Every finding on record at Rochester Rehabilitation and Living Center

Based on observation, interview, and record review, the facility failed to ensure residents were comprehensively assessed for self-administration of medications for 2 of 2 residents (R3, R15) reviewed for self-administration of medications.Findings include:R3R3's quarterly Minimum Data Set (MDS) assessment, dated 4/27/26, indicated R3 was cognitively intact with no signs of delirium or behaviors. R3 had no upper body impairment and bilateral lower body impairment. R3 required setup for eating and oral hygiene, partial assist for toilet hygiene, bathing, and upper body dressing, and substantial assist for lower body dressing, footwear, and personal hygiene. R3 also required substantial assist with bed mobility and transfers to/from bed/chair.R3's careplan indicated R3 required 1 assist for transfers and activities of daily living.During observation and interview on 6/22/26 at 6:45 p.m., an unlabeled bottle of fluticasone nasal spray was noted on R3 bedside table. R3 stated she administers it on her own in the morning and in the evening. R3's medication administration record (MAR) lacked an order for fluticasone nasal spray. R3's self-administration medication assessment dated [DATE] indicated R3 did not wish to self-administer medications or keep medications at bedside. During observation and interview on 6/23/26 at 9:16 a.m., R3 was returning from breakfast and stated she administered the fluticasone nasal spray prior to breakfast. The nasal spray was located on R3's bedside table next to her water glass. R3 stated her family member brought the nasal spray in for her. At 9:21 a.m., registered nurse (RN)-A entered R3's room with morning medications, reached across R3's bed and picked up the water glass. After administering R3's medications, RN-A placed the water glass back on the bedside table, picked up the nasal spray, looked at both sides of the spray, and placed it back on the bedside table. R15R15's quarterly MDS assessment, dated 4/14/26, indicated R15 was cognitively intact with no delirium and no behaviors. R15 had no upper or lower body impairment, was independent with oral and personal hygiene as well as bed mobility. R15 required set-up for meals, partial assist for upper and lower body activities of daily living, and was dependent on staff for transfers. R15 was also receiving dialysis. R15's careplan indicated R15 required 1 staff assist with activities of daily living and transfers and received dialysis treatments. During an observation and interview on 6/22/26 at 1:10 p.m., a bottle of Pepto Bismol (over the counter medication used to treat diarrhea and stomach upset) was on the nightstand between R15's recliner and bed. The bottle was 3/4 full. R15 stated she used it when she had diarrheal episodes about a month ago and likes to keep the bottle on hand incase another episode creeps up on her. R15's MAR record lacked an order for Pepto Bismol.R15's most recent self-administration assessment dated [DATE] indicated R15 does not wish to keep medications at bedside. R15's facility progress notes indicated R15 had 2 diarrheal episodes on 5/1/26 however no mention to having Pepto Bismol in her room. During observation on 6/23/26 at 8:48 a.m., the Pepto Bismol bottle remained on the nightstand. The bottle measures 473 milliliters and does not have a pharmacy label. During an interview on 6/23/26 at 11:39 a.m., registered nurse (RN)-B stated if a medication was found in a resident's room, the medication is removed and the nurse manager or director of nursing (DON) is notified. If a resident wishes to administer a medication independently, a self-administration assessment is performed to make sure the resident is safe to administer the medication independently. If there is no order for the medication, the medication is removed, and an order is obtained by the provider. During an interview on 6/23/26 at 12:59 a.m., RN-A stated it was her first time working down that hall. RN-A stated if a medication is found in a resident's room, the medication is removed and verified against existing orders. The provider and pharmacy would also be notified. If there was no order for the medication, RN-A stated she would investigate where it came from and not leave the medication in the room. RN-A stated a provider order is required if a resident requests to administer a medication independently. RN-A confirmed R3 did not have an order for fluticasone and said did I leave it in her room? I don't recall giving it to her this morning. RN-A also confirmed R3 did not have a self-administration order from the provider. RN-A stated R15 was already at dialysis at the start of her shift, so she had not been in R15's room yet. RN-A entered room and confirmed bottle of Pepto Bismol on the nightstand and confirmed it was 3/4 full with no pharmacy label. RN-A confirmed R15 did not have an order for Pepto Bismol. During an interview on 6/23/26 at 1:14 p.m., RN-C stated if a resident brings in medications from home, the family is asked to take it with them. The facility is only permitted to dispense medications from the pharmacy. If a resident requests to administer a medication independently, a self-administration assessment is performed. An order is then obtained from the provider authorizing the resident to administer the medication independently. RN-C stated medications should not be left in a resident's room without a self-administration assessment and providers' order. RN-C reviewed R3's medical record and confirmed R3 did not have an order for fluticasone. RN-C confirmed R3's last self-administration assessment was dated 1/26/26 and indicated R3 did not wish to self-administer or keep medications at bedside. RN-C then reviewed R15's medical record and confirmed R15 did not have an order for Pepto Bismol. RN-C also confirmed R15's most recent self-administration assessment dated [DATE] indicated R15 did not want to self-administer medications or have medications left in her room. During interview on 6/23/26 at 1:57 p.m., the director of nursing (DON) stated if family brought in medication from home, the facility would verify the medication is correct, make sure it is labeled, and make sure there is a provider order. Medications should remain locked up in the medication cart. If a resident requested to self-administer a medication, a self-administration assessment is performed and an order would be obtained from the provider. The director of nursing confirmed R3 did not have an order for fluticasone and R15 did not have an order for Pepto-bismol. A policy titled Self-Administration of Medications dated 5/22/18 indicated It is the right of the resident to self-administer their medications if the interdisciplinary team has assessed and evaluated that the resident is able to physically and cognitively, safely administer the prescribed medication. The policy continues If the resident wishes to self-administer their medications, at the time of admission and during stay at the facility, the interdisciplinary team will initiate a Self-Administration of medication Assessment to determine if the resident is capable and clinically appropriate, based on the resident's cognition, physical ability, functionality and status of health conditions. A physician order will be obtained by the nurse prior to proceeding with self-administration. To ensure safe and accurate self-administration, education will be provided to the resident to ensure that a resident is able to: state the name, dose, strength, route, frequency, and purpose for use of his/her medications. The policy also states the resident should understand the possible side effects of his/her medications and that he/she should notify facility staff if he/she experiences any side effects. The resident should demonstrate correct and timely administration of the medication and demonstrate and consistently maintain, safe storage of his/her medications in a locked storage. Each resident self-administering their medications will have their individualized self0administration plan defined on their careplan. This will include the specific plan for the self-administration including the specific medications the resident is responsible for, the monitoring plan, the reassessment plan, the storage plan-including self-storage, reordering plan. The facility staff should document the self-administration of medications on the resident's MAR/TAR according to the medication administration schedule. The policy also indicates the facility should document in the resident's careplan whether the resident or facility staff is responsible for the storage of the resident's medications. If the resident is responsible for the storage, the facility should provide a secure compartment for storage of such medications in accordance with facility policy, applicable law, the State Operations Manual.

Based on observation, interview, and record review the facility failed to provide activities of daily living (ADL) for 2 of 2 residents (R41, R20) who were dependent on staff for timely assistance for personal hygiene.Findings Include: R41 R41's quarterly Minimum Data Set (MDS) was not completed at time of survey; R41 admitted to the facility on [DATE]. R41's care plan dated 6/9/26 indicated R41 required extensive assistance to total assistance with personal hygiene and grooming. R41's care plan lacked resident-specific directions about facial hair/removal. R41's provider orders dated 6/9/26 indicated R41 was to have weekly skin checks and vital signs every evening shift every Saturday for bath day, if resident refuses, document reason and attempts. The treatment administration record (TAR) indicated the skin checks and vital signs had been completed; the TAR lacked documentation a bath had been performed. R41's 30 day look back for point of care task history for bathing/showering indicated R41 had not had a shower or bath since her admission. During observation and interview on 6/22/26 at 12:45 p.m., R41 had multiple long hairs on her upper left and upper right lip, additionally, R41 had a patch of long grey hairs on her bottom right chin and several long hairs on her bottom left chin. R41 stated she does not like facial hair, it was embarrassing for her to have facial hair; stating this is a reason she doesn't like to leave her room. During an interview with R41 on 6/22/26 at 1:57 p.m., R41 looked upset with a frown on her face and stated this chin hair really, really bothers her and she is really really upset about it. During an interview on 6/23/26 at 1:56 p.m., registered nurse (RN)-B, stated residents should have facial hair removed, per their preference, on bath days. Additionally, nursing assistant (NA)-C stated R41 did get a bath today and would expect the resident to have gotten her facial hair removed if that was her preference. NA-A stated she did not notice any facial hair on R41 when she gave her a bath today. During an interview on 6/23/26 at 2:24 p.m., R41 stated she was given a bath today, but stated she continued to have facial hair. R41 stated as someone who likes fashion, facial hair is very embarrassing for her. She wishes it was all gone. R41 stated she tried to remove her facial hair on her own but was unable to remove all the hairs, she wished they would help her with this. R20 R20's MDS dated [DATE] indicated R20 had no cognitive impairment and required partial to moderate assistance with personal hygiene, including shaving. R20's care plan dated 6/1/26 indicated R20 required extensive assistance to total assistance with personal hygiene and grooming. R41's care plan lacked resident-specific directions about facial hair/removal. R20's provider orders dated 6/9/26 indicated R20 was to have nursing weekly bath/skin checks and vital signs, if resident refuses, document reasoning and attempts. The treatment administration record (TAR) indicated the skin checks and vital signs had been completed; the TAR lacked documentation a bath had been performed. R20's 30 day look back for point of care task history for bathing/showering indicated R20 completed baths on 6/6/26, 6/9/26, 6/13/26, 6/16/26, 6/20/26, and 6/23/26. R20 had not refused a bath or personal hygiene cares. During an observation and interview on 6/22/26 at 2:18 p.m., R20 had a patch of chin hair on her upper right lip and a patch of hair on her bottom right and left chin. R20 stated she does not like the chin hair, but the facility had not helped her remove it. During observation and interview on 6/23/26 at 11:12 a.m., R20 was sitting outside her room, she stated she was waiting for someone to come take her to a bath. R20 stated she hoped they would assist her with removal of her facial hair; thinks bath time is the perfect time to remove facial hair. During observation and interview on 6/24/26 at 9:49 a.m., R20 stated she had gotten her bath yesterday. However, R20 stated she was disappointed they did not remove her facial hair. R20 stated the bath would have been the best time to remove her facial hair. During an interview on 6/23/26 at 2:06 p.m., nursing assistant (NA)-A, stated she gave R20 a bath today. NA-A stated she did not notice if R20 had any facial hair; acknowledging facial hair on female residents could be distressing to them. Again stating, she did not notice facial hair on R20. During an interview on 6/24/26 at 10:35 a.m., the director of nursing (DON) stated it is an expectation to address facial hair during bath days and complete removal per the resident's preferences. Female residents should specifically be addressed for facial hair because it is not normal for them to have facial hair. The DON stated she would expect both R41 and R20 to have had their facial hair removed during their bath time yesterday. A facility policy titled Activities of Daily Living (ADL)'s dated 5/1/25, the purpose of the policy is to establish consistent expectations for providing ADL care and services that preserve resident dignity, promote independence, and prevent avoidable decline in function across all long-term and skilled nursing facilities. Additionally, a resident who is unable to carry out ADL's will be provided the necessary care and services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview, and document review the facility failed to monitor, comprehensively assess, develop, and implement individualized interventions to prevent/mitigate the risk of pressure ulcers and/or deterioration for 3 of 4 residents (R1, R4, R5) reviewed for pressure ulcers. This caused actual harm to R1 who developed an avoidable unstageable pressure ulcer on her coccyx which needed surgical debridement and hospitalization. Findings include: Pressure Ulcer/Injury (PU/PI) is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury occurs because of intense and/or prolonged pressure or pressure in combination with shear. Eschar is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound. i Stage 2 Pressure Ulcer: Partial thickness skin loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink, or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis, intertriginous dermatitis (inflammation of skin folds), medical adhesive related skin injury, or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Ulcer: Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. Stage 4 Pressure Ulcer: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the wound bed, it is an unstageable PU/PI. Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration: Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) should only be removed after careful clinical consideration and consultation with the resident's physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur. Moisture Associated Skin Damage: inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, sweat, wound drainage, saliva or mucus. R1's face sheet dated 3/27/26, identified diagnoses of primary progressive multiple sclerosis (MS), hereditary spastic paraplegia, obesity, pressure induced deep tissue damage to left heel. R1's nursing home nurse practitioner (NP) note dated 2/6/26, identified R2 had a stage 2 pressure ulcer on left buttocks that had resolved and a deep tissue injury to the left heel. R1's hospital Discharge summary dated [DATE], identified R1 had been hospitalized for an insertion of a pain management pump. R1 had a preexisting pressure induced deep tissue damage to the left heel and a new gluteal cleft lesion for which the wound nurse had been consulted. R1's hospital after visit summary (AVS) dated 2/24/26, identified R1 had irritant contact dermatitis on her bilateral gluteal cleft and had treatment to cleanse area twice daily and apply barrier cream three times per day and as needed. R1's Braden Scale for Prediction of Pressure Ulcer Risk Evaluation dated 2/24/26, identified R1 was high risk for developing pressure ulcers due to being slightly limited to respond to verbal commands, cannot always communicate discomfort or need to be turned, being constantly moist, chairfast, very limited mobility due to making only slight changes in body or extremity position but unable to make frequent or significant changes independently, probably inadequate nutrition, and potential problem with friction and shear. R1's ADL focus care plan dated 10/31/25, identified R1 triggered in ADL's because she had preferences and other items of need. Goal to maintain current level of ADLs. Interventions as follows: -Assist of two for bed mobility. (dated 2/24/26) -Assist of two using full body mechanical lift for transfers. (dated 2/24/26) R1's physician orders identified an order dated 11/7/25 to frequent every 2 hours repositioning for wound care. R1's Skin focus care plan revised on 2/24/26, identified R1 had an actual pressure injury related to MS, increased need of activities of daily living (ADL) assistance with mobility, history of ulcer prior to admission and a deep tissue injury to left heel identified on 1/8/26. Goal to show no complications in skin integrity. Interventions as follows: -Inspect skin daily with cares. (dated 10/31/25) -Follow wound care orders. (Dated 11/11/25) -Weekly skin checks completed by nursing. (dated 12/15/25) -Pressure ulcer care to left heel as ordered. (dated 1/15/26) -Nutritional supplements per dietician order to support wound healing. (Dated 2/2/26) -Gel mattress applied 2/13/26. (dated 2/16/26) R1's Nursing Data Collection Admission/readmission form dated 2/24/26, identified an unstageable pressure ulcer on left heel that was present on admission/readmission, with no measurements or characteristics of the wound. R1 also had contact dermatitis of the left and right gluteal fold, with no measurements or characteristics. Nursing Data Collection identified R1 could not reposition while lying in bed, did not ambulate, not able to reposition when sitting in chair or wheelchair, had a pressure reducing wheelchair cushion in place and had a pressure reducing mattress. R1's Significant Change Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition, no behaviors, no rejection of care, dependent for toileting hygiene, had lower extremity limitation of range of motion, used a wheelchair, substantial/maximum assistance to roll left and right in bed, dependent for transfers, did not ambulate, occasionally incontinent of urine, always continent of bowel, was at risk for pressure ulcers, had one or more unhealed pressure ulcers/injuries, had one unstageable pressure ulcer that was not present on admission, no arterial/venous ulcers, had moisture associated skin damage (MASD), had pressure reducing device for chair and bed, nutrition or hydration intervention to manage skin problems, pressure ulcer/injury care, had application of non-surgical dressing other than feet, application of ointments/medication other than feet, had application of dressings to feet. R1's Nursing Weekly Skin Check dated 2/27/26, identified R1 had an unstageable pressure ulcer to the left heel and contact dermatitis to the left and right gluteal fold. Weekly Skin Check did not identify measurements or other wound characteristics. Review of R1's Treatment Administration Record (TAR) from 2/1/26 through 2/28/26, included a physician order dated 11/7/25 to reposition R1 every 2 hours. Documentation noted one refusal marked on 2/12/26 at 2:00 a.m. Repositioning not signed off on 2/25/26 at 8:00 a.m.; 2/26/26 at 10:45 p.m.; and 2/27/25 at 10:45 p.m. R1's Nursing Weekly Skin Check dated 3/3/26, identified R1 had a stage 2 pressure ulcer on her coccyx with measurements of 1.84 centimeters (cm) x 1.14 cm (no depth was documented even though the record identified the wound as stage 2 pressure ulcer.) Additional wound was unstageable pressure ulcer on left heel that measured 2.29 cm x 2.15 cm x 0.1 cm. (no other characteristics included). Contact dermatitis on left and right gluteal fold (no measurements or further description included). Comment of new coccyx pressure ulcer stage 2 and will be seen by wound nurse tomorrow. R1's record identified a Situation, Background, Assessment, Response (SBAR) dated 3/3/26 to inform physician of stage 2 pressure ulcer on coccyx. Nursing intervention to cleanse with normal saline, place Mepilex (name brand of foam) dressing to area daily (in accordance with facility standing orders) and as needed if soiled or dislodged. Also stated need recommendations for restriction 30 degrees so resident is not bedbound. SBAR also indicated that will talk with R1 about adding back air mattress. SBAR did not indicate measurements of wound, nor any other wound characteristics. During an interview on 3/25/26 at 9:32 a.m., environmental services director (ESD) stated his department moved R1 to a different room on 3/4/26, however, the gel mattress never got moved to her new bed. R1's Interdisciplinary Team (IDT) Team Initial Post Investigation Review dated 3/5/26 at 12:00 p.m., identified a new skin condition from 3/3/26 in which after the review of investigation the IDT's root cause of the incident was that R1 was staying in bed more often, per choice and is incontinent of bowel and bladder and is extensive assistance with bed mobility, unable to make micro-shifts. R1's care plan was reviewed and root cause identified. R1 was high risk for skin breakdown due to reasoning as the forementioned. Treatment interventions are put in place and carried out. R1's Wound Nurse Practitioner visit note dated 3/5/26, indicated reason for visit was wound follow up of left heel and a new coccyx wound. R1's heel continues to improve and is nearly closed, has a new open area on her bottom. R1 spends a lot of time in bed and encouraged to offload when in bed and wheelchair. The area is over a bony prominence and appears to be pressure related. Plan for coccyx wound was to cleanse and pat dry and cover with foam dressing, air mattress, pressure offloading, dietician consult for wound supplement recommendations. Review of R1's record from 3/3/26 through 3/16/26 identified the care plan had not been revised nor evident that an air mattress had been placed on R1's bed per wound nurse recommendations on 3/5/26. Review of R1's TAR from 3/1/26 through 3/20/26, identified a physician order dated 11/7/25 to reposition every 2 hours; did not identify R1 had any refusals of repositioning, however, repositioning had not been signed off as completed on 3/2/26 at 10:45 p.m. R1's Incontinence focus care plan revised on 11/3/25, identified R1 had altered elimination, needed treatment/monitoring/cares due to neurogenic bladder. Corresponding interventions dated 11/12/25 directed to empty Purewick (external urine collection system) and on 12/4/25 directed to Change Purewick cannister per order. R1's IDT Final Post Review Follow Up dated 3/10/26 (signed on 3/23/26), identified R1's new skin issue (did not identify what skin issue). Interventions were put in place after incident that team reviewing were wound care treatment ordered, repositioning and incontinent care increased. Effectiveness of the interventions put in place after the incident was documented as resident will refuse repositioning, though staff are still encouraging. R1's care plan did not reflect revision for any increases in repositioning since 11/7/25, nor did the incontinence care get increased, and not evident an individualized toileting program or schedule was developed and implemented. During an interview on 3/25/26 at 4:11 p.m. director of nursing (DON) explained the 3/10/26 IDT Final Post Review follow up indicated there would be an increase in incontinence care because she had heard R1 had been falling asleep on the bed pan, however, R1's care plan had not been revised to reflect she should not use the bedpan and should be using a commode instead. R1's Skin Issue Wound assessment dated [DATE], identified R1 had a pressure ulcer/injury to middle coccyx that was stable: previously deteriorating; was in house acquired with onset date of 3/2/26. The assessment identified coccyx wound measurement of 1.79 cm x 4.03 cm which indicated worsening from the previous assessment on 3/3/26 measurement of 1.84 cm by 1.14 cm. The 3/12/26 assessment also described the wound as no tunneling, surrounding skin fragile, and no exudate. The assessment did not include any other characteristics. R1's coccyx wound's corresponding image taken 3/12/26, identified a large dark purple line on the left buttocks that extended to the right side of the buttocks. An unopened blister was noted on the left buttocks near the lateral part of the purple area. R1's skin surrounding the wound was red in color. During an interview on 3/25/26 at 11:14 a.m., registered nurse case manager (RN-CM) stated she assessed R1's coccyx wound on 3/3/26 and 3/12/26, however, during the 3/12/26 assessment R1's wound appeared stable to her. RN-CM confirmed R1's wound had increased in size and had a change in color which could indicate the wound was beginning to worsen. RN-CM stated the purple discoloration in the image did not appear as purple to her but more of a brown color and appeared more like a scab. RN-CM could not identify the type of wound associated with the purple discoloration she had documented on the 3/12/26 assessment. RN-CM indicated during the assessment she did not identify R1's bed did not have the gel mattress according to the care plan. RN-CM reported she did not notify the physician of the increase in size of the wound or the change in color. During an interview on 3/25/26 at 4:11 p.m., DON stated RN-CM described R1's coccyx wound to her on 3/12/26, and by the description she believed that R1's coccyx wound had begun to change. DON explained she had instructed RN-CM to notify the physician; however, DON had not evaluated the wound herself to see what the changes were. DON further explained she had not followed up to ensure that the physician had been notified nor evaluated if R1's pressure relieving interventions were effective. DON reviewed R1's record and explained R1's wound assessment that had been completed on 3/12/26 showed a change in R1's wound from previous assessments showing deterioration. DON further explained R1's wound had not been staged in the assessment and should have been identified as a deep tissue injury. DON stated the physician should have been notified and R1's turning and repositioning schedule should have been reevaluated/increased, however, was not completed. R1's progress note dated 3/16/26 at 10:25 p.m., identified after R1's bath skin was assessed and noticed that coccyx area was dark purple/black in color with an odor. R1's record did not identify any other characteristics of the wound including measurements nor physician notification of newly identified discoloration. R1's progress note dated 3/17/26 at 4:41 p.m., was called to R1's bedside due to change sacral dressing due to soilage. Wound noted to be increased in size and drainage noted. Management updated. R1's progress note dated 3/17/26 at 5:00 p.m., identified R1 had a decline in her wound characteristics. R1 agreed to have staff come in and reposition her every 2 hours from her left to her right side (which was the original treatment order dated 11/7/25, identifying no increase in frequency). R1also stated she did not want to use the bed pan anymore and agreed to use the bedside commode for toileting needs. Email was sent to the nurse practitioner and wound nurse. Primary nurse practitioner will be in house tomorrow and will assess the wound. Air mattress was placed on R1's bed. During a follow up interview on 3/25/26 at 12:15 p.m., ESD explained a request had been made on 3/17/2 to place an air mattress on R1's bed, however, the maintenance staff mistakenly marked off that it was completed prior to being placed and R1's air mattress had not been placed on her bed until 3/18/26. According to an earlier interview on 3/25/26 at 9:32 a.m. ESD indicated that's when we found out the gel mattress had not moved to the new room with her on 3/4/26. R1's Skin Issue progress note dated 3/17/26, identified an evaluation of R1's middle coccyx wound. Issue type listed as a Kennedy terminal ulcer/End of Life stage 4 pressure ulcer that was in house acquired. The note identified the wound was deteriorating (from the previous assessment 3/12/26 noted 1.79 cm x 4.03 cm.) measurements on 3/17/26 documented as 4.11 cm x 7.93 cm x 1.0 cm; no tunneling; 10% slough; 90% eschar; moderate drainage that was seropurulent (thin, watery, cloudy wound discharge that is yellow to tan or pink in color indicating early signs of infection); surrounding tissue with erythema (redness); with moderate dressing saturation and pain described as sharp. R1's progress note dated 3/17/26, identified wound assessment dated [DATE], documented as a Kennedy terminal ulcer/End of Life. Upon further clinical review, R1 was not actively dying and did not meet the criteria for a Kennedy terminal ulcer. R1's wound was more consistent with a pressure injury related to immobility, moisture exposure, and high-pressure injury risk. The wound will be managed according to the facility pressure injury protocol and wound care recommendations. Wound measurements, staging, and treatment orders remain accurate and ongoing monitoring will continue. R1's skin focus care plan was revised 3/17/26 to include the following interventions: -Turn and reposition every 2 hours and as needed, with continued staff encouragement and education if declines. -Provide prompt incontinence care and keep skin clean and dry to prevent moisture related skin breakdown. -Provide coccyx wound care as ordered. R1's elimination focus care plan revised on 3/17/26 to include the following interventions: -Use bedside commode and no longer use the bedpan. -Offer bedside commode every 2-3 hours and as needed. Able to state when need to use the bathroom and will also ask for assistance. During an interview on 3/25/26 at 4:11 p.m., DON stated on 3/17/26 R1's toileting care plan had been revised to not use the bedpan because she had heard from staff that R1 was falling asleep while sitting on the bedpan and this likely caused the development of a deep tissue injury on 3/12/26. DON explained that R1's care plan should have been revised at the time she heard about R1 falling asleep on the bedpan and not waited until R1's wound worsened on 3/17/26. R1's nurse practitioner note dated 3/18/26, identified nursing had notified NP about wound concerns with a worsening wound to coccyx. New orders to wound to cleanse with normal saline, pat dry, apply skin prep to surrounding intact skin, apply iodosorb (a sterile antimicrobial wound dressing used to remove slough/debris and killing bacteria) mixed with hydrogel to open wound, place foam dressing, change daily and as needed if soiled or dislodged. Nursing had implemented a scheduled offloading pressure every 2 hours and will no longer be using a bedpan. R1 now has an air mattress to relieve pressure. Review of R1's care plan identified the additional intervention of the air mattress on 3/18/26. During an interview on 3/25/26 at 4:11 p.m., DON stated she thought the NP was going to physically assess R1's buttock wound on 3/18/26, however, the NP only reviewed image from 3/17/26 and gave orders. R1's progress note dated 3/18/26 at 8:51p.m., identified R1's wound had an increase in foul smelling odor and pain increased since yesterday assessment. R1 continues to have blanchable redness to surrounding skin, wound bed with 90% necrotic (dead, non-viable tissue) tissue and 10% slough (yellow or white, soft that delays healing). Call placed to on-call physician to update on wound characteristics and will await call back. R1's Emergency Department (ED) Telemedicine (the use of delivery of healthcare services from a distance using a computer) note dated 3/18/26 at 9:38 p.m., identified R1 had been seen due to a sacral wound that has changed significantly in the past 48 hours with concern for infection as well as the skin around the wound seems red. Noted foul smell to the wound, normal vital signs, and not complaints related to the wound. Assessment identified that the wound was the size of the palm, wound itself is dark which was consistent with an eschar, surrounding redness that is blanchable. Area feels firm to nursing at bedside and wound itself is dry. The wound itself is expanding which is a concern given R1's ambulatory status, but it is difficult to ascertain whether the surrounding tissue is due to expansion of the wound and is not a stage 1 versus infection. Given the wound is dry and the patient remains clinically stable, elected not to transfer to the ED and will have wound assessed by the in-house provider tomorrow morning. ED note stated if the provider is not able to arrange for a provider to assess R1 at bedside in the morning, she will be transferred to the ED for evaluation at that time. R1's progress note dated 3/19/26 at 10:17 a.m., identified that a call placed to physician asking to have a provider to assess R1's wound. Note received from physician assistant regarding response from situation, background, assessment, and recommendation (SBAR) that was sent on 3/19/26. Electronic health record reviewed to include photo of wound taken 2 days prior (3/17/26), telehealth ED visit and phone call with an on-call provider. Response to SBAR sent was as followed: known difficulties assessing skin condition with telehealth visits, therefore, given lack of symptoms and photo from two days ago does show surrounding redness, not of concern at that time, will not send to the ED at this time. Orders to continue current wound treatment as ordered on 3/18/26. Continue scheduled offloading. Check vital signs every shift for 5 days. R1's progress note dated 3/19/26 at 10:22 a.m., identified writer talked with R1 regarding providers decision to wait until tomorrow and nursing to continue monitoring. Wound culture had been requested due to foul smelling odor, eschar to the wound with black/mixed purulent drainage, increase drainage and increase in pain from 3/17/26. During an interview on 3/25/26 at 4:00 p.m., DON stated on 3/19/26 she had sent an SBAR to see if a physician could assess R1's wound in person as per the Tele ED recommendations because the certified wound nurse practitioner had not been available to assess R1's buttocks wound. DON explained that the physician assistant sent back a response to continue to monitor in facility and not send R1 to the ED for evaluation. DON explained she felt R1's wound appeared infected and needed to be seen in the ED, but since the physician assistant declined to give an order to send to the ED, they continued to monitor R1 in the facility. DON confirmed that the facility had an order to send R1 to the ED if a physician could not see R1 in person on 3/19/26, however, did not send her to the ED for her possible infected wound and she should have just been sent. R1's nurse practitioner note dated 3/20/26, identified R1 had been seen for assessment of an unstageable (deep tissue injury) pressure wound that was contiguous (sharing a common border, touching, or being in proximity) site of back buttocks and hip. Nursing was concerned for infection and over the past 3 days the wound had increased in size and was malodorous (having an unpleasant, foul, or stinky smell). R1was afebrile (without fever) and declined pain. Dressing removed and had a large amount of purulent malodorous drainage; peri-wound was erythematous (redness) with area of eschar expanded in the past 3 days. Concern for infection and gave orders to send R1 to emergency department (ED) for further evaluation and management. R1's progress note dated 3/20/26, identified R1 left facility at 11:20 am with emergency management services. R1's ED note dated 3/20/26, identified R1 presented for concerns for an infected coccygeal wound. R1 had a large irregular wound over the coccyx with eschar and a little bit of slough. Redness to the left glute that is warm and firm. Yellowish drainage that was foul smelling on the dressing. R1 was afebrile and hemodynamically stable. R1 was admitted for consideration of wound debridement and antibiotics. Computed tomography (CT) did not identify a discrete abscess or suggestion of osteomyelitis. Impression was sacral decubitus ulcer with associated left gluteal soft tissue phlegmons (a severe, spreading, non-encapsulated bacterial inflammation of soft tissue) with no evidence of osteomyelitis. R1's hospital History and Physical Hospital note dated 3/20/26, identified R1 was admitted for concerns for an unstageable pressure ulcer. A couple of days ago, nursing staff had a ED telemedicine activated and recommended short term in-person follow up. Evaluation revealed the wound note to be foul smelling with a large necrotic area surrounded by erythema (redness). R1 will need debridement of this large wound. R1 was treated empirically with intravenous antibiotics. R1's hospital note dated 3/21/26, identified R1 had surgical debridement on 3/21/26. R1 had new and worsening anemia with studies consistent with anemia or chronic disease. R1's A1C was markedly elevated which although confounded her anemia may explain the fast worsening of her wound. R1's hospital general surgery consult note dated 3/21/26, identified R1 had been admitted for management of an unstageable pressure ulcer. R1's wound in the sacral area was malodorous and had necrotic eschar with surrounding induration and erythema. R1's wound will need to be surgically debrided and would require multiple return trips to the operating room, dressing changes versus wound VAC placement. The operative note report dated 3/21/26, identified R1 had a debridement and irrigation of ulcer to the ischium/sacrum. Findings included necrotic fat with pockets of foul-smelling purulence, R1 had an excisional debridement of sacral wound down to healthy bleeding tissue that measured 11.5 cm x 9.5 cm x 3.0 cm. Pale muscle fibers at the base of the wound were left. R1's infectious disease hospital note dated 3/24/26, identified R1 had been admitted due to a necrotic sacral wound that was debrided on 3/21/26 with culture that grew Proteus, Staphylococcus epidermidis, and Enterococcus. Plan to treat R1 for 2 weeks using broad spectrum antibiotics while in hospital and switching to oral antibiotics. During an interview on 3/25/26 at 2:55 p.m., nursing assistant (NA)-B stated she had not been aware R1 was supposed to be on a gel mattress and relies on looking at the resident's care plan to identify if they were on a special mattress. NA-B indicated she was unaware of R1's current care plan that directed no bedpan and to use commode at bedside. NA-B stated she had heard R1 had fallen asleep on a bedpan and that was the reason her bottom had gotten worse but was not aware when or who left R1 on a bedpan for an extended period of time. During an interview on 3/24/26 at 3:57 p.m., NA-D stated when she worked with R1 she would sometimes fall asleep on the bedpan and forget to ask for staff to take her off, however, NA-D stated staff should be aware if they placed a resident on a bedpan to ensure to take them off in a timely manner to prevent a sore from developing. NA-D had not heard R1 was not supposed to use the bedpan until after her sore had already worsened. During an interview on 3/24/26 at 3:44 p.m., NA-E stated he was not aware of which residents were at risk for skin breakdown, because his paper care guide did not identify those residents were on a repositioning program. NA-E stated he had not repositioned any resident since he came on shift at 6:00 a.m. NA-E explained he had not received any recent education on pressure ulcer prevention and if he had a resident with a new open area on a resident's skin he would make sure to clean the area, apply a barrier cream, and then tell the nurse next time he saw them. During an interview on 3/25/26 at 4:11 p.m., DON stated she had not been aware that R1's gel mattress had not been moved to her new bed on 3/4/26 until she assessed R1's wound on 3/17/26 and identified R1's wound had deteriorated. DON identified R1 should have had an air mattress put in place on her readmission on [DATE] due to spending more time in bed than she had before. DON stated the IDT team had reviewed R1's coccyx pressure ulcer on 3/5/26 and 3/10/26, however, had not amended R1's pressure reduction intervention to mitigate the risk of her pressure ulcer from worsening. DON explained she had been informed prior to the 3/10/26 IDT meeting R1 had been left on a bedpan for an undetermined amount of time, however, had not made any changes to her not using the bedpan until R1's buttocks pressure ulcer worsened on 3/17/26. DON confirmed she had completed the wound assessment of R1's coccyx wound on 3/17/26 and initially identified her ulcer as a [NAME] Ulcer/End of Life Ulcer and then changed her ulcer to a stage 4 pressure ulcer. DON stated R1's ulcer at the time of the assessment had been incorrectly identified as a stage 4 pressure ulcer when it should have been identified as an unstageable pressure ulcer. DON believe the root cause of R1's getting a pressure ulcer was due to being left on the bedpan for an extended period of time and not have a gel mattress on her bed since 3/4/26. During an interview on 3/26/26 at 4:07 p.m., physician assistant (PA) stated she had been informed via SBAR to see if she was available to assess R1's worsening buttocks wound in person on 3/19/26, however, there was not physician available to assess R1's wound in person, so she gave recommendation for monitoring in the facility until her wound could be assessed on 3/20/26. PA stated she was aware of R1's pressure ulcer and had been informed by the NP that the likely cause was due to R1 sitting on a bedpan for an undetermined time. PA stated her expectation for the facility was to put pressure relieving measures in place immediately to prevent a pressure ulcer and/or to avoid deterioration of an existing pressure ulcer. During a return phone call on 4/1/25 at 11:36 a.m., NP stated when he had assessed R1's wound on 3/20/26 it appeared to be infected and had a large amount of purulent drainage and had foul odor and proceeded to send R1 to the ED for further evaluation of her wound. NP stated she had been informed at an earlier time that R1 had been left on the bedpan for an unknown amount of time and this likely caused the unstageable pressure ulcer. NP stated R1's toileting plan should have been changed as soon as it was identified she had been sitting on the bedpan for a long time and that she had not been informed R1's gel mattress had not been in place on her bed since 3/4/26. NP explained that by R1 not having her gel mattress in place could have likely caused R1's buttocks wound to deteriorate, and her pressure ulcer could have been avoided if all of the interventions had been in place. During an interview on 3/26/26 at 2:12 p.m., medical director (MD) stated it is his expectation for the facility to ensure all residents who are at risk for pressure ulcers have interventions put in place immediately to mitigate the risk of developing a pressure ulcer. If the resident develops a pressure ulcer the treatment/interventions need to be continually evaluated to ensure the pressure ulcer does not deteriorate. R1 not having a gel air mattress, by not altering pressure reducing interventions could have caused deterioration in her pressure ulcer thus making the pressure ulcer avoidable. During an interview on 3/24/26 at 2:29 p.m., administrator stated during the facility investigation of R1's worsened

