Every finding on record at Springfield Suites Rehab and Nursing

Based on observation, interview, and record review, the facility failed to properly store medication and label insulin vials for 4 of 6 residents in a sample of 37 residents residing in the facility.Findings include:On 9/29/2025 at 1:07 PM the facility's F Hall medication cart was inspected. The cart contained the following:1. 2 of R21's open and partially used multi dose Lantus Subcutaneous Solution 100 UNIT/ML vials. The vials documented no open or expiration date. 2. An open and partially used Humulin R vial. The vial documented no name, and no open or expiration date.3. R7's open and partially used multi dose Tresiba FlexTouch Subcutaneous Solution Pen-injector 200 UNIT/ML. The pen documented no open or expiration date.On 9/29/2025 at 1:09 PM V8, Licensed Practical Nurse (LPN) stated that the R21's Lantus vials were open and in use. V8 stated that the Humulin R vial was open and in use. V8 stated that the vials are to be labeled with an open date when open. V8 stated that the Humulin R multidose vial is a stock medication that anyone can use if they have an order and no allergy. On 9/29/2025 at 1:20 PM the facility's C Hall medication cart was inspected. The cart contained the following:4. R88's open and partially used multi dose Insulin Lispro Injection Solution 100 UNIT/ML vial. The vial documented no open or expiration date. 5. R100's open and partially used multi dose Insulin Lispro Injection Solution 100 UNIT/ML vial. The vial documented no open or expiration date.The Long-Term Care Facility Application for Medicare and Medicaid (CMS 671), dated 9/29/2025, documents 63 total residents in facility. The facility's Storage, Labeling of OTC Medication, Destruction & Disposal of Medication, dated 9/2021, documents Purpose: To ensure that medications and biological are stored in a safe, secure storage and safe handling. Procedure 3. No discontinued , outdated or deteriorated medications should be available for use in the facility. Stock Medications & Labeling 3. OTC medications must be dated upon opening the container.

Based on interviews, observations, and record reviews the facility failed to complete hand hygiene prior to conducting resident care, prior to and after donning gloves, and failed to apply a gown for enhanced barrier precautions for 5 of 8 residents (R14, R60, R57, R44 and R67); reviewed for infection control in a sample of 37.Findings include:1.R14's Facesheet documented he was admitted to the facility on [DATE] with diagnosis of spinal stenosis, acute pancreatitis, and peripheral vascular disease. 2.R60's Facesheet documented she was admitted to the facility on [DATE] with diagnosis of senile degeneration of brain, nausea, and palliative care. 3.R57's Facesheet documented she was admitted to the facility on [DATE] with diagnosis of spinal stenosis, generalized osteoarthritis, and vitamin deficiency. 4.R44's Facesheet documented she was admitted to the facility on [DATE] with diagnosis of senile degeneration of brain, palliative care, and chronic pain. On 9/29/25 at 12:20 PM, V5 Certified Nursing Assistant (CNA), V6 (CNA) and V7 (CNA) came out with the meal cart, all wearing gloves already. V5, V6 and V7 all served food without completing hand hygiene or glove changes in between each resident for R14, R60, R57 and R44. V7 cut up R14's food without hand hygiene or glove change. V5 removed gloves and did not complete hand hygiene prior to assisting R60 with tucking a towel into the collar of her shirt. V5 then sat down next to R57 and applied new gloves without completing hand hygiene to feed her. On 9/29/25 at 12:39 PM, V5 (CNA) sat down again next to R57, removed her old gloves and applied new ones without completing hand hygiene to feed R57 dessert. On 12/2/25 at 1:37 PM V23 (CNA) stated hand hygiene is supposed to be conducted before assisting residents with feeding, serving their trays, applying gloves and after, and before and after resident care. On 12/2/25 at 1:40 PM, V22 (CNA) stated hand hygiene is supposed to be completed before and after glove use, before serving food trays and before and after resident care. On 12/2/25 at 1:58 PM, V2 Director of Nursing (DON) stated she expects staff to be performing hand hygiene at a minimum between each resident. V2 stated for hand hygiene to also be completed before and after resident care, before and after glove use and before and after serving meal trays. 5. On 09/30/2025 at 9:00 AM, V11, RN, entered R67 room, donned gloves without benefit of hand hygiene and did not don an isolation gown prior to administering medication via R67's enteral feeding tube. R67's door to her room had a sign on it that read Enhance Barrier Precautions. R67's Face sheet, dated 12/2/2025, documented diagnoses of Cerebral Infarction, Dysphagia and Dysphagia following Cerebral Infarction. R67's MDS, dated [DATE], documented that her cognition was not intact. R67's Physicians order sheet, dated 9/5/25 documented, Infection precautions - enhanced barrier Staff wear gown/ gloves when in direct patient contact R67's Care Plan, dated 10/1/2025, documented, Enhanced barrier in place for high contact care activity per facility policy. On 12/02/2025 at 1:09 PM, V11, RN stated that she would wash her hands before putting gloves on and wear an isolation gown when giving medication through an enteral feeding tube. On 12/02/2025 at 1:21 PM, V13, RN stated that she would wash her hands before putting gloves on and wear an isolation gown when giving medication through an enteral feeding tube. On 12/02/2025 at 1:25 PM, V9, LPN, stated that she would wash her hands before putting gloves on and wear an isolation gown when giving medication through an enteral feeding tube. The facility's policy, Enhanced Barrier Precautions, dated 10/28/2025, documented, High-contact resident care activities include but are not limited to: 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. It continues, PPE for enhanced barrier precautions is only necessary when performing high-contact care activities. It continues, Staff will wear a clean, non-sterile gown to protect skin and prevent soiling of clothing during procedures and resident care activities that are likely to generate splashes or sprays of blood or body fluids, secretions, or excretions and during specific high-contact resident care activities. The facility's policy, Hand Hygiene, dated 4/24/2024, documented, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, resident, and visitors. This applies to all staff working in all locations within the facility.

