50 Micrograms/MCG, Loratadine 10 mg, Myrbetriq Extended Release 25 mg, Omeprazole 20 mg, Primidone 150 mg, Multivitamin with Mineral, Amino Acids Protein Hydrolysate 30 milliliters/ml, Tamsulosin 0.4 mg, Colace 100 mg, and Sodium Bicarbonate 650 mg. R5's Nursing Note dated 5/7/24 at 3:15 PM, documents that it was found that R5 received a second dose of morning medication. R5's Medication Error Form dated 5/7/24 at 8:30 AM, documents that V5/LPN did not sign out the medications and they were given twice. V6 discovered the med error. The following medications were given twice: Fluticasone Furoate Vilanterol 1 puff, Fish Oil 1200 mg, Folic Acid 1 mg, Furosemide 10 mg, and Vibegron 75 mg. (This list of meds is not accurate. Vibegron was not given and there are 11 meds not listed that were given. On 5/25/24 at 10:02 AM, V4 sent an electronic message that documents V6 said V6 printed out the MAR when she filled out the med error form but must have missed a couple pages.) The medications were given around 7:00 AM and repeated around 8:00 AM. It was noted on a different resident that a narcotic had already been given and after an interview with the night shift nurse (V5) it was discovered this resident had also received his medications. V5 gave morning medications and did not sign the MAR. MAR resulting in the day nurse (V6) also giving the medication.

Based on interview and record review the facility failed to ensure the designated Infection Preventionist was certified. This failure has the potential to affect all 52 residents residing in the facility. Findings include: The facility's undated Infection Control Specialist Job Description documents, Under the direct supervision of the Director of Nursing, within scope of practice, the Infection Control Specialist will track, analyze, and look for trends in infection . 10. Will maintain current knowledge of CDC (Centers for Disease Control) guidelines, and appropriate procedures. 11. Will be responsible for completing infection control log on a daily basis, analyzing, and looking for trends on a monthly basis and completion of monthly infection control report. Is responsible for surveillance, identification, prevention, control and reporting of infections. Qualifications include Education/experience in nursing administration, infection control standards, and/or geriatric nursing is desirable. Will have knowledge on current infection control procedures and practices. The facility's undated Director of Nursing Job Description documents Under the supervision of the Nursing Home Administrator, the Director of Nursing is responsible for the overall operation of the nursing department 24 hours a day, 7 days a week. Essential Position Functions: 6. Cooperate with the Administrator in the planning of staff development programs that will enhance staff knowledge in providing quality resident care . 9. Maintain professional competence through continuing education . 11. Stay current with the Illinois Department of Public Health and Public Aid directives and ensure department's compliance with such directives . 12. Ensure that the nursing department's is in compliance with State Code Requirements . 21. Ensure that the nursing staff is aware of their responsibilities. On 11/15/23 at 8:30 AM, Signage was posted to the front entrance door that documents the facility is currently in a COVID-19 outbreak. During the facility tour there were no residents being isolated for COVID-19. The facility Infection Control binder does not include any documentation for infections for the months of October or November and does not indicate there are currently any residents positive for COVID-19 or in contact or droplet isolation. On 11/15/23 at 10:36 AM, V3 ICP (Infection Control Preventionist) stated she works part time at the facility as the ICP and the facility just came out of a COVID-19 outbreak and there are currently no residents or staff testing positive. V3 ICP stated she is requiring all staff to wear a N95 mask while working in the facility until the facility has two weeks of no positive COVID tests as the last positive resident came out of isolation on 11/14/23. V3 ICP stated she completed each of the Infection Control Preventionist modules and provided copies of completed Modules 1 through 15 that document successfully completed for each. V3 ICP stated she only remembers taking a test at the end of each Module and does not recall taking another exam after completing all the Modules. On 11/15/23 at 2:30 PM, V1 Administrator confirmed the only documents she has for V3 ICP having taken the Infection Control Preventionist program was the completion of the Modules and was unable to provide a Certification of completion of the 19-hour program or exam completion. V3 ICP should have taken the Infection Control exam for certification. On 11/16/23 at 3:30 PM V3 ICP stated she managed to get back into the training course and was currently taking the exam. As of this date and time V3 ICP was unable to provide the Certification for the Infection Control Preventionist Course documenting the completion of the 19-hour program or the exam completion. V3 ICP stated again, I cannot say definitively that I took the exam or not. The Long-Term Care Facility Application for Medicare and Medicaid, CMS (Central Management Services) Form 671, signed and dated on 11/14/23 by V1 Administrator documents there are 52 residents currently residing in the facility.

Based on observation, interview and record review the facility failed to provide humidified oxygen, physician ordered oxygen flow rates and failed to date oxygen humidifier bottles for six residents (R6, R14, R15, R17, R19, R42) of seven residents reviewed for oxygen therapy in the sample of 34. Findings include: On 11/15/23 between 1:30pm and 1:45pm the following residents with current orders for oxygen administration were seen with V4, RN (Registered Nurse): 1) R6 was in bed receiving oxygen via a nasal cannula at flow rate of 4 liters per minute. R6's nasal cannula was attached to the oxygen concentrator that did not have a humidification bottle. R6's Current Physician Order Report Summary indicates Change nasal cannula tubing every Sunday evening and humidification every Sunday night shift for maintenance. Replace all oxygen equipment per facility policy. Report also indicates (R6) may use oxygen at 2-4 liters to maintain SPO2 (oxygen saturation) greater than 93% (order date 11/3/23). 2) R14 was in bed receiving oxygen via a nasal cannula at flow rate of 2.5 liters per minute. R14's nasal cannula was attached to the oxygen concentrator humidification bottle that was undated and completely empty. At that time V4, RN confirmed R14's oxygen humidification bottle was empty and stated (The bottle) is not dated - that's even worse. R14's Current Physician Order Report Summary indicates May use oxygen at 2-4 liters to maintain SPO2 (oxygen saturation) greater than 93% (order date 11/4/22). 3) R15 was in bed receiving oxygen via a nasal cannula at flow rate of 2.5 liters per minute. R15's nasal cannula was attached to the oxygen concentrator humidification bottle that was undated and completely empty. R15's Current Physician Order Report Summary indicates Oxygen at 2 liters per nasal cannula as needed (order date 11/1/20). R15's current care plan indicates Give oxygen as ordered by the physician. 4) R17 was seen in her room in a recliner chair at multiple times throughout the day on 11/14/23 and 11/15/23. All observations found R17 receiving oxygen at 3.5 liters via nasal cannula. R17's nasal cannula was attached to an oxygen humidification bottle that was empty and dated 10 (October) - the day of the month was smudged and unreadable. On 11/15/23 at 1:35pm V4, RN confirmed R17's humidification bottle was dry and last dated sometime in October. Current Physician Order Summary Report indicates R17 May use 2-4 liters to maintain SPO2 (oxygen saturation) >93% (date initiated 8/12/23). Current Care Plan - focus area CHF (Congestive Heart Failure) and CAD (Coronary Artery Disease) indicates R17 utilizes oxygen therapy per physician orders. R17's Care Plan did not include a specific focus area for oxygen/respiratory therapy. 5) R19 was in bed receiving oxygen via a nasal cannula at flow rate of 1 liter per minute. R19's nasal cannula was attached to the oxygen concentrator humidification bottle that was undated and contained a very small amount (approximately 1 inch) of cloudy water. At that time V4, RN stated the water in the bottle should not be cloudy and needs to be replaced. Also at that time, R19 asked what the oxygen flow rate indicated on her concentrator - V4 responded 1 liter. R19 responded I'm supposed to be on 2 liters. Current Physician Order Summary Report indicates R19 May use 2-4 liters to maintain SPO2 (oxygen saturation) >93% (date initiated 4/12/23). R19's current care plan indicates Give oxygen as ordered by the physician. 6) R42 was in bed receiving oxygen via a nasal cannula at flow rate of 2 liters per minute. R15's nasal cannula was attached to the oxygen concentrator humidification bottle that was undated and completely empty. Current Physician Order Summary Report indicates R42 May use 2-4 liters to maintain SPO2 (oxygen saturation) >93% (date initiated 6/30/23). R42's current care plan indicates Oxygen therapy per physician orders. Replace oxygen and nebulizer tubing and humidification weekly. On 11/15/23 at 1:45pm V4, RN stated she has worked for the facility for one year and didn't know if oxygen orders need to include humidification or if all residents should have humidification. On 11/15/23 at 2:45pm V4, RN stated if a resident is receiving oxygen at 2 liters or under, humidification can be used for comfort. If flow rate is 2 liters or greater - should have humidification. Facility Policy/Oxygen Administration dated 2/8/21 documents: It is the responsibility of the Charge Nurse to ensure that residents who have an order for oxygen are receiving the proper amount via the proper way, per physician order. Procedure: Adjust the delivery device so that it is comfortable, and the proper flow of oxygen is being administered. Label (pre-filled) humidifier with date and time opened. For re-usable humidifiers: Fill with sterile distilled or sterile ionized water to fill line. Attach humidifiers to flow meter by screwing nut onto flow meter. Set flow meter to the rate ordered by the physician. Label humidifier with date and time opened. Precaution: Constant flow of oxygen can cause drying and thickening of normal secretions resulting in laryngeal ulceration.