Based on observation, interview, and document review the facility failed to timely revise the care plan to include an individualized toileting/incontinence plan for 1 of 3 residents (R1) who were reviewed for impaired skin integrity that had impaired skin integrity. Findings include: R1's face sheet dated 3/27/26, identified diagnoses of primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, pressure induced deep tissue damage to left heel.R1's Significant Change Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition, no behaviors, no rejection of care, dependent for toileting hygiene, had lower extremity limitation of range of motion, used a wheelchair, substantial/maximum assistance to roll left and right in bed, dependent for transfers, did not ambulate, occasionally incontinent of urine, always continent of bowel, was at risk for pressure ulcers, had one or more unhealed pressure ulcers/injuries, had one unstageable pressure ulcer that was not present on admission, no arterial/venous ulcers, had moisture associated skin damage (MASD), had pressure reducing device for chair and bed, nutrition or hydration intervention to manage skin problems, pressure ulcer/injury care, had application of non-surgical dressing other than feet, application of ointments/medication other than feet, had application of dressings to feet.R1's Skin focus care plan revised on 2/24/26, identified R1 had an actual pressure injury related to MS, increased need of activities of daily living (ADL) assistance with mobility, history of ulcer prior to admission and a deep tissue injury to left heel identified on 1/8/26. Goal to show no complications in skin integrity. Interventions as follows:-Inspect skin daily with cares. (dated 10/31/25)-Follow wound care orders. (Dated 11/11/25)-Weekly skin checks completed by nursing. (dated 12/15/25)-Pressure ulcer care to left heel as ordered. (dated 1/15/26)-Nutritional supplements per dietician order to support wound healing. (Dated 2/2/26)-Gel mattress applied 2/13/26. (dated 2/16/26).R1's care plan did not include an individualized toileting plan.R1's Nursing Weekly Skin Check dated 3/3/26, identified R1 had a new stage 2 pressure ulcer on her coccyx with measurements of 1.84 centimeters (cm) x 1.14 cm and contact dermatitis on left and right gluteal fold.R1's IDT Final Post Review Follow Up dated 3/10/26 however was signed on 3/23/26, identified R1's new skin issue (did not identify what skin issue). Interventions were put in place after incident that team reviewing were wound care treatment ordered, repositioning and incontinent care increased. Effectiveness of the interventions put in place after the incident is that resident will refuse repositioning, though staff are still encouraging. R1's care plan did not reflect a revision to include any repositioning schedule nor incontinence care increased until 3/17/26 (seven days after the IDT review).Review of R1's care plan from 3/3/26 through 3/16/26 did not identify revisions pertaining to increased incontinence care.R1's progress note dated 3/17/26 at 5:00 p.m., identified R1 had a decline in her wound characteristics. R1 agreed to have staff come in and reposition her every 2 hours from her left to her right side. R1also stated she did not want to use the bed pan anymore and agreed to use the bedside commode for toileting needs. Email was sent to the nurse practitioner and wound nurse. Primary nurse practitioner will be in house tomorrow and will assess the wound. Air mattress was placed on R1's bed. R1's Skin Issue progress note dated 3/17/26, identified an evaluation of R1's middle coccyx wound. Issue type listed as a Kennedy terminal ulcer/End of Life. Progress listed as deteriorating; wound characteristics listed as deteriorated; Pressure ulcer staging as a Stage 4 pressure ulcer; wound in house acquired; increase in exudate (drainage); increase in size and smell; pain described as sharp; measurements recorded as 4.11 cm x 7.93 cm x 1.0 cm; no tunneling; 10% slough; 90% eschar; moderate drainage that was seropurulent (thin, watery, cloudy wound discharge that is yellow to tan or pink in color indicating early signs of infection); surrounding tissue with erythema (redness); with moderate dressing saturation. R1's skin focus care plan was revised on 3/17/26 to include the following:-Provide prompt incontinence care and keep skin clean and dry to prevent moisture related skin breakdown. R1's elimination focus care plan revised on 3/17/26, identified R1 had incontinence due to neurogenic bladder. Goal to cooperate in establishing a routine for urine elimination. Interventions as follows:-Use bedside commode and no longer use the bedpan.-Offer bedside commode every 2-3 hours and as needed. Able to state when need to use the bathroom and will also ask for assistance.During an interview on 3/24/26 at 3:57 p.m., nursing assistant (NA)-D stated when she worked with R1 she would sometimes fall asleep on the bedpan and forget to ask for staff to take her off, however, NA-D stated staff should be aware if they placed a resident on a bedpan to ensure to take them off in a timely manner to prevent a sore from developing. NA-D had not heard R1 was not supposed to use the bedpan until after her sore had already worsened.During an interview on 3/25/26 at 4:11 p.m., DON stated R1care plan had not been revised to include a turning and repositioning schedule, nor did her toileting care plan revised to not have R1 use the bedpan until 3/17/26. DON explained R1's care plan should have been revised as soon as she heard that R1 was falling asleep while sitting on the bedpan and not waited until 3/17/26 until after R1's pressure ulcer had worsened.Review of the facility's Comprehensive Care Plan Policy dated 4/11/25. Identified The purpose of this policy is to ensure that all residents receive individualized, person-centered care through the timely development, implementation, and ongoing review of comprehensive care plans. This policy ensures alignment with federal regulations and professional standards by outlining processes that assess resident needs and preferences, coordinating interdisciplinary team input, and promoting culturally competent and trauma-informed care.Development of the Care Plan. The comprehensive care plan must be:(a) Developed both: Within seven (7) days after completion of the comprehensive assessment, and Within 21 days after the resident's admission.(b) Prepared by an IDT that includes but is not limited to:The attending physician or, if unavailable, the designated non-physician practitioner (NPP) who is involved in the resident's care, to the extent permitted by state law.A registered nurse with responsibility for the resident.

Based on observation, interview, and document review the facility failed to comprehensively assess an area of moisture associated skin damage and failed to notify the physician for 1 of 1 resident (R3) reviewed for non-pressure skin issues. Findings include:R3's face sheet dated 3/27/26, identified diagnoses of diabetes, Crohn's disease, and kidney transplant.R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 had intact cognition, no behaviors, no rejection of care, needed partial/moderate assistance for transfers, was occasionally incontinent of bowel, has no pressure ulcers, had no venous or arterial ulcers, had no moisture associated skin damage, had an application of non-surgical dressing other than feet, application of ointment other than feet and receives dialysis. R3's Wound assessment dated [DATE], identified R3 had a resolved moisture associated skin damage (MASD) to his right gluteus. R3's progress note dated 3/9/26, identified sacral wound cleansed and creams applied to sacrum as well. Sores are still open and present and R3 experienced pain with application of creams. R3's record did not identify measurements of the wounds or any other wound characteristics, nor evident of physician notification.R3's Wound assessment dated [DATE], identified R3 had an open lesion to the right gluteus that measured 0.3 centimeters (cm) x 0.21 cm. R3's wound assessment did not identify the type of wound nor other wound characteristics. R3's record did not identify physician had been notified or any treatment for open lesion. R3's Wound assessment dated [DATE], identified R3 had an open lesion to the right gluteus that measured 0.6 cm x 0.74 cm. No other characteristics were documented.R1's progress note dated 3/20/26, identified nurse practitioner in facility to assess R3's right gluteal fold wound. NP is going to send new orders for wound care via fax. Instructed to cleanse, apply skin prep to surrounding tissue, apply Medihoney (an ointment that supports the removal of necrotic tissue and aids in wound healing) to wound bed and cover with foam dressing. R3's nurse practitioner note dated 3/20/26, identified R3 had a stage 3 pressure ulcer on left buttocks that measured 1.0 cm x 0.3 cm x less than 0.2 cm with 100% slough (yellow-tan necrotic tissue) in wound bed. Plan to cleanse daily with wound cleanser, pat dry, apply MediHoney to open wound, apply skin prep to peri wound, cover with 2 x 2 protective foam bordered dressing. Turn and reposition frequently and have dietician evaluate for nutrition support and wound healing. R3's physician orders identified the following order: -Cleanse buttocks and pat dry, apply house barrier cream twice daily and as needed for incontinence cares. (3/5/26 through 3/20/26)-Left buttocks: Cleanse with wound cleanser, apply Medihoney to open wound, apply skin prep to peri wound, cover with 2 x 2 protective foam dressing, change daily and as needed at bedtime. (dated 3/20/26) R1's record did not identify a treatment to the right gluteus wound. R3's progress note dated 3/24/26, identified a nutrition/dietary had a review of R3 due to new wound on gluteus that per registered nurse (RN) was considered a stage 2.R3's progress note dated 3/24/26 at 1:00 p.m., identified an email sent to the nurse practitioner (NP) wanting to follow up on the staging of a previously moisture associated skin damage to R3's right gluteal area that was staged as a stage 3 pressure ulcer. Will wait for a response from NP regarding wound classification. During an interview on 3/26/26 at 1:45 p.m., director of nursing (DON) stated she had sent an image of R3's right gluteal wound to the nurse practitioner to evaluate prior to doing rounds on 3/20/26. DON explained R3's wound had not had a notification or gotten treatment until 3/20/26 and the physician should have been notified as soon as the wound was identified. DON was unaware the NP had labeled R3's wound as his left buttocks when it was his right gluteal area nor that it was classified as a stage 3 pressure ulcer. DON believed the wound may be moisture associated skin damage and was reaching out to a different provider to assist with the determination of the wound. During an interview on 3/26/26 at 2:12 p.m., medical director (MD) stated he had received a call from the facility to review an image of R3's right gluteal wound to assist with classification of the wound. MD stated he will be doing a telehealth video visit today (3/26/26) to assess R3's wound on his right gluteal area to see if he would be able to classify what type of wound it was. During an interview on 3/26/26 at 4:30 p.m., R3 stated he has this recurring area on his right buttocks that is painful. R3 stated he leaked stool ever since he had surgery a long time ago and staff put a special pad near his rectum to try and catch the stool. R3 got a special cushion for his wheelchair seat but a donut cushion for his chair was on order to help his bottom not hurt so bad. Just waiting for it to be delivered. During an observation and interview on 3/26/26 at 4:39 p.m., DON performed a telehealth visit with the medical director (MD) to assess R3's right gluteal wound. DON removed R3's brief where a foam dressing was on R3's right gluteus. DON removed the dressing where an approximately 0.5 cm x 0.5 cm open wound was present over what appeared to be a scar- pink skin was noted at the base of the wound, with maceration (occurs when the skin is exposed to moisture for too long) surrounding the wound. R3 stated he had an anal fistula (a tunnel that develops between the inside of the anus and the outside of the skin) repair over 40 years ago and had leaked stool ever since and believed it was in that same area of the wound. MD then assessed R3's wound and explained that the wound was not pressure related, and he would classify the wound as MASD due to the continued leaking stool and wanted to continue the current treatment and have the certified wound nurse practitioner evaluate the wound the next day to give further recommendations. During an interview on 3/26/26 at 5:15 p.m., registered nurse (RN)-D stated R3's wound was never on his left buttocks, however, the wound orders were for the left buttocks, but she just thought it was a mistake and had been applying the treatment to the right gluteal open area since there was no open area on the R3's left buttocks. During an interview on 3/26/26 at 2:01 p.m., director of nursing (DON) stated R3's right gluteus wound was identified as an open lesion, due to not feeling comfortable in being able to assess the type of wound R3 had on his buttocks. DON stated when the NP assessed the wound on 3/20/26 she identified it on the left buttocks, which was incorrect due to the wound his right gluteus that was assessed and as a stage 3 pressure ulcer and gave orders. DON initially thought the wound was a stage 2 pressure ulcer, but after review of R3's chart identified R3 had a history of MASD in the same areas in February. DON stated she relied on the certified wound nurse to assist with staging or to identify the type of wound, however, had not reached out to get clarification on R3's wound type. During an observation and interview on 3/27/26 at 7:31a.m., certified nurse practitioner wound nurse (CNP-WOC) assessed R3's right gluteal wound and classified the wound as MASD and changed the treatment order to the following: wash with normal saline, pack wound with collagen (wound dressing that promotes healing by stimulating new tissue growth), cover with foam, change daily and as needed soiling, may use barrier cream to surrounding peri wound for redness or irritation. Review of the facility's Wound Treatment Policy dated 1/21/26, identified Residents with wounds will receive necessary treatment and services, in accordance with provider orders and professional standards of practice, to promote healing, prevent infection, and prevent the development of new wounds unless clinically unavoidable. Wound treatment will be delivered using evidence-based practices, individualized to each resident's assessed needs, and documented, monitored, and reviewed to ensure effectiveness and regulatory compliance.I. General Requirements:Based on the comprehensive assessment of a resident, the facility will ensure that residentswith pressure injuries and other types of wounds receive necessary treatment and services,consistent with professional standards of practice, to promote healing, prevent infection,and prevent the development of new wounds unless clinically unavoidable.Wound treatment and monitoring will be:Individualized based on the wound's etiology, contributing factors, and the residents.overall condition, goals, and preferences.In accordance with the residents' comprehensive care plan; andConsistent with professional standards of practice.II. Comprehensive Wound Assessment:A comprehensive assessment will be completed for each wound to determine etiology andcontributing factors. This assessment will include:Underlying causes of the wound (e.g., pressure, shear, friction, vascular insufficiency,moisture, trauma, or other etiology);Contributing conditions or risk factors (e.g., nutrition, hydration, perfusion, mobility,incontinence, comorbidities, medications); andConsistent measurement of wound characteristics, including location, size, depth,tunneling, undermining, exudate, tissue type, and condition of the peri-wound skin.III. Treatment Orders:Wound treatments will be provided in accordance with provider orders, including:The cleansing method,Type of dressing, andFrequency of dressing changes.In the absence of treatment orders, the licensed nurse will notify the provider to obtain.orders. This may be the designated treatment nurse or the assigned licensed nurse in theabsence of the treatment nurse.Treatment orders will be guided by current evidence-based wound care practices andinterdisciplinary input when needed (e.g., wound specialist, dietician, therapy staff).Pain associated with wound care will be assessed and managed in accordance with provider.orders and pain management policies and procedures.IV. Treatment Decisions:Treatment decisions will be based on:Etiology of the wound:Pressure injuries.Non-pressure wounds (e.g., arterial, venous, diabetic, moisture-related skindamage).Surgical wounds.Incidental injuries/wounds (e.g., skin tear, medical adhesive-related injury).Atypical injury/wound (e.g., dermatological, or cancerous lesion, pyoderma,calciphylaxis).Characteristics of the wound:Pressure injury stage or level of tissue destruction if not a pressure injury.Size, including shape, depth, and presence of tunneling and/or undermining.Volume and characteristics of exudate.Presence of pain.Presence of infection or need to address bacterial bioburden.Condition of the tissue in the wound bed.Condition of peri-wound skin.Location of the wound; andGoals and preferences of the resident or their representative.Guidelines for dressing selection may be utilized in obtaining provider orders.