Based on observation, interview and record review, the facility failed to check residual, for 1 of 1 (R67) resident, reviewed for enteral gastrostomy tube maintenance, in a sample of 37.Findings include:On 09/30/2025 at 9:00 AM, V11, Registered Nurse (RN), prepared medications for R67, she then entered R67's room donned a pair of gloves, and administered Modafinil 100 milligrams (mg), Norco 7.5 mg/325 milliliters (ml), Vitamin B-1 100 mg and an 81 mg chewable aspirin through R67's enteral feeding tube without out checking for residual or placement. R67's Face sheet, dated 12/2/2025, documented diagnoses of Cerebral Infarction, Dysphagia and Dysphagia following Cerebral Infarction. R67's MDS, dated [DATE], documented that her cognition was not intact.R67's Physicians order sheet, dated 9/5/25 documented Specify: Flush with 50 ML's water before and after admin of tube feed. Flush with 30 ML's water before and after each med administration, It continues, Infection precautions - enhanced barrier Staff wear gown/ gloves when in direct patient contact R67's Care Plan, dated 10/1/2025, documented, Enhanced barrier in place for high contact care activity per facility policy. It continues, Check for tube placement and gastric contents/residual volume per facility protocol and record.On 12/02/2025 at 1:09 PM, V11, RN stated that she would check residual prior to administrating medication via an enteral feeding tube. On 12/02/2025 at 1:21 PM, V13, RN stated that she checks residual before giving medications to a resident through an enteral feeding tube. On 12/02/2025 at 1:25 PM, V9, Licensed Practical Nurse (LPN0, stated she would check residual of a residents enteral feeding tube before administering medication through it. The facility's policy, Tube Care, dated 11/28/2025, documented, Medication Administration. It continues, 10. Verify ube placement check for residual gastric contents by aspirating the syringe. 11. Return gastric contents removed during residual check back into stomach.

Based on observation, interview and record review the facility failed to check food temperature of all food items prior to serving and provide food at the correct temperature. This has the potential to affect all 65 residents residing at the facility. Findings include:On 11/15/2025 at 9:23AM R1 stated she eats breakfast in her room, but all other meals in the dining room. R1 stated at times food is not correct temp (cold) R1 stated staff will warm up if she asks.On 11/15/2025 at 1:20PM R4 stated the food is not always the correct temp, On 11/17/2024 at 11:42AM V18, cook checked the food temperature of pasta with red sauce, and pasta without sauce on the steam table. V18 did not check the food temperature of California blend vegetables, green beans, mechanical soft pasta or mechanical green beans. On 11/17/2025 at12:00PM prior to first plate food temps taken at steam table by surveyor. Mechancial soft green beans in food processor plastic container sitting on steam table 116 F. On 11/17 2024at 1:24PM test tray removed from cart after staff passed last tray. Pasta with red sauce 117.1F, mechanical pasta with red sauce 110F, and pasta plain cheese without sauce 105F. Plain pasta with cheese was cold to taste and mechanical pasta with red sauce barely warm to taste. On 11/17/2025 at 11:42AM V18, [NAME] stated residents have complained of food being cold. V18 stated the food is ok when leaves the kitchen but once trays are sent to the halls they are not always delivered timely. On 11/17/2025 at 1:44PM V1, administrator stated she would expect food to be served at correct temperatures and menus to be followed, and food temps taken.The facility policy Food Temperatures dated December 30,2024 documents food stored hot will be kept at 135 degrees or above. The policy documents food will be cooked to the appropriate internal temperature per regulations. The policy documents temperature or food items will be checked prior to service to the residents and as frequently as necessary when being stored hot for service.The facility roster dated 11/15/2025 documents census of 65.

Based on interview and record review, the Facility failed to ensure pain medications were readily available for administration in order to prevent increasing pain/discomfort for 2 of 4 (R2, R3) residents reviewed for pain medications in the sample of 4. Findings include: 1.) R3's Face Sheet documents admitted [DATE]. Diagnoses include Noneffective Gastroenteritis and Colitis, Intestinal Bypass and Anastomosis Status, Spinal Stenosis, Diarrhea, and Volvulus. R3's Minimum Data Set, MDS, dated [DATE] documents R3 has no cognitive impairments. MDS documents R3 requires partial assist with transfers and supervision with bed mobility. R3's Care Plan updated 12/21/2024 documents R3 currently has an alteration due to pain related to Arthritis. Scheduled Norco and Tylenol effective. As needed, PRN, pain medication available when needed. Interventions include administer medication & treatments ordered by Medical Doctor (MD) and monitor for side effects and effectiveness to current medication regimens. R3's physician order sheets dated 12/1/2024 documents Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) *Controlled Drug* Give 1 tablet by mouth two times a day for pain. R3's Medication Administration Records, MAR, dated 12/1/2024-12/31/2024 documents Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth two times a day for pain. Start Date-12/01/2024 at 8:00 PM. There is no documentation that the medication was administered on 12/25/2024 PM dose, 12/26/2024 AM & PM dose, 12/27/2024 AM & PM dose, 12/28/2024 PM dose, 12/29/2024 AM & PM dose, 12/30/2024 AM & PM dose, 12/31/2024 AM & PM dose. R3's Medication Administration Records, MAR, dated 1/1/2025-1/31/2025 documents Hydrocodone-Acetaminophen Oral Tablet 5-325 MG(Hydrocodone-Acetaminophen) Give 1 tablet by mouth two times a day for pain. Start Date-12/01/2024 at 8:00 PM. There is no documentation that the medication was administered on 1/1/2025 AM & PM dose and 1/2/2025 AM & PM dose. R3's Medication Administration Records, MAR, dated 2/1/2025-2/28/2025 documents Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth two times a day for pain. Start Date-12/01/2024 at 8:00 PM. There is no documentation that the medication was administered on 2/19/2025 PM dose and 2/20/2025 AM & PM dose. R3's Progress Notes dated 12/25/2024 - 1/22/2025 documents Hydrocodone-Acetaminophen Oral Tablet 5/325 MG. Give 1 tablet by mouth two times a day for pain, Unavailable. R3's Pain level assessment dated [DATE] at 8:00 PM documents pain level 5. R3's Pain level assessment dated [DATE] at 8:00 PM documents pain level 3. R3's Progress Notes dated 12/26/2024 at 11:40 AM documents Made call out to Physician's office to request updated script for Norco refill, message left. R3's Progress Notes dated 12/27/2024 at 9:12 AM Call out to Physician's office for Norco script. R3's Progress Notes dated 12/30/2024 at 2:41 PM documents Made another call out to Physician's office in regard to Norco refill, have left several messages and no returned call and script has not been filled. Reception stated, will put back urgent. R3's Progress Notes dated 12/31/2024 at 11:38 AM