Based on observation, interview and record review the facility failed to provide procedures, protocols, and training for the use of a manual feeding tube declogging device and failed to follow physician orders for feeding tube site wound treatment for one resident (R9) of two residents reviewed for feeding tubes in the sample of 34. Findings include: Manufacturer Instructions (insert) for Use of (declogging device) dated 2021 documents: Intended use: The intended use of the declogger is to clear clogs from enteral feeding tubes and thereby reduce the occurrence of feeding tube replacement procedures. Indications for use: The declogger is indicated for use only in clearing occlusions and/or clogs in feeding tubes (G/Gastrostomy, J/Jejunostomy, and/or PEG/Percutaneous Endoscopic Gastrostomy style) in sizes from 14Fr (French) - 22Fr. User instructions indicate there are five different sizes of decloggers and that both the size (diameter) and length of the feeding tube should be known to use the appropriate size declogger. Protocol/Policy for use of the declogger: The declogger should be used every week to maintain unimpeded flow of an enteral formula. The declogger device will also be used to achieve patency of a tube that has become clogged with semi-solid formula. The declogger should be disposed of after single use. The following protocol should be followed according to the desired need. Blocked Jejunostomy tube - 1. Determine the size of the gastric or jejunostomy tube. CAUTION: Verify that the tube has not been modified i.e., shortened. 2. Select appropriate size of declogger device that corresponds to the size of the tube. 4. Insert the declogging device to reach the blockage and slowly rotate two times in a clockwise direction then reverse and rotate two-times in a counterclockwise direction while removing it. Do not attempt to force the declogging device through the entire blockage. 5. Repeat the entire process until the stop disk of the declogging device is reached without difficulty. 6. Flush tube with 30-60cc's (cubic centimeters) of water. CAUTION: If the declogging device becomes imbedded in the blockage and cannot be easily dislodged, the enteral feeding tube will need to be replaced. DO NOT attempt to physically remove the declogging device. WARNINGS: If the declogging device becomes imbedded in the blockage and cannot be easily dislodged, the entire feeding tube will need to be changed. DO NOT attempt to physically remove the declogging device. Cross Contamination Risk: Do not reuse the declogging device as this may spread contamination from one patient to another patient. Residual Risk: Risk associated with the use of this product has been reduced as far as possible, but the product cannot completely eliminate potential patient or user harm arising from the following: Harm from mechanical hazards Harm from misuse, or user error Harm from unanticipated origins. Facility Policy/Enteral Tube Feeding dated 9/30/21 documents: When a G-tube becomes displaced, plugged, damaged, or comes completely out it may be replaced or declogged unless contraindicated. Observe the insertion site frequently and report any signs and symptoms of skin breakdown or infection to nurse immediately. Protect skin from further breakdown with appropriate interventions. No policy, protocol/procedure for use of a physical declogging device was presented. Nurse Note dated 11/11/23 at 8:09am indicates R9 was sent to the hospital for J-tube dislodgement after R9's J-tube was found lying beside R9 in her bed with the bulb intact. Note indicates R9's J-tube was reinserted to maintain patency of the stoma. Note indicates R9's J-tube was last surgically replaced on 9/22/23. Note dated 11/11/23 at 9:33am indicates R9 returned to the facility and per hospital staff R9's J-tube was reinserted, however no paperwork was provided by the hospital to confirm tube placement. Note dated 11/11/23 at 12:56pm indicates that while attempting to flush R9's J-tube and start R9's feeding, the nurse was unable to aspirate or flush fluids. Note indicates nurse then attempted to utilize declogger but met with resistance past where declogging device could be visualized. Note indicates hospital physician was contacted and stated to use G-tube until R9 could be scheduled for surgery to replace the J-tube. On 11/16/23 at 1:00pm V5, RN (Registered Nurse) stated that she had to go to another unit (not part of the Skilled Nursing/Long Term Care Unit) to obtain the declogging device that she used to try to declog R9's J-tube on 11/11/23. V5 stated that she just used the size of declogger that the nurse on the other unit gave her to use and that she did not know the size of R9's G or J tubes The sizes of the tube are on the actual tubes. At that time, it was noted that the size of R9's G-tube was 24 Fr with a 7-10ml (milliliter) balloon, and the J-tube was a 22 Fr with a 7-10ml balloon. R9's feeding tubes did not indicate the length of the tubes - only the size (diameter). Neither the size or the length of R9's enteral tubes were found in R9's physician orders or care plan. On 11/16/23 at 2:00pm V7, NP (Nurse Practitioner) stated she is not that familiar with an enteral tube declogging device and wouldn't use one unless she had some training. V7 stated the manufacturer instructions should be followed. On 11/16/23 at 2:50pm V2, DON (Director of Nursing) stated that she was trained by a floor nurse on how to use a declogging device. V2 stated she has never provided any training or instruction to the nurses on how to use the declogger and there is no specific policy, procedure, or protocol for their use. On 11/16/23 at 1:10pm V5, RN was changing the stoma dressings on R9's two feeding tube sites which included a G-tube (on upper abdomen) and J-tube (mid abdomen). Both stoma sites had crusted reddish-brown discharge under and around the skin-side flange. Neither sites had a dressing in place. At that time V5 stated that she usually removes the old dressing, cleans the site, and replaces with a new dressing There should be a dressing. R9's current Physician Order Summary Report indicates Cleanse G/J tube site with soap and water every shift and as needed. Apply dressing as needed every 8 hours and as needed.

Based on interview and record review the facility failed to administer the pneumonia vaccine for two (R2 and R50) of five residents reviewed for immunizations in the sample of 34. Findings include: The facility's Pneumo (pneumococcal) Vaccination policy and procedure, dated 10/16/09, documents According to the National Institutes of Health, everyone [AGE] years of age and older should get the pneumococcal vaccine as well as younger people with certain qualifiers. All facility staff will follow the facility policies on Pneumo Vaccinations. All residents will be offered the Pneumo vaccine every 5 years per Center for Disease Control Guidelines recommendations. It is the responsibility of the DON (Director of Nursing)/Designee to ensure that all residents receive the Pneumo Vaccine and proper documentation is done every 5 years. The facility's undated Pneumonia Shot (pneumococcal vaccine) resident education form documents Who should get the pneumococcal vaccine? People age 65 or older; People with a chronic illness such as advanced breast cancer, heart or lung disease, or diabetes; People with a weak immune system due to illness and/or the effects of chemotherapy; Residents of nursing homes and other long-term care facilities. The facility's Pneumococcal Vaccine Resident Consent Form includes education and place for signature and date of acceptance or decline of the vaccine. 1. The current Physician Orders for R2, documents May Administer Pneumococcal vaccine every 5 years if not contraindicated. The Immunization Record for R2 documents R2 received the influenza vaccine on 9/28/23 and the pneumococcal vaccine is documented as Immunization Required. The Pneumococcal Vaccine Resident Consent Form for R2, signed and dated 6/25/23, documents R2's consent to receive the Pneumococcal Vaccine. 2. The current Physician Orders for R50, documents May administer Pneumococcal Vaccine every 5 years if not contraindicated. The Immunization Record for R50 documents R50 received the influenza vaccine on 9/25/23 and the pneumococcal vaccine is documented as Immunization Required. The Pneumococcal Vaccine Resident Consent Form for R50, signed and dated 9/4/23, documents R50's consent to receive the Pneumococcal Vaccine. On 11/16/23 at 1:30 pm, V2 DON (Director of Nursing) stated flu vaccines are given during flu season, but the Pneumococcal vaccines can be given at any time. V2 DON stated V3 ICP (Infection Control Preventionist) oversees the facility's immunizations. On 11/15/23 at 12:48 pm, V3 ICP confirmed consent was obtained for R2 on 6/25/23 and R50 on 9/4/23. V3 ICP stated she does not give the Pneumococcal vaccines until the flu vaccinations are given and only orders the pneumonia vaccine when she has enough residents who have consented.