Based on observation, interview, and document review the facility failed to ensure proper handwashing/hand hygiene was implemented for 1 of 3 residents (R3) observed during wound care. In addition, the facility failed to ensure enhanced barrier precautions (EBP) were utilized during a transfer for 1 of 3 residents (R3).Findings include:R3's face sheet dated 3/27/26, identified diagnoses of diabetes, non-pressure chronic ulcer of right lower leg, and kidney transplant.R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 had intact cognition, no behaviors, no rejection of care, needed partial/moderate assistance for transfers, was occasionally incontinent of bowel, has no pressure ulcers, had no venous or arterial ulcers, had no moisture associated skin damage, had an application of non-surgical dressing other than feet, application of ointment other than feet and received dialysis. R3's care plan dated 7/24/25, identified R3 needed EBP. Goal that staff will maintain enhanced barrier precautions when performing high contact resident care activities. Interventions as follows:-Don (apply) gown and gloves during wound care. (dated 7/24/25)-Don gown and gloves for the following high-contact resident care activities (dressing, bathing/showering, transferring, providing hygiene, changing linens, changing brief or assisting with toileting, catheter care.) (dated 7/24/25)R3's Wound assessment dated [DATE], identified R4 had an open lesion on his right gluteus (group of muscles in the buttocks) that measured 0.5 centimeters (cm) x 0.74 cm.During an observation on 3/26/26 at 3:20 p.m., R3' room had a sign near the door that indicated R3 needed EBP for high contact care activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, changing brief, or assisting with toileting, catheter care.During an interview on 3/26/26 at 3:22 p.m., nursing assistant (NA)-G stated R3 needed EBP (gown and gloves) for high contact care activities because he had a wound on his right buttocks. During an observation and interview on 3/26/26 at 4:39 p.m., director of nursing (DON) was outside of R3's room, performed hand hygiene and applied a gown prior to entering R3's room. DON then entered R3's room where R3 was lying in bed. R3 was informed that a physician wanted to assess R3's right gluteal wound via a telehealth (video visit) in which R3 agreed. DON then placed the computer on R3's bed, went into the bathroom and applied gloves, without performing hand hygiene. DON then removed R3's brief and proceeded to remove a foam dressing that was near R3's right gluteal area. R3's foam dressing had stool on the left corner of the dressing. DON then placed the dressing in the trash, removed gloves, then applied new gloves, without performing hand hygiene prior to application of the new gloves. Surveyor intervened and asked DON when should hand hygiene/hand washing be done in which the DON stated hand hygiene should be done when hands/gloves are visibly soiled, before and after removing/applying gloves. DON confirmed she had not performed hand hygiene each time she had removed/applied gloves. DON then removed her gloves, performed hand hygiene, and applied new gloves. DON then completed the wound dressing change and performed hand hygiene appropriately. During an observation and interview on 3/27/26 at 7:31 a.m., R3 was seated in his chair in his room. An unknown nursing assistant (NA) who had a gown and gloves on then entered R3's room with a sit-to-stand mechanical lift. DON then applied the lift harness under R3's arms, cinched the waist strap while encountering R3's clothes in the process. DON then hooked up the harness to the machine, moved R3's left hand toward the handle on the lift with ungloved hands. DON and NA then transferred R3 to the bed when DON then pulled R3's pants down. R3 was then removed the harness while touching R3's clothes. Certified Nurse Practitioner Wound Nurse (CNP-WOC) then removed the dressing on R3's right gluteal area with gown and gloves on and assessed R3's wound and applied a new dressing. Hand hygiene was performed during the dressing change. DON then sat up R3 on the edge of the bed, touching his upper body with gown but no gloves, applied the lift harness under his arms and around R3's waist with a gown, but no gloves. R3 was then hooked up to the lift and as R3 stood, DON pulled up R3's pants and adjusted R3's shirt. Upon exiting R3's room, DON stated EBP was only needed if performing catheter or wound care and was not needed during transfers. DON then read the EBP sign that was outside of R3's room and identified that EBP was needed during any high contact resident care activities including transfers.Review of the facility's Enhanced Barrier Precautions Policy undated, identified It is the policy of this facility that Enhanced Barrier Precautions, in addition to Standard and Contact Precautions will be implemented during high-contact resident care activities when caring for residents that have an increased risk for acquiring a multidrug-resistant organism (MDRO) such as a resident with wounds, indwelling medical devices or residents with infection or colonization with an MDRO. The purpose of Enhanced Barrier Precautions is to prevent opportunities for transfer of MDROs to employees' hands and clothing during cares, beyond situations in which staff anticipate exposure to blood or body fluids. High-Contact Resident Care Activities include:DressingBathing/showeringTransferringProviding hygieneChanging linensChanging briefs or assisting with toiletingDevice care or use: central line, urinary catheter, feeding tube.Wound care: any skin opening requiring a dressing. ProcedureStandard Precautions should be applied to all residents at all times.Transmission-based precautions should be applied to all residents when standard precautions alone do not prevent pathogen transmission.Enhanced Barrier Precautions are to be implemented in addition to Standard Precautions when other Transmission-Based precautions do not apply, when facility identifies any resident with:MDRO infection or colonization when Contact Precautions do not otherwise apply. If resident is infected or colonized with any MDRO and has secretions or excretions that are unable to be covered or contained, the resident should be placed on contact precautions.Wounds or skin openings such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers Shorter-lasting wounds such as skin breaks or skin tears covered with an adhesive bandage would not need Enhanced Barrier PrecautionsAny indwelling medical device, regardless of MDRO colonization status, for example: Central linesPeripheral intravenous line is not considered an indwelling medical device for the purposes of EBP.2Urinary cathetersFeeding tubesTracheostomy/ventilatorPersonal Protective equipment is required for all staff providing high-contact resident care activities to include: Gown and gloves with: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, Wound care:any skin opening requiring a dressing.

Based on observations, interviews, and record reviews, the facility failed to ensure the safe and accurate administration of prescribed medications to residents, resulting in Immediate Jeopardy. Systemic Failures were identified across multiple areas, including transcription errors, incorrect dosing, and medication omissions. The facility did not consistently follow the five rights of medication administration, nor did it implement effective systems to identify, prevent, investigate, or track medication errors. These failures directly impacted two residents. Resident R1 did not receive two prescribed diuretic (manage fluid overload) medications, resulting in ongoing congestive heart failure. Resident R4 received 50 mg of prednisone instead of the prescribed 5 mg of a potent anti-inflammatory medication, leading to new cardiac symptoms, hospitalization, and admission to the intensive care unit (ICU), where he remains. The facility's lack of oversight and failure to implement corrective actions placed all residents at risk for serious harm, injury, or death, and necessitated immediate intervention to protect resident health and safety.The immediate jeopardy (IJ) began on 7/21/25 when the interdisciplinary team identified R1's medication errors but failed to conduct a comprehensive analysis of their pharmacy protocols or medication errors to uncover systemic failures in medication management. This led to R4 receiving 10 times the prescribed dose of Prednisone that resulted in ICU admission. The interim administrator, director of nursing were notified of the IJ on 8/14/25 at 12:58 p.m. The IJ was removed on 8/22/25 at 2:51 p.m., but non-compliance remained at a lower scope and severity of D meaning no actual harm with potential for more than minimal harm that is not widespread. Findings include A facility reported incident dated 7/18/25, identified R1's Metolazone (diuretic medication given to treat fluid retention) was not given in accordance with physician orders. R1's annual minimum data set (MDS) dated [DATE], identified R1's cognition was intact and had diagnoses of biventricular heart failure (a severe form of heart failure where both the left and right sides of the heart are unable to pump blood effectively, leading to symptoms of both left-sided (shortness of breath, fatigue) and right-sided (swelling in the legs, abdomen) heart failure), hypertensive heart and chronic kidney disease (where high blood pressure damages the heart and kidneys, while damaged kidneys exacerbate high blood pressure) and hypertension. Further identified R1 received diuretics. R1's order summary dated 1/8/25 through 7/21/25, directed to give Metolazone give one 2.5 mg tablet daily 30 minutes before AM Torsemide (diuretic medication given to treat fluid retention) when weight is 165 pounds or greater, related to hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease.R1's medication administration record (MAR) dated July 2025, identified R1 was given doses of metolazone when R1's weight was below 165 lbs., not in accordance with physician orders. Administrations included: -7/7/25 weight was 161 pounds, and medication was signed as given.-7/10/25 weight was 163.6 pounds, and medication was signed as given. -7/12/25 weight was 163.6 pounds, and medication was signed as given.-7/18/25 weight was 158 pounds, and medication was signed as given. R1's progress note dated 7/18/25, at 1:03 p.m., identified an aide initially shared to this writer that R1 was complaining of not feeling well while in her wheelchair and leaned forward in her tray table but still conversant. She assisted her to the bathroom, as requested. Vital Signs (VS) checked as resident is still complaining of not feeling well. VS checked and noted initial BP (blood pressure) to be 56/34 (Normal blood120/80 mmHg). and immediately informed this writer of the low BP. Immediately attended to and saw R1 seated on the toilet. R1 was initially conversant but gradually passed out and observed to have inward stiffening of upper extremities and stopped responding, lasting for about a minute. R1 gradually regained consciousness and was transported back to bed. The note also indicated R1 said, I wasn't feeling well and 'I have a little hard time breathing earlier but it's better.' Will inform NP and continue to monitor. At 2:08 p.m., Writer informed and updated NP about R1's condition and ordered to send her to the ED for further investigation. Informed R1 and agreed. At 2:15 p.m., ambulance came and left the facility at 2:25 p.m.R1's emergency department (ED) note dated 7/18/25, at 5:48 p.m., identified R1 was diagnosed with vasovagal syncope (triggered by an overstimulation of the vagus nerve that leads to a sudden drop-in heart rate and/or blood pressure, resulting in temporary loss of consciousness due to reduced blood flow to the brain). Nursing home reported R1 was hypotensive to the 50's and had lost consciousness when they found her. R1 was still seated on the toilet with her head leaning on the wall to her right. R1 reported similar episodes in the past where she was hypotensive and had similar symptoms. R1 also reported that she checks her weight each day and when she is above a certain weight, she takes her diuretic. R1 stated she took her pill yesterday and went down 10lbs overnight. (Weight loss was not consistent with R1's record).R1's MAR dated July 2025, identified the following weights:-7/16/25: 166.2 pounds-7/17/25: 161.2 pounds; reflecting a 5 lb. weight loss in one day7/18/25: 158 pounds; reflecting an 8.2 lb. weight loss in two days. R1's NP visit dated 7/21/25, reviewed the 7/18/25 syncopal event and added recurrent hypotensive episodes linked to diuretic use, particularly Metolazone, the note identified a plan to adjust Torsemide 40 mg in the am and 20 mg in the pm for more consistent diuresis, trying to eliminate the need for PRN (as needed) metolazone and identified metolazone 2.5 mg discontinued.R1's Medication Error Report dated 7/21/25, at 11:00 a.m., identified on 7/18/25 R1 was given Metolazone dose when her weight was 158 pounds, had a syncopal episode and transferred to the ED. Report further identified the same error had occurred on 7/7/25, 7/10/25, and 7/12/25 Metolazone order has been discontinued. Weight parameters have been adjusted. R1‘s IDT team initial post investigation review form dated 7/21/25 at 11:00 a.m., identified the root cause of the medication error was medications are currently kept with routine medications which could lead to this medication being pulled out of the cart with other morning medications. NP noted that Metolazone was given when the weight parameters for giving it had not been met on 7/18. The investigation had identified errors had occurred several times before 7/18 with the Metolazone. IDT discussed options to possibly move medications that are PRN to different location in the cart so they are not inadvertently given with routine meds. Further indicated discussion of changing where and how the order was transcribed into EHR (i.e. put in with the daily weight order so that when wt. is > 165 initiate PRN Metolazone order, or possibly changing the FONT of the order to make it more pronounced with caps or bold face to bring it to nurse's attention more.) In this particular case the NP decided to eliminate the metolazone altogether which eliminated the need to move med or change where order is written or how it is written.R1's IDT progress note was reviewed in conjunction with the IDT Final Post Review Follow Up form both dated 7/28/25, identified IDT reviewed the Medication Error incident. The intervention(s) put in place was a new process (was implemented) whereby the order for daily weights will be edited and further instructions for when the NP/MD orders a medication to be given in response to the weight. We feel this will provide the nurses with increased cues as they enter the weight to know if the resident needs it or not. IDT determined the effectiveness of the interventions put into place are effective at this time. There were two parts to this error- 1. nothing was cuing the nurse to check PRN meds post entering of weights. 2. Nurses had kept the medication with the routine meds and this was moved also. Lastly the doctor did decide to discontinue this medication altogether for this resident. Review of R1's medication error documentation reviewed between 7/18/25 through 8/7/25 did not identify if audits had been completed to determine extent of medication errors that resulted from staff not following rights of medication administration and/or medication cart organization and/or transcription of orders with parameters. Further there was no indication staff were provided with education pertaining to systems or re-educated on the rights of medication administration. R1's Nurse practitioner (NP) visit dated 8/1/25, identified R1 was being seen for congestive heart failure and weight gain. R1 reported to nursing her legs are feeling more swollen and weight was above parameter at 166.2 pounds. New order to give torsemide 40 mg twice a day for edema. (Order dated 7/21/25 included continue daily standing weights notify provider of weight less than 155 lb. or greater than 165 lb.) R1's MAR included multiple orders for physician orders for Torsemide and identified R1 was administered Torsemide not in accordance with physician orders. On 8/1/25 R1 was administered 40 mg for the a.m. block (7:00 a.m. -11:00 a.m.) dose, administered 20 mg at 3:00 p.m. then 40 mg at 7:00 p.m. - for a total of 100 mg which was 20 mg over what was prescribed. -On 8/2/25 R1 was administered 40 mg at 6:00 a.m., administered 40 mg for the a.m. block (7:00 a.m. -11:00 a.m.) dose, administered 20 mg at 3:00 p.m. then 40 mg at 7:00 p.m. - for a total 140 mg which was 60 mg over the prescribed dose. -On 8/3/25 R1 was administered 40 mg at 6:00 a.m., administered 40 mg for the a.m. block (7:00 a.m. -11:00 a.m.) dose, administered 20 mg at 3:00 p.m. then 40 mg at 7:00 p.m. - for a total 140 mg which was 60 mg over the prescribed dose. -On 8/4/25 R1's 6:00 a.m. and block (7:00 a.m.-11:00 a.m.) dose of 40 mg was blank indicating doses were not administered. The MAR indicated this dose and dosing time were discontinued on 8/4/25 at 8:56 a.m. R1's NP visit dated 8/4/25, identified R1 presented with increased fluid retention and shortness of breath related to heart failure. R1 had increased shortness of breath especially during conversation, notable episode of dyspnea at a social event, symptoms have lessened over the last two days with reduced talking, abdominal distention which decreased when lying down, increased lower extremity swelling. Torsemide ordered on 8/1/25, to give 40 mg twice a day however medication error occurred, nurse confirmed R1 received a total of 120 mg per day for 3 days. New order for torsemide give 80 mg twice a day x 3 days, then reduce back to 40 mg twice a day. R1's MAR on 8/4/25 through 8/7/25 R1 continued to not receive the correct dose of Torsemide per physician order. The MAR identified the aforementioned physician order for 80 mg twice day x 3 days, however the start date was for the morning of 8/5/25 at 8:00 a.m. The MAR identified the following: -On 8/4/25, R1 was administered 40 mg of Torsemide at 3:00 p.m. and 80 mg at 4:22 p.m. for a total of 120 mg, equating to 40 mg under the prescribed dose. -On 8/6/25, R1 did not receive any doses of Torsemide. -On 8/7/25, R1 was administered 40 mg at 8:00 a.m. and the 2:00 p.m. dosing time was blank. R1's progress note dated 8/7/25 at 12:56 p.m., identified writer noted R1's increasing weight despite her diuretic revision recently. During conversation, a while ago, R1 claimed that she had to pause for some time after wheeling herself and noted her legs to be more swollen. Observed to be speaking in phrases but no obvious labored breathing nor complains of chest pain. Auscultation to lungs revealed minimal crackles, bibasilar (lower portion of both lungs) with no wheezing appreciated. Situation, Background, Assessment, and Recommendation (SBAR) sent and called NP. She agreed to increase back the Torsemide for a couple of days. Will be waiting for orders later this afternoon. R1 informed of this, and she acknowledged.R1's new physician order dated 8/7/25, at 3:01 p.m., directed Torsemide 40 mg give two tablets twice until 8/12/25 at 10:00 a.m., take 1-2 tablets (40-80 mg total) by mouth 2 times a day. 80 mg by mouth two times a day x 5 days starting 8/7/2025; then reduce back to 40 mg by mouth twice a day. R1's MAR on 8/7/25 identified R1 received a total of 120 mg of Torsemide which was 40 mg under the prescribed dose. R1's Medication Error Report dated 8/7/25 did not identify all the medication errors, the report identified that Torsemide 40 mg dose was omitted on 8/4/25 at 7:00 a.m., and on 8/7/25 at 2:00 p.m. Immediate intervention identified- only included management was alerted to medication error on 8/11/25 at 6:00 p.m. while doing a whole house audit. The error report did not identify or include medication errors that occurred on 8/1/25, 8/2/25, 8/3/25, 8/4/25, 8/6/25, and 8/7/25. During an interview on 8/11/25 at 2:28 p.m., registered nurse manager (NM)-A verified R1 had med errors where she received metolazone 2.5 mg in error on 7/7/25, 7/10/25, 7/12/25 and 7/18/25; R1's NP found those errors in which the three nurses who made the four errors were not following the rights of medication administration by looking at the actual physician order. NM-A was not aware of any subsequent errors involving R1. NM-A was provided and reviewed R1's record, NM-A confirmed R1 had not received her torsemide as ordered; on 8/4/25 lacked 40 mg dose, 8/6/25 was completely omitted, and 8/7/25 lacked a 40 mg dose. NM-A stated on 8/7/25, R1 was displaying signs and symptoms of CHF so she called the NP to keep torsemide at 80 mg twice a day for an additional 5 days. NM-A stated she was not aware of the torsemide medication errors until just this moment, the errors should have been identified earlier. NM-A was unsure of the process for medication errors and stated she would just report it to the director of nursing (DON). During an observation and interview on 8/11/25, at 12:38 p.m., R1 was seated in her wheelchair in her room, R1's legs were swollen and had wraps on them. R1 explained she was a former nurse. R1 reported she was getting Metolazone when her weight was above 165 pounds, it helped get rid of the swelling in her legs. R1 stated a few weeks ago she blacked out in the bathroom and had to be sent to the ED because her blood pressure dropped in the 50's. R1 was wondering if the nurses were reading the orders right for her diuretics because she had been exhibiting signs and symptoms of congestive heart failure for the last two weeks such as shortness of breath, feeling weak, bad swelling in her legs, just in the last week she had noted shortness of breath with just talking. R1 stated as far as she knew there had been no medication errors with her diuretics but wondered if the nurses had been giving them to her correctly with the increase in symptoms, leg swelling and weight gain.During an interview on 8/11/25 at 1:11 p.m., registered nurse (RN)-G stated R1 currently received torsemide 40 mg twice a day until 8/12/25. No one had reported to her that R1 was having any shortness of breath. RN-G wrapped R1's legs earlier in the morning and noted them to be more swollen, R1's last reported weight was 168.8 pounds and would have to notify the provider if her weight goes above 165. (Nurses progress note dated 8/11/25 at 3:06 p.m. included physician notification identifying R1's weight was outside the parameters).During an observation and interview on 8/13/25 at 10:58 a.m., registered nurse (RN)-B was standing at the medication cart. RN-B removed five cards of R1's Torsemide with the original pharmacy labels which included: -Torsemide 10 mg tablets-give 2 to 4 tablets two times per day (give 40 mg in the a.m. and 20 mg in the p.m.) Prescription date of 7/21/25 with 29 tablets remaining-Torsemide 20 mg tablets-give 2 tablets twice daily. Prescription date 8/1/25 with 14 tablets remaining on one card and second card with 30 tablets. -Torsemide 20 mg tablets-give 2 to 4 tablets (40-80mg) two times per day; 80 mg twice daily for 3 days starting 8/4/25 then reduce back to 40 mg twice daily. Prescription date 8/6/25 with 12 pills remaining.-Metolazone 2.5 mg tablets-give 1 tablet 30 minutes prior to a.m. Torsemide when weight is greater than 165 pounds. Prescription dated 5/6/25, with 10 pills remaining. When RN-B pulled R1's Torsemide cards out of the medication cart and compared it with R1's physician order in the MAR, RN-B could not articulate what R1's current Torsemide medication order was when reading it in the MAR. RN-B stated it would be 80 mg twice per day which would mean she would give 40 mg in the morning and 40 mg in the evening totaling 80 mg (instead of 80 mg twice for total of 160 mg). RN-B was unsure of what she administered to R1 for the morning dose of Torsemide. RN-B explained R1 would receive a dose of metolazone if her weight was greater than 165 pounds; her weight was 169.2 pounds this morning, so R1 would get a dose. RN-B was unaware that R1's Metolazone had been discontinued on 7/21/25, and the Metolazone bubble pack was in the medication cart and stated she would have given it. During an interview on 8/13/25 at 2:18 p.m., licensed practical nurse (LPN)-A stated R1's current Torsemide order was very confusing and hard to understand what the exact dose was to administer which could increase the risk of an error reoccurring. LPN-A indicated she had not received any training on how to transcribe physician orders in the EHR. LPN-A was not able to articulate the process on how to complete a medication error report and how to contact the pharmacy if a medication was not available to administer. During an interview on 8/13/25 at 4:19 p.m., Health unit Coordinator/licensed practical nurse (HUC/LPN) stated there were no processes in place to ensure discontinued/changed medications were removed from the medication carts. HUC/LPN further stated when she transcribed a new prescription order in the electronic health record (EHR) she sometimes would place a sticky note on the medication cart to inform the nurses the medication needs to be removed. HUC/LPN indicated she does not ensure the medication bubble packs are always removed from the cart with new medication orders. During an interview on 8/13/25 at 2:36 p.m., RN-C stated she had noticed a problem with medications that had been discontinued/changed related to the bubble packs being left in the medication carts. This could be a recipe for a disaster and could lead to medication errors if the nurse does not verify the prescription cards to the MAR. RN-C had not received any education on rights of medication administration, preventing medication errors, or entering/verifying new orders. RN-C stated all new orders should be entered by the HUC/LPN, the DON, or the nurse managers and at times they (nurses) were not even told what orders were new or have changed.R1's NP visit dated 8/13/25, identified despite recent increases in torsemide, R1 continued to exhibit signs and symptoms of CHF such as bilateral lower extremity edema, increased weights, and shortness of breath. Current weights twice a week, unable to successfully titrate the torsemide back down. Unable to use Metolazone due to syncope and hypotension in the past. New orders identified to continue Torsemide 80 mg twice a day. Will implement daily weights. R1's August 2025 MAR, dated 8/18/25, at 1:24 p.m., identified physician order for Torsemide to give 100 mg twice a day for 3 days. 2:00 p.m. dose of 100 mg of torsemide was left blank. During an observation and interview on 8/20/25 at approximately 10:30 a.m., DON indicated she had transcribed the order into the EHR on 8/18/25 and directed the nurse to give the medication. DON indicated she was informed via an offsite auditor just this morning (two days later) the medication record did not identify the medication was administered. DON confirmed she had not reviewed R1's MAR on 8/18/25 nor on 8/19/25 to assure the dose was given. DON was unaware and unable to articulate how to reconcile medications in order to determine if the dose had been administered. During an interview on 8/11/25 at 4:06 p.m., director of nursing (DON) stated R1's medication error with Metolazone in July 2025, resulted in R1 being sent to the ED with a syncopal event. DON stated they did not review any other resident charts to ensure there were no other medication errors. DON stated the facility did not really have a system in place for nurses who were identified that made the error; there was not we are not tracking it or doing any education. DON indicated typically with a medication error we would be expected to fill out a risk management report, notify the provider, resident/representative and follow provider orders. DON indicated since R1's July med error they were not doing any audits to identify similar medication errors. DON indicated she was not aware of R1's missed torsemide doses on 8/4/25, 8/6/25 and 8/7/25. R4 R4's face sheet dated 8/12/25, identified diagnoses of end-stage renal disease (a condition in which the kidneys lose the ability to remove waste), hypertensive heart disease (heart damage cause by long-term high blood pressure), post kidney transplant (a surgical procedure that replaces a damaged kidney with a healthy one from a donor), atrial fibrillation (an irregular, often rapid heartbeat that commonly causes poor blood flow), and diabetes (a condition where the body uses glucose as fuel). R4's care plan focus identified end stage renal disease with a kidney transplant and immunocompromised. Interventions included: medications for anti-rejection (medications taken to prevent organ rejection) as ordered and monitor for side effects of medications such as increased blood pressure.R4's significant change Minimum Data Set (MDS) dated [DATE], identified R4's cognition was intact. R4's diagnoses included, end stage renal disease, dependence on renal dialysis, and kidney transplant status. R4's physician orders included the following orders:-Prednisone (steroid used to reduce inflammation and suppresses the immune system) 5 mg tablets one tablet daily for renal (kidney) transplant (start date 7/24/25) R4's medication administration record (MAR) from 7/24/25 through 8/12/25, identified the physician order for 5 mg of prednisone and indicated R4 was administered 17 doses of the 5 mg prednisone tab. However, R4's Medication Error form dated 8/11/25, identified R4 had been receiving 50 mg prednisone instead of 5 mg of prednisone for the last 17 days due to pharmacy sending the wrong dosage. Immediate action taken was that medication was pulled from the cart and the physician was made aware. R4's Post Incident Medication Error Report form dated 8/11/25, identified the prednisone error as mentioned as well as the root cause of pharmacy error, in addition to nursing staff were not following the rights of medication administration. Neither form included a comprehensive analysis/investigation nor strategies to prevent or mitigate the risk of recurrent like errors. Review of R4's record identified between 7/29/25 and 8/12/25, R4 had increased blood pressures without identification of an overdose of prednisone had been administered at any point as a result of not reconciling medication against physician order upon delivery and then six licensed staff were not performing the rights of medication administration prior to administration to ensure the dose was accurate. R4's records identified the following course of events that ultimately lead to hospitalization as a result of the prednisone medication errors. R4's NP progress note dated 8/1/25, identified R1's blood pressure was elevated today however had been stable otherwise. Blood pressure reading was 161/80 (normal BP is 120/80). R4's NP note dated 8/6/25, identified R4 had elevated blood pressure readings. The note also included new orders for blood pressure medication in addition to a diuretic. 8/1/25 at 8:06 a.m., 161/60 at 3:50 p.m., 178/798/4/25 at 7:27 a.m., 192/59 at 3:26 p.m., 184/76, at 5:48 p.m., 188/778/5/25 at 12:21 p.m., 139/708/6/25 at 10:14 a.m., 166/73Review of R4's occupational therapy (OT) notes from 7/29/25 through 8/12/25, identified R4 did not feel well on 7/29/25; R4 had elevated blood pressures on 8/6/25 of 160/78 and 8/7/25 of 160/78 millimeters of mercury (mmHg) and 169/78 mmHg. Review of R4's physical therapy (PT) notes from 7/29/25 through 8/11/25, identified R4 had elevated blood pressures on 7/31/25, 8/6/25, 8/8/25, and 8/11/25. R4 also had shortness of breath on 8/6/25, 8/8/25, and 8/11/25. R4's NP progress note dated 8/11/25, identified an addendum that nursing reported a medication error where R4 had been receiving 50 milligrams (mg) of prednisone daily since 7/24/25, rather than receiving 5 mg daily. Blood glucose has been stable however R4 has been hypertensive. Further identified R4 received prednisone for immunosuppressive therapy. Last week losartan (high blood pressure medication) was increased to 50 mg daily on non-dialysis days and remains hypertensive. Today's blood pressure was 184/88, rechecked and was 168/75. Will collaborate with NP in nephrology who manages R4's dialysis. Consideration of increasing losartan daily since R4 was hypertensive on dialysis and non-dialysis days but would like a better understanding of what R4's blood pressures are during dialysis.R4's OT treatment encounter notes dated 8/12/25, identified vital signs were monitored during therapy session. R4 then got a call from the hospital regarding monitor which was reporting R4 was in atrial fibrillation yesterday with variable heart rates. Checked pulse manually and beat was steady at 68. Did have nursing clinical manager come in therapy room per R4's request and R4 had nursing talk to the hospital. Hospital reported they will put notes in for NP. Relayed R4's vital signs to nursing.R4's progress note dated 8/13/25, identified during a therapy session R4 began having chest pain and shortness of breath and was sent to the emergency department (ED) for evaluation. R4's ED note dated 8/13/25, identified R4 was seen due to chest discomfort and shortness of breath. R4 needed oxygen at 4 liters/min (L/min), had pitting edema in bilateral (both) feet and was in atrial fibrillation. R4's Pro BNP (a blood test used to help diagnose heart failure) was greater than 70,000 -which roughly three months ago was 13,000 and was showing some concerns for new heart failure and needing intravenous (IV) diuresis and was admitted to cardiology. R4's hospital Discharge summary dated [DATE], identified R4 had received and incidental increase dose of prednisone for several weeks. R4's heart failure exacerbation (the process of making a problem worse) and atrial arrhythmia were felt to be related to the prednisone error. R4 received dialysis twice and underwent ultrafiltration (a treatment that focuses only on fluid removal, using pressure to push water through a membrane without significant solute (dissolved substance) exchange. R4's discharge diagnoses were as follows:1.Acute dyspnea in the setting of acute on chronic heart failure, likely related to #2 and #3.2.New onset atrial arrhythmias, intermittent, likely related to #1 and #3.3.Accidental/unintentional overdose on prednisone, reported 13 days of Prednisone 50 mg (normally takes 5 mg day). During an interview on 8/13/25, at 2:18 p.m., LPN-A indicated she worked on 8/9/25, and was responsible for administering R4's medications. LPN-A explained when she looked at R4's prescription card did not match the physician order on the displayed MAR on 8/9/25; R4's MAR order directed to give Prednisone 5 mg tablet give one tablet daily, however, the label on the prescription card was Prednisone 50 mg tablets-give one tablet daily. Because there was a discrepancy, she referenced the pharmacy prescription order summary and found on 7/24/25 prednisone 50 mg had been filled and assumed that was the correct order. She did not know how to find the original physician order in the electronic health record (EHR) to compare and verify the dose, she denied contacting the pharmacy, or calling the physician to verify the dosage was correct and administered R4 his morning dose (on 8/9/25). LPN-A further stated she was not aware the dose she administered to R4 was given in error and did not receive any communication and/or education from the director of nursing (DON) that she had made prednisone error for R4. During an interview on 8/13/25 at 5:23 p.m., LPN-B stated he had not been made aware he made a medication error for R4's prednisone dose on 7/29/25 and 8/6/25. LPN-B had not received any education on medication error prevention or the rights of medication administration. During an interview on 8/13/25 at 4:19 p.m., HUC/LPN stated on 8/11/25, she received a phone call from the pharmacy informing her that R4's prednisone order that had been dispensed 7/24/25, had accidently been dispensed as prednisone 50 mg tablets instead of 5mg. HUC/LPN immediately went to the medication cart and removed the R4's prednisone prescription (Rx) card and identified the pharmacy was correct in that prednisone 50 mg tablets had been dispensed to the facility on 7/24/25, and the card was almost empty. She then had RN-E try to identify if there was a discrepancy between the pharmacy order and the physician order, however RN-E was not able to identify an issue with the prescription. HUC/LPN then brought R4's prednisone prescription card immediately to the DON to inform her of the error. HUC/LPN stated no new process had been put in place to ensure all new prescriptions that are entered into the physician orders and are the correct prescription received form the pharmacy. During an interview on 8/13/25 at 5:29 p.m., DON stated R4's medication error was due to pharmacy error, however, the nurses had not performed the rights of medication administration to identify the incorrect dose even though the label on the prednisone card identified it as 50 mg and not 5 mg as ordered. Had nurses performed the rights of medication administration, the error may have been identified sooner or not occurred. DON also stated she had not made any process changes to ensure prescriptions being delivered from the pharmacy are correct to prevent a similar error. During an interview on 8/13/25 at 12:18 p.m., NP stated R4 began having symptoms of increased blood pressure and weight gain over the past week. R4 was currently in the ED due to shortness of breath, chest pain, and was currently in atrial fibrillation with ventricular rate. R4 received multiple increased doses of prednisone likely caused his symptoms and even if the pharmacy had dispensed the incorrect dose when R4 was re-admitted to the facility on [DATE]. NP stated R4 receiving so many higher doses of prednisone put R4 at risk for serious harm or even death. NP stated R1's Metolazone being administered when it should not have been given could have led to her syncopal episode on 7/18/25. NP stated R1's Metolazone had been discontinued on 7/21/25, and the med card should have been removed from the medication cart at the time of it being discontinued. R1 having multiple cards of torsemide in the cart with different doses/directions put her at risk for an incorrect dose being given and could be the contributing factor to R1 not having improvement in her CHF symptoms. NP stated the type of errors for R1 had the potential to cause serious harm or even death. During a phone interview on 8/12/25 at 12:55 p.m., consultant pharmacist (CP) was not aware of several recent medication errors that were found regarding transcription, not available and omission of medications with several different residents and several different nurses. CP stated she meets with the quality assurance committee quarterly and attended lasts months meeting, stating they discuss significant medication errors but could not remember if it was discussed what prevention measures were in place. CP further stated for prevention with each medication error there should be a root cause analysis performed, the nurse making the error should be notified and educated. The facility could be performing education with staf