documents: Made another call out to Physician's office regarding Norco script update for refill. Message states office is closed for holiday until Thursday 1/2. Writer requested on call physician to return call. R3's Progress Notes dated 12/31/2024: Made another call out to Physician's office due to script still not received at pharmacy. Verified place, fax, and phone number. Physician did not have the correct phone number or fax but did have correct pharmacy and location. Numbers updated and will send updated script today. R3's Progress Note dated 2/19/2025 at 10:48 AM, documents Made call out to Medical Doctor's office to request updated Norco script for refill. R3's Progress Notes dated 2/19/2025-2/20/2025 documents Hydrocodone-Acetaminophen Oral Tablet 5/325 MG. Give 1 tablet by mouth two times a day for pain, Unavailable. R3's pain level assessment dated [DATE] at 8:00 PM documents pain level 1. R3's pain level assessment dated [DATE] at 8:00 AM documents pain level 5. R3's Progress Note dated 2/20/2025 at 1:18 PM, documents Medical Doctor's office confirmed Norco Rx(script) sent this AM. Writer confirming with pharmacy at this time. On 3/21/2025 at 9:35 AM R3 stated the facility has ran out of her prescription for Hydrocodone-Acetaminophen in the months of December and February. R3 stated in December she had to go without her pain medication for almost 10 days. R3 stated during the time she had to go without her pain medication, she was in pain. R3 stated she has taken the pain medication for many years and without it, it is hard to function due to being in pain. R3 stated while not getting her pain medication for so long, she experienced increased pain. On 3/21/2025 at 2:07 PM V3, Nurse Manager, stated R3 did go a while without her prescription pain medication back in December and recently for about 2 days in February. V3 stated R3's primary care provider is the doctor who prescribes R3's Hydrocodone. V3 stated the facility reached out to R3's primary care provider before R3's script for Hydrocodone ran out in December and then the primary care provider's office closed for the holidays. V3 stated the facility reached out to the on-call physician to see if they would fill R3's script for Hydrocodone and the on-call doctor would not fill it. V3 stated since the on-call doctor would not write the script for R3's medication, R3 had to go without her pain meds. V3 stated R3 did not receive her Hydrocodone on 2/19/20 or 2/20/25 due to the facility waiting for a new prescription from the MD (doctor). On 3/25/2025 at 11:46 AM V8, R3's Primary Care Doctor's Licensed Practical Nurse (LPN), stated R3's Primary Care Doctor is a [NAME] when it comes to a facility following his prescriptions the way it is written. V8 stated R3's Primary Care Doctor expects the facility to give a resident their medications as ordered and written. V8 stated with R3's medical diagnoses, if R3 went without her pain medication as prescribed it puts R3 at risk for increased and unnecessary pain. 2.) R2's Face Sheet documents admitted [DATE] with medical diagnoses of Chronic Pain Syndrome, Disorders of Muscle, and Hypertension. R2's Minimum Data Set, MDS, dated [DATE], documents R2 has no cognitive impairments. MDS documents R2 requires supervision or touching assistance with transfer and bed mobility. R2's Care Plan dated 3/3/25, documents R2 has an alteration due to pain related to chronic pain syndrome. Interventions include Encourage PT/ OT participation, administer medication & treatments ordered by MD and monitor for side effects and effectiveness to current medication regimens. R2's Physician Order dated 3/11/25, documents Hydrocodone-Acetaminophen (Norco) Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen) *Controlled Drug* Give 1 tablet by mouth every 8 hours as needed for moderate pain (5-7 on pain scale) and Give 2 tablets by mouth every 8 hours as needed for severe pain (7-10 on pain scale). R2's Medication Administration Records, MAR, dated 3/3/25-3/31/25 documents Hydrocodone Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 8 hours as needed for moderate pain (5-7 on pain scale) **DO NOT GIVE WITH DIAZEPAM** -Start Date 03/11/2025 1345 and Hydrocodone-Acetaminophen Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen) Give 2 tablet by mouth every 8 hours as needed for severe pain (7-10 on pain scale) **DO NOT GIVE WITH DIAZEPAM** -Start Date 03/11/2025 1345. There was no documentation that medication was administered on 3/18/25 AM and PM dose. R2's Progress Note dated 3/18/25 at 8:46 AM documents Writer contacted pharmacy due to Norco refill did not come with delivery. Pharmacy stated, MD needs contacted due to oral route missing on script that was sent. Writer contacted the MD and Nurse Practitioner and requested script be corrected. R2's Progress Note dated 3/18/25 8:46 AM documents Nurse Practitioner stated, script corrected and updated and sent to pharmacy. R2's Progress Note dated 3/19/25 at 12:40 AM documents Guest very upset with facility; writer continues to wait on pharmacy for Norco. R2's Progress Note dated 3/19/25 at 1:08 AM documents Guest pain medication did not arrive with pharmacy delivery. R2's Progress Note dated 3/19/25 at 8:50 AM documents Writer contacted pharmacy related to Norco script did not come with delivery again after script was corrected by MD and staff is unable to pull medication from medication machine due to facility does not carry the Norco 10/325 mg dose needed. Pharmacy stated, script was corrected by Nurse Practitioner and received yesterday, medication will come with delivery today. R2's Progress Note dated 3/19/25 at 9:53 AM documents Writer contacted Nurse Practitioner and made aware of situation, requested temporary script for Norco 5/325 mg prn because it is available to staff in the medication machine. Nurse Practitioner gave new order, okay for Norco 5/235 mg 2 tablets every 8 hours as needed for 24 hours until Norco 10/325 mg script arrives. Facility nurse made aware, and medication given to guest as ordered. R2's daytime pain level assessment dated [DATE] documents pain level 5. R2's nighttime pain level assessment dated [DATE] documents pain level 3. R2's daytime pain level assessment dated [DATE] documents pain level 5. On 3/21/2025 at 8:24 AM, R2 stated she recently did not receive her prescribed pain medication Hydrocodone-Acetaminophen for almost 2 days. R2 stated the facility informed her they did not have her pain medication. R2 stated she has taken the prescribed pain medication for years due to multiple medical issues and without the pain medication she is pain and cannot complete her therapy as ordered. R2 stated during the time she did not receive her pain medication she was experiencing increased pain. On 3/21/2025 at 9:23 AM, V5, Licensed Practical Nurse, stated she has heard the facility has ran out of R2's prescribed pain medication recently. On 3/21/2025 at 2:07 PM V3, Nurse Manager, stated the facility did recently run out of R2's prescription for Hydrocodone-Acetaminophen and R2 had to go about a day and a half without her medication. V3 stated the facility reached out to the MD for a new script and when he sent the script to the pharmacy, he did not write the