Based on record review and interview the facility failed to notify the Resident or Resident Representative, in writing of Transfers/Discharges to the Hospital. This failure has the potential to affect all 52 Residents residing in the Facility. Findings include: Facility Application for Medicare and Medicaid Report (CMS/Central Management Services Form 671), dated 11/14/23, documents 52 Residents residing in the Facility. Facility Discharge/Transfer Policy, revised 5/29/18, documents: the purpose is to provide the Facility with guideline for appropriate discharge and transfer procedures; it is the responsibility of all staff to ensure that transfer and discharge are appropriate; and it is the responsibility of the Administrator and Director of Nursing to monitor for compliance with transfer and discharge procedures; when the Facility transfers or discharges Resident under any circumstances appropriate documentation shall be made in the Resident's clinical record; and before the Facility transfers a Resident to a hospital, the Facility must provide written information to the Resident/family Member/Legal Representative that specifies the duration of the Facilities bed to hold policy and the Facilities policies regarding bed hold periods. R4's Census List, dated 11/16/23, documents Hospital Discharge/Unpaid Leave dates of 2/22/23, 3/29/23, 6/14/23, 8/26/23 and 9/15/23. R9's Census List, dated 11/16/23, documents Hospital Discharge/Unpaid Leave dates of 2/28/23, 6/16/23, 8/13/23 and 9/21/23. R17's Census List, dated 11/16/23, documents a Hospital Discharge/Unpaid Leave date of 8/8/23. R27's Census List, dated 11/16/23, documents a Hospital Discharge/Unpaid Leave date of 8/29/23. R34's Census List, dated 11/16/23, documents a Hospital Discharge/Unpaid Leave date of 11/7/23. R50's Census List, dated 11/16/23, documents Hospital Discharge/Unpaid Leave dates of 6/24/23 and 8/1/23. On 11/16/23 at 2:00 pm, the Facility could not provide written notification documentation of the Resident/Family Member/Legal Representative for hospital transfers/discharges. On 11/14/23, at 10:30 am, V6 (R50's Spouse) stated, (R50) has been sent to the hospital a couple times, and I do not remember receiving anything in writing on the hospitalization . On 11/14/23 at 2:00 pm, V1 (Administrator) stated, I cannot provide you with any written documentation that representatives were given written notification for any of our Resident hospital transfers because I cannot find anything in any of our Resident medical records, or even any nursing progress notes on them either. Written notifications of hospital transfers have not been getting done.

Based on record review and interview the Facility failed to notify the Resident/Resident Representative, in writing of the Facility Bed Hold Policy. This failure has the potential to affect all 52 Residents residing in the Facility. Findings include: Facility Application for Medicare and Medicaid Report (CMS/Central Management Services Form 671), dated 11/14/23, documents 52 Residents residing in the Facility. Facility Discharge/Transfer Policy, revised 5/29/18, documents: the purpose is to provide the Facility with guideline for appropriate discharge and transfer procedures; it is the responsibility of all staff to ensure that transfer and discharge are appropriate; when the Facility transfers or discharges Resident under any circumstances appropriate documentation shall be made in the Resident's clinical record; and before the Facility transfers a Resident to a hospital, the Facility must provide written information to the Resident/Family Member/Legal Representative that specifies the duration of the Facilities bed to hold policy and the Facilities policies regarding bed hold periods; the Resident/Responsible Party will be given the Resident Rights Regarding Bed Holds; and will be given a copy of the jointly signed and dated Bed Hold form and a copy will be placed in the Resident's medical record until the Resident is readmitted ; and if the Resident's hospital visit should for any reason exceed 24 hours, then the State of Resident's Rights Regarding Bed Hold shall be provided to the Resident/family Member/Legal Representative. R4's Census List, dated 11/16/23, documents Hospital Discharge/Unpaid Leave dates of 2/22/23, 3/29/23, 6/14/23, 8/26/23 and 9/15/23. R9's Census List, dated 11/16/23, documents Hospital Discharge/Unpaid Leave dates of 2/28/23, 6/16/23, 8/13/23 and 9/21/23. R17's Census List, dated 11/16/23, documents a Hospital Discharge/Unpaid Leave date of 8/8/23. R27's Census List, dated 11/16/23, documents a Hospital Discharge/Unpaid Leave date of 8/29/23. R34's Census List, dated 11/16/23, documents a Hospital Discharge/Unpaid Leave date of 11/7/23. R50's Census List, dated 11/16/23, documents Hospital Discharge/Unpaid Leave dates of 6/24/23 and 8/1/23. On 11/14/23, at 10:30 am, V6 (R50's Spouse) stated, (R50) has been sent to the hospital a couple times, and I do not remember receiving anything in writing on the bed hold policy. On 11/16/23 at 2:00 pm, the Facility could not provide written notification documentation of the Resident/Family Member/Legal Representative for Bed Hold Policy for hospital transfers/discharges. On 11/14/23 at 2:00 pm, V1 (Administrator) stated, I cannot provide you with any written documentation that representatives were given to written notification of Bed Holds for any of our Resident hospital transfers, for the last year, because I cannot find anything in any of our Resident medical records, or even any nursing progress notes on them either. I looked back, when I was trying to find any documentation for this, and I noticed that we got 'cited' for this exact issue back in 2019 on a survey. When we got that citation, our plan of correction was that our Marketing Director, at that time, started going to the hospital and getting the Bed Hold's signed in person, but she is no longer employed here, so it has not been getting done since. We are not doing them for anyone (written notification of bed hold policy).