Based on observation, interview, and record review, the facility failed to ensure the Quality Assessment and Performance Improvement (QAPI) plan and program identified, analyzed, implemented corrective actions, and re-evaluated corrective actions to address adverse events and quality deficiencies. This deficient practice had the potential to affect all 35 residents in the facility. Actual harm occurred related to the quality of care to two residents (R4 and R1). Findings include:See F755, facility failed to identify and prevent medication errors due to complete systemic failure. The facility's failures resulted in an immediate jeopardy (IJ) with over 79 medication errors occurred in six weeks, resulting in actual harm for 2 of 5 residents (R4, R1) reviewed who had medication errors. R4 (cardiac ICU admission) and R1 (ongoing CHF exacerbation). The facility lacked systems to prevent errors, notify providers, and investigate incidents-demonstrating a widespread failure in medication management. Further review of medication errors revealed a lack of analysis of root causes, and there were no implemented corrective actions, and re-evaluated corrective actions to address adverse events and quality deficiencies.Review of the requested facility QAPI plans and minutes for April, May, June and July 2025, did not identify a focused topic of medication errors, had not mention of medication error rates, and not evident quality activities to identify and monitor the effectiveness of the facility's pharmacy services were developed or implemented. During an interview on 8/22/25 at 4:00 p.m., interim administrator reviewed QAPI minutes from April 2025 to July 2025 and verified the quality plans did not address medication errors and should have. Facility policy, Quality Assessment and Assurance/Quality Assurance Performance Improvement (QAA/QAPI) Committee Policy and Procedure dated 11/21, identified when improvement or innovation is indicated based on outcomes and/or new information, Performance Improvement Plans (PIP's) will be chartered as needed, a Root Cause Analysis (RCA) or equivalent process will be completed when needed to define the problem or need, the QAPI team will define who is on the PIP team which will utilize the Model for Improvement process to determine what change is indicated based on the RCA findings and additional information identified, the team then proceeds with testing the change, making any necessary changes, and then designing an implementation plan and once the plan is completed a sustainability (monitoring) plan is created. The metric or process to monitor this issue will be added to the QAPI Surveillance Data and Reporting Schedule as the feedback loop for on-going monitoring.

Based on observation, interview and document review the facility failed to provide the necessary care and services in accordance with the professional standards of practice to comprehensively assess, monitor and evaluate 3 of 4 residents (R3, R1, R4) for congestive heart failure management. Findings include: R3's face sheet dated 8/12/25, identified R3 had diagnoses of heart failure (a condition where the heart does not pump blood as well as it should), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and edema (swelling).R3's care plan focus dated 8/1/25, identified R3 had a cardiac diagnosis requiring monitoring and medication/treatments. Interventions included the following: notify physician and family with any change in condition and medications per physician orders.R3's nurse practitioner (NP) note dated 8/5/25, identified a physician order to continue daily weights for 7 days until 8/12/25 and leg compression/wraps on bilateral legs: apply in the morning and take off in the evening.R3's physician orders included the following:-compression wraps to bilateral lower extremities apply in morning and take off in the evening (start date 8/5/25) -Daily weights. (start date 8/5/25 with a stop date of 8/12/25) R3's medication administration record (MAR) reviewed 8/6/25 through 8/17/25, identified a physician order for daily weights and compression wraps, however, had not been signed off on 8/6/25 and 8/11/25. During an interview on 8/11/25 at 1:11 p.m., registered nurse (RN)-G stated if a resident needs to have a daily weight, it should be done in the morning, however, R3's was not a daily weight, therefore, it had not been obtained today. RN-G stated there is a binder at the nurse's station that will tell staff which residents need to have a daily weight, and the aides will use this book to obtain them and document the weight. RN-G stated R3 had a tad bit of swelling in both of her legs when she applied her wraps, however, did not comprehensively assess R3 for congestive heart failure symptoms like edema, lungs sounds, and shortness of breath. A follow up interview at 1:39 p.m., RN-G stated the daily weight binder has not been updated since 7/30/25, and this is where she would look to see which resident gets a daily weight to be able to document in the EHR.During an interview on 8/11/25 at 1:25 p.m., nursing assistant (NA)-B stated she was unaware of binder at the nursing station to tell staff what daily weights were to be taken each day. During an interview on 8/11/25 at 2:28 p.m., registered nurse/nurse manager (NM)-A stated R3's daily weights were not always being done and if not done per physician order, then the physician should be notified which had not always been done. During an observation and interview on 8/15/25 at 10:25 a.m., R3 was seated in a recliner with both feet in a dependent (hang or dangle) position. R3 stated staff had not applied her compression wraps on her legs. R3 pulled up both of her pant legs showing her feet with slippers with no compression wraps; R3's legs were both swollen with shiny skin. At 10:27 a.m., R3's family member (FM)-C arrived to visit R3. FM-C stated he was an intensive care nurse and had been taking care of R3 while she was at home. FM-C stated R3 used compression wraps at home on her lower extremities to reduce swelling due to her congestive heart failure. FM-C stated many days when he arrived to visit R3 after lunch R3's leg wraps had not yet been wrapped in the morning like they were supposed to be and would have to ask staff to put them on. During an interview on 8/15/25 at 10:40 a.m., registered nurse (RN)-B stated R3's compression wraps were supposed to be applied at 7:00 a.m., however, had not applied R3's wraps today due to being too busy. RN-B was unable to articulate what type of assessment she would perform to evaluate for signs and symptoms of fluid overload related to congestive heart failure, nor the rationale for compression wraps, nor how she would determine if a resident's edema were worsening. RN-B further stated she had not received any formal training for edema monitoring and, I feel I could benefit from some training. During an interview on 8/11/25 at 4:06 p.m., director of nursing (DON) stated R3 did not have her weight obtained on 8/6/25 or 8/11/25 and should have been obtained.During a follow up interview on 8/15/25 at 2:52 p.m., DON stated R3's compression wraps should have been applied prior to R3 getting up for the day and signed off in the MAR, however, were not signed off on 8/6/25 and 8/11/25. DON stated that residents with heart failure and/or edema should be monitored daily for worsening edema and increased CHF symptoms but had not done consistently. DON further stated that nurses had not received any specific to edema and/or CHF monitoring. Review of the facility's Heart failure patient care policy, revised August 19, 2024, identified Heart failure is a progressive clinical condition in which one or both ventricles of the heart cannot fill with or eject blood efficiently due to a structural or functional disorder. -The role in the care of a patient with heart failure includes assessing and monitoring the patient for signs and symptoms of worsening heart failure, assisting with medication management, fluid management.-Ask the patient about the presence and severity of common heart failure symptoms, including chest pain; shortness of breath at rest and with exertion; difficulty sleeping and the number of pillows needed for positioning; the presence and description of cough, fatigue, weakness, dizziness, syncope, abdominal pain, decreased appetite or early satiety, nausea and vomiting, decreased urination during the day and increased urination at night, sudden weight gain, and swelling. Note any changes or trends in the patient's symptoms. ---Assess the patient for confusion, disorientation, and other cognitive difficulties (such as impaired memory or concentration) because decreased cardiac output may impair blood flow to the brain and affect mentation.-Obtain the patient's vital signs because tachypnea, tachycardia, hypertension, and hypotension may be signs of heart failure.-Weigh the patient in similarly weighted clothing, on the same scale, and at the same time of day that the patient normally performs daily weight measurements to ensure comparable data.-Assess the skin of the patient's extremities, and note their color and temperature, Pale, cyanotic, and cool extremities suggest poor peripheral perfusion. Assess capillary refill time in the patient's fingers and toes. Delayed capillary refill time suggests poor peripheral perfusion. Palpate the patient's peripheral pulses and note their strength on a scale from 0 (absent) to +3 (bounding) because weak or absent pulses may indicate poor peripheral perfusion. Palpate the patient's extremities for pitting edema. If edema is present, note the degree on a scale from 0 (no edema) to +4 (pitting).

Based on observation, interview, and document review the facility failed to ensure timely identification, evaluation, and treatment of a worsening skin infection for 1 of 3 residents (R1) reviewed for quality of care. This resulted in actual harm for R1 who developed a worsening infection in the wound in which necessary treatment and care were delayed. In addition, the facility failed to complete comprehensive skin assessments for non-pressure skin impairments (surgical wounds) for 3 of 3 residents (R1, R4, R5) reviewed for non-pressure (surgical incisions) skin impairments.Findings include:R1's face sheet dated 6/27/25, identified diagnoses of cellulitis (a potentially serious bacterial skin infection) of left lower limb, absence of left leg below the knee, heart failure (a condition where the heart does not pump as well as it should), and diabetes mellitus (a disease that results in too much sugar in the blood).R1's hospital after visit summary (AVS) dated 5/9/25, identified R1 had been hospitalized for a infection in left foot and had a surgical wash out and I &D (incision and drainage) where they found 5.4 millimeters (mm) of glass found in her foot along with purulent drainage (composed of pus, a thick yellowish or greenish fluid associated with infection). R1 had a magnetic resonance imaging (MRI) with no signs of osteomyelitis (bone infection). R1 had been discharged to the skilled nursing facility on oral antibiotics. R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had a surgical wound of the foot, needed maximum assistance for transfers and cognitively intact. Despite the hospital discharge summary and the admission MDS identifying the presence of a surgical wound R1's record did not include an admission skin assessment. R1's focus care plan dated 5/9/25, identified R1 had an alteration in skin integrity related to surgical incision on left foot. Interventions included: observe my site daily for signs of infection or poor healing (drainage, odor, redness, warmth at incision line and notify physician of any signs of infection.R1's physician orders for left foot incision were as follows:-5/11/25-6/9/25: Keep surgical incision clean and dry every shift.-5/12/25-5/15/25: two times a day removing packing strips x 2, cleanse foot wounds top and bottom of foot with Vashe, pack plantar and dorsal foot wound with 1/4 inch iodoform packing, cover with 4 x 4's, loosely wrapping with kerlix.-5/12/25-6/9/25: apply betadine (iodine) to incision three times per week. Review of R1's record from 5/9/25 to 5/21/25 it was not evident comprehensive wound assessments were completed and no indication consistent routine monitoring for changes was completed between 5/9/25 through 5/31/25.R1's orthopedic follow up note dated 5/15/25, identified R1 did not need additional iodoform packing required of foot wound and recommended twice dry dressing with gauze and betadine swabs on Monday, Wednesday, and Friday. R1's wound would need an expedited (quickly) workup including emergency department (ED) if systemic changes including fever/night sweats, worsening drainage, spreading erythema (redness) or foul odor from the foot. Review of R1's medical record identified the order for the dressing changed was transcribed into the record, however, revealed no evidence that the directive-to transfer R3 to the emergency department upon signs of systemic symptoms-had been documented or acknowledged. R1's nurse practitioner (NP) visit note dated 5/19/25, identified R1 expressed concern that her wound care was not being completed accurately and was tearful about this. The incorrect dressing was in place with iodosorb packing present on the top of the foot and xeroform placed over the incision to the top and bottom of the foot (instead of using betadine swab and gauze). NP informed the nurse manager and the director of nursing of the incorrect dressing. R1's Wound Evaluation assessment dated [DATE], identified R1's surgical wound on the left dorsum foot measuring 7.29 centimeters (cm) x 0.57 cm with no depth. Wound had 70% epithelial tissue (regenerating tissue), 20% slough (dead tissue), and 10% eschar (dead tissue that forms in a wound). Has light serosanguinous (fluid that contains liquid with blood) drainage. Review of R1's corresponding picture dated 5/22/25, identified nine sutures on the top of the foot with sutures not approximated (edges together). Wound base had a yellow substance at the top and bottom of the wound and a dark red area in the middle. The 3rd and 4th toe had a reddish scab like between the toes. R1's foot had swelling on the top of the foot and in the toes. Noted dark brownish skin on the left side of the wound without redness.R1's wound nurse note dated 5/22/25, identified R1 was evaluated for a wound consult for a left foot surgical incision. R1 reported recent infection and subsequent surgery on her left foot. R1 was not having pain but having itching on the central part of the incision. No signs of infection and to follow up with surgeon. To follow up on weekly wound rounds.R1's clinic internal medicine note dated 5/27/25, identified that communication had been received from the facility on 5/24/25 regarding left wound had increase in drainage, no odor but white slough in stitches. Wound cleansed per order and wrapped. Physician assistant said to follow up with in facility provider on 5/28/25. Review of R1's progress notes on 5/24/25 to 5/27/25 did not identify an expedited workup including sending R1 to the ED for increased drainage had been completed per the physician orders from 5/12/25. R1's NP nursing home visit note dated 5/28/25, identified a large piece of callused skin naturally removing from the healthy skin on the bottom of the left foot had begun to pull on the sutures on the bottom of the left foot and had become uncomfortable for R1. NP removed a small amount of devitalized material with surgical scissors. No obvious signs of infection observed. End of last week nursing noted a small amount of drainage on the gauze and over the weekend they noticed slough at the distal (situated away from the center of the body) portion of the sutures on the top of the foot. Will review with orthopedics. Review of R1's record did not identify orthopedics had been notified of the findings.R1's Wound Evaluation dated 5/29/25, identified a surgical wound on the left dorsum foot measuring 7.11 centimeters (cm) x 0.65 cm with no depth. Wound had 50 % epithelial tissue, 10% granulation (pink or red, bumpy, and moist tissue that fills in the wound bed), 20 % slough (dead tissue), and 10% eschar. Has light serosanguinous drainage. Review of the corresponding image dated 5/29/25, identified nine sutures on the top of the foot with incisional line not approximated (edges together) with open areas between the width of the sutures (consistent with dehiscence). Wound base had a yellow substance (consistent with slough) in the entire wound bed. Between the 3rd and 4th toe had an opening with a yellow substance in the base of he wound between the toes. Skin was dry and flaky on the entire foot with swelling on foot. Skin above the sutures near the ankle were dark purple in color and a brownish scab noted on the lateral side of the sutures. [AO1] R1's wound nurse note dated 5/29/25, identified R1 was seen for a wound follow up of left foot. R1 denied pain or concerns with her foot. R1 did complain of itching of foot and stated she was tender in the toe, with a lot of dry and peeling skin. Wound appeared slightly improved today. Wound plan was the following:-twice daily dressing changes. Apply gauze top and bottom of foot over incision. Wrap with Kerlix and secure with tape. Betadine swabs to surgical wound top and bottom of foot Monday/Wednesday/and Friday.-follow up with surgeon-suture removal by surgeon-recommend applying lotion to dry skin daily.R1's progress note dated 5/31/25, identified R1 was sent to the emergency department (ED) for evaluation of suspected infected surgical site of left lower extremity. R1 had swelling and purulent drainage from the surgical incision.R1's hospital admission note dated 5/31/25, identified R1 admitted to the hospital after being seen in the ED for evaluation and treatment of a recurrent left foot infection with progressive drainage, pain, and dehiscence (splitting or bursting open) over the past several days. Computed tomography (CT) scan showed increased gas and fluid collection along the dorsum (top) of the left foot now extending into more laterally and further into the 3rd and 4th toe metatarsophalangeal (joints located in the forefoot) joints. R1 stated her foot became more erythemic (reddened), more swollen, and had some dehiscence after stopping antibiotics a week ago.R1's hospital orthopedic trauma surgery consult note dated 5/31/25, identified R1 was seen in the emergency department (ED) with an apparent recurrent infection in her left foot. R1foot wound showed dehiscence of the distal incision as well as spreading erythema and purulent drainage. R1 reported in the ED that the incision started looking worse over the past few days with increasing drainage. R1's hospital Discharge summary dated [DATE], identified R1 was hospitalized for ongoing treatment of an recurrent left foot infection. R1 was given intravenous (IV) antibiotics and had an (MRI) of the left foot which revealed a dorsal abscess with osteomyelitis (bone infection) and ultimately had a below the knee amputation of the left leg on 6/4/25. R1 was discharged back to the skilled nursing facility on 6/9/25.During an interview on 6/25/25 at 12:32 p.m., licensed practical nurse (LPN)-A stated when she performed R1's left foot wound care on 5/30/25, R1's foot it looked infected. LPN-A stated she then brought registered nurse (RN)-A to evaluate R1's foot and RN-A told her R1's foot had been seen by the nurse practitioner the day prior and the wound appeared the same. LPN-A did not look at the notes or the image of R1's foot that had been taken the day prior. LPN-A then used the facility phone and took an image of R1's left foot, because she believed R1's foot looked terrible. LPN-A stated she did not notify the nurse managers, primary physician, or orthopedics of her concern for infection. LPN-A waited until she returned to work the next day and then proceeded to send the image of R1's foot to facility nurse managers and then was instructed by management to send R1 to the ED. LPN-A was not aware of an order for R1 to send her to the ED if the wound had appeared worse and no order was in the electronic health record to her knowledge.During an interview and observation on 6/25/25 at 12:30 p.m., LPN-B explained nurses had an incident phone to communicate to management about any concerns during their shifts. LPN-B obtained the incident phone and identified two images were on the phone of R1's foot with a date of 5/30/25 at 1:16pm. The corresponding images of R1's left foot had a surgical incision on the bottom of the foot near the 4th toe with 3 sutures that had dark blackish spot underneath the sutures, under the 4th toe there was a circular shaped area with yellowish material in the center and another area with toes swollen and reddened. 9 sutures on the top of the foot which appeared to be not holding the skin together-inside the wound had a thick yellow-pus like material. The skin surrounding the wound appeared shiny, red, and swollen. In between the 3rd and 4th toe was thick yellowish material. LPN-B further stated the wound appeared like it had drastic change from the last time she had seen it and was taken by the nurse due to a concern for infection. During an interview on 6/25/25 at 3:17 p.m., registered nurse (RN)-A stated she observed R1's left foot on 5/30/25 with LPN-A. RN-A explained she thought the foot looked the same, however the night shift had to change R1's dressing due to it being saturated. RN-A did not document her evaluation of R1's wound in her chart or call the physician to update on the increase drainage and was not aware of the recommendation from the orthopedic appointment on 5/15/25 to send R1 to the ED if increase drainage. RN-A stated it would be normal standard of practice for a nurse to communicate to the provider a change in the condition of a surgical wound and would not need to have an order in the chart to give us direction, however, did not think the wound appeared worse when she looked at the wound on 5/30/25. During an interview on 6/27/25, registered nurse (RN)-C observed the wound images of R1's left foot that had been taken on 5/29/25 and 5/30/25. RN-C stated left foot appeared definitely worse on 5/30/25. RN-C stated she would have notified the physician right away and sent R1 into the ED for evaluationDuring an interview on 6/24/25 at 4:06 p.m., R1 stated a nurse had taken a picture of her left foot a few days prior to her being sent to the hospital because she felt her wound looking infected, and by the time she was sent to the ED the infection had went to the bone and needed to have an amputation. The first nurse thought her foot was infected, she brought a second nurse to come and look at her foot and she stated it looked fine. R1 stated she was so glad the pictures were sent to management, and she was sent to the ED. R1 further stated, the nurse that took them the pictures, Basically saved my life. During an interview on 6/27/25 at 11:18 a.m., nurse practitioner (NP) reviewed R1's images of her left foot taken on 5/29/25 and again on 5/30/25 and stated the wound appeared to be worse on 5/30/25 and staff should have made provider notification on 5/30/25 and not waited until 5/31/25, however it would have not changed the outcome of her having the amputation due to her diabetes and the extent of infection she had in her foot. During an interview on 6/25/25 at 1:09 p.m., director of nursing (DON) stated the director of nursing at the time on 5/31/25 directed LPN-A to send R1 to the ED after first seeing the photo. In a follow up interview at 6:18 p.m., DON stated if she had been aware of R1's foot looking infected on 5/30/25 she would have had the nurse send her into the ED on that day. DON further stated it is a standard of practice for a nurse to notify the physician if they feel a wound appeared worse to get direction from the provider and confirmed that this was not done until 5/31/25 when she was sent into the ED for evaluation.R4's face sheet dated 6/27/25, identified diagnoses of end stage renal disease, immunodeficiency, diabetes mellitus, and kidney transplant.R4's hospital Discharge summary dated [DATE], identified R4 had been hospitalized from [DATE] to 6/2/25 after having sustained an injury to his right lower extremity after hitting his leg on his scooter. and has a significant right lower extremity hematoma (a localized collection of blood outside of the blood vessels) which needed to be evacuated (a surgical procedure to remove) on 5/11/25. necrotic tissue and fat removed. R4 had subsequent surgical debridement (a medical procedure to remove dead, damaged, or infected tissue from a wound to promote healing) on 5/12, 5/16/25, and 5/22/25. R4 was discharged to the facility on 6/2/25.R4's hospital after visit summary dated 6/2/25, identified R4 had a wound on his right lower extremity and the beefy red tissue to be covered with a saline moistened gauze and then covered with an ABD and then gauze roll to hold dressing in place.R4's nurse practitioner note dated 6/4/25, identified wound orders changed to the following: cleanse with normal saline, pat dry, cover entire area of debridement (fascia and granulation tissue) with double layer xeroform gauze, cover with one to three layers of ABD for absorption, securing with gauze and paper tape. R4's Wound Evaluation dated 6/5/25, identified a surgical wound on front right lower leg that was present on admission. Wound measured 27.65 cm x 7.21 cm, with 60% granulation, and 40% slough. Wound had heavy bloody drainage. Review of R4's record from 6/6/25 to 6/25/25 did not identify any comprehensive weekly wound assessments had been completed. R4's trauma surgery follow-up note dated 6/16/25, identified R4's right lower leg wound had progressed quite well and the facility should continue to monitor the wound for signs of infection, which would include fever, chills, nausea, vomiting, purulent drainage, expanding redness from the wound, or increased or new abdominal pain. The new order was to place xeroform over the exposed fascia (connective tissue) and moist to dry dressings to the remainder of the wound bed twice daily. R4's nurse practitioner note dated 6/18/25, identified right lower leg stable with increase in pain in recent days. R4 described the pain as burning or poking pain. Pain medication added every six hours as needed. Note identified R4 was seen two days prior by general surgery and wanted wound care orders to be adjusted and she will follow up for clarification.During an interview on 6/25/25 at 3:30 p.m., licensed practical nurse (LPN)-B stated R4 did not have consistent weekly wound evaluations done by the wound nurse practitioner due to him being out for dialysis appointments on the days she came to look at the wounds. LPN-B was not aware if another nurse in the facility had been assigned to complete the weekly wound assessments if the wound nurse was not able to see the residents on her rounds.During an observation and interview on 6/25/25 at 5:44 p.m., R4 was lying in bed and registered nurse (RN)-B was performing wound care. R4's right lower had a white gauze dressing in place, the dressing had moderate amount of wet liquid with a no color. When the dressing was removed another dressing was covering the wound, upon removal, it was noted to have moderate amount of clear liquid. R4 denied pain with the dressing removal. The wound was irregular in shape. Noted area of beefy red skin in the wound with clean edges and without discoloration. At the 12 o'clock position there was a white area approximately 4.0 cm in diameter. This area had a yellowish mesh, which RN-B called xeroform. that had been covering the wound. R4 stated his wound is healing slowly due to his immune system being impaired, but it looked better. Wound was measured and 25.0 cm x 11.0 cm per RN-B, and stated the wound looks better than since the last time she had seen it. Review of R4's progress notes on 6/26/25, did not identify any documentation of the wound evaluation completed on 6/25/25.During an interview on 6/26/25 at 12:01 p.m., wound nurse practitioner (WNP) stated R4's wound had not consistently been evaluated each week due to R4 being out of the facility on the days she came to the facility. WNP was unsure whether other staff in the facility had been trained to use the skin and wound application to do the weekly assessment if she missed seeing a resident. WNP further stated the purpose of a weekly wound assessment of a resident's wounds would be to track and to monitor healing and inform the physician if the wound was not healing to possibly change the treatment of the wound. WNP further stated the lack of comprehensive wound assessments being consistently completed could put a resident at risk for a worsening wound. During an interview on 6/26/25 at 3:30 p.m., director of nursing (DON) stated that they utilize a wound nurse to come and do the weekly comprehensive wound assessments and she uses the wound application in the electronic health record (EHR). The DON indicated wound assessments had not been completed consistently because staff nurses were not trained on completing wound assessments in the absence of the contracted wound practitioner. DON stated the weekly comprehensive wound assessments are important to evaluate the healing of a wound and without having them done consistently it could lead to a deterioration in a wound, an infection could be missed and could cause an increased risk of serious complications.R5's face sheet dated 6/27/25, identified diagnoses of joint replacement surgery, obesity (excessive body fat), and chronic kidney disease (damage to the kidneys).R5's hospital Discharge summary dated [DATE], identified R5 had been hospitalized to perform a left hip arthroplasty (replacement) due to an infection and inflammatory reaction of the left hip prosthesis. R5 was discharged to the skilled nursing facility on 6/16/25.R5's hospital After Visit Summary dated 6/16/25, identified R5 had a wound vac (a medical device used to help wounds heal) and was to be left on for one week after surgery. R5's physician orders identified a wound vac over the incision and was discontinued on 6/18/25. Review of R5's chart from 6/16/25 to 6/25/25 did not identify a comprehensive wound assessment had been completed on the surgical wound. R5's progress note dated 6/25/25, identified surgery team notified of drainage to the distal (situated away from the center of the body) part of the surgical wound and strong odor noticed. R5's record did not identify a wound evaluation was completed on 6/25/25.R5's Skin and Wound Evaluation dated 6/26/25, identified a surgical wound located at the left front trochanter (hip) that was present on admission. Wound measured 37.90 cm x 1.80 cm x 0.1 cm Noted light serosanguinous drainage. Area marked as a new wound.R5's progress note dated 6/26/25, identified surgery team will see R1 on 6/27/25 for labs and in clinic visit to evaluate wound.R5's orthopedic surgery note dated 6/27/25, identified that wound appeared normal for this stage of surgery and continued oral antibiotics for two more weeks.During an interview on 6/26/25 at 5:40 p.m., medical director (MD)-H stated her expectation would be for the facility to document a weekly wound assessment for all wounds to track and monitor healing and allows them to look for changes in the wound and is needed to avoid the risk of the wound becoming worse.Review of the facility's Notification of Changes policy dated 12/16, identified immediate notification of the resident; consult with the resident's physician is to be done in the following situations:-A significant change in the resident's physical, mental, or psychosocial status including a deterioration in the health, mental, cognition, medication change, or psychosocial status in either life-threatening conditions or clinical complications.Review of the facility's Wound Assessment Protocol dated 2/24/25, identified comprehensive wound assessment is necessary during every dressing change. Comparing the assessment results to the previous findings helps monitor, communicate, treat, and document wound healing progression or complications. Documentation associated with wound assessment included:-date and time of the wound assessment.-general appearance of the skin and bony prominences-location, size, and appearance of the wound site-presence or absence of