route on the script, therefore the pharmacy would not fill R2's medication. V3 stated she was able to reach out to the Nurse Practitioner and the Nurse Practitioner sent a new script to the pharmacy. V3 stated once the pharmacy received the script, staff were able to pull it from their in-house medication machine. On 3/21/2025 V3, Nurse Manager, stated if the facility's on call doctor will not write for a prescription when a resident's primary care doctor is the ordering physician, the resident will have to go without that medication until the resident's primary care doctor sends the facility a prescription. V2, Director of Nursing, stated the facility's medication machine does contain Hydrocodone that the staff can pull a resident's needed mediation from once a script is received by the pharmacy, until their package of medication arrives. On 3/25/25 at 12:30 PM, V9, Facility Medical Doctor, stated it is expected that the facility gives residents their prescriptions as written and ordered. V9, Facility Medical Doctor, stated if a resident goes without receiving their pain medication, the resident can experience unnecessary pain and an increase in pain. The facility's Administering Medication Policy and Procedure revised 10/15/2023, documents Purpose: To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations. Procedure: Medications shall be administered according to physician's written/verbal orders upon verification of the right medication, dose, route, time and positive verification of the resident's identity when no contraindications are identified, and the medication is labeled according to accepted standards. Should a drug be withheld, refused, or given other than at the scheduled time, the individual administering the mediation shall chart in the Electronic Medical Record (eMAR) and sign off for that particular drug and document a rationale. Should a medication be withheld or refused, the physician will be notified when three (3) consecutive doses or a pattern of frequent withholding or refusal is noted. Documentation identifying the explanation of withholding or reason for refusal will be documented in the medical record. The facility's Pain Management and Assessment Policy and Procedure revised 11/22/2021, documents Policy: to provide a broad spectrum of treatments for pain management as they apply specifically to older people and with specifically to older people with specific recommendations to aid in decision making about pain management. To develop clinical practice guidelines for the management of acute or chronic pain.

Based on interview and record review, the facility failed to provide an appropriate number of staff to assist in a transfer in 1 of 5 residents (R2), reviewed for falls in the sample of 7. Findings include: R2's Face Sheet, undated, documents R2 has the following diagnoses: Fracture of the Thoracic Vertebra, Pulmonary Embolism (PE), Fusion of Spine, Post Laminectomy Syndrome and Spinal Stenosis. R2's Minimum Data Set, dated dated [DATE], documents R2 has a Brief Interview for Mental Status Score of 13, indicating R2 is cognitively intact, requires partial/moderate assist with transfers and has a history of falls with fractures. R2's Care Plan, dated 8/30/24, documents R2 is at risk for falls with interventions dated 9/23/24 to have therapy evaluate R2's transfer status and educate staff on R2's transfer status. R2's care plan goes on to document that R2 has an activities of daily living deficit with and requires an assistance of two with transfers. R2's Progress Note, dated 9/22/24 at 9:45 AM, documents the following: Summoned to guest's room per CNA (Certified Nursing Assistant). Guest sitting on floor in bathroom facing the wall next to the toilet. Guest states she was assisted to bathroom with CNA using wheelchair. Upon attempting to stand from wheelchair with assist, guest states her knees gave out and she sat down on the floor. She denies any pain, just weak. Guest requesting not to go to hospital, states she would like to get back in the bed. Guest assisted back to wheelchair and then to bed with assist of 2 using gait belt. R2's Physician notified with NNO (no new orders). Guest's son also notified of incident. Continuing to monitor closely. R2's Fall Event Investigation, dated 9/22/24, documents R2 fell while transferring off of the toilet with assist, knees gave out and R2 was assisted to the floor. The interventions are as follows: therapy to evaluate transfer status, staff educated on transfers, R2 to use a full mechanical lift until therapy evaluates R2. R2's Mobility Kardex, completed by the therapy department, dated 9/23/24, documents R2 requires an assist of 2 staff with a transfer belt for transfers to the wheelchair/bed and toilet. R2's Progress Note by V11, Licensed Practical Nurse (LPN), dated 9/30/24 at 4:16 PM, documents the following: CNA approached writer around 3:40 PM and stated resident had fallen when getting up from toilet. Writer went to guest's room and found her on her knees holding on to the grab bar. She stated her legs hurt really bad. Moved resident to a sitting position and attempted to get her off the ground with the help of the aide. We were unsuccessful and she screamed of intense pain. Resident was lowered back to ground. 911 called. Therapy aide assisted in cleaning resident's perineal area and pulling pants up. Large red spot noted to bottom right side of her hip and back. She complains of 10/10 pain here. EMT (Emergency Medical Technician) arrived and were able to get resident off of floor after carefully using sliding sheet. Resident going to local hospital. Paperwork given, warned EMT's of possible UTI (Urinary Tract Infection), brown dark urine. Family aware and meeting resident at hospital. R2's Progress Note, dated 10/1/24 at 8:39, documents R2 was admitted to the local hospital for PE (pulmonary embolism). R2's Fall Event Investigation, dated 9/30/24, documents R2 fell while being transferred off of toilet with staff, increased weakness. Per staff witness, guest lost balance and fell . R2's Grievance completed by V2, Director of Nurses (DON), dated 10/3/24, documents there was a concern of an improper transfer. One on one education was provided with the staff member and will address with any remaining staff during upcoming skills day. On 9/5/24 at 12:30 PM, V8, Therapy Program Director, stated R2 required an assistance of 2 staff with a gait belt for a long time because she had a hard time remembering the steps during a transfer, so they took it slow with her. On 12/6/24 at 9:00 AM, V11, LPN, stated R2 was always up with an assist of 2 because her knees gave out. V11 stated when R2 was on F hall, unsure of exact date, she (R2) asked to go to the bathroom and the CNA took her by herself, R2's knees gave out, she fell , and she was sent out to the hospital and admitted for a PE (pulmonary embolism). On 12/6/24 at 9:10 AM, V2, DON, V2 stated she believes R2 was an assist of one with transfers at the time of her falls but isn't sure. The Fall Policy, undated, documents the purpose is to identify interventions related to the guest's specific risks and causes to try and prevent the guest from falling and minimize complications from falling.