Based on observation, interview, and record review, the facility failed to provide pain management for one of one resident (R41) reviewed for pain management in the sample of 24. This failure resulted in R41, who is a resident on hospice services with the diagnoses of malignant neoplasm of her right lung, cervix, trachea, and adrenal gland, refusing to get out of bed and reposition because of R41's extreme pain with any kind of movement. Findings include: The facility's Management of Pain policy, dated 5/29/18, documents, Our mission is to facilitate independence, promote resident comfort and preserve resident dignity. The purpose of this policy is to accomplish that mission through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. We will achieve these goals through: Promptly and accurately assessing and diagnosing pain; Encouraging residents to self-report pain; Increasing comfort and reducing depression and anxiety in residents; Monitoring treatment efficacy and side effects; Preventing and minimizing anticipated pain when possible; Using pain medication judiciously to balance the resident's desired level of pain relief with the avoidance of unacceptable adverse consequences. For the purpose of this policy, pain is defined as 'whatever the experiencing person says it is, existing whenever the experiencing person says it does.' Procedure: Residents and families will be asked to periodically measure satisfaction related to pain and its management. Physician Communication and Involvement-Pain will be assessed and managed in a timely fashion, especially if it is of recent onset. The physician will be notified of resident's complaint of pain when not relieved by medication as ordered by the physician. Thorough communication with the physician will ensure an appropriate pain management plan. On 12/06/22 at 02:17 PM, R41 was alert and oriented lying-in bed on her right side. R41 stated she has lots of pain from her lung cancer, kidney stones, and my leg issues. A few nights ago, the nurse (V9 Licensed Practical Nurse) would not give me my pain medicine for some reason. I put my light on around 11:00 p.m. and asked her for a pain pill. She told me I couldn't get it just yet because I still had an hour before I was due. I was ok with this no big deal. So, an hour went by she told me the same thing again. 1 am went by, 2 am went by 3 am went by, 4 am went by, 5 am went by and she never brought me pain medication. She was in the room at 6 am finally and I asked her where my pill was. She told me I was sleeping when she came in. If I was sleeping it wasn't very good. I was in so much pain all I could do was doze off not actually sleep. She treated me like a dog. I'm in pain and I asked for a pain pill, but she says I don't even look like I'm in pain. If I get off my routine of pain medication it throws it completely off, and then I have to start all over again to try and get it under somewhat control. Unable to contact nurse. R41 was unable to reference a date. R41's MDS (Minimum Data Set), dated 10/23/22, documents that R41 scored a 13 on her BIMS (Brief Interview for Mental Status) assessment signifying that R41 is cognitively intact. A facility Grievance/Complaint form, dated 12/6/22, documents, (R41) stated that (V9) did not give her PRN (as needed) pain meds over the weekend. Resident could not give exact time or date. The form also documents, Follow Up Action Taken: Upon investigation, interviewed V9. She stated on 12/5/22 at 3:00 a.m., R41 asked for a pain pill. V9 stated when she brought the pain pill to R41, she was sleeping at that time. V9 attempted to wake R41 by calling her name. R41 did not wake up. Approximately at 5:30 a.m., V9 stated CNAs (Certified Nursing Assistant) informed her R41 was asking for a pain pill. At that time V9 stated she was in another resident's room that was having an emergency. V9 instructed the CNAs to let R41 know she would be down with her pain medicine as soon as she was done helping the resident that was having the emergency. V9 then stated informed the oncoming nurse at 6:00 a.m. that the resident asked for pain medicine. R41 received pain medicine at 6:05 a.m. R41's Controlled Drug Receipt/Record Disposition Form, dated 11/30-12/7/22, documents that R41 received Norco 10/325 mg one tablet on 12/4/22 at 8:10 p.m., and the next dose was not administered until 12/5/22 at 6:05 a.m. R41's Physician's orders, dated 12/7/22, documents that R41 has the following orders: Morphine Sulfate Solution 100 mg (milligrams)/5 ml (milliliters). Give 0.25 ml orally every six hours as needed for mild pain; Norco 10-325 mg one tablet by mouth every four hours as needed for pain. R41's Care plan, dated 4/19/22, documents, I have altered respiratory status related to Lung Cancer. Intervention: Use pain management as appropriate. Monitor/document side effects and effectiveness. R41's History and Physical, dated 10/16/22, documents, Chief Complaint: Pain. History of Present Illness: R41 complains of diffuse pain and achiness especially in her back but seems to be generalized. She has known metastatic lung cancer. Not currently undergoing active treatment. Impression and Plan: Chronic pain. R41's Pain Assessment, dated 10/23/22, documents that R41 has frequent severe pain, and that she complains of pain daily. R41's Significant change MDS, dated [DATE], documents in Section J Health Conditions that R41 has frequent severe pain R41's Medicare Daily Progress note, dated 10/23/2022 at 11:33 a.m., documents, R41 refused to be repositioned in bed or get up for meals. R41 has been deciding if she wants hospice or not and R41 has decided that she does not want to treat lung cancer and prefers to have hospice services. R41's medical record has no documentation of physician follow up. R41's Medicare Daily Progress note, dated 10/26/2022 at 09:56 a.m., documents, As needed pain medications given with effectiveness noted, R41 states that she is still having pain. R41 refused to get up for AM meal. R41 is able to feed self but requires set up assistance. R41 has poor appetite and fluid intake and has been educated on coming to dining room but still refuses. R41 refused to go to appointment for renal scan. R41 has decided on hospice and hospice will be here today to evaluate R41. Staff offered to reposition R41 and R41 refused. R41's record documents she was admitted to Hospice on 10/27. R41's Nurses' note, dated 10/27/22 at 9:41 a.m., documents, R41 refuses to get up for meals despite staff encouragement. Staff offered to reposition R41, and she refused. R41 prefers to lay on right side despite being educated on skin breakdown. R41's Nurses' note, dated 10/27/2022 at 12:42 p.m., documents, R41 is admitted to hospice. New order to discontinue Norco 7.5 mg/325 mg every 4 hours as needed. Start Norco 10 mg/325 mg every 4 hours as needed. R41's Care plan, dated 10/28/22, documents, Terminal illness-admit to hospice due to Cancer diagnosis. Goal: Myself and my family's will be maintained, and I will be comfortable without observable indications of pain and/or other physical, mental, or psychological symptoms thru staff monitoring and intervention. Intervention: Provide Pain/Discomfort medications per physician order. Monitor effectiveness and side effects. Report changes in pain, uncontrolled pain, and adverse effects of medications to the physician. R41's Nurses' note, dated 10/28/22 at 9:35 a.m., documents, Refuses to get up for meals. R41 has poor appetite. R41's Hospice Admission Orders, dated 10/28/33, documents that R41's primary diagnosis for admission to hospice is malignant neoplasm of R41's right lung. The orders also document R41's related diagnoses are malignant neoplasm of the adrenal gland, trachea, and cervix. R41's Nurses' note, dated 10/30/22 at 12:47 p.m., documents, R41 states pain is all over. R41's Behavior Note, dated 11/1/22 at 2:24 a.m., documents, No behaviors noted or reported from change in pain and anxiety meds. Continues asking for pain meds on same schedule as before. R41's Nurses' note, dated 11/3/22 at 8:28 p.m., documents, Maintaining comfort as much as possible. R41's Behavior note, dated 11/3/2022 at 02:30 a.m., documents, R41 received a 10-325 Norco at 01:00 a.m. and rang her call light at 02:30 a.m. asking for another pain pill. R41 stated, 'she would not tell anyone if I gave her another one early.' R41 was told that we would not be administering anything early to her. R41 has been increasing her requests for pain pills and at denials she continues to ask for other medications that have been discontinued or not available to her like Diazepam and oxycodone-acetaminophen. R41's Behavior note was signed by V9. R41's Behavior note, dated 11/3/2022 at 4:00 a.m., documents, R41 request another pain pill at 03:50 a.m. I told her it has been less than 4 hours since her last pill and this is her 3rd request since being administered a pain pill at 01:00 a.m. She stated, 'it was okay to give it to her early since it's only like 10 minutes early.' I told her it was more than an hour early and I would not be issuing her medications early. I also explained due to the increasing requests and attempts at bargaining for more pills we have to chart all of the attempt times as well and would not be going against the orders to give them early. When entering her room to answer the call light she was asleep and woke up when turned the call light off. R41's Behavior note was signed by V9. R41's Medical record has no documentation of R41's physician or hospice being notified of R41's requesting pain medication, on 11/3/22, prior to being scheduled due to pain not being controlled. On 12/08/22 at 9:54 AM, V2 (Director of Nursing) confirmed that V9 should have notified the physician or hospice of R41's increased pain, but V9 did not do that. R41's Nurses' notes, dated 11/6/22 at 6:29 p.m., documents, Appears in no pain. However, the note also documents, Requesting Norco when available. R41's Nurses' note, dated 11/8/22 at 10:48 a.m., documents, R41 refuses to get up for meals. R41's Nurses' notes, dated 11/9/22 at 9:16 a.m., document, R41 refused to get up for meal. R41's Nurses' notes, dated 11/11/22 at 6:26 p.m., documents, Comfort maintained as much as possible. R41's Nurses' note, dated 11/13/2022 at 09:21 a.m., documents, Resident refuses to get up for meals. She is a total staff assist for transfers, ADLs (activities of daily living), and tray set up. She is hospice status. Her pain is controlled with as needed pain medications. However, R4's Nurses' notes also documents, Resident refuses to be repositioned. Stating 'if I move, I hurt.' Staff will continue with current plan of care. R41's MAR (Medication Administration Record), dated 11/22, documents that R41's tolerable pain is a 4 (on a pain scale of 0-10). R41's Pain assessments document that 17 out of 30 days, R41's pain level exceeded her tolerable pain rating it from a 5-10 (on a pain scale of 0-10). The MAR also documents that R41 is being administered Norco 10-325mg on an average of daily two to four times a day with the exception of five days when R41 requested it one time during the day. In addition to the Norco, R41 was started on Morphine as needed 11/3/22, and R41 requested the Morphine (11/3-11/30/22) one time a day nine days and twice a day four days. On 12/08/22 at 12:08 PM, V8 (Certified Nursing Assistant) stated, (R41) complains a lot of being in pain. She doesn't show facial expressions of pain, but I'm not in her body so I don't know what she is feeling. When we provide incontinent care to R41, R41 cry's out and will be saying, 'Oh that hurts' the whole time especially if we have to roll her to her left side. On 12/08/22 at 9:54 AM, V2 (Director of Nursing) stat (R41) does have frequent pain. On 12/08/22 at 10:43 AM, V5 (MDS-Minimum Data Set Coordinator) stated, (R41) frequently requests a change in her pain medication or an increase. V5 also confirmed that a person can build up a tolerance to pain medication, and that R41 has active cancer. On 12/08/22 at 11:00 AM, V6 (Hospice Registered Nurse) was assessing R41. R41 stated, My pain is just all over. I'd say it's a 7 (scale of 0-10) right now. It's stabbing and aching. The main places it hurts are my kidneys and my lungs. My cancer is primarily in my lungs. I don't get out of bed because I hurt too much. I can't even move to roll over let alone get out of bed the pain is so bad. I can only lay in one position to help with the pain. My heart has also been fluttering and beating fast more lately. While R41 was speaking she was constantly fidgeting and facial grimacing throughout the conversation. V6 explained to (R41), Your pain is a vicious cycle. You hurt then you start getting anxious. If your pain isn't controlled, you get even more anxious and your pain keeps going up because your body is getting anxious and worked up. V6 also stated, I feel like (R41) would benefit from changing her Norco to something like Methadone because I feel that her body may have built up a tolerance and she needs a constant schedule to keep ahead of her pain. (R41) has lung cancer and has had multiple fractures so she for sure has pain. On 12/09/22 at 10:15 a.m., V1 (Administrator) stated that (R41) is on hospice for her diagnosis of cancer, but she feels that (R41) is just a pain medication seeker because she is always wanting more pain medications.