Based on interview and document review the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee identified, investigated, analyzed, and responded to wound assessments not being completed by developing and implementing action plans for process improvement. This had the potential to affect all 36 residents that resident in the facility. Findings include:See F684: Based on observation, interview, and document review the facility failed to ensure timely identification, evaluation, and treatment of a worsening skin infection for 1 of 3 residents (R1) reviewed for quality of care. This resulted in actual harm for R1 who developed a worsening infection in the wound that delayed treatment and care. In addition, the facility failed to complete comprehensive skin assessments for non-pressure skin impairments (surgical wounds) for 3 of 3 residents (R1, R4, R5) reviewed for non-pressure (surgical incisions) skin impairments.During the facility resident record review on 6/25/25 for resident sample selection revealed from 5/9/25 to 6/25/25, the facility had three residents that did not have consistent wound evaluation assessments completed on surgical wounds. Review of R1's record from 5/9/25 to 5/21/25 did not identify a comprehensive wound assessment had been completed for a surgical wound on her left foot.Review of R4's record from 6/6/25 to 6/25/25, identified there was a wound assessment completed on 6/5/25, however was not completed again until 6/26/25.Review of R5's record from 6/16/25 to 6/25/25 did not identify a comprehensive wound assessment had been completed on the surgical wound. A copy of the facility's current quality action plans was received on 6/30/25, and did not identify any plan for assessing or monitoring of skin related issues.During an interview on 6/27/25 at 12:19 p.m., director of nursing (DON) stated prior to the beginning of the survey, a few weeks ago (but could specify a date), she had been informed by the certified wound nurse practitioner that wound assessments had not been completed consistently on the residents with current wounds. DON stated she had not brought the practitioner's concerns forward to the quality team nor did she create an action plan to address the issue. DON further stated, the quality team met on 6/26/25 (during the survey) to discuss the concerns with the facility's wound management program and were currently working on a plan to correct. The quality team had been monitoring pressure related skin issues, however, DON indicated non-pressure related skin concerns were not being addressed and would be monitoring those concerns at the next quality meeting. Review of the facility's Quality Assessment and Assurance/Quality Assurance Performance Improvement (QAA/QAPI) Committee Policy and Procedure dated 11/21, identified the following:-When improvement or innovation is indicated based on outcomes and/or new information, Performance Improvement Plans (PIP's) will be chartered as needed. -A Root Cause Analysis (RCA) or equivalent process will be completed when needed to define the problem or need.-The QAPI team will define who is on the PIP team which will utilize the Model for Improvement process to determine what change is indicated based on the RCA findings and additional information identified.-The team then proceeds with testing the change, making any necessary changes, and then designing an implementation plan.-Once the plan is completed a sustainability (monitoring) plan is created. The metric or process to monitor this issue will be added to the QAPI Surveillance Data and Reporting Schedule as the feedback loop for on-going monitoring.

Based on interview, observation, and document review, the facility failed to follow physician orders, complete assessments, monitor or input appropriate interventions and recognize changes in condition, for 6 of 6 residents (R31, R201, R21, R194, R6, R18) reviewed for quality of care. As a result of the facility's failures, an immediate jeopardy (IJ) situation was identified for R31 who had displayed respiratory distress with labored breathing, increased anxiety and required additional medication, R201 who had displayed signs of a UTI and was transferred to the ER for treatment, R21 who had displayed signs of a urinary tract infection (UTI) and was transferred to the hospital ER for treatment. The immediate jeopardy began on 4/12/25, when R31's daily weight were not completed as ordered and facility was not monitoring, which led to R31's respiratory distress, and failed to identify, monitor and assess R201 and R21 for change of condition related to blood in the catheters led to kidney/bladder infections. The administrator, assistant administrator, director of nursing (DON), regional vice president was notified of the immediate jeopardy at 5:47 p.m. on 4/18/25. The immediate jeopardy was removed on 4/21/25 at 1:07 p.m., but noncompliance remained at the lower scope and severity level of G - isolated, scope and severity level, which indicated actual harm that is not immediate jeopardy. Findings include: R31 was admitted on [DATE] and admission Minimum Data Set (MDS) assessment dated [DATE], identified the MDS was In progress with no information completed. R31's electronic medical record (EMR), included diagnoses of chronic obstructive pulmonary disease (COPD) with acute exacerbation, acute and chronic respiratory failure with hypercapnia (increased levels of carbon dioxide in the blood) and hypoxia (insufficient oxygen at the tissue level), Cor pulmonale (enlargement and failure of the right ventricle of the heart as a response to increased vascular resistance or high blood pressure in the lungs), essential hypertension, anxiety disorder, shortness of breath, and was dependent on supplemental oxygen. R31's physician orders, dated 4/11/25, included the following: Oxygen via nasal cannula 2 L/min (liters per minute) at rest while awake, 4 L via nasal cannula with exercise or activity and 2 L via BiPAP when BiPAP is on; and daily fasting weight for edema and to notify the provider of a two (2) pound weight gain in two days or five (5) pound gain in seven days. Lasix 20 mg (milligrams) daily for edema. R31's post hospital follow up visit note dated 4/11/25, nurse practitioner (NP), indicated R31 had presented to theER on [DATE] for shortness of breath and was found to be in hypoxic respiratory failure, and tachypneic (abnormally rapid and shallow breathing). R31's was admitted to the intensive care on 3/28/25 to 4/3/25 and was treated for volume overload, pneumonia, and COPD exacerbation. While in the Intensive Care Unit (ICU), R31 was aggressively diuressed (the excretion of a large amount of fluid). R31 required supplemental oxygen via nasal cannula 2 L at rest while awake, 4 L via nasal cannula with exercise or activity and 2 L via BiPAP while sleeping and medications. NP continued the current order of Lasix 20 milligrams (mg) daily and asked nursing to complete daily standing fasting weights and to notify provider of weight gain of two (2) pounds in two (2) days or five pounds in seven days and will follow up the following week to determine dry weight goal. R31's care plan dated 4/11/25, included R31 respiratory diagnosis with abnormal lung sound and shortness of breath. Interventions were identified to administer medications as prescribed by physician, give nebulizer treatment and oxygen therapy as ordered, and to notify physician if increased coughing occurs. The care plan also indicated R31 was at nutritional risk related to diagnoses of COPD, respiratory failure, oxygen dependence, altered skin integrity and recent weight loss with low body weight. Interventions were identified to observe changes in weight and to notify physician. R31's daily weight record from 4/11/25 to 4/18/25 revealed R31 had not been weighed 6 of the 7 days: -4/11/25, wt. (weight) 142.56 lbs. -4/12/25, wt. not taken -4/13/25, wt. not taken -4/14/25, wt. not taken -4/15/25, wt. not taken -4/16/25, wt. not taken -4/17/25, wt. not taken -4/18/25, wt. not taken During observation on 4/16/25 at 10:42 a.m., R31 was sitting in his room with oxygen on. R31 was observed to have labored breathing. During observation on 4/18/25 at 11:32 a.m., R31 was laying in bed with oxygen on. R31 was observed to have labored breathing. During interview on 4/17/25 at 11:57 a.m., registered nurse (RN)-A stated residents who have an order for daily weights should have their weight obtained in the morning before breakfast. RN-A stated any staff can obtain a weight and document the weight in the electronic medical record (EMR). RN-A said whoever obtains the weight are responsible for charting it. During interview on 4/18/25 at 12:09 a.m., NP stated R31 was extremely complicated and fragile. NP stated R31 was experiencing labored breathing, had diminished lung sounds and was on the incorrect oxygen setting while lying in bed during the visit. NP stated R31's oxygen orders were for two liters at rest although was found to be set at four liters while lying in bed. NP stated she had wanted R31 to go to the ER for evaluation although R31 refused. NP stated she had also offered R31 Dilaudid (medication that reduces respiratory rate and reduces breathing difficulties) to help with his breathing and hydroxyzine for anxiety, NP indicated R31 refused. NP stated she was not sure if the Lasix (newly added medication from hospital) was effective or if R31 was having fluid buildup because she did not know what R31's weights were due to facility not following orders to obtain daily weights. NP stated she expected facility to obtain daily weight and to record them and follow any parameters in order to initiate interventions/treatments to help prevent resident from fluid buildup which can make breathing difficult. R31's weight obtained per NP on 4/18/25, was 156.6 lbs, a 14.1 pound increase. During a follow up interview on 4/18/25 at 3:11 p.m., NP stated R31 had slightly improved from the first visit and an action plan was made with R31 and R31's son. NP stated she obtained R31's weight today of ~157 pounds. NP stated R31's dismissal weight from the hospital was 142 pounds. R31 had a 14.4-pound weight gain in the past week. NP stated she was going to increase R31's Lasix. NP stated she felt like R31 could have been in respiratory failure this morning upon her initial assessment. NP stated oxygen orders were not initiated or started over the weekend from 4/11/25 (date of admission) to 4/14/25 and staff were administering the oxygen at whatever liter per minute R31 told them to put it on or whatever they felt was appropriate. NP stated son was very concerned as he noted a change in R31's breathing over the weekend. NP stated she notified the facility of this and that is when the facility initiated and entered the oxygen orders in R31's EMR. NP stated she expected staff to obtain a full set of vitals on residents every day to monitor for any changes in condition. During interview on 4/18/25 at 3:22 p.m., occupational therapist (OT) stated R31 had slowed down while in therapy over the past couple of days and did not have therapy today due to the NP holding therapy services until further notice. During interview on 4/17/25 at 12:03 p.m., licensed practical nurse (LPN)-G stated if there was a change in condition with a resident, she would notify the charge nurse, or the provider and document change in a progress note in the resident's chart. LPN-G stated if a resident had an order for daily weights, it would be reflected on the medication/treatment administration record. LPN-G stated the nursing assistants (NA)'s obtain the weight and would notify a nurse with weight results, who would then document weight in the EMR. LPN-G stated there is not a good system in place regarding weights as weights are missed. LPN-G reviewed R31's chart and confirmed R31 had an order for fasting daily weights and the last recorded weight was on 4/11/25. LPN-G stated it was important to get the daily weights on R31 due to his fragile health concerns and that the provider needed to be notified of any weight change to allow for immediate intervention to be done. During interview on 4/17/25 at 3:02 p.m., RN-C stated when a resident has an order for daily weights, she obtains the daily weight as it is needed and important due to condition and respiratory failure. During interview on 4/18/25 at 2:44 p.m., LPN-A stated the NA's obtain the daily weights but if the nurse noticed it was not completed the nurse should obtain the weight. LPN-A stated daily weights should be done by 10:00-10:30 a.m. but could be delayed due to other factors that may arise. NA's know what weights to be obtained by looking in the EMR under their tasks. LPN-A stated if a daily weight does not get done then she would expect that resident to be the first one obtained the following day. During interview on 4/18/25 at 2:47 a.m., NA-B stated the nurse lets her know and she would write down which residents need weights. Once she got the weight, she would then give it to the nurse who would document. During interview on 4/18/25 at 3:11 p.m., NA-C stated the nurse gives her a paper log at the beginning of the shift, which is where she would write the weights on it and would return it to the nurse to document at the end of the shift. During interview on 4/17/25 at 2:00 p.m., director of nursing (DON) stated the admissions nurse, health unit coordinator (HUC), nurse manager and herself are responsible for processing and entering orders. DON stated the floor nurses are allowed to process orders if order was received after hours. DON stated all orders are verified by another nurse to ensure it was correct. During a follow-up interview on 4/18/25 at 4:25 p.m., DON stated daily weights are to be completed in the morning and if there are parameters in place for a resident and the weight is outside the parameter, she would expect staff to notify the provider of any change. DON confirmed R31 had an order, with parameters for fasting daily weights and the order was not followed. DON stated daily weights are important to be done for a person with any cardiac issues in order to identify immediately. DON confirmed the oxygen order was received on 4/11/25 although was not entered until 4/14/25. R201 R201's was admitted on [DATE] and admission MDS assessment dated [DATE], identified the MDS was In progress with no information completed. R201's EMR, included diagnoses of acute pyelonephritis (kidney infection), urinary tract infections, and chronic kidney disease (stage 4). R201's physician orders, dated 4/11/25, included the following: right nephrostomy (tube inserted into the kidney to drain urine directly into a collection bag outside the body) site care - cleanse with normal saline daily, pat dry and cover with split gauze and paper tape daily every evening shift. R201's care plan dated 4/7/25, indicated R201 had altered elimination and would need treatment/monitoring/cares due to weakness and immobility. Interventions identified R201 had a nephrostomy. Care plan also indicated R201 had an alteration in skin integrity related to surgical incision. Intervention identified staff to observe site daily for signs of infection or poor healing: drainage, odor, redness, warmth of incision line and to notify physician of any signs of infection. The care plan lacked location of surgical incision. During observation and interview on 4/14/25 at 6:28 p.m., R201's nephrostomy bag contained dark red urine. R201 stated she was informed by staff she had an episode this morning where R201 became unresponsive and lethargic. During observation on 4/15/25 at 11:27 a.m., R201 just returned from therapy and nephrostomy bag contained dark red urine. During observation on 4/16/25 at 8:49 a.m., R201 was lying in bed with nephrostomy bag with dark red urine present. R201's EMR lacked documentation of monitoring of urine output (change in urine color), nor notification to provider of any changes in condition. During interview on 4/14/25 at 6:44 p.m., R201's family member (FM-B) stated they were not notified of an event related to unresponsiveness and when she went to the nursing station to inquire about the event, FM-B was told that R201 went unresponsive for a few seconds, was ashen (pale gray color) in color and was lethargic following event. During interview on 4/14/25 at 6:47 p.m., RN-C stated she was told in report R201 was hard to wake up that morning and became lethargic. RN-C confirmed there was no documentation in R201's EMR regarding event. R201's progress note, dated 4/16/25 at 4:16 p.m., indicated R201 was sent to ER by provider for further evaluation. During interview on 4/17/25 at 9:26 a.m., FM-B stated when the NP came to R201's room for a regular visit, during her assessment she noticed the urine in R201's nephrostomy bag was red. NP recommended R201 be sent to the ER for further evaluation. FM-B stated R201 had been hospitalized for a kidney and bladder infection and was having a stent exchanged in the morning. During interview on 4/17/25 at 11:57 a.m., registered nurse (RN)-A stated standard catheter, nephrostomy care consisted of ensuring urine is flowing appropriately and monitoring the amount and color of the urine. RN-A stated if there was something abnormal, she would document in the EMR and notify the provider. RN-A stated she did not receive a lot of training on nephrostomies and had only one observation of a nephrostomy. During interview on 4/17/25 at 12:03 p.m., licensed practical nurse (LPN)-G stated NA's empty nephrostomy bag and would notify her of any changes or concerns such as flowing of urine, dark colored urine. LPN-G stated she would notify the charge nurse and would encourage resident to drink more fluids. LPN-G stated she would assess urine for odor, assess resident for change in cognition and would monitor. LPN-G stated she would document abnormal findings in a progress note. LPN-G stated nephrostomy bag is emptied once to twice per shift. LPN-G stated she had not received any training regarding nephrostomies. During interview on 4/17/25 at 2:00 p.m., DON stated if there was a skill, task, or diagnosis not cared for in the facility, we would complete in person training for staff. DON stated the admission nurse would inform the DON prior to admission with what cares may need training on. This will allow the facility to initiate education ahead of time. During interview on 4/17/25 at 2:26 p.m., RN-D stated there were no specific training related to nephrostomies. During interview on 4/17/25 at 3:02 p.m., RN-C stated NA's empty R201's nephrostomy bag and write down the urine output which she would then document in the EMR. RN-C stated NAs notify her of any changes. RN-C stated she would go and assess the abnormality (such as blood in the bag) and would call the provider to obtain an order. RN-C stated she was not notified of the dark red urine in R201's nephrostomy bag by any NA's. During a follow up interview on 4/18/25 at 11:40 a.m., DON stated if a resident is suspected to have a UTI or is displaying symptoms of a UTI, she would expect staff to monitor vital signs and symptoms, update the provider, increase fluids, enter progress note with information and initiate a nursing order on the MAR (medication administration record) for monitoring. During interview on 4/18/25 at 12:03 p.m., NP confirmed she was not notified R201's urine output was red. NP stated when she went to check in on R201 on 4/16/25, she had noticed red urine and had staff send R201 to the ER for further evaluation. NP confirmed when the resident previously had blood in her urine, it was an indication of a kidney, bladder infection. NP confirmed if she had been notified, she may have been able to prevent the visit to the emergency room by ordering a urine test to test for infection. During interview on 4/18/25 at 2:47 p.m., NA-B stated she emptied nephrostomy/catheter bags in the beginning of her shift and again at the end of her shift, document the amount drained. NA-B stated if she noticed a change in the urine, such as blood, she would let the nurse know immediately. During interview on 4/18/25 at 4:25 p.m., DON stated she expected there to be an order to obtain and monitor output for a resident with a nephrostomy/catheter. DON stated monitoring should consist of checking for redness around the insertion site, urine output and characteristics of the output, and any signs of drainage. DON stated she would expect staff to notify the provider immediately of any changes. DON stated staff should have notified the provider immediately when blood was noticed for direction from the doctor on what to do. DON confirmed there was no documentation of notification to the provider regarding dark red urine. 51379 R21 R21's MDS assessment dated [DATE], indicated intact cognition. R21 had a functional impairment of both lower extremities. R21 required substantial assistance with toileting and hygiene. R21 had an indwelling catheter requiring substantial assistance for care. R21's medical diagnosis included benign prostatic hyperplasia (overgrowth of cells causing organ enlargement) with lower urinary tract symptoms causing urinary retention. This diagnosis is further complicated by obstructive and reflux uropathy (blockage preventing urine from flowing normally). R21's care plan for Foley Catheter dated 9/13/23 included R21 will be free of signs and symptoms of urinary tract infections, will receive catheter cares per order, have catheter emptied every shift, monitor and record output every shift, and monitor/record/request/report to provider change in amount, color, consistency, or odor. R21's physician orders include catheter change every month on the 11th, routine catheter care twice daily, change urinary drainage bag once a week on Mondays, and flush catheter with 30 ml (milliliters) of normal saline every shift as needed. During observation on 4/14/25 at 1:49 p.m., R21 had a leg bag for catheter drainage of urine. The drainage in the leg bag was red in color and filled approximately three quarters of the leg bag. R21 stated he was not in pain, did not recall if the drainage was new, and was unsure when staff had changed the catheter or the drainage bag. During observation on 4/14/25 at 6:09 p.m., R21 continued to have dark red urine in the catheter leg bag. R21's progress note dated on 4/15/2025 at 7:20 a.m., indicated R21 had approximately 600 ml's of blood in his urinary leg bag. The progress note lacked indication if staff notified a provider about the amount or color of the drainage in the urinary leg bag. R21's TAR indicated R21 had routine catheter care performed twice a day for the last seven days. R21's progress note dated on 4/15/2025 at 4:15 p.m., indicated R21 was sent to the emergency department and his son was notified. R21 returned to the facility after emergent evaluation; was diagnosed with a urinary tract infection and started on an oral antibiotic. During interview on 4/17/25 at 11:57 a.m., registered nurse (RN)-A could not state what routine catheter care entailed. RN-A stated she just looked to make sure the catheter was still flowing, what the output looked like, and if the catheter might need to be flushed. RN-A stated she charts the amount of urine output, not the characteristics. RN-A stated if the urine looked abnormal, such as redness, she would enter a progress note and notify the provider via a situation/background/assessment/recommendation (SBAR) note. RN-A confirmed a progress note and SBAR notification was not charted for R21. During an interview on 4/16/25 at 10:33 a.m., the nurse practitioner (NP)-A indicated an unawareness of R21's output included blood. NP-A confirmed when the resident previously had blood in his urine, it was an indication of a urinary tract infection. NP-A confirmed if she had been notified, she would have been able to help prevent the visit to the emergency room by ordering a urine test to test for infection and would start oral antibiotics. During interview on 4/16/2025 at 12:48 p.m., director of nursing (DON) identified the facility charting does not have a location to document urine characteristics such as color, clarity, and odor. The DON indicated if a provider was notified about a change the staff are expected to input a progress note. The DON confirmed staff communicate these components of urine output via word of mouth or a progress note. DON identified a progress note of R21's urine characteristics dated 4/15/2025 at 7:20 a.m., although DON would have expected a progress note of R21's urine characteristics and notification to the provider when the blood was identified on 4/14/25. The Immediate Jeopardy was removed on 4/21/25, at 1:07 p.m. when it was determined the facility provided re-education and competency testing to licensed nursing staff on the facility's policies/procedures pertaining to change of condition, notification of changes, physician's orders, congestive heart failure, nephrostomy, COPD and catheters to include standards of documentation. In addition, the facility developed and implemented an auditing system for monitoring. R194 R194's admission Minimum Data Set (MDS) assessment was not completed in full at time of survey. R194's cognitive function was noted to be intact. R194 admitted on [DATE], following surgical repair of spinal stenosis (condition that narrows the space in the spine, putting pressure on the spinal cord or nerves). R194 diagnosis included atrial fibrillation (irregular heart rhythm), early ventricular depolarization (electrical signal in the heart come from lower chambers instead of upper chambers), atherosclerosis of the aorta (plaque buildup in the heart), bilateral carotid artery stenosis (partial or full blockage of the carotid artery located on each side of the neck), and hypertensive heart disease (develops due to prolonged high blood pressure, causing heart failure and abnormal heart muscle thickening). R194's care plan dated 3/28/25, identified a cardiac diagnosis and a pacemaker requiring monitoring, medications, and treatments. R194 care plan did not include person-centered interventions. R194's admission medication orders on 3/28/25 included amiodarone 200 mg each morning (used for irregular heart rate), metoprolol tartrate 75 mg twice per day (used for irregular heart rate and high blood pressure), apixaban 5 mg twice per day (used as a blood thinner), nitroglycerin 0.4 mg sublingual tablet every 5 minutes for 4 doses as needed (used for acute chest pain), and torsemide 10 mg every morning (used to treat fluid retention). During an interview on 4/14/25 at 1:47 p.m., R194 stated he fell earlier this morning due to low blood pressure (a condition called hypotension). R194 stated he started to feel dizzy in physical therapy (PT) and the physical therapist was assisting him back to his room. R194 stated he felt dizzy and thinks he might have passed out in the hall on his way back to his room. R194 stated he had been given all his normally scheduled cardiac medications. R194's medication administration record (MAR) identified R194 was administered his scheduled medications. R194's blood pressure summary indicated he had not had his blood pressure (BP) checked before administering the cardiac medications. R194's fall report dated 4/14/25 at 10:45 a.m., included vital signs of a BP result of 83/40, heart rate (HR) of 83, and an oxygen saturation of 89%. At 11:09 am., upon returning to his room BP was 115/49. R194's post fall progress note dated 4/14/25 at 11:30 a.m., read the appropriate staff were notified, provider and family. R194's follow-up blood pressure was not documented until 4/14/25 at 5:06 p.m., with results being 123/52. R194 vital signs dated 4/15/25 at 10:56 a.m., included a BP of 86/64, a subsequent BP at 10:57 a.m., was noted to be 69/33. During an interview on 4/15/25 at 11:11 a.m., R194 was in his room with his wife and stated he was at PT this morning when he became dizzy again and not able to complete PT. The results of his BP was low and R194 was returned to his room. R194 stated he had been given his normally scheduled BP medications this morning and indicated the staff did not take his blood pressure prior to administering the medications. R194 and his wife were uncertain whether the provider had been notified of R194's recent low BP's. During an interview on 4/15/25 at 11:20 a.m., registered nurse (RN)-A said staff would need an order to check a BP, blood sugar, or oxygen level before administering some medications. RN-A indicated she was aware R194 had an episode of low BP the previous day. RN-A confirmed she did not check the BP prior to giving the scheduled medications this morning. RN-A indicated some of the medications given could potentially have lower 194's BP. RN-A confirmed she did not check R194's BP due to the last results were with in normal range and because there was no order to check vital signs prior to administering medications. RN-A stated she would hold a BP medication if the systolic (first number) BP was less than 90. RN-A stated she would hold a BP medication if the resident was experiencing symptoms such as dizziness, weakness, or falling. RN-A stated she would call an ambulance if the BP was less than 80 and the resident had symptoms of dizziness, weakness, or falling. RN-A confirmed the resident had a BP less than 80 and he has had episodes of dizziness and falling. RN-A stated she had notified licensed practical nurse (LPN)-B (position as a nurse manager) about R194's low BP from this morning. RN-A stated LPN-B would fill out a situation background assessment recommendation (SBAR) report and send to the provider. RN-A reviewed R194's vitals and verified last charted BP was 69/33. During interview on 4/15/25 at 11:35 a.m., physical therapist (PT)-A stated she worked with R194 on 4/14/25 and today (4/15/25). PT-A stated today they were monitoring R194's BP closely. At approximately 10:50 a.m., R194's BP was within normal limits while on the stationary bike, however, when he sat down in a regular chair, he stated he felt like his BP was low again. PT-A stated she called the nursing staff who assisted R194 back to his room. During observation on 4/15/25 at 11:48 a.m., R194 was seated in his room, leaning towards the left; his appearance pale and R194 stated when he gets up, he has a lot of pressure in his head. During observation and interview on 4/15/25 at 1:02 p.m., R194 confirmed he has not had his BP checked since he returned from therapy. He stated he is feeling ok, although felt his BP was still low. R194 confirmed he had not seen a provider. During observation and interview on 4/15/25 at 1:07 p.m., RN-A confirmed there was no follow up BP checks after R194's last results were 69/33 and had not been directed by a physician to retake. Surveyor encouraged RN-A to verify R194's BP, taken manually the results were 120/72. RN-A confirmed she had not heard back from the provider and had not attempted to reach out to the provider regarding the recent low blood pressures. During an interview on 4/15/25 1:32 p.m., LPN-A and LPN-B stated an SBAR report was sent to the provider regarding R194's low blood pressures although had not received any new orders. LPN-A stated SBAR's are faxed to the providers for less emergent issues and phone calls are made for concerns with urgent situations to include a change in alertness, multiple falls, vital signs are abnormal or passing out. LPN-B confirmed R194 had experienced abnormal vital signs, two falls, and an episode of passing out and confirmed the provider was not phoned. During an interview on 4/15/25 1:55 p.m., director of nursing (DON) stated she was aware R194 experienced recent low blood pressures with two episodes of lightheadedness and dizziness which resulted in falls. DON confirmed the provider had been sent an SBAR report 4/15/25. DON stated she would consider anything less than 100/60 as low and anything less than 50/30 to be emergent, requiring a call to the provider or a call to 911. DON verified R194's documented BP of 69/33. DON confirmed no call was made to the provider. DON's expectation would be to continue monitoring R194 given his status and his cardiac history. DON stated she would expect a complete set of vital signs to include BP, heart rate, respiratory rate, and oxygen saturation prior to giving additional cardiac medications. DON also included their procedure for post-fall monitoring included vitals sign monitoring every 8 hours for 24 hours, notify provider, and document in a progress note. DON confirmed lack of post-fall documentation or provider notification for 4/14/25 or 4/15/25 falls. During interview and observation on 4/15/25 at 3:42 p.m., Medical Doctor (MD)-C visited R194 in the physical therapy room accompanied by the DON. PT-A and DON provided a brief update about R194. During this update, R194 stated he had experienced another fall at approximately midnight. The DON stated she was unaware of the 2nd fall on 4/14/25. MD-C instructed staff to return R194 to his room and complete a full set of orthostatic blood pressures and notify his regular provider with the results and encouraged R194 to remain in his room until seen by his normal provider on 4/16/25. During an observation on 4/16/25 at 7:20 a.m., LPN-C completed R194's necessary orthostatic BP levels without documenting the correlating heart rate. LPN-C stated an unawareness orthostatic BPs required a heart rate. During an interview on 4/16/25 at 7:56 a.m., MD-B confirmed an unawareness of R194's condition and incidents from 4/14/25 and 4/15/25 and would expect staff to notify a provider by phone immediately when there is a significant change in BP readings. MD-B stated staff could call 911 for immediate attention with symptoms of dizziness, falls, or general unwellness like R194 experienced. During an interview on 4/16/25 at 10:13 a.m., nurse practitioner (NP)-A stated she was notified of R194's falls and very low BP's upon arriving to the facility. NP-A stated she would have expected to be notified when a resident's BP is less than 90, and not just a receipt of an SBAR report being faxed. NP-A confirmed 911 should have been called for a BP less than 80 with symptoms such as falling, dizziness, and lightheadedness. NP-A confirmed the expectation is to complete a full set of vital signs prior to administering more than one cardiac medication, NP-A confirmed R194 received more than one cardiac medication. NP-A confirmed the expectation was to monitor vital signs, including a blood pressure, frequently after a fall that was suspected to be due to low blood pressure. NP-A confirmed the process for completing orthostatic BP's included laying, sitting, standing-waiting 3-5 minutes in between position changes with a correlating heart rate. During interview on 4/16/2025 at 12:48 p.m., DON stated it is the expectation to complete a full set of vital signs after a fall; to include BP, pulse, temperature, respirator rate and oxygen saturation. DON confirmed R194 had a BP completed although lacked the remainder of vital signs after his falls. DON confirmed the late entry in the medical record regarding the fall at midnight on 4/15/25. DON confirmed the fall should have been documented at the time of the fall. DON stated an orthostatic blood pressure is completed at laying, sitting, standing positioning, waiting 3-5 minutes between positions with a correlating heart rate. DON confirmed R194 did not receive accurate orthostatic BP's. DON confirmed R194 had fallen 3 times, had not received po [TRUNCATED]