Based on interview and record review, the Facility failed to ensure residents are treated with dignity and respect by providing timely care which promotes quality of life for 2 of 24 residents (R117, R11) reviewed for dignity, in the sample of 44. This failure resulted in R117 experiencing prolonged pain and feeling undignified, and R11 feeling embarrassed. Findings include: 1. On 11/18/2024 at 9:53 AM, R117 stated he turned on his call light the night prior, to request pain medication. R117 states he has a lot of pain due to a broken left hip as well as chronic pain in both legs. R117 stated it was approximately two hours before he received his pain medication, which did provide some relief after he received it. R117 stated the nurse chewed him out about using my call light too much and that once is enough. R117 stated he had to use it more than once to get help. R117 stated he did not tell anyone about it because he did not feel like it was abusive, but it did make him feel like I don't matter much. On 11/19/2024 at approximately 12:10 PM, R117 stated he wrote the times down when he first pressed his call light and when he received his pain medication. R117 stated he activated his call light at 7:45 PM and received his pain medication at 9:15 PM. R117's Minimum Data Set (MDS) dated [DATE] documents R117 is cognitively intact. R117's Medication Administration Record (MAR) documents on Sunday 11/17/2024 R117 received his Oxycodone 15 milligrams (mg) at 1:07 PM and again at 9:07 PM. 2. R11's Facesheet, undated, documents R11 was admitted to the facility on [DATE] with diagnosis of Internal right knee prosthesis, Sepsis, Encephalopathy, Type 2 Diabetes Mellitus (DM), Parkinson's disease, Depression, and Benign prostatic hyperplasia (BPH), Overactive bladder, and Dementia. R11's Care Plan, dated 11/11/24, documents At risk for falls related to weakness, impaired mobility, balance, age. R11 is alert and oriented with confusion at times related to dementia. R11 has had falls in the past 6 months/year, but number is unknown. Interventions: Toilet after meals, educate wife to notify staff when leaving, bed and chair alarm, fall risk assessment on admit and per protocol, keep personal items and frequently used items within reach, encourage to call for assistance as needed, assist to toilet upon request, fall risk. It continues R11 has an Activities of Daily Living (ADL) deficit. Interventions: R11 requires assist of two with transfers and 1-2 with ADL's. R11 has a bed/chair alarm, and the bed is in low position. There are no other interventions for fall precautions seen in R11's room. R11's Minimum Data Set (MDS), dated [DATE], documents R11 has a moderate cognitive impairment and requires partial/moderate assistance from staff for ADLs. R11 is occasionally of both bowel and bladder. On 11/20/24 at 10:00 AM, R11 sitting in recliner with Intravenous (IV) antibiotic running into left upper arm Peripheral Inserted Central Catheter (PICC) line. R11 had t-shirt on and no pants, only an incontinence brief which appeared to be saturated. R11 has his wife V4, and visitors in the room with him. R11 was seen with a folded bath blanket across his lap and kept pulling it up to cover himself with it. V4 was visibly upset and in tears. V4 stated she arrived to the facility around 9:00 AM this morning and found R11 like this. V4 stated that R11 wanted to use the restroom and she put the call light on, and a Certified Nursing Assistant (CNA) came in and stated she couldn't get R11 up until the nurse disconnects his IV and that the CNA let the nurses know. V4 stated R11's IV pump had been going off for at least 30 minutes and they still have not gotten anyone in the room to assist R11. V9, Licensed Practical Nurse (LPN), was notified and stated she was not able to disconnect R11's IV due to the PICC line and that it had to be a Registered Nurse (RN). V13, RN, entered to disconnect R11's IV. V14, CNA, entered to assist R11 to restroom. V14 applied gait belt around R11 and put walker in front of him. V14 stood and walked to restroom to use toilet. Upon R11 standing, his incontinence brief dropped to the floor due to being so heavy and saturated with urine, and his chair alarm did not go off. V14 held brief up while R11 walked to restroom and was assisted to the toilet. On 11/20/24 at 10:20 AM, V13, RN, stated that she was the one who got R11 out of bed and to his chair this morning to start his IV antibiotic. V13 stated she did not perform incontinent care at that time. On 11/20/24 at 10:25 AM, V7, CNA, stated that she normally gets R11 out of bed and to the shower early morning and she cleans him up at that time. V7 stated when she walked in, the nurse had already gotten R11 up to a chair and she could not get him up with the IV infusing. V7 stated she did not do incontinent care on R11 this morning. On 11/20/24 at 10:57 AM, when asked if sitting in his chair with a wet brief on while he had visitors was embarrassing to him, R11 stated Well two weeks ago I would have been embarrassed, but since I've been here, it seems like everyone wants to see my butt. The Facility's Resident Rights Policy, dated 11/14/16, documents Residents have basic rights guaranteed by Federal and State laws. Residents will receive equal access to care regardless of diagnosis, severity of condition, or payment source. Residents are entitled to exercise their rights and privileges to the fullest extent possible without interference, coercion, discrimination or reprisal from the facility and will be supported in the exercise of their rights. Each resident will be treated with dignity and respect and receive care that promotes, maintains, or enhances quality of life, recognizing each resident's individuality. The Facility's Call Lights policy documents, Purpose: To meet the guest's requests and needs within an appropriate time period. It continues, All staff is responsible for answering call lights for all guests. A call light should be answered as soon as possible. It further documents. Respond to the guests call light asking,'What can I do for you today?' If you are unable to assist the guest, find a staff member who can. 40701

Based on interview and record review, the Facility failed to ensure residents pain was addressed, assessed and medication provided in a timely fashion for 1 of 24 residents (R117) reviewed for pain management, in the sample of 44. This failure resulted in R117 experiencing prolonged, unrelieved pain. Findings include: R117's Face Sheet, undated, documents R117 was admitted to the facility on [DATE] with diagnoses including left femur fracture and chronic pain syndrome. On 11/18/2024 at 9:53 AM, R117 stated he turned on his call light the night prior, to request pain medication. R117 states he has a lot of pain due to a broken left hip as well as chronic pain in both legs. R117 stated it was approximately two hours before he received his pain medication, which did provide some relief after he received it. On 11/19/2024 at 1:56 PM, V20, Minimum Data Set (MDS) and Care Plan Coordinator, stated R117 was on scheduled Oxycodone for pain, but it was changed to a PRN (as needed) order on 11/13/2024. V20 stated R117 was on Oxycodone prior to experiencing his fracture due to chronic pain and cancer. On 11/19/2024 at 2:24 PM, R117 stated he wrote the times down when he first pressed his call light to request his pain medication and when he received his pain medication. R117 stated he activated his call light at 7:45 PM and received his pain medication at 9:15 PM. On 11/21/2024 at 9:25 AM, R117 stated occasionally the nurses ask him to rate his pain, but not usually. R117 stated the night of 11/17/2024, when he requested his pain medication, his pain was at a 7 on a 1-10 pain scale. R117 stated his pain level went up to a 9 by the time he received his pain medication. R117's Medication Administration Record (MAR) documents on Sunday 11/17/2024 R117 received his Oxycodone 15 milligrams (mg) at 1:07 PM and again at 9:07 PM. On 11/21/2024 at 8:34 AM, V2, Director of Nursing (DON) stated she would expect for the nurse to have address resident pain in a more timely fashion. The Facility's Pain Management Policy, undated, documents, Purpose: Guests will receive the best level of pain control that can safely be provided in order to prevent unrelieved pain. Policy: To provide guidelines to caregivers in how to assess, treat, and assist in managing a guest's pain. Pain is whenever the experiencing person says it is, existing whenever he/she says it does. Self-report is the preferred indicator of pain. Pain relief is the alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the guest and is demonstrated by a decrease in the guest's pain scale rating.