Based on interview and record review, the facility failed to complete the CPR (cardio [MEDICAL CONDITION] resuscitation) checklist and initiate CPR for a resident whose advance directive indicated full code status for one of 15 residents (R47) reviewed for advance directives in a sample of 33. This failure resulted in one resident (R47) not receiving CPR and expiring in the facility. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at a Severity Level 2 as the facility continues to monitor the effectiveness of educated nursing staff on CPR policy and protocol. Findings include: The facility's Initiation of C.P.R. policy revised [DATE] documents the following: To provide guidelines for facility licensed professional staff to follow to ensure appropriate initiation of CPR and to prevent initiation of CPR on a resident who is assessed to be clinically dead and cannot respond to CPR. Licensed professional staff, upon finding a non-responsive resident, who is a full code status, will conduct a thorough assessment to determine if resuscitation efforts should be initiated. 1. When a resident is not a DNR (Do Not Resuscitate), having a full code, or CPR only status, it is through the assessment process, that no less than two (2) licensed professionals will determine whether or not resuscitation efforts are warranted. 2. Upon finding the resident, at least two (2) licensed staff will be called to the resident room/location of resident. 3. The licensed professionals will assess the following to determine if there are clinical, biological and irreversible signs of death. a. Temperature of skin (On scale of ,[DATE], 10 being the coldest). If skin is ice cold and there are no signs of vitals, proceed through the checklist. If skin is warm to touch initiate CPR immediately if resident is a full code, or CPR only status. b. Pupils fixed and dilated (Shine a flash light into the eyes of the expired resident to adequately assess for any reaction). c. Any visible, spontaneous signs of respirations, pulse, movement. d. Attempt to obtain blood pressure. e. Check upper/lower extremities for mottling (pooling of blood). f. Assess nail beds for capillary refill and/or cyanosis. g. Check around resident oral cavity for cyanosis. h. Check arm, legs, jaws, for rigidity. 4. There must be a minimum of two (2) licensed professionals who are conducting the assessment together. If there is a physician in the facility page them to the room immediately. R47's POS (physician's orders [REDACTED]. R47's POS documents R47 is a full code. R47's POLST (Physician order [REDACTED]. R47's MDS (Minimum Data Set assessment) dated [DATE] documents R47 cognitively intact with no problems with memory/orientation. R47's nursing notes dated [DATE] at 6:01 am document that a CNA (Certified Nursing Assistant) notified V6 (Registered Nurse/RN) that R47 appeared to not be breathing. V6 entered room. Resident skin yellowish. No visible breath sounds noted. No apical heart rate or breath sounds noted after a minute of listening for each vital sign. (V7, LPN/Licensed Practical Nurse) confirmed absence of breath sounds and heart rate at 0601. On [DATE] at 9:43 AM, V6 stated on [DATE] about 6:00 am she was coming on duty when a CNA said R47 had passed. V6 went to his room and R47 was yellowish, waxy and cold with no pulse or respirations. V7 came and also checked R47's vital signs which were absent. V6 stated R47 was a full code even though he was on hospice. V6 stated she did not start CPR because R47 was cold and gone. On [DATE] at 2:26 PM, V6 stated R47 did not have rigor mortis or lividity when she assessed him. V6 does not remember checking R47's pupils, taking his blood pressure, checking for mottling or capillary refill. V6 stated R47's nail beds looked white and did not notice cyanosis. On [DATE] 10:45 AM, V7 stated she worked the night of [DATE] with R47. V7 stated R47 was in pain that night and was up and watching TV. V7 stated R47 was alert when she gave him [MEDICATION NAME] at about 5:30 am for pain. About 6 am, V6, another nurse, called her to R47's room. R47 was cold and had no heart beat and no respirations. V7 stated she knew R47 was a full code. V7 stated based on R47 being cold and having no pulse or respirations, they did not initiate CPR. R47's (MONTH) 2019's MAR (Medication Administration Record) documents [MEDICATION NAME] 5 mg (milligrams) was given orally at 5:37 am by V7. On [DATE] at 9:40 am and 10:15 am, V12 (Certified Nursing Assistant/CAN) stated she worked the day shift with R47 on [DATE]. V12 stated R47 was up watching TV, in an ok mood and was being normal. V12 stated R47 went out for breakfast and lunch with his brother on Saturday, [DATE]. On [DATE] at 11:47 AM, in a follow-up interview, V6 verified that she knew R47 was a full code and that she did not check for mottling and that R47 looked yellow and waxy. V6 stated she moved R47's hands off his chest to listen for a pulse. V6 stated she couldn't remember turning R46 to check for lividity. On [DATE] at 1:37 P.M., in a follow-up interview, V7 stated she does not recall turning R47 to check for pooling of blood and V7 also stated R47 wore socks and (pressure relieving boots) and stated those were not removed to check for mottling. V7 also stated she could not recall R47 having rigor mortis. V7 denied attempting to take R47's blood pressure. V7 stated there was a light already on in R47's room and that she waved her hand over R47's eyes to check pupillary response. V7 did not use a flash light. On [DATE] at 11:24 [NAME]M., in a follow-up interview, V11 (Registered Nurse) stated she stepped into R47's room with V7, V6 and V7 listened with a stethoscope to R47's heart and lungs. V11 stated, R47's lips were blue and he was cold to the touch. (V6 and V7) both pronounced R47 and I made the phone calls after that. I did not witness R47's pupils being checked or his blood pressure being checked. He was very pale. I did not see anyone sternal rub him while I was in the room. CPR was not initiated because he was cold, blue lips, and no pulse or respirations. V11 stated she was aware that R47 was a full code. On [DATE] at 11:46 AM, V24 (R47's Attending Physician's Nurse) verified R47 was a Full Code. According to the Mayo Clinic article titled, Cardiopulmonary Resuscitation First Aid dated [DATE] documents, If you're well-trained and confident in your ability, check to see if there is a pulse and breathing. If there is breathing or pulse within ten seconds, begin chest compressions. If you have previously received CPR training but you are not confident in your abilities, just do chest compressions at a rate of 100 to 120 a minute. CPR can keep [MEDICATION NAME] blood flowing to the brain and other vital organs until more definitive medical treatment can restore the normal heart rhythm. On [DATE] at 1:30 PM, V9 (Hospice team manager) stated R47's hospice records indicate R47 was a full code at the time of passing. He was admitted to hospice at [DATE] for malnutrition and was declining, becoming weaker with less intake. V9 stated if a resident is a full code at the facility, they need to be coded unless family or the physician says not to. On [DATE] at 8:15 am, V10 (R47's family) stated hospice talked with him and R47 several days before R47 expired. V10 stated R47 was declining in health but they told hospice they were not ready yet to make R47 a DNR (Do Not Resuscitate). The Immediate Jeopardy was identified on [DATE] at 3:30 P.M. The Immediate Jeopardy began on [DATE] when the facility failed to initiate CPR on a resident with a full code status. V1 (Administrator) and V21 (Regional Director of Operations) were notified of the Immediate Jeopardy on [DATE] at 3:30 P.M. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. All nursing and CPR certified staff were trained on initiating CPR for residents per their advanced directives/wishes. 2. All nursing and CPR certified staff were trained on the facility's Initiation of CPR Policy for determining if CPR is recommended or not. 3. The following Nurse Managers completed this training: V3 (Assistant Director of Nursing/Registered Nurse); V23 (Care Plan Coordinator/Registered Nurse); V2 (Director of Nursing/Registered Nurse); V22 (Registered Nurse/Infectionist); V5 (Registered Nurse/MDS Coordinator). 4. All nursing and CPR certified staff demonstrated competency via post test on when to initiate CPR for residents per their advanced directives/wishes. 5. All nursing and CPR certified staff demonstrated competency via post test on when CPR is recommended per the facility's Initiation of CPR policy. 6. All nursing and CPR certified staff exhibited competency on how to assess a resident's need for CPR per the facility policy. 7. All nursing and CPR certified staff were trained upon notification of the abatement plan on [DATE]; as of 7:15 P.M. on [DATE] (the facility) is fully functional with all staff working having been trained and deemed competent. 8. Training included the following: CPR Initiation policy in its entirety. 9. Trainings were completed on [DATE] beginning at 4:15 P.M. with the staff present in the facility and oncoming shifts and ending at 7:15 P.M. Training was completed in person either individually or in groups no larger than three. Training was completed on this date by the following nurse managers: V2 RN/DON, V3 RN/ADON, V5 RN/MDS Coordinator, V23 RN/CPC, and V22 RN/Infectionist. 10. Trainings will be completed for all staff scheduled prior to staff returning to work.