Based on interview and document review, the facility failed to accurately complete comprehensive assessment of a resident's needs, strengths, goals, life history and preferences to determine a resident's functional capacity. In addition, the facility failed to ensure Minimum Data Set (MDS) was completed in a timely and/or in a comprehensive manner to facilitate accurate evaluation of resident' conditions for 5 of 5 residents (R6, R24, R194, R199, and R201) reviewed for MDS accuracy. Findings include: The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated 10/2023, identified the MDS as an assessment tool which facilities are required to use. The manual directed comprehensive assessments, include the completion of both the MDS and the CAA process, as well as care planning. The CMS RAI manual also identified the RAI process (i.e., MDS) was completed to help evaluate resident' strengths and areas for care-planning. The manual listed all types of assessments to be completed along with corresponding timeframe's for them via a graph labeled, RAI OBRA-required Assessment Summary. This directed a quarterly MDS should be completed (i.e., signed) within, ARD + 14 calendar days. R6 R6's quarterly MDS, dated [DATE], identified R6 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. R6's diagnoses included progressive neurological condition, multiple sclerosis, neurogenic bladder, paraplegia, anxiety and depression. Each resident electronic medical record (EMR) listed a section labeled, MDS, which listed MDS's assessments to date for each resident. R6's quarterly MDS, with an assessment reference date (ARD) dated 3/10/25, although was listed and indicated completed on 4/14/25. R6's medical record was reviewed and lacked reason why the MDS was not completed timely. R24 R24's MDS list indicated Medicare 5 day was completed on 11/29/24 with no assessments listed after that date. R24's medical record was reviewed and lacked why the MDS had not been completed timely. R194 R194's admission MDS, dated [DATE], identified the MDS was In progress. R194's admission MDS, with an assessment reference date (ARD) 4/10/25, was listed but categorized as, In Progress. The MDS was not completed with multiple sections being red-colored and having little or no data entered and being labeled, In Progress. The uncompleted sections included, Hearing, Speech and Vision, and Behavior, and Bladder and Bowel, among several others. R194's medical record was reviewed and lacked reason why the MDS had not been completed timely. R199 R199's admission MDS, dated [DATE], identified the MDS was In progress. R199's admission MDS, Medicare 5 day assessment, Discharge return anticipated assessment and Medicare 5-day assessment was listed but categorized as, In Progress. All above MDS assessments were not completed with multiple sections being red-colored and having little or no data entered and being labeled, In Progress. The uncompleted sections included, Hearing, Speech and Vision, and Behavior, and Bladder and Bowel, among several others. R199's medical record was reviewed and lacked evidence why the MDS had not been completed timely. R201 R201's admission MDS, dated [DATE], identified the MDS was In progress. R201's Medicare 5 day assessment, Discharge return anticipated assessment and Medicare 5-day assessment, Admission/Medicare 5 day, Discharge return anticipated were listed but categorized as, In Progress. All above MDS assessments were not completed with multiple sections being red-colored and having little or no data entered and being labeled, In Progress. The uncompleted sections included, Hearing, Speech and Vision, and Behavior, and Bladder and Bowel, among several others. R201's medical record was reviewed and lacked evidence why the MDS had not been completed timely per the RAI manual. During interview on 4/21/25 at 3:22 p.m., MDS-A stated she was a consultant and was asked to assist facility with completing MDS assessments last week. MDS stated she received access and started on 4/17/25 but was off on 4/18/25. MDS-A verified they help complete the MDS for the campus. MDS-A confirmed the above noted assessments were not finished and or reported timely. During interview on 4/21/25 at 4:49 p.m., administrator confirmed MDS assessment were behind and/ or had not been completed. Administrator stated they had just hired an external company to help with the MDS process. The facility Minimum Data Set (MDS)/Resident Assessment Instrument (RAI) policy, dated 5/18/23, identified the resident assessment process is completed by the interdisciplinary team (IDT) in accordance with the federal requirements to provide a baseline of the resident's functional status on admission with scheduled assessments to determine ongoing functional status and changes.

Based on observation, interview, and record review, the facility failed to implement enhanced barrier precautions (EBP) for 2 of 2 (R138, R140) residents reviewed for infection prevention related to presence of peripherally inserted central catheter (PICC) line (enters a peripheral vein and extends to the supervisor vena cava of the heart). Findings include: R138 quarterly Minimum Data Set (MDS) assessment dated [DATE] was incomplete at the time of survey; cognitive function was intact. R138 was receiving IV antibiotic infusions. R138 was admitted on [DATE] with a diagnosis of right knee prosthesis infection and inflammation. R138 had a PICC line inserted into a peripheral vein in the upper right chest. R138's orders dated 3/31/25 did not include orders to change the PICC line dressing. Medication orders stated to administer ertapenem (IV antibiotic) 1 gram every 24 hours starting 3/28/25 at 11pm. R138's orders did not include orders for enhanced barrier precautions. During observation on 4/14/25 at 6:32 p.m., a PICC line was noted in R138's peripheral vein in the upper right chest. R138's room lacked any indication of enhanced barrier precautions or personal protective equipment (PPE). During observation on 4/15/25 at 13:56 p.m., registered nurse (RN)-A was observed entering R138's room to administer medication, RN-A did not put on PPE. R140 quarterly Minimum Data Set (MDS) assessment dated [DATE] was incomplete at the time of survey; cognitive function was intact. R140 was receiving IV antibiotic infusions. R140 was admitted on [DATE] with a diagnosis of left knee prosthesis infection. R140 had a PICC line inserted into a peripheral vein in the right upper arm. R140's orders dated 3/31/25 included changing PICC line dressing every 7 days and as needed if dressing was loose, soiled, or wet. Medication orders stated to administer ceftriaxone (IV antibiotic) 2 grams every 24 hours starting on 3/31/25 at 9pm. R140's orders did not include orders for enhanced barrier precautions. During observation on 4/14/25 at 1:16 p.m., a PICC line was noted in R140's peripheral vein in the right upper arm. R140's room lacked any indication of enhanced barrier precautions or personal protective equipment (PPE). During observation on 4/15/25 at 9:48 a.m., RN-A was observed entering R140's room to administer medications, RN-A did not put on PPE. During interview on 4/16/25 10:24 a.m., nurse practitioner (NP)-A stated both R138 and R140 should have been placed in EBP precaution upon admission due to both having PICC lines placed prior to admission at facility. During interview on 4/15/25 at 11:20 a.m., RN-A stated it is common to use EBP for residents with urinary catheters, indwelling lines, ostomies, or other things coming out of the body. RN-A stated if a resident required EBP then they should have and EBP sign placed on the door. RN-A stated the health unit coordinator (HUC) or admission nurse would place the EBP signs on the doors. During interview on 4/16/2025 at 12:48 p.m., director of nursing (DON) stated EBP precautions are used for residents who have open wounds, catheters, PICC lines, or a known infection. DON confirmed R138 and R140 did not have enhanced barrier precautions initiated at admission. Per undated facility policy titled IPC Manual Chapter 8 Transmission Based Precautions, EBP precautions are initiated for residents with PICC lines, urinary catheters, and feeding tubes. Further, clear signage should be hung on the door with an isolation cart containing PPE placed outside the room.

Based on interview and document review, the facility failed to ensure 2 of 5 residents (R194 and R199) reviewed for immunizations were offered and/or provided the pneumococcal vaccination series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 11/21/24, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult who had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer, after 5 years, the Pneumococcal 20-valent Conjugate Vaccine (PCV20) or Pneumococcal 21-valent Conjugate Vaccine (PCV21) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. This also identified an adult over [AGE] years old, who received one dose of PPSV23 at any age should be offered either option A (PCV20 or PCV21) or option B (PCV15) after one year. R194's face sheet dated 4/22/25, indicated he admitted to the facility 3/28/25 and was [AGE] years old. The immunization record dated 4/18/25, indicated he received a PPSV23 on 11/02/06 and a PCV13 on 12/19/14. The record lacked evidence of shared clinical decision making with his physician for PCV20 at least 5 years after the last pneumococcal dose. The record lacked evidence that R5 was offered or received PCV20. R199's face sheet dated 4/21/25, indicated she admitted to the facility 3/10/25 and was [AGE] years old. The immunization record dated 4/18/25, indicated she received a PPSV23 on 5/5/10 and a PCV13 on 3/9/15. The record lacked evidence of shared clinical decision making with her physician for PCV20 at least 5 years after the last pneumococcal dose. The record lacked evidence that R5 was offered or received PCV20. During interview on 4/21/25 at 2:34 p.m., the director of nursing (DON) stated she was responsible for the facility infection control program including ensuring resident eligibility for and offering routine vaccinations. The DON stated the facility procedure and expectation was to determine each resident's vaccine history and eligibility for vaccines upon admission. The DON acknowledged R194 and R199 had been eligible for the PCV20 however had not been educated on the risk and benefit or offered the PCV20 vaccine per CDC guidelines. The facility Pneumococcal Vaccine Program Policy dated 5/17/23, indicated residents will be offered immunizations again pneumococcal disease in accordance with CDC recommendation on vaccinations. Pneumococcal disease is a serious illness that can cause sickness and even death. Adults [AGE] years and older: CDC recommends pneumococcal vaccination for all adults [AGE] years or older. The tables below provide detailed information. For adults [AGE] years or older who have not previously received any pneumococcal vaccine, CDC recommends you: *Give 1 dose of PCV15 or PCV20. o If PCV15 is used, this should be followed by a dose of PPSV23 at least 1 year later. The minimum interval is 8 weeks and can be considered in adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak. o If PCV20 is used, a dose of PPSV23 is NOT indicated. For adults [AGE] years or older who have only received PPSV23, CDC recommends you: *Give 1 dose of PCV15 or PCV20. o The PCV15 or PCV20 dose should be administered at least 1 year after the most recent PPSV23 vaccination. o Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For adults [AGE] years or older who have only received PCV13, CDC recommends you either: *Give 1 dose of PCV20 at least 1 year after PCV13 Or *Give 1 dose of PPSV23 at least 1 year after PCV13.

Based on observation, interview, and document review, the facility failed to follow up on a resident requested medication change in a timely manner for 1 of 1 residents (R138) reviewed for choices. Findings include: R138's quarterly Minimum Data Set (MDS) assessment was not completed at time of survey. R138 had intact cognition and had no rejection of cares. R138 had a diagnosis of right knee prosthesis infection and inflammatory response requiring intravenous (IV) antibiotic therapy. R138 required ongoing limited assistance for dressing and limited assist for hygiene. R138's medication orders included: Ertapenem (medication for infection) 1 gram IV infusion over one hour every day for infection of right knee prosthetic with a start date of 3/28/25. The first dose available at the facility was administered at 11pm. During interview on 4/14/25 at 6:32 p.m., R138 stated she would like to have the Ertapenem infusion done earlier in the evening around 7 or 8 p.m. R138 stated the nurses must wake her up at 11 p.m. to start the infusion and then again in an hour when the infusion is complete. She has asked the nursing staff to change this or request to change this, but the change has not been made. During interview on 4/14/25 7:00 p.m., licensed practical nurse (LPN)-E stated R138 had previously asked him to administer the Ertapenem dose sooner; he had stated to her that the medication could not be done sooner. LPN-E confirmed a situation background assessment recommendation (SBAR) report had not been completed for this request. During interview on 4/16/25 at 9:07 a.m., registered nurse (RN)-A stated the resident had previously told her she wanted medication to be given during the day but told the resident the medication time could only be changed by a provider or a pharmacist. RN-A stated she had not completed a SBAR report to submit the request to the provider. During interview on 4/16/25 at 10:29 a.m., nurse practitioner (NP)-A stated the antibiotic could be moved to any time R138 preferred. NP-A confirmed she was unaware R138 wanted to change the time of the antibiotic administration. NP-A confirmed she would expect this kind of request to come on the standard SBAR communication. During interview on 4/16/2025 at 12:48 p.m., director of nursing (DON) stated medication change requests are completed on a SBAR document. DON confirmed anyone can fill out the SBAR on the resident's behalf. DON confirmed R138 did not have an SBAR note requesting medication administration times. R138 medication administration time for Ertapenem continues to be administered late and was given on 4/17/25 at 12:04 a.m. A policy regarding resident choices was requested and not provided.