Based on observation, interview, and record review, failed to provide ongoing tracking and trending of residents' and employees' infections, failed to update infection control policies, failed to implement infection control precautions, and failed to provide hand-hygiene during medication administration and resident care to prevent the spread of infections. This has the potential to affect all 58 residents in the facility. Findings include: 1.On 11/18/24, the facility provided the infection control log. There was no infection control log for November 2024. On 11/19/24, at 2:54 PM, V2, Director of Nursing (DON), stated the infection control log was a work in progress. On 11/21/24 at 11:11AM V2, Director of Nursing stated she pulls the antibiotic list from the facility's system. She stated she attempts to pull the antibiotic list weekly and then transfers the information to the log. She said that she has not completed November. She said that she does review the cultures. She said that if a resident is admitted from the hospital with an antibiotic, and they do not receive a laboratory result as to why they are on the antibiotic, she will sometimes she call the hospital but most of the time she doesn't. She noted that she tracks and trends the infections by using the log which is listed by halls. She said it list the infection type and the resident's name. She said that is where she trends the infections also. When questioned regarding tracking employee illness, she said she does not but will start. 2. The facility's Infection Control policy, undated, documents Purpose: To ensure that nosocomial infections are prevented, if possible, and monitored. The policy documents 3. The facility has an established infection control program which has been designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of infection. 4. The Infection Control program investigates, controls, and prevents infections in the facility; decides what procedures, such as isolation, should be applied to a particular guest; and maintains a record of correction actions related to infection control necessary. On 11/21/24, at 2:25 PM, V1, Administrator, was asked to clarify why there were no dates on the infection control policies. V1 confirmed there were no dates on the policies and stated the policies were old and they would update if issues came up. She stated the some of the policies used are from (Company that provides healthcare facilities policies and procedures) which were encouraged when the facility was attempting to get accredited by Commission on Accreditation of Healthcare Organizations (JCAHO) Accreditation. On 11/21/24, the facility provided a grouping of infection control policies covering different areas. The (Company that provides healthcare facilities policies and procedures) were dated 2001 with revision dates of 2009, 2011 and 2012. The policies that were provided from the facility, undated were titled Isolation Initiating Transmission-Based Precautions, Isolating Discontinuing Transmission-Based Precautions, and Clostridium Difficile. 3. On 11/18 through 11/21/24, R31 resided on B-hall. On 11/18/24 at 12:08 PM, R31 had bottle of tube feeding hanging on a tube feeding poll. On 11/21/24 at 1:20 PM, there was no signage R31's door regarding Enhanced Barrier Precautions. 4. On 11/18 through 11/21/24, R119 resided on B-Hall On 11/20/24, R119 stated he had issues with urinary leakage about 3 years ago and had a suprapubic catheter placed. R119's Physician's Order (PO), dated 11/5/24, documented Suprapubic cath site: Cleanse with NS (normal saline) or wound wash BID (twice daily). On 11/21/24, there was no signage on R119's door regarding Enhanced Barrier Precautions. R119's Resident Progress Note, dated 11/17/24, documents Suprapubic catheter in place with clear amber urine. R119's Progress Notes from day of admission on 11/5/24 through 11/17/24, had no documentation that R119 was on Enhanced Barrier Precaution. On 11/21/24, V17, Licensed Practical Nurse, who was the nurse on the B-hall, stated that there was no one on Enhanced Barrier Precautions on B-hall. On 11/21/24, at 11:43 AM, V2 stated that the facility does not use Enhanced Barrier Precautions. She stated that they should, but they just talked about this in the last few weeks. When asked if anyone would be a candidate for Enhanced Barrier Precautions, she stated she did not know and would have to check. V2 provided Infection Control Policies on 11/21/2024. The policies included Isolation Initiating Transmission-Based Precautions, Isolation Transmission-Based Precautions, and Isolation which were undated. This policies did not address Enhanced Barrier Precautions. The Centers for Disease Control and Prevention (CDC), website, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), April 2, 2024, documents Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. The website documented Because enhanced Barrier precautions do not impose the same activity and room placement restrictions as Contact Precautions, they are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of indwelling medical device that placed them at higher risk. The Facility's Long-Term Care Application for Medicare and Medicaid, CMS 671, dated 11/18/24, documents there are 58 residents living in the facility.