Based on observation, interview and record review the facility failed to protect the resident from implementing a strict visual status, limiting the resident's access to areas of the facility, limiting the resident's visitation and threatening the resident with the police as initiated by the facility Administrator for one of five residents (R1) reviewed for seclusion and discharge in a sample of 18. This failure resulted in R1 feeling unsafe in the facility and fearing retaliation from administration. Findings include: R1's current electronic quarterly MDS (Minimum Data Set) dated 4/22/2018 documents the following: Section C, Cognitive Patterns documents R1 has a BIMS (Brief Interview for Mental Status) of 15 indicating R1 is cognitively intact. On 6/11/18 at 10:06 AM and 6/13/18 at 12:30 PM R1 stated the following, The facility says I am a harm to others; I can't be outside with (R2). I am not allowed to go to the 200 wing to see my friend (R2). They are trying to send me to another facility far away and trying to get rid of me for no reason. I picked my friend up (manually transferring R2 to wheelchair) when the CNA said they did not have time to get him up because we wanted to smoke and CNAs said we had to wait until they had time. I didn't hurt either one of us but I know I should not do it again. I do everything for (R2) and they know that; he is my third cousin. I am not trying to cause problems and I won't try to transfer him again. On 6/13/2018 R2 stated he likes to visit R1 but the facility tries to keep R1 and R2 apart. R2 stated V1 (Administrator) is a bi*tch and does not like R1. R2 stated V1 changes the rules in the facility every 5 minutes so I just try to mind my own business and stay clear of V1. R2 stated he has no other complaints or concerns. R1's progress note dated 4/17/18 at 3:03 PM documents the following: (R1) resting quietly in bed at this time. Alert and oriented, cooperative with cares. R1's progress note dated 4/17/18 at 4:29 PM documents the following: at 1615 (4:15 PM) I (V10, ADON, Assistant Director of Nursing) spoke with (R1) in regards to his roommate (R2) being placed in wheelchair without staff assist. (R1) stated that he was just trying to help and did place roommate in wheelchair but would never do it again. I (V10, ADON) explained to (R1) that his roommate can only be transferred by staff members. (R1) again stated that he would never transfer his roommate to wheelchair again. R1's progress note dated 4/17/18 at 3:03 PM documents the following: on 4/17/18 at 5:31 PM (R1) was issued notice of involuntary discharge/transfer due to severity of incident (endangering the safety of individuals in this facility). I (V10, ADON) explained the right to appeal this notice to (R1), at which point he requested an appeal. On 4/17/5:35 PM R1's progress notes document R1 was moved to 100 wing to a private room, and a 1:1 was placed for the safety of other residents. R1's electronic care plan documents the following focus areas with goals and interventions that were initiated on 4/18/2018: I have been placed in a private room on 100 wing related to a recent action of mine (manually transferring another resident to wheelchair) that endangered the safety of another individual in the facility. R1's goal for this focus area documents the following: I will remain under 1:1 observation until my appeal for immediate transfer/discharge has been heard (in 30 days). This electronic care plan does not document any behaviors prior to 4/18/2018. R1's medical record did not contain documentation of alternatives tried or education given to R1 regarding not transferring residents. On 6/11/18 at 1:09 PM V1 (Administrator) stated, (R1) picked up (R2) and transferred him from the bed to the wheelchair. He (R1) is a risk to others so I initiated an involuntary discharge, moved him to 100 hall and placed a 1:1 with him. Staff are scared of him. The staff have been instructed to call the police for anything regarding R1 from now on. I do not like him (R1). He (R1) thinks this is a frat house. (R1) went to the hospital recently and I was not going to take him back but I was told I had to because he is appealing the discharge. I did not notify (V4 Physician) of the Involuntary Discharge; he does not get involved too much. He gives (R1) whatever he wants. We have not offered him counseling. On 6/11/18 at 10:06 AM and 6/13/18 at 12:30 PM R1 stated the following:,(V1) said I can't visit (R2). I fear the facility is going to stage something against me to get the police involved. This is lie, cheat and steal ville, everyone is intimidated by (V1, Administrator). If the staff tell me I did wrong, that's fine. I will quit. The staff make up lies about me. I am homeless, I do not want to lose this, I am trying to find a place. (V1) is trying to send me to a psychiatric facility and I am not crazy. I have never seen a psychiatrist or been given a psychiatric diagnosis. Optimally I want to stay here until I find a place. If I walk down the hall staff yell at me. V11 (LPN, Licensed Practical Nurse) hates me. I did not have any issues with staff prior to the incident when I transferred my friend (R2). I do not want to be around V3 (DON, Director of Nursing); she puts me in fight or flight, she wants to send me to the mission. I have not been established as a harm. I am willing to do what it takes to be a normal human being. They won't help me. I feel I need to leave and go stay with a friend before they stage something and call the police. I do not have a criminal record and I do not want one. R1 stated, Why do I need a person outside my door watching me all of the time? I am an adult. I also do not understand why I had to be moved from sharing a room with R2; we are friends and I would not hurt him. R1's electronic medical record did not include any documentation of a psychiatric diagnosis. On 6/11/18 the facility provided a list of interviewable residents on the same hall as R1. On 6/11/18 at 11:15 AM R6 and R7 stated they feel safe and no residents bother them. R6 and R7 stated they do not hear or see any residents yelling or acting out. On 6/11/18 through 6/13/18 from 9:00AM - 3:00PM R1 was pleasant to staff and other residents. When staff would enter the room to check on him every 15 minutes R1 would yell you don't need to come in my room, get out! On 6/11/18 through 6/13/18 at various times ranging from 9 AM - 3:00PM R1 had a 1:1 outside of his door or following him at all times while he was in the facility. On 6/13/18 at 9:23 AM V3 (DON - Director of Nursing) stated R1 has a 1:1 while he is in the building but is not required to have one if he signs himself out. V3 stated R1's behaviors are cussing and making negative comments about administration. V3 stated the facility is trying to find better placement for R1. V3 stated R1 has not done anything to other residents. V3 verified V4 (Physician) was not informed of R1's involuntary discharge. On 6/18/18 at 12:18 PM V11 (LPN - Licensed Practical Nurse) stated, (R1) was not supposed to be on the 200 wing at all but if he tries to go he is to be supervised. (V11) stated, I am not sure of the exact rule regarding (R1) visiting (R2). (V11) stated on one occasion when (R1) was trying to go from 100 hall to 200 hall (V11) tried to redirect (R1) and he told (V11) to mind (V11's) business. (V11) stated (V11) continued to try to redirect (R1) from 200 hall back to 100 hall and when (R1) would not go, (V11) threatened to call the police. (V11) stated after threatening to call the police is when (R1) returned to his room on 100 hall. On 6/13/18 V2 (CNA - Certified Nursing Assistant) stated R1 does not like me, he makes rude comments to me. I am not assigned to take care of him. I have never seen R1 become violent or be a danger to another resident. On 6/13/18 at 9:50 AM V8 (RN - Registered Nurse) stated V8 has never had problems with R1 but knows others have. V8 states R1 feels the 1:1 are an invasion of his privacy. R1 is easily re-directed and admits when he has done wrong. On 6/12/18 from 10:30 AM - 11:00 AM V5 (RN - Registered Nurse), V6 and V7 (CNAs - Certified Nursing Assistants) stated R1 is not a harm to other residents. He cusses a little bit and acts silly. R1 is always pleasant.