Based on interview and record review, the facility failed to notify resident representative following provider order changes in a timely manner for 1 of 1 residents (R18) who received an order for antibiotics for a urinary tract infection (UTI). Findings include: R18's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R18 was severely cognitively impaired with no behaviors and was incontinent of bladder and bowel. R18's care plan for incontinence/altered elimination indicated R18 had ongoing incontinence and could not communicate the need to void. Interventions included: assist perineal hygiene after toileting, encourage fluid intake, observe for signs/symptoms of UTI (difficulty with urination, frequency, urgency, lower abdominal pain and discomfort, back pain, blood in the urine and report to medical doctor/nurse practitioner (MD/NP), offer toileting upon rising, before and after meals and bedtime and as needed (PRN). R18's medication administration record included: cefdinir 300 mg take 1 capsule by mouth two times a day for UTI for 5 days. Take before morning and evening meals dated 4/11/25 and in/out catheter to get UA (urine analysis) sample dated 4/9/25. R18's provider progress notes indicated the following: -4/8/25 family is noting increased confusion since 4/7/25 and is concerned of UTI. Family is requesting UA. -4/9/2025 indicated order for urine specimen to be sent to lab. -4/11/25 indicated positive urinalysis (test to check for infection) and order for cefdinir 300 mg take 1 capsule by mouth twice a day before morning and evening meal x 5 days. -4/13/25 indicated sensitivities confirming continued use of cefdinir. R18's progress notes lacked resident representative was notified after UA results and R18 was diagnosed with a urinary tract infection, or changes to medication orders. During interview on 4/17/25 at 4:39 p.m., R18's family member (FM)-A reported requesting staff to obtain a urinalysis on 4/4/25 due to R18 having increased vocalizations, however the urine sample was not obtained until 4/10/25. FM-A arrived at the facility on 4/14/25 and still had not heard any updates regarding R18's urine status. At the time FM-A was told R18 was on something for 5 days. FM-A stated it causes so much stress having to dig for information about [R18]. During interview on 4/18/25 at 11:40 a.m., the director of nursing (DON) stated resident representatives should be notified of any change in condition, medication changes, and anything abnormal, or for clarification of anything. All nurses can update resident representatives of changes. The DON stated occasionally, the provider will update the resident or representative regarding recommendations however, it is expected staff would document notification of representative in a progress note. The DON reported, staff have been updated regarding notifying families and have seen improvement, however this instance must have been missed. A facility policy titled Notification of changes dated 12/2016, indicated immediate notification of the resident and/or representative is to be done in situations including a need to alter treatment/plan of care significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form or treatment). It continues, document, in the resident's medical record, the time called, the person spoken with, what was reported, and their response if any.

Based on interview and document review, the facility failed to implement person-centered interventions for cardiac diagnosis for 1 of 1 residents (R194) reviewed for care plans. R194's admission Minimum Data Set (MDS) assessment was not completed in full at time of survey. R194's cognitive function was noted to be intact. R194 admitted on [DATE], following surgical repair of spinal stenosis (condition that narrows the space in the spine, putting pressure on the spinal cord or nerves). R194 diagnosis included atrial fibrillation (irregular heart rhythm), early ventricular depolarization (electrical signal in the heart come from lower chambers instead of upper chambers), atherosclerosis of the aorta (plaque buildup in the heart), bilateral carotid artery stenosis (partial or full blockage of the carotid artery located on each side of the neck), and hypertensive heart disease (develops due to prolonged high blood pressure, causing heart failure and abnormal heart muscle thickening). R194's admission care area assessment (CAA) report dated 3/28/25 identified a cardiac diagnosis requiring monitoring, medications, and treatments without specific person-centered interventions R194's CAA also identified R194 had a pacemaker requiring monitoring, medication, and treatments on an ongoing basis; no specific person-centered interventions were noted. R194's goals of evaluation for the cardiac diagnosis included R194 would be free of signs and symptoms of complications related to cardiac condition. R194's goals of evaluation for the pacemaker diagnosis included R194's pacemaker checks will be within normal limits. R194's goal of pain management diagnosis was R194 would demonstrate minimal discomfort or absence of acute pain and identify positive coping behaviors for chronic pain. During interview on 4/15/25 1:32 p.m., licensed practical nurse (LPN)-A stated the admission assessment is completed by a health unit coordinator (HUC) or the nurse assessment coordinator. Once the admission assessment entry is complete, the electronic medical record (EMR) will auto-populate a generic care plan. Within 48 hours the nurse assessment coordinator will enter the specific person-centered interventions. LPN-A confirmed R194 had a completed admission assessment, performed on 3/28/25. LPN-A confirmed R194 record did not have person-centered interventions. LPN-A confirmed R194 should have resident specific interventions due to his significant cardiac history and recent surgical procedure which would require pain monitoring and management. During interview on 4/16/25 at 7:27 a.m., RN-A confirmed R194 did not have specific resident-centered interventions. RN-A confirmed R194 should have interventions to include ongoing blood pressure monitoring, vital sign parameters, medication parameters in relation to the current vital signs, and interventions to address cardiac symptoms of dizziness and lightheadedness. During interview on 4/16/2025 at 12:48 p.m., director of nursing (DON) stated each resident should have an admission assessment completed when they arrive. DON confirmed R194 had an admission assessment upon arrival on 3/28/25. DON confirmed an initial generic care plan was generated for R194 on 3/28/25. DON confirmed R194 did not have a resident-specific care plan with interventions completed within 48 hours of admission. A facility policy titled Comprehensive Care Plan dated 10/2022 stated, the interdisciplinary team (IDT) will create an individual resident-specific care plan with individual interventions to communicate the resident's individual care within 48 hours of admission.

Based on observation, interview, and record review, the facility failed to ensure proper management of indwelling urinary devices for 1 of 1 residents (R6) reviewed for catheter care. R6's quarterly Minimum data Set (MDS) assessment dated [DATE] indicated R6 had severe cognitive impairment with no behaviors, is dependent on staff for all activities of daily living (ADLs) and has an indwelling catheter and ostomy. MDS also included R6 had diagnoses of multiple sclerosis (a progressive disease of the nervous system), neurogenic bladder (disease where the bladder does not function properly), and history of recurrent urinary tract infections. R6's care plan for catheter/urostomy/nephrostomy indicated R6 would remain free from signs and symptoms of urinary tract infections. Interventions included: catheter bag cover when in bed and wheelchair, change catheter as ordered by physician, empty catheter every shift and record output, keep catheter tubing free of kinks, keep drainage bag below bladder level, secure catheter to leg to avoid tension on urinary meatus (opening). Monitor, record, report to MD change in amount, color, consistency, or odor, infection signs and symptoms, chills, fever, nausea/vomiting, and pain. R6's medication administration record included: -suprapubic catheter (a tube inserted into the bladder through the abdomen) 18f change the 28th of every month -suprapubic catheter change drainage bag weekly -routine catheter care every day and evening shift -suprapubic catheter check tubing for proper positioning and cath care every shift -suprapubic catheter monitor intake and output every shift During observation on 4/15/25 at 10:43 a.m., R6 was sitting in common dining area for an activity with catheter drainage bag hanging on the armrest of the wheelchair at a level equal to resident's pelvis. During interview on 4/16/25 at 10:42 a.m., nursing assistant (NA)-B stated, sometimes I put the catheter bag under the chair and sometimes I hang it on the side. NA-B reported the catheter bag continues to drain properly if hanging on the side of the wheelchair. During observation on 4/16/25 at 1:41 p.m., R6 was sitting in wheelchair in the room with catheter bag hooked to arm rest of wheelchair at a level equal to resident's pelvis. During interview on 4/17/25 at 10:04 a.m., NA-D indicated catheter bags are clipped under the wheelchair so the bag does not drag. During interview on 4/17/25 at 1:06 p.m., the medical director (MD)-B stated drainage bags should be placed where gravity works to allow for proper drainage. During interview on 4/17/53 at 1:53 p.m., the director of nursing (DON) stated catheter drainage bags should be placed under the wheelchair to allow for proper drainage, otherwise staff should utilize a leg bag. Catheter bags should remain below the level of the bladder to prevent urine reflux and damage to the bladder. The DON stated drainage bags should not be placed on the arm of a wheelchair. A facility policy titled Indwelling urinary catheter (Foley) care and management dated November 18, 2024 indicated: Keep the drainage bag below the level of the patient's bladder to prevent backflow of urine into the bladder, which increases the risk of CAUTI [catheter-associated urinary tract infection]

Based on observation, interview, and document review, the facility failed to ensure a peripherally inserted central catheter (PICC) (enters a peripheral vein and extends to the supervisor vena cava of the heart) was appropriately managed based on professional standards of practice and in accordance with physician orders for 2 of 2 residents (R138, R140) reviewed for intravenous (IV) medications. Findings include: R138 quarterly Minimum Data Set (MDS) assessment dated [DATE] was incomplete at the time of survey; cognitive function was intact. R138 was receiving IV antibiotic infusions. R138 was admitted on [DATE] with a diagnosis of right knee prosthesis infection and inflammation. R138 had a PICC line inserted into a peripheral vein in the upper right chest. R138's orders dated 3/31/25 lacked orders to change the PICC line dressing. Medication orders stated to administer ertapenem (IV antibiotic) 1 gram every 24 hours starting 3/28/25 at 11pm. During observation and interview on 4/14/25 at 6:32 p.m., R138 stated she was concerned because her PICC dressing had not been changed since 4/4/25. The written date on the PICC line dressing was found to be 4/4/25; the top left corner of the dressing was peeling away from the skin. Resident was also concerned the PICC line medication tubing looked old. PICC line tubing lacked a date as to when it was placed. R138's medication administration record (MAR) indicated ertapenem was administered on 4/14/25 at 12:20 a.m. and 4/15/25 at 12:03 a.m. R138's treatment administration record (TAR) reflected the PICC site care was completed on 4/16/25. R138's quarterly Minimum Data Set (MDS) assessment for R140 dated 4/8/25 was incomplete at the time of survey; cognitive function was intact. R140 was receiving IV antibiotic infusions. R140 was admitted on [DATE] with a diagnosis of left knee prosthesis infection. R140 had a PICC line inserted into a peripheral vein in the right upper arm. R140 R140's orders dated 3/31/25 included changing PICC line dressing every 7 days and as needed if dressing was loose, soiled, or wet. Medication orders stated to administer ceftriaxone (IV antibiotic) 2 grams every 24 hours starting on 3/31/25 at 9pm. During observation and interview on 4/14/25 at 1:16 p.m., R140 stated he is on IV antibiotics for post-operative knee infection. Confirmed the PICC site dressing was undated. PICC site dressing is peeling up on the top left corner and down towards the bottom left corner. The PICC line tubing did not have a date. R140's MAR reflected the ceftriaxone was administered on 4/14/25 at 9:54 p.m. and 4/15/25 at 8:19 p.m. R140's TAR reflected the PICC site care was completed on 4/16/25. During interview on 4/15/25 at 11:20 a.m., RN-A stated PICC site care should be done once per week and PICC line medication IV tubing should be replaced every 24 hours. RN-A stated if she encountered a PICC line dressing without a date, if there was an order, she would change the dressing. If there wasn't an order to change the PICC line dressing, she would submit a situation background assessment recommendation (SBAR) report to ask the provider for an order. During interview on 4/16/25 at 10:29 a.m., nurse practitioner (NP)-A stated it is an expectation that PICC site dressing changes are done every 7 days. NP-A confirmed it is an expectation PICC line medication IV tubing is replaced every 24 hours. NP-A confirmed she had instructed nursing staff on 4/11/25 the PICC site dressing needed to be changed on 4/11/25. During interview on 4/16/2025 at 12:48 p.m., director of nursing (DON) stated the general parameters, and expectation is PICC site dressing changes are done every 7 days. DON confirmed the expectation is to date the dressing with the date it was changed. DON stated she would expect staff to change the PICC site dressing if it was due even if there was not an order to do so. DON would expect staff to change the PICC site dressing if it was undated. Staff can fill out an SBAR to request an order after the PICC site dressing has been changed. DON confirmed the expectation is to change PICC line medication IV tubing every 24 hours. Per facility policy titled Central Vascular Access Device Dressing Change dated 6/1/24 a PICC line site care should be changed every 7 days from the date on the dressing label or more frequently if integrity of the dressing is compromised (wet, loose, or soiled). Per facility policy title Administration of an Intermittent Infusion dated 6/1/21 a PICC line medication IV tubing is replaced every 24 hours.

Based on observation, interview and document review the facility failed to comprehensively assess pressure ulcers and monitor for skin breakdown to prevent and/or mitigate the risk of deterioration resulting in actual harm when 1 of 1 residents (R1) admitted with a stage 1 pressure ulcer developed into an unstageable pressure ulcer that caused pain and required antibiotic treatment. Findings include: Definitions of pressure ulcers: Pressure Ulcer/Injury (PU/PI) is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skin and may be painful. The appearance will vary depending on the stage and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. Stage 1 Pressure Injury: Non-blanchable erythema of intact skin. Intact skin with a localized area of non-blanchable erythema (redness). In darker skin tones, the PI may appear with persistent red, blue, or purple hues. The presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Unstageable pressure ulcer: Full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. If the slough or eschar is removed, a stage 3 or 4 pressure ulcer will be revealed. R1's admission Minimum Data Set (MDS) dated [DATE] identified R1 had diagnoses of dementia and malnutrition. Further identified R1 was at risk for pressure ulcers. Interventions included a pressure reducing device for chair and bed. No pressure ulcers were identified on the MDS. R1's Braden Scale For Predicting Pressure Sore Risk assessment dated [DATE] identified a score of 16 indicated R1 was at risk for pressure ulcers. R1's Nursing Skilled Services Data Collection assessment, dated 7/29/24 identified R1 had a stage 1 pressure ulcer to the left buttock. R1's pressure ulcer assessment lacked measurements and description of pressure area, presence of pain, and lacked the treatment plan. Although the assessment identified a stage 1 pressure ulcer on 7/29/24, it was not evident R1's wound was comprehensively assessed nor ongoing monitoring was completed until 8/16/24, 18 days later when the record identified an unstageable pressure ulcer on R1's coccyx. R1's Nursing Skilled Services Data Collection assessment, dated 8/8/24 did not identify any skin concerns. R1's Incident-Post Incident Review note dated 8/16/24 at 6:00 p.m., identified R1 had an unstageable pressure ulcer to coccyx area, nursing assistant (NA)-C found the wound while changing R1's brief. R1's Nursing Skilled Services Data Collection assessment, dated 8/16/24 identified R1 had an unstageable pressure ulcer. The assessment did not identify where the pressure ulcer was or description. Interventions were to reposition more often, air mattress in place and to perform wound assessment with monitoring. R1's progress note dated 8/16/24 at 6:23 p.m., identified R1 had an unstageable pressure ulcer to the coccyx area measuring 1.4 centimeters (cm) x 2.4 cm with surrounding redness measuring 0.5 cm, area was cleansed and a Mepilex (absorbent foam dressing) was applied. Wound bed had 95% slough (white or yellow soft dead tissue) and 5% eschar (dry, black, or brown, hardened scab-like covering of dead tissue that forms over deep wounds). In review of R1's record, the care plan was not revised until 8/29/24 and no immediate interventions including wound treatments and monitoring were implemented until 8/20/24, 4 days after the wound was identified. Further not evident the wound was treated or monitored between 8/17/24 through 8/20/24. R1's Nurse Practitioner (NP) visit note dated 8/20/24 identified R1 had a bilateral gluteal cleft wound that measured 2.0 cm x 2.5 cm, irregularly shaped, macerated peri wound with 100% white/yellow slough in the wound bed. Assessment and plan: Remove old dressing cleanse with saline, pat dry, open capsule of metronidazole (antibiotic) and sprinkle on the wound. Cut silver alginate (wound dressing to treat infected wounds or high risk for infected wounds) dressing to size of wound. Cover with Mepilex dressing and change daily. R1's treatment administration record (TAR) dated August 2024, included the aforementioned physician treatment order however, identified R1's pressure ulcer treatment was not implemented until 8/21/24. R1's Skin and Wound Evaluation dated 8/23/24, identified R1 had an in house acquired unstageable pressure ulcer due to slough and/or eschar that was staged by a health care provider. Pressure ulcer measurements were 1.8 cm x 1.2 cm, 70% wound filled with slough, increased pain and warmth noted. Exudate was moderate serosanguineous drainage with no odor. Peri wound was warm, fragile, erythema (redness) and was excoriated (superficial loss of tissue). R1 was on antibiotic therapy for the wound, had some moderate pain in the area that was controlled with pain medications and pharmacological interventions. R1's care plan revised 8/29/24 identified a focus, R1 has potential for pressure ulcer. Risk factors include pain development of PU/skin condition and fluid risk . Interventions dated 8/16/24 identified an air pressure mattress and on 8/29/24 indicated to reposition every two hours along with incontinence management, inspect skin daily and with cares, report any concerns to the nurse, monitor for signs and symptoms of infection, weekly wound progress assessment and daily monitoring of wound by nurse. During an observation on 9/9/24 at 1:37 p.m., R1 was lying in bed on her back. R1 stated, my butt is sore I just have to get up. R1 tried to reposition self in bed but was unsuccessful. Staff came in and toileted R1 and brought R1 back to bed and positioned R1 on her right side. R1 stated, yes that is better. During an interview on 9/9/24 at 10:29 a.m., via phone family member (FM)-A stated a nurse called her on 8/16/24 and told her that R1 had one little pressure ulcer upon admit they think she got it in the hospital. The nurse explained the facility had missed it until 8/16/24 when nursing had found the ulcer unstageable. R1 was supposed to discharge but could not now because R1 had to have wound care every day. R1's bottom had been very sore, R1 would grimace and moan. During an interview on 9/9/24 at 2:17 p.m., licensed practical nurse (LPN)-A stated there was an unstageable pressure ulcer on R1's coccyx and had changed the dressing this morning. The wound was looking better since the treatment had been started. LPN-A stated on admission we do a full body skin assessment; this would be documented under Data Collection assessment. Weekly skin checks were completed on each resident usually on their scheduled bath days. LPN-A stated pressure ulcer assessments and documentation needed to include the stage, wound bed, peri wound, drainage, measurements, and any signs and symptoms of infection. During an interview on 9/9/24 at 2:48 p.m., NA-C stated he worked on 8/16/24 and had helped R1 with incontinent care. NA-C indicated he had seen a Mepilex dressing on her coccyx that was not dated, was very soiled with bowel movement, and looked like it had been there for awhile. NA-C got the nurse to change the dressing, when the nurse took the dressing off of R1's wound it was bad looking and had black in it. NA-C remembered he had seen a Mepilex to the area a week prior that was not dated and questioned if the dressing he found on 8/16/24 was the same one. NA-C stated R1 would have pain with transfers and toileting in the coccyx area. During an interview on 9/9/24 at 2:30 p.m., licensed practical nurse (LPN)-B stated she worked on 8/16/24 when NA-C alerted her to go to R1's room to change the coccyx dressing. LPN-B stated R1 did not have any orders for a dressing at that time. When LPN-B went to R1's room, she removed the soiled Mepilex that had a large amount of yellow and brown pus. R1 had a large unstageable pressure ulcer to her coccyx that smelled bad, like dead skin and the wound bed was gray and black. LPN-B immediately reported to the nurse manager LPN-C. LPN-B stated that was on a Friday, when she came back on Monday August 19th, she went to assess R1's wound and change the dressing, however there was no dressing on R1's coccyx and there was not a physician ordered wound treatment. LPN-B again reported her findings to the nurse manager so a treatment order could be put into place. During an interview on 9/9/24 at 3:46 p.m., registered nurse (RN)-A and LPN-C indicated R1's unstageable pressure ulcer to the coccyx was first identified on 8/16/24. RN-A stated on 9/16/24 she measured the coccyx wound and LPN-C identified she documented RN-A's findings. RN-A indicated R1's wound was odd shaped and had eschar in it, there was no treatment order at that time. RN-A and LPN-C referenced the physician's standing orders for wound care which did not include a treatment for unstageable pressure ulcers, so it was determined to follow the treatment for a Stage 3 ulcer. RN-A cleaned the wound with normal saline and applied a Mepilex to it per the standing house orders. LPN-C stated she completed an SBAR (communication tool used to report changes to physician) for the nurse practitioner to notify and request treatment orders. Both RN-A and LPN-C stated they had not revised the care plan and/or developed nursing orders that would inform staff of the pressure ulcer, direct them to monitor the wound, and apply any wound dressings or treatments. Treatment orders were not ordered until 8/20/24 indicating R1's wound was not monitored and/or treated for 4 days. LPN-C indicated R1's skin assessment on 7/29/24, indicated R1 had a stage 1 pressure ulcer to coccyx and a full body skin assessment was not performed again until 8/25/24. RN-A stated full body skin assessments should be done on admit, weekly and with changes. RN-A stated when doing a wound assessment, it should be staged, measured, description of the wound bed, peri wound, drainage, pain, and any signs and symptoms of infection. Both LPN-C and RN-A indicated they had not completed record reviews or audits on other residents at risk for pressure ulcers and/or residents with existing wounds in order to determine if the care plan and treatment was appropriate. During an interview on 9/9/24 at 4:40 p.m., interim director of nursing (IDON) indicated upon admission residents should have a full comprehensive skin assessment, then weekly and with any changes. IDON stated with any skin changes family and provider were supposed to notified and also to ensure a treatment plan was in place. IDON stated to ensure a pressure ulcer was comprehensively assessed for treatment it should be staged, measured, description of the wound bed, peri wound, drainage, pain and any signs and symptoms of infection, IDON verified the facility policy was not followed for wound assessments and monitoring for R1. IDON stated since R1's wound was missed and the process was not followed the facility implemented an additional tracking system within the electronic health record with a plan for completing weekly skin inspections. However, the facility had not reviewed other residents possibly effected by the deficient practice which would include residents who were at risk for pressure ulcers and residents who had existing pressure ulcers. Facility, Standing Orders for Skilled Nursing Facilities, revised April 2022, identified under Skin and Wound Management to institute facility wound management if available. If facility wound management process not available .stage 2 or 3 Pressure injuries (moderate to heavy drainage): cleanse with normal saline or non-cytoxic wound cleanser. Apply adhesive foam dressing (facility stock); change every 2-3 days and prn. Notify provider next business day. Stage 2 or 3 Pressure injuries (minimal drainage): cleanse with normal saline or non-cytoxic wound cleanser. Apply hydrogel (facility stock) to wound bed. Cover with nonadherent dressing Change every 3 days and prn. Notify the provider the next business day. The Standing House orders does not identify a treatment for unstageable pressure ulcers. Facility policy reviewed, Prevention and Treatment of Pressure Ulcers/Pressure Injury, revised 11/22/22, identified It is the policy of Volunteers of America National Services (VOANS) to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to professional standards of care. I. Prevention of Pressure Ulcers: A. Braden Scale* and Skin Risk Data Collection form will be done: Upon admission, Weekly for the first 4 weeks post admission, Quarterly, and With a change in status (i.e., pressure ulcer development, change in mobility, continence status, change in cognition, nutrition, etc.). B. Nursing: Monitoring of Skin Integrity: Skin will be observed daily with cares by the nursing assistant. If any skin concerns are noted, they are to be reported immediately to the designated nurse. Weekly skin audits will be performed by the Licensed Nurse (Refer to Body Audit Policy and Procedure). An alert will trigger from question B of the assessment to the clinical dashboard that will notify the IDT that a new skin issue has occurred and follow up is needed. If a dressing is ordered, it will be monitored for appropriate placement on resident. If a skin concern is noted, refer to section II. Treatment of Pressure Ulcers and Lower Extremity Ulcers (arterial, venous, neuropathy/diabetic, or mixed) procedure and Wound Care Protocols. If the assigned nurse identifies a wound upon the admission body audit. The nurse will need to complete the 1st weekly wound documentation and notify resident and/or resident representative as appropriate and the Physician/PA/CNP will be notified and the nurse will obtain orders utilizing the 3 M Protocol, complete an individualized care plan, and notify the IDT. If post admission there is an identification of a wound, the assigned nurse will complete the E-Interact COC or Paper SBAR, complete the Risk Management New Skin Integrity Concern. The Care Plan for Skin Integrity is to be evaluated and revised based on response, outcomes, and needs of the resident. II. Treatment of Pressure Ulcers and Lower Extremity Ulcers (arterial, venous, neuropathy/diabetic, or mixed) If a resident is admitted with or there is a new development of a pressure ulcer or lower extremity ulcer the following procedure is to be implemented: 1. Notify Physician/PA/CNP and Resident and/or Resident Representative 2. Initiate physician wound orders or 3M Wound Care Protocols, until order is obtained. 3. Notify Supervisor/Designee as assigned. 4. Notify Dietary for nutritional interventions. 5. Notify Therapy Department for seating surface evaluation and possible treatment interventions. 6. Notify other interdisciplinary team members as appropriate. 7. Initiate Braden Scale and Skin Risk Data Collection form. 8. Update the residents individualized Care Plan for Skin Integrity and nursing assistant Kardex with any skin concerns and interventions. Include appropriate risk factors, turning intervals and interventions as appropriate. 9. Initiate Weekly Wound Documentation to be completed every seven days and PRN in electronic health record which will include: type of wound, location, date, stage (pressure ulcers only) or indicate partial or full thickness (arterial, venous, neuropathy/diabetic ulcers), length, width, and depth; wound base description, wound edge description and if present: drainage, odor, undermining, tunneling, and/or pain. The Weekly Wound Documentation Progress Form should only have ONE WOUND per form. See Weekly Wound Documentation Progress Sheet & Wound Documentation Guidelines for instructions. 10. When a wound is present, daily wound monitoring should include: An evaluation of the wound, if no dressing is present, An evaluation of the status of the dressing, if present, The status of the area surrounding the ulcer/wound (that can be observed without removing the dressing), The presence of possible complications, such as signs of infections, Whether pain, if present, is being adequately controlled. Document on any changes or concerns in the nurses notes and re-evaluate prior steps 1-9 as appropriate. 11. Periodically IDT team review the resident for intervention for prevention and healing of pressure ulcer/pressure injury. 12. Notify the Physician/CNP, Resident and/or Resident Representative as appropriate and Supervisor/Designee if the ulcer(s) has not shown progress in 2 weeks and/or is deteriorating unexpectedly. Re-evaluate plan of care as appropriate.