Based on observation, interview, and record review, the facility failed to ensure food was stored in a manner that prevents potential contamination and failed to ensure required kitchen staff wear beard coverings. This has the potential to affect all 58 residents living in the facility. Findings include: On 11/19/24 at 9:26 AM, an initial tour was conducted of the kitchen and the following was noted: On 11/19/24 at 09:26 AM V10, Food and Beverage Manager, had a facial beard and was not wearing beard guard or cover. On 11/19/2024 at 9:40 AM, in the dry storage area, three bags of spaghetti noodles were open, unsealed, and not dated or labeled. A bag of dry corn cereal, dry multi-colored cereal, and dry frosted cereal were found to be open, unsealed, and not dated or labeled. A bag of all-purpose flour was open, unsealed, and not dated or labeled. On 11/19/2024 at 9:43 AM, in the walk-in refrigerator, a bag of shredded white cheese and a bag of shredded orange cheese were rolled up, unsealed and not dated or labeled. Two containers of barbeque sauce were open and undated. Two containers of chicken base paste were open and undated. On 11/19/2024 at 9:47 AM, in the walk-in freezer there were bags of French fries, garden vegetables, and egg omelets that were opened, but were not dated upon opening. All three bags had been opened and not resealed, leaving the content open to air. Solid ice noted to floor in the freezer. On 11/19/24 at 11:40 AM, V10 was not wearing a beard cover and had a beard. On 11/19/24 at 11:50 PM, V10 was preparing resident's food trays with no beard covering. On 11/19/2024 at 12:50 PM, there was condensation dripping from light fixture in walk in freezer. There was liquid dripping onto a large box containing seventy-five 4-ounce cartons of chocolate shakes. The pipes extending from the freezer condenser were covered with a solid ice build-up. There was a box of chocolate shakes under the condenser covered with a solid chunk of ice. Condensation was dripping from two conductor fans and piping underneath fan system onto another box of chocolate shakes. There was ice buildup on the floor of freezer, and on bottom of the freezer door. On 11/19/2024 at 2:14 PM, V10 was not wearing covering to beard. On 11/20/2024 at 12:54 PM, three bags of spaghetti pasta noodles that was previously observed opened are still not sealed or dated. A box containing graham cracker crumbs found open to air. Four bags containing dry cereal continues to be rolled up, not secure, or dated. On 11/20/2024 at 12:56 PM, a line of ice noted to the floor in front of the freezer door. Freezer's light fixture is covered with icicles. There continues to be a box of chocolate shakes covered in a thick layer of ice from drippings of condenser fan. The pipes under the condenser fan are covered in ice. There were boxes of hushpuppies, egg omelets, fried eggs, and chicken tenders that had been opened and the plastic inside was not resealed, leaving the contents open to air. The boxes were not dated upon opening. On 11/21/2024 at 2:20 PM, a line of frozen ice still on floor and in front of door in the walk-in freezer. Light fixture still covered with icicles. There continues to be a box of chocolate drinks covered in a thick layer of ice. The pipes under the condenser fan continue to be covered in ice. On 11/21/2024, at 2:20 PM, V10 denied any current issues with the freezer and stated the freezer is serviced monthly. V10 stated the ice formations in the freezer are likely due to the staff coming in and out of the freezer frequently and for long periods of time. V10 stated every now and then the freezer will have some condensation and it will drip, however there is not a current system issue with the freezer. V10 stated he expects the kitchen staff to wrap, seal, label, and date all products once they are opened. V10 stated he is currently conducting in house training on the topic on food storage. V10 stated all kitchen staff is expected to wear a hair covering. V10 stated staff who have beards that are crazy are expected to wear a beard covering especially if they are a cook or aide. V10 still currently not wearing a beard covering. When asked about beard covering V10 stated it is no shave November and he usually does not have a beard. The facility's Hair Restraint/Jewelry/Nail Polish undated policy documents, Food and nutrition service employees shall wear hair restraints and beard guards. Hairnet will be worn at all times in the kitchen. [NAME] guards or masks will be worn as indicated. The facility's Food Storage (Dry, Refrigerated and Frozen) policy reviewed 08/12/2023 documents food storage areas will be clean. Dry, and maintained at temperatures as required to ensure food safety. Food shall not be stored in any of the following areas: under leaking water lines, sprinkler head or condensers. All open products (as able) will be sealed (rolled, closed, wrapped closed, with lid closed, etc.) to ensure quality and prevent contamination against pests or rodents. Goods that have been opened with no date, left on the floor, or not properly sealed will be discarded. Dry foods: all open products are sealed, labeled, and dated. Refrigerated foods: open products are sealed, labeled, and dated. The Facility's Long-Term Care Facility Application For Medicare And Medicaid dated 11/18/24 documents there are 58 residents living in the Facility.

Based on observation, interview, and record review, the facility failed to develop a comprehensive policy and procedure for Quality Assurance Improvement Plan and failed to ensure corrective actions/performance improvement is sustained. This has the potential to affect all 58 residents living in the facility. Finding include: 1. On 11/18/24, the facility provided Quality Assessment and Assurance Policy, effective date of 11/28/16. This was a one-page document. The policy documents The committee will: Meet at least quarterly, and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality improvement projects required under the QAPI program, are necessary; AND Develop and implement appropriate plans of actions to correct identify quality deficiencies; AND Regularly review and analyze data, including data collected under the QAPI Program and data resulting from drug regimen review, and act on available data to make improvements. This policy did not address procedures regarding how the facility will obtain feedback from residents and staff, how data will be collected and monitored, and how the facility will identify, report, track and monitor concerns. On 11/21/24, at 9:51 AM, V1, Administrator, confirmed that the policy given was the only policy for QAPI. V1 stated that there was no policy or documentation regarding the process and explanation of the process. V1 stated she could update the policy. 2. The last annual survey, dated 12/14/23, the facility was cited pharmacy services related to label/store drugs and biologicals. On 11/19/24, at 8:47 AM, V5, Licensed Practical Nurse, LPN, was passing medication. V5 had multiple cups of medications prepared with no labels indicating residents' names. At 8:55 AM, V5 stated, I just go in order, room number so I don't label the cups. During the medication storage labeling review, on 11/20/24 at 12:45 PM, there was a medicine cup with three pills in the top drawer of the medication cart on C-hall. V9, LPN, noted that she had prepared medications for R168 in the morning but R168 did not want the medications, so she was holding the medication. The cup was not labeled as to the contents or the resident's name. In this medication cart was an Insulin pen with no name or date on it. There was a vial of Tuberculin with no opened date and the box noted it should be stored in the refrigerator. There were miscellaneous pills stored in the section of the top drawer and no labeling as to who these pills belong to. On 11/21/24, at 9:51 AM, V1 stated that the Pharmacy Service deficiency cited last year, the facility did in servicing, daily rounds for 3 months and then backed off because they were in compliance. V1 stated that the nurse manager will do daily audits, check rooms for pre-poured medications, and CNAs will report if they see any medications left in the room. She was unaware of the issue regarding labeling and storing of medications. On 11/21/24, at 10:59 AM, V2, Director of Nursing (DON), stated she was not aware of the pre-pouring of medications and labeling issues noted during the current survey. V2 stated after the facility was cited for Pharmacy Services the last previous survey, they provided education, did audits, came in on all shifts and weekends, and would randomly audit the medications carts. The facility's Long-Term Care Application for Medicare and Medicaid, dated 11/18/24, documents the facility has 58 residents.