Based on record review, observations, and interviews the facility failed to keep one of three residents (R1) from falling during during bed linen change. R1 suffered fracture to C1 vertebrae and two hematomas to his head. Findings including: R1 current face sheet notes that R1 has [DIAGNOSES REDACTED]. Facility report dated 1/10/17 notes that on 1/7/17, E3 (Certified Nurse's Aide) was assisting R1 with a bed pan. R1's linens needed to be changed, so E3 assisted R1 with rolling back and forth in the bed. When E3 rolled R1 away from E3 towards R1's left side, R1 rolled off the bed onto the floor. R1 was immediately sent to the local emergency room for an evaluation. R1 was diagnosed with [REDACTED]. On 1/19/17 at 10:00 A.M. E3 stated that on 1/7/17 while changing R1's linens, she rolled R1 away from her towards R1's left side and R1 rolled off the bed onto the floor. E3 stated that R1 was to have one or two staff assisting him with positioning while in bed. E3 stated that there was no specific method to determine when R1 would need one or two staff for assistance. E3 stated that R1 did not have any side rails on his bed, so there was nothing for R1 to grab onto. E3 stated that before this fall, she had asked management for side rails for R1 but nothing was ever done about E3's request. E3 stated that R1 would have been able to use side rails to assist with turning if he would have had them on his bed. R1's care plan dated 12/27/16 reads, Bed Mobility: Resident requires staff assistance X 1-2 to reposition and turn in bed. Care plan gives no explanation on how to determine when to use one or two staff with this task. On 1/19/17 at 3:45 P.M. R1 was observed lying in bed in the local hospital. When R1 was asked if he was able to use side rails, R1 grabbed the side rail and pulled himself more onto his left side. R1 verified that at the time of the fall, the facility bed did not have side rails. R1 stated that E3 rolled R1 away from her, instead of towards E3 when the fall occurred. R1 was noted to be wearing a neck brace due to the C1 fracture.

Based on interview and record review, the facility failed to safely transfer, assess transfer status, and failed to thoroughly investigate a fall for two of three residents (R1, R2) reviewed for falls in the sample of three. These failures resulted in a fracture of R1's humerus. Findings include: A Transfer Policy dated 6/15/05, documents the transfer technique used for the resident will be evaluated and determined by the nurse...a minimum of two staff members is recommended when transferring with a full mechanical lift...if a sit to stand mechanical lift is being used, ensure resident is able to stand. A Fall Policy dated 1/12/13, documents to provide ongoing risk reducing interventions...identify and implement related care link interventions, review and discuss potential root cause of a fall, complete follow-up event documentation as clinically indicated, and new or changes in current interventions will be discussed by the interdisciplinary team and the care plan will be updated accordingly. 1. An Accident/Incident Report dated 4/3/15 at 7:00 p.m., documents R1 was being transferred by E4 and E5, CNAs (Certified Nursing Assistant) using a sit to stand mechanical lift. R1 let go of the sit to stand and was lowered to the floor. Accident/Incident Report documents R1 was "assessed and denies pain." An Investigation Interview dated 4/6/15, documents E11 (Certified Nurse Aide) reported that R1 started complaining of shoulder pain on 4/4/15 at approximately 6:15 a.m. A Nurses Note dated 4/4/15 at 7:45 a.m., documents R1 complained of right arm/shoulder pain and that R1 stated it had been hurting since the night before. The Nurses Note also documents R1 had limited range of motion to right arm and shoulder. X-ray report for R1 dated 4/4/15 documents a fracture of the proximal right humerus at the surgical neck. Indication is documented as, "Patient fell last night with injury to right humerus." emergency room Note Report for R1 dated 4/4/15 documents R1 was dropped to floor at nursing home last night (4/3/15) causing fracture of right humerus. R1's MDS (Minimum Data Set) dated 10/19/14 documents R1 is cognitive and understands. The MDS documents R1 requires extensive assistance of two for transfers. R1's Mobility assessment dated [DATE] documents R1 has poor muscle strength in shoulders, hips, knees and ankles. The Mobility Assessment also documents R1 is not able to bear weight. R1's Care Plan (initiated 10/6/14), visible on computers by the Certified Nursing Assistants, for Transfers documents, "Resident Requires staff assistance times two and full mechanical lift with transfers." On 4/20/15 at 10:59 AM, E10, Registered Nurse/MDS Coordinator, stated the mobility assessment information is gathered from CNAs, Nurses, Restorative Aid, Observation and Section G of the MDS. E10 then looks at nurses notes and asks nurses or Restorative Aid how resident is transferred. E10 states there is not a score for the mobility assessment which would indicate which type of lift should be used. E10 also stated she had never observed R1 being transferred. R1's Investigation Summary dated 4/4/15, documents "it is concluded that it is likely that the injury (fracture) was caused from chronic dislocation of (R1's) shoulder." On 4/20/15 at 9:44 a.m., E2 (Director of Nursing) verified the investigation of R1's fractured humerus was completed by E2. E2 was asked how E2 came to the conclusion that R1's incident on 4/3/15 and the fracture on 4/4/15 were not related. E2 stated "I came to that conclusion after (R1's) family told (E2) about (R1's) history of shoulder dislocation. E2 could not explain how a fractured humerus and a shoulder dislocation correlate. E2 also stated that the conclusion was not based on communication with a physician. On 4/16/15 at 10:20 a.m., R1 stated R1 only remembered blacking out and falling to the floor on 4/3/15. On 4/16/15 at 9:30 AM, Z1 (anonymous) stated a sit to stand mechanical lift is not an appropriate transfer for R1 due to R1's inablility to bear weight and to hang on to the bars. On 4/16/15 at 11:20 AM, Z2 (R1's Power of Attorney) stated staff used a sit to stand when R1 required her adult brief to be changed. Z2 stated R1 preferred being transferred by a full mechanical lift because it made R1 feel more secure. Z2 stated R1 was not able to hold onto the sit to stand because R1 did not have the strength. On 4/20/15 at 3:03 PM, Z3 (R1's emergency room Physician) stated R1 sustained a fracture to her right arm which was diagnosed with [REDACTED]. Z3 stated information from the nursing home stated R1 was dropped during a transfer on 4/3/15. Z3 stated the x-ray did not indicate a shoulder dislocation. On 4/16/15 at 10:35 AM, E8, CNA, stated E8 always uses a full mechanical lift to transfer R1. On 4/20/15 at at 10:47 AM , E6, CNA stated E6 only used a sit to stand to transfer R1 on shower days. A full mechanical lift was used at all other times. E6 stated after R1 fractured her arm a full mechanical lift is used for all transfers. On 4/20/15 at 10:18 AM, E5, CNA, stated E5 usually used a full mechanical lift to transfer R1. E5 stated E5 was unsure if R1 could bear weight or was able to stand. E5 stated a sit to stand was used on 4/3/15 in order to change R1's wet adult brief. E5 stated R1 let go of the handles on the sit to stand. E5 stated R1 was lowered to the floor without hitting head or anything. On 4/20/15, attempts to contact E4 (Certified Nurse Aide) were unsuccessful. An Investigation Interview (provided by E2) dated 4/6/15, documents E4 reported "(R1) was being lifted up when (R1) leg go of the bars on the sit to stand which caused (R1's) bilateral arms to go upward." 2. An Accident/Incident Report dated 4/1/15 at 3:00 p.m., documents E3 (Certified Nurse Aide) transferred R2 from wheelchair to bed via a full mechanical lift when the lift sling broke causing R2 to fall to the floor. The Accident/Incident Report documents R2 sustained a skin tear and scrapes to the left arm. The Investigation follow up dated 4/2/15, does not document that only one staff member (E3) transferred R2 using the full mechanical lift when the sling broke. A Minimum (MDS) data set [DATE], documents R2 requires total assistance of two staff with transfers. R2's Plan of Care initiated on 12/15/14, documents "resident requires staff assistance of two with transfers, using a (full mechanical lift)." On 4/20/15 at 10:50 a.m., R2 verified E3 was the only staff present on 4/1/15 when the lift sling broke and R2 fell to the ground. R2 stated "I am thankful I wasn't hurt worse than I was. It made me very sore, especially since I already had a fractured hip that was healing." On 4/20/15 at 11:10 a.m., E2 (Director of Nursing) stated two staff are required for all full mechanical lift transfers. E2 stated E3 had not been counseled as of the present time. E2 verified R2's investigation from the fall on 4/1/15 did not include the fact that only one staff performed the transfer.