Based on interview and document review the facility failed to administer the right prescribed medications to right residents for 2 of 3 residents (R1, R2). R1 had a sudden change in cardiac status and required hospitalized . This resulted in an immediate jeopardy (IJ) for R1, the facility immediately implemented correction and is being issued at past non compliance. The immediate jeopardy (IJ) began on [DATE], when registered nurse (RN)-A failed to verify identity of R1 prior to the administration of prescribed medications on the morning of [DATE]. The administrator and director of nursing were notified of the IJ on [DATE], at 3:30 p.m. The IJ was removed on [DATE], and the deficient practice was corrected on [DATE], prior to the start of the survey and was therefore Past Noncompliance. Findings include: The facility Incident Report #2070 dated [DATE], at 10:07 a.m. identified on [DATE], at 8:00 a.m. registered nurse (RN)-A mistakenly administered R2's medication to R1 which included [MEDICATION(S)] 7.5 mg (blood pressure medication (med)), Aspirin 325 mg, [MEDICATION(S)] 3.125 mg (blood pressure med), [MEDICATION(S)] 5 mg (prostate med), [MEDICATION(S)] 60 mg (blood pressure med), [MEDICATION(S)] 25 mg (blood pressure med), [MEDICATION(S)] 1 packet (med used for constipation), Ocular Vitamin, Senna Plus (med used for constipation), and Tamsulosin HCL capsule 0.4 mg (prostate med). Incident Report #2070 further identified RN-B called PA-A and new orders were received for checking (R1's) blood pressure and pulse every hour. PA-A was contacted when the blood pressure of ,d+[DATE] was obtained, and directed R1 be transported to the hospital for further monitoring. The identified root cause indicated RN-A was not familiar with the residents; when she said a name the resident responded to that name. R1's Face Sheet indicated R1 was admitted to the facility on [DATE], and discharged [DATE], to hospital. R1's admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Date Set (MDS) dated [DATE], indicted R1 had moderate cognitive impairment. R1's Care Plan with target date [DATE], indicated R1 was a new admit to the short term stay unit and desired to be discharged from the facility to his assisted living apartment; demonstrated cognitive loss and directed staff to allow adequate time for R1 to respond and not rush supply words; had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Aceon tablet 2 mg (blood pressure medication (med)). Give 2 tablets by mouth one time a day for stage IV chronic kidney disease. -Daily-Vite multiple vitamin tablet. Give 1 tablet by mouth one time a day for supplement. -[MEDICATION(S)] (med to relieve constipation). Give 1 packet by mouth one time a day for constipation. -[MEDICATION(S)] 40 mg (acid reflux med). Give 1 tablet by mouth one time a day for gastric bleed; give before breakfast. -Glimepiride1 mg (med to lower blood sugars). Give 1 tablet by mouth one time a day for diabetes. Give with breakfast. -Do not take a [MEDICATION(S)] within 2 hours before or after taking other medications. Senna Plus Tablet Give 2 tablets by mouth two times a day for constipation. -[MEDICATION(S)] tablet extended release 24 Hour 25 mg. Give 0.5 tablet by mouth one time a day for hypertension ([CONDITION(S)]). Do not crush or chew. R1's progress note dated [DATE], at 10:07 a.m. included (R1) had an incident of medication error this shift. The incident occurred at [DATE] 8:00 a.m. (R1) was evaluated for injuries, physician, family, and appropriate staff notified. R1's progress note dated [DATE], at 10:18 a.m. included Resident received another resident's medication which included [MEDICATION(S)] 7.5 mg, Aspirin 325 mg, [MEDICATION(S)] ,d+[DATE].25 mg, [MEDICATION(S)] 5 mg, [MEDICATION(S)] 60 mg, Larsartan Potassium 25 mg, [MEDICATION(S)] 1 packet, Ocular vitamin, Senna Plus, and Tamsulosin. Called the provider and new orders were received of checking blood pressure and pulse every hour. Provider contacted with blood pressure of ,d+[DATE] and got order to send him to the hospital for further monitoring. R1's progress note dated [DATE], at 11:48 a.m. included Resident sent to emergency room for follow up monitoring after medication error. Systolic blood pressures ranged anywhere from ,d+[DATE] (normal range is between 90 and 120). Resident denied any symptoms but received several blood pressure medications. Resident left facility via ambulance at 11:00 a.m. R1's hospital care summary dated [DATE], indicated R1 was admitted to the ED with [CONDITION(S)] (low blood pressure) and drug overdose. Poison Control was contacted and advised to admit R1 to the hospital given R1's severe aortic stenosis and being administered five anti-hypertension agents. R1 was admitted to inpatient care and promptly went into cardiac arrest upon arriving to the medical unit. R1 subsequently died . R2's face sheet indicated R2 was admitted to the facility on [DATE] and remains a resident at the facility. R2's admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Care Plan with target date [DATE], indicated R2 demonstrated cognitive loss and allow adequate time to respond, and do not rush or supply words. R2 had cardiac diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Had hearing loss, had vision problem, and had difficulty with speech. R2's MDS dated [DATE], indicated R2 had severe cognitive deficit; had hearing aides; sometimes unable to express his ideas or wants and for staff to understand his needs; and impaired vision. R2's prescribed medication list on [DATE] included: -[MEDICATION(S)] tablet 25 mg. Give 1 tablet by mouth every 8 hours as needed for blood pressure give if systolic blood pressure is >160. -[MEDICATION(S)] for constipation as needed for bowel movement production. -[MEDICATION(S)] 3 -125 mg. Give 1 tablet by mouth two times a day related to [CONDITION(S)]. -[MEDICATION(S)] extended release 24 Hour 60 mg. Give 1 tablet by mouth 1 time a day for [CONDITION(S)]. -[MEDICATION(S)] tablet 2.5 mg. Give 2 tablets by mouth 1 time per day for [CONDITION(S)]. -Aspirin Tablet 325 mg. Give 1 tablet per day for prevention. -[MEDICATION(S)] tablet 40 mg (cholesterol med). Give 1 tablet by mouth at bedtime for [CONDITION(S)]. -[MEDICATION(S)] Tablet 5 mg. Give 1 tablet per day for benign prostate hypertension. -[MEDICATION(S)] tablet 25 mg. Give 1 tablet per day for [CONDITION(S)]. -[MEDICATION(S)] Powder. Give 1 packet by mouth one time a day for constipation. -[MEDICATION(S)] Tablet Delayed Release 40 mg. Give 1 tablet by mouth in the morning before breakfast for gastroesophageal reflux disease. -Tamsulosin capsule 0.4 mg. Give 2 capsules by mouth one time a day for benign prostatic hypertension. Open and put 1 capsule at a time into applesauce. -Ocular Vitamins. Give 1 tablet 2 times per day for supplement. -Senna Plus Tablet 8.,d+[DATE] mg. Give 1 tablet by mouth two times a day for constipation; hold for loose stools. -Acetaminophen tablet 500 mg. Give 2 tablets every 6 hours for pain -[MEDICATION(S)] Sulfate tablets 0.125 mg. Give 1 tablet sublingually every 4 hours for increased secretions. R2's progress note dated [DATE], at 10:44 a.m. documented R2 received R1's medication which included Senna Plus, Aceon, [MEDICATION(S)], [MEDICATION(S)], and daily vitamin tablet. Provider was notified and new orders were given to give R2 his morning meditations and check his blood sugar now and a half hour after lunch and supper. Will continue to monitor. Review of progress notes from [DATE] to [DATE] identified R2 did not have adverse effects from the medication error. Facility's investigation included hand written statement by RN-A dated [DATE]. The statement identified RN-A confirmed she switched R1 and R2's morning pass medications. Statement included it made it hard to tell which resident was who when they were in dining room to eat breakfast and R1 is not usually in the dining room. I said their name, and each responded to the name. I noticed the mistake after giving R2, R1's medication that was actually R1 and notified someone right away what I did. During interview on [DATE], at 10:14 a.m. RN-A indicated that morning R2's medications had been prepared for administration. She had thought it was R2 who had been sitting at the dining room table alone. So, she approached who she thought was R2 and said good morning R2, who responded good morning. Since R2 responded the medications that had been prepared were administered. Shortly after who she thought was R1 arrived to the dining room table. RN-A greeted R1 good morning, and R1 replied good morning and administered R1 his pills. RN-A stated in this encounter she did not state R1's name but surmised it was R1 because R2 had already received his medications. RN-A indicated something did not feel right. RN-A returned to the medication cart and accessed R1's electronic medical record and reviewed R1's picture and realized she had made medication errors. RN-A stated she gave R1's medications to R2 and R2's medications to R1. RN-A indicated she should have looked at the pictures of the residents before administering their medications and she did not confirm it was the right resident. RN-A also verbalized that maybe the residents did not hear what she was saying, because she was wearing a mask. During interview on [DATE], 8:25 a.m. ADM stated he took the lead on the investigation and root cause analysis with RN-A's medication errors. ADM convened the Quality Assurance and Process Improvement (QAPI) committee to review the facility policies on medication administration. It was determined by QAPI that the facility had appropriate policies and procedures and RN-A did not follow the facility policies and procedures, nor standard nursing practice for medication administration. RN-A is a supplemental contracted nurse and was terminated from returning to the facility. During an interview on [DATE], at 12:47 p.m. physician assistant (PA)-A stated she received a telephone call from the facility regarding the medication errors for R1 and R2. PA-A stated she was most concerned with R1's blood pressure and directed staff to closely monitor R1's blood pressures. PA-A directed if R1's blood pressure is at ,d+[DATE] or less, to contact her and she will place an order to transport R1 to the emergency department (ED). PA-A stated R1 was not a fragile patient and was doing well on his own, living in assisted living. Review of the facility 7 Rights of Medication Administration procedure Pathway Health, not dated, directed staff to check if it is the right resident, right medication, right dose, right route, right time, right reason, and right documentation. Review of the facility General Dose Preparation and Medication Administration with revision date [DATE], directed staff should verify that the medication name and dose are correct when compared to the medication order on the medication administration record. Review of Oral Drug Administration, Lippincott Medical Books revised [DATE], directed staff to confirm the patient's identity using at least two patient identifiers; and verify that you're administering the right medication at the proper time, in the prescribed dose to reduce the risk of medication errors. The immediate jeopardy that began on [DATE], was removed on [DATE] when it was verified and confirmed by observation, interview, and document review the facility immediately implemented the following actions: -On [DATE] facility immediately suspended, followed by terminating RN-A's employment; further reported to the MN Board of Nursing -On [DATE] all licensed staff and trained medication assistants were educated on medication administration policy with focus on 7 rights of medication administration. Followed by developing and implementing a hands-on competency evaluation. Additionally developed an ongoing plan to continue education/competency until all staff have completed prior to their next shift. -On [DATE] Facility completed record review audits to ensure all residents potentially effected to ensure no further medication errors were identified. -On [DATE] facility reviewed the medication error with QAPI. -By [DATE] Reviewed all their policies and procedures relating to medication administration and found to be appropriate. -By [DATE] reviewed medication errors to ensure no identifiable trends related to rights of medication administration that could have warranted further analysis and intervention; no trend was identified.

Based on interviews and document reviews, the facility failed to assess a change in condition when family member (FM)-A approached facility staff to report increased secretions for 1 of 1 residents (R1). Furthermore, a nurse handed a medication to FM-A to administer to R 1 without a nursing assessment. This resulted in an immediate jeopardy (IJ) when the facility failed to assess change in condition during end of life. R1 died shortly after. The IJ began on [DATE] when FM-A reported concerns of R1's increasing secretions to licensed practical nurse (LPN)-A. LPN-A failed to complete an in person assessment of R1's condition, instead, gave FM-A a medication to administer to R1 and left the unit. The facility administrator and director of nursing (DON) were notified of the IJ on [DATE] at 1:06 p.m. The IJ was removed on [DATE], at 5:30 p.m However, noncompliance remained at the lower scope and severity level 2: D- meaning isolated, and no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R1 was receiving hospice services, was able to understand others and could make herself understood. R1 was not assessed to have been depressed, nor had she made any statements indicating she felt life was not worth living or wishing for death. The MDS included R1 was able to participate in her daily cares, but required extensive assistance with mobility and repositioning. The MDS indicated R1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] a tracking MDS was completed indicating R1 had died at the facility. R1's last Care Plan Review dated [DATE], included a focus problem area for terminal illness with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident may become very anxious when she is experiencing symptoms as she had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident has cognitive impairment which may have impact upon her ability to process declines/changes as she approaches death. Associated interventions included: follow comfort measures, advanced directives, provide diversional activity such as soft music, 1:1 visits etc., encourage relaxation techniques, watch for pain/discomfort, provide peaceful/comfortable environment, provide support to family and significant others, notify family/MD/NP of changes in condition. During an interview on [DATE], at 10:32 a.m. FM-A stated he had visited R1 each evening, usually between 5 p.m. and 10 p.m. On [DATE] FM-A arrived around 5:30 p.m. and did not notice anything out of the ordinary. R1 had her supper tray in her room and was feeding herself and watching television. Shortly after, FM-A noticed R1 was grabbing tissues and trying to clear [MEDICATION(S)] from her mouth. FM-A said he went to the nurses' station which was next to R1's room and told LPN-A, R1 was having some difficulty with secretions. FM-A stated, LPN-A handed FM-A a pill. FM-A said he returned to R1's room and gave R1 the medication without staff present . After giving R1 the medication, FM-A stated, things were happening quickly and R1 complained she was having trouble breathing. She began to look alarmed and scared. FM-A stated he went to the nurses' station. FM-A walked around but could not see any other staff and returned to R1's room. FM-A stated R1 was having difficulty catching her breath and FM-A attempted to apply oxygen which did not seem effective. FM-A stated he looked for the nurse again, and at some point turned the call-light on. FM-A stated R1 had been in distress for ,d+[DATE] minutes, and he did not want to leave her alone, but after making at least three attempts to find the nurse, he finally went to another unit where he located LPN-B. FM-A and LPN-B returned to R1's room to find R1 leaning forward in her recliner, slumped over with some sort of thick liquid, mucous or phlegm coming from her mouth. FM-A recalled asking the staff to call 911. FM-A stated he thought LPN-A came to R1's room. LPN-B said they should lean R1 back in her recliner, but FM-A stated he thought the emergency medical staff (EMS) on the phone had told the LPN's to lay her down in bed and place her on her side. EMS arrived assessed R1 and informed FM-A, R1 did not have a pulse, and was deceased . FM-A recalled R1 had had a similar problem about a month prior. On that evening, the nurse had remained with R1 until R1's condition improved. FM-A also stated medications at the facility had been routinely given by nurses, and he had never before given a medication while R1 was residing at the facility. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Dose was documented as having been given at 5:50 p.m. on [DATE]th. The effectiveness of this PRN dose was marked as unknown. No other doses of [MEDICATION(S)] Sulfate were documented as having been given in August of 2022. According to R1's health record, R1 was assessed on [DATE] at 8:40 a.m. as having an oxygen saturation of 98% , at 11:39 a.m., R1's temperature was recorded as 96.4 F; pulse 77 beats per minute. R1's medical provider's recertification note dated [DATE], read a hospice nurse practitioner (NP)-A indicated R1 had initially been admitted to hospice services on [DATE] with a primary terminal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . NP-A wrote that a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 exhibited wheezing in her lungs during the provider's assessment and had increasing [CONDITION(S)] of her lower limbs which was reported as difficult to manage with medications due to her low blood pressures. NP-A noted a history of swallowing problems but had not had any recent pneumonia related to that problem. R1 was described as lethargic, but easily aroused with normal attention and mood. R1's progress note dated [DATE], at 12:35 a.m. LPN-A wrote, Resident passed away at 1830 [6:30 p.m.] tonight. She had gone to breakfast and to lunch out in dining room earlier. Ate in her room for supper with her [FM-A]. At 1745 [5:30 p.m.] [FM-A] told me he thought she needed some [MEDICATION(S)] for increased secretion's which I gave to him, said he would give it to her himself. At 1815 [6:30 p.m] while I was out on a break, I was brought back in and informed she was having a hard time breathing. Her secretion's had increased with labored breathing and she had become less responsive. We tried to upright her to make her breathing easier. [FM-A] had requested an ambulance, so went to give them directions to the facility and to her room on the phone. Went back into room and laid her on her side in bed per suggestion from the EMT tech on phone. She had grown very pale by this time. EMT arrived then, 1825? [6:25p.m.] and took over evaluation. They said there was no pulse at this time, 1830 [6:30 p.m.]. Hospice was called, DON and ED informed. Many family arrived and then she was taken to Rochester Cremation Society facility around 2000 [8:00 p.m.]. No papers were requested or signed at this time. During an interview on [DATE], at 11:51 a.m. LPN-A stated he recalled FM-A was visiting R1 on [DATE] as the evening meal was being served. LPN-A stated FM-A often visited during the evenings. On that evening, LPN-A remembered FM-A reporting R1 was having increased secretions, and recalled he had gone to the medication cart and retrieved a dose of [MEDICATION(S)] Sulfate, handed it to FM-A and instructed him to place it under R1's tongue. LPN-A also recalled discussing some cookies FM-A wanted to give to R1. LPN-A stated he did not go to R1's room to do a nursing assessment of her condition, and was unable to describe her appearance. LPN-A stated he had learned in his nurse's training that when a person had excess oral or respiratory secretions it was important to reposition them, and make sure their airway was open. LPN-A stated he had not gone in to see R1 because FM-A did not express any crisis, and because FM-A thought she was stable enough to eat cookies. LPN-A stated he knew it was not standard practice for families to give medication, but stated FM-A had agreed to it and everything seemed okay at that time. LPN-A stated before giving a PRN medication, a nurse generally would check the resident to see what the situation was, but he had not done so because, [FM-A] was there every day taking care of her and he knew how she would respond. He would take her to the bathroom and everything. LPN-A stated he had gone on his break after giving FM-A the medication to administer to R1. LPN-A recalled staff coming to find him in the break area, telling him R1 was having trouble breathing. LPN-A stated he had returned to the unit, obtained a vital sign (VS) machine and went to R1's room. LPN-A was unable to obtain VS using the machine and stated he did not have a stethoscope to listen to her heart or lungs and did not take a manual pulse. LPN-A recalled that LPN-B was present and FM-A was trying to wipe mucous from R1's mouth as she was having trouble breathing. LPN-A stated they attempted to reposition R1 in the chair so she could breathe better but were not successful. He then went to talk to emergency response on the phone. When he returned, LPN-A recalled R1 was very pale. LPN-A stated they laid R1 down in bed and opened her airway, but she was so white. LPN-A stated, ,d+[DATE] minutes after he had returned to the room, the emergency response team arrived and declared R1 deceased . During an interview [DATE], at 1:35 p.m. hospice registered nurse (RN)-A stated nursing standards are to assess a patient prior to giving any PRN medication. In the case of increasing respiratory secretions, RN-A stated a nurse should at least put eyes on the patient, monitor their respiratory rate, watch for nonverbal signs of distress and try to determine if this was a new symptom or not. If warranted, do a full respiratory assessment. RN-A stated a facility nurse could call hospice if needed, to discuss the treatment regime as hospice services are supportive of the facility in providing comfort to the resident. RN-A stated R1 had several medications that could be given for respiratory discomfort: [MEDICATION(S)]/[MEDICATION(S)] for dyspnea, pain or shortness of breath or [MEDICATION(S)] Sulfate which can help reduce secretions. RN-A stated she had been a professional hospice nurse for approximately ten years, and had observed patients experiencing increased respiratory secretions and shortness of breath. RN-A described the patient may experience feeling scared, panicked, worried and having a sense of impending doom. During an interview on [DATE], at 2:21 p.m. a certified nurse practitioner (NP)-A stated a nurse should follow the facility and hospice protocol when administering medication. NP-A stated a nursing assessment was generally expected when giving a PRN medication unless otherwise written in facility protocol. NP-A stated residents or family could not administer medications in a facility without a provider's written order. During an interview on [DATE], at 2:34 p.m. DON stated, when a resident has excess respiratory/oral secretions, a nursing assessment should be done. DON described this as the nurse going to where the resident might be, monitoring respiratory status-the breathing rate and oxygen saturation, determining if anything was abnormal. DON stated a nurse should not have a family member administer medication unless there was an order allowing this. DON stated there was no order for family to give medications to R1. DON stated if R1 required a PRN medication, LPN-A should have done a nursing assessment, but she understood he had not. DON said she had had a conversation with LPN-A after reading a progress note indicating LPN-A had given a medication to FM-A. DON stated she then informed the staff development nurse (SD-RN) of the incident and a need to re-train LPN-A, but did not know if any training had been provided since the incident. DON stated SD-RN would communicate with her regarding if training is done, but she did not recall such communication. DON did not have any written records of any training being done with LPN-A. During an interview on [DATE], at 3:45 p.m. the facility administrator stated nurses needed to follow policy for medication administration, and they should follow the MAR for specific orders. The administrator stated he thought the DON had started an investigation related to the incident with R1 on [DATE], but did not know what follow-up had occurred with LPN-A. The administrator stated that was the responsibility of the staff development nurse who was out, but stated an expectation of SD-RN to have kept a record of any education provided. The administrator stated he did not know if the Human Resources department had been involved, but they would keep any records related to employee corrections. During an interview on [DATE] at 9:25 a.m. SD-RN handed over two typed documents, one dated [DATE] and one dated [DATE]. Neither document was signed by SD-RN, LPN-A or any other person. SD-RN stated the papers were records she kept regarding educating LPN-A. SD-RN stated the incident with R1 on [DATE] was unusual so I took it upon myself to talk to all the staff members to debrief. I wanted to talk to them to see how they feel and see if we needed hospice to come re-educate. I did set it up, but we haven't had it yet, but will have hospice come educate on what to do at end-stage of life. Also, what to do if family wants to change something or doesn't understand what DNR means. SD-RN said LPN-A told her he was off the floor on break when the incident occurred, but arrived back from his break when LPN-B went to the unit to call paramedics per FM-A's request. SD-RN stated she understood from her discussion with LPN-A nothing unusual had occurred prior to going on break, and the meal trays had not yet been delivered. SD-RN stated nurses are not allowed to leave the unit after meal trays have been delivered, and they are to stay present until the meal is complete. SD-RN stated she talked with all staff involved in the incident briefly on Monday [DATE] or Tuesday [DATE] and at some point the DON asked her to review the medication pass policy with LPN-A and watch him do a medication administration pass because he had given a med to [FM-A] to give to [R1]. She (DON) wanted to ascertain what was going on. At that time I did not know what the medication was, but [LPN-A] came in on Thursday ([DATE]) and I spoke with him. SD-RD stated she and LPN-A had discussed symptom management and whether R1 had been drinking or eating, and how to deal with her symptoms. SD-RD stated an expectation for LPN-A to have assessed R1 before giving a PRN medication, and stated a nurse should know to look at a resident and listen to lungs if there are increased secretions, and said, I thought, why would you hand it off to [FM]-A? SD-RD then stated she had reviewed the facility policies related to giving PRN medications with LPN-A, and then said she had watched him pass medications on [DATE], and had no concerns. SD-RD stated going forward, I need to check that [LPN-A] still gets it and his practice pattern is strong. SD-RD stated she had not gone back to determine if LPN-A required further evaluation or information, but planned to do so. During a follow-up interview on [DATE], at 11:17 a.m. LPN-A stated on [DATE] he was not due to give R1 any routine medications until about 8 p.m., and stated he had not seen her or assessed her prior to returning from his break that evening. LPN-A stated he had not received any nurse to nurse report that R1 was undergoing a change in condition. LPN-A stated he had not gone into the room to do an assessment because he felt R1 was stable because FM-A was going to give her cookies, and because about a month prior, R1 had had a similar incident and had responded to the medication given by the nurse immediately. Following the incident, LPN-A stated he had gone to the facility on Monday or Tuesday to talk with the DON to clear the air. LPN-A stated he had not received any training after the event, saying, not yet, but I am expecting that will happen. LPN-A stated he had had a discussion with SD-RN about the night of the incident, but stated SD-RN had not mentioned him giving the medication to the son. LPN-A said, she may not have been aware of it on Thursday, probably she wasn't or she would have said something. LPN-A stated, I have been expecting it. Normally they do that. I would expect to do some refresher stuff. LPN-A stated he had not been provided any policies to review, and did not recall SD-RN being on the unit on [DATE] when he was passing medications. During a follow up interview on [DATE], at 4:41 p.m. the director of nursing stated she did not know why the incident prior to R1's death had not been fully investigated as a vulnerable adult incident, nor why LPN-A had not been removed from the schedule until it was determined that LPN-A understood the facility policies on medication administration, PRN medication administration and nursing assessments or the facility policy on self-administration of medications or change in condition response. Facility provided a policy last revised [DATE] and titled: 6.0 General Dose Preparation and Medication Administration. The policy indicated facility staff should comply with applicable law and State Operations Manual when administering medications. Procedural steps included: identify the resident, position the resident properly, inform the resident what is to occur, provide any necessary instructions and observe the resident's consumption of the medication. Facility also provided standards of medication administration as given by Pathway Health and Leading Age Minnesota which included the following bullet points: recognition of the problem/need, assessment/diagnosis, medication administration, management, monitoring and documenting. Facility provided a policy dated [DATE], titled Self-Administration of Medications, Right to Self-Administer Medications. The policy reviewed the resident right to self-administer medication is assessed to be competent to do so; however, the policy did not include any information about a family member being able to administer medication to the resident. Facility provided several policies regarding resident change of condition; however, all of these policies were in relation to notification of medical providers or family members and did not include nursing actions, such as assessment or interventions to be taken when a change in condition has been reported or identified. The immediate jeopardy that began on [DATE] was removed on [DATE], 5:30 p.m. when the facility retrained nursing staff in policies and procedures related to nursing assessment and response to a change of condition, and in medication administration and facility policies related to self-administration of medications. Audits of nursing actions taken in relation to the provision of PRN (as needed) medications were initiated, and retraining of nurses implemented for any break in protocol. Additionally, LPN-A received individualized training and evaluation in medication assessment and nursing assessments as outlined by the facility policies with a plan in place to monitor medication administration for competency.