Based on record review and interview, the facility failed to thoroughly assess, follow their policy for wound care, and seek physician directions in a timely manner for one of five resident, (R19) reviewed for pressure ulcer care in a sample of fifteen. This failure resulted in inaccurate assessment of the wound, delay of pressure ulcer treatment, and deterioration of the pressure ulcer. Findings include: R19's physician orders [REDACTED]. Physician orders [REDACTED]. A Progress Note dated 8/07/14 at 11:18 p.m., states, "Crease between leg and buttocks has a skin tear approximately 3 cm (centimeter) wide and 2 cm long. (R19) states (R19) thinks this was from (R19's) underwear rubbing against skin. Dressing applied and will request wound nurse to evaluate." A Skin/Wound Assessment form dated 8/07/14 does not include an assessment of R19's left buttock wound but states, "Surgical incision has closed/healed." Another Progress Note, dated 8/14/14 at 10:40 p.m., states, "Put dressing over wound, will leave on report sheet asking for wound nurse to check to see if different treatment needs applied." A Progress Note, dated 8/19/14 at 6:10 p.m., states, "Dressing change to bottom. Color is black with borders red. Foul odor noted. No drainage at this time. Size is larger, 4.5 cm by 3.5 cm." A policy titled Pressure Ulcer Prevention, Identification, and Treatment dated 5/20/11 states, "Documentation of pressure ulcer must occur upon identification and at least once a week until healed. Assessment is to include: a) characteristics: (i.e. size, depth, color, drainage) b) presence of granulation tissue, necrotic tissue, c) treatment and response to treatment, and d) prevention technique (i.e. turning and positioning, skin care, protective devices). The DON (Director of Nursing)/Designee and nurses are to make pressure sore rounds every week and discuss each residents' progress and make necessary changes. A weekly skin report will be completed." A Skin/Wound assessment dated [DATE] documents R19 has an open area on R19's left gluteal fold measuring 5.0 cm by 6.5 cm. The Assessment classifies the wound as a skin tear. E6 (Wound Care Nurse) documented on the form, "Found in charting on (8/07/14) states resident had skin tear from (R19's) underwear. Today (8/21/14) is the first (this) wound nurse knew of wound. 100 (percent) wound bed white slough. Surrounding tissue dark red fading to pink. Resident (complained of) pain/burning with dressing change. Minimal serous drainage. (Treatment): (honey based product), gauze, (wound prep) to surrounding tissue, then (occlusive type dressing) to seal from urine/(bowel movement) entering wound." On 12/04/14 at 3:18 p.m., E6 (Wound Care Nurse) stated, "I put down it was a skin tear because that's how they say it started out. I wasn't aware of it until I read the nurses' notes. That's how I found out about it. It (R19's left gluteal wound) was there a couple weeks before I knew about it. (R19) said it was from the elastic of (R19's) underwear. It was right there in the butt crease. I was concerned that the wound deteriorated as quickly as it did. The corporate nurse looked at it and said it wouldn't be classified as a skin tear but a pressure sore because of where it was, how it looked, and how it was deteriorating. I only put it as a skin tear because that's what the resident told me." E6 reported when staff find an open area they are suppose to complete a "skin sheet" and turn it into E6. E6 stated staff did not complete a skin sheet for R19's left gluteal fold wound. E6 stated, "One of the nurses finally told me." E6 indicated Z1 (R19's Attending Physician) was not notified of R19's open area on the left gluteal fold until 8/19/14. E6 reported R19's left gluteal wound was unstageable. A policy titled Pressure Ulcer Prevention, Identification, and Treatment dated 5/20/11 states, "The policy states an ulcer is "Unstageable" when there is full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed. A policy titled Pressure Ulcer Prevention, Identification, and Treatment dated 5/20/11 states, "When a pressure ulcer is identified, whether in-house, or upon a resident's admission, the area will be assessed and initial treatment started per physicians orders. The physician is to notified when A) pressure ulcer develops, B) when there is a noted lack of improvement after a reasonable amount of time, C) and/or upon signs of deterioration. Physician order [REDACTED]. On 12/05/14 at 12:20 p.m., Z1 (R19's Attending Physician) stated Z1 examined R19 on 8/19/14. Z1 stated, "(R19) had a pressure ulcer on a prominent area of the buttock. It was a pretty deep ulcer. I started antibiotics. It was a pretty ugly looking by that time (8/19/14)." The Medication Review Report shows, on 8/19/14, Z1 gave an order stating, "Wound nurse to evaluate buttocks wound, determine whether it needs debridement. Get wound culture. Bactrim (Double Strength by mouth twice daily for ten days). Do not start antibiotic until after wound culture." A laboratory report dated 8/20/14 shows heavy growth of [MEDICAL CONDITION] Resistant Staph Aureus (MRSA) in R19's left gluteal fold ulcer culture. A Skin/Wound assessment dated [DATE] documents the wound measurements are unchanged but the wound bed has "100 (percent) soft, brown slough". A 9/12/14 wound assessment shows R19's left gluteal fold wound measured 5 cm by 8.5 cm. A 9/18/14 wound assessment states R19's gluteal fold wound measured 5.5 cm by 9.1 cm with 90 (percent) of the wound be covered with yellow/brown slough and 10 (percent) red granulated tissue. R19's wound assessment dated [DATE] documents R19's left gluteal fold wound measured 5.5 cm by 9.5 cm and "(Four) open areas have occurred due to tape. Edges flat, no drainage. Painful to touch." The opens areas due to tape are documented as a) 1.4 cm by 1.4 cm by 0.1 cm, b) 0.7 cm by 2.7 cm by 0.1 cm, c) 0.9 cm by 2.3 cm by 0.1 cm, and d) 2.5 cm by 1.5 cm by 0.1 cm.