Based on observation, interview and record review, the facility failed to post the daily nursing staff hours daily. This failure has the potential to affect all 58 residents residing in the facility. Findings include: On 11/19/24 at 11:30 AM, the survey team observed the posted daily nursing staffing hours by the front entrance to the facility. This document was dated 11/14/24. On 11/20/24 at 1:43 PM, V1, Administrator stated that the nursing department hours are supposed to be posted every day and she does not know why it had not been posted since 11/14/24 when the nursing department staffing post was observed by the survey team on 11/19/24. V1 stated V21 is responsible for posting the daily nursing department staffing hours. On 11/21/24 at 10:08 AM, V21, Scheduler stated that she is the one responsible for posting the daily nursing department hours. V21 stated that she does not know who is responsible for posting the nursing department hours on the weekends. V21 stated that her shift does not start until 10 AM and she does not know why the last daily nursing staff hours posted was dated 11/14/24 when observed by the survey team on 11/19/24. On 11/25/24 at 11:15 AM, V1, and V2, Director of Nursing (DON), both stated the facility does not have a policy for posting their staffing available for everyone to see. The CMS 671 Form dated 11/18/2024 documents there are 58 residents residing at the Facility.

Based on interview and record review, the facility must have an Infection Preventionist (IP) who has completed professional training before becoming the IP in the facility and implements infection control procedures which is applicable with standards of practice. This has the potential to affect all 58 residents living in the facility. Findings include: 1. On 11/21/24 at 11:11 AM V2, Director of Nursing (DON)/Infection Preventionist (IP) stated she been at the facility for the last 2 years and has been doing the infection control for about 1 year. She stated she just recently got her certification. V2 stated that currently she does not track or trend employee illness as part of the infection control program. V2's Center's for Disease Control and Prevention (CDC) certificate for Completion for Nursing home Infection Preventionist Training Course was dated 10/29/24. On 11/21/24, at 1:19PM, V1, Administrator stated I do have my certification but (V2) is in charge of infection control. I actually did infection control during COVID, but she does it now. 2. On 11/18/24, the facility provided the infection control log. There was no infection control log for November 2024. On 11/19/24, at 2:54 PM, V2 stated the infection control log was a work in progress. On 11/21/24, at 11:11 AM, V2 stated that she did not have the November 2024 infection control log done. She stated that her procedure was to pull the antibiotic list from the facility's system and then transfer that information on the log. 3. During the survey from 11/18 through 11/21/24, R6 and R119 were receiving antibiotics for Urinary Tract Infections. R6's Physician's Order, dated 11/9/24, documented she received ciprofloxacin hcl (antibiotic) for urinary tract infection (UTI). There was no urinalysis or culture and sensitivity in R6's medical record. R119's Physician's Order, dated 11/20/24, documented he was to receive Macrobid (antibiotic) daily and no stop date-prophylactic tx (treatment). There was no urinalysis or culture and sensitivity in R119's record or medical justification for the use of the prophylactic antibiotic. On 11/21/24, at 11:11 AM, V2 stated that she does not always ask for or follow-up with the hospital to obtain culture and sensitivity if the resident is admitted with from the hospital on an antibiotic for UTI. She also stated that if a resident is on an antibiotic they will ask the physician why. 4. During the survey from 11/18 through 11/21/24, the R119 had a suprapubic catheter, R41 and R118 had indwelling catheters, and R31 had a gastrostomy tube. None of these residents were on Enhanced Barrier Precautions. On 11/21/24 at 11:43 PM, the infection control binder provided by V2 contained signage for contact, and droplet transmission precaution. There was none for enhanced barrier precautions. V2 stated the facility does not use Enhanced Barrier Precautions. V2 stated she was aware that the facility should implemented EBP, but they just started to talk about this in the last few weeks. I know we should. She was unable to identify any resident in the facility who may require EBP. The Centers for Disease Control and Prevention (CDC), website, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), April 2, 2024, documents Because enhanced Barrier precautions do not impose the same activity and room placement restrictions as Contact Precautions, they are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of indwelling medical device that placed them at higher risk. On 11/25/24 at 11:55 AM, V2 stated We don't have a policy on Infection Preventionist or the job description for the IP position, that is something that we have to work on yet. The facility's Long-Term Care Application for Medicare and Medicaid, CMS 671, dated 11/18/24, documents the facility has 58 residents.

Based on observation, interview, and record review, the facility failed to safely prepare medication, properly store medication, and to date medication bottles when opened, the Tuberculin (TB) vial was opened and undated and is used for all staff and residents. This has the potential to affect all residents living at the facility. Findings include: On 11/19/24 at 8:55 AM, V5, LPN (Licensed Practical Nurse) was observed with 5 unlabeled medication cups containing multiple pills that were placed on top of the F hall medication cart. Surveyor asked V5 how she safely administers the medications to the residents when the cups are unlabeled and already pre-poured into the individual unlabeled medication cups. V5 stated I just go in order by room number, so I don't label the cups. V5 then proceeded down the F hall with the 5 medication cups in her hands and passed the medications to R64, R47, R44, R27, and R17. V5 did not perform hand hygiene at any time during administration of the medications. V5 assisted with repositioning R47 during this observation and at no time did V5 perform hand hygiene before nor after caring for R47. V5 then proceeded to administer medications without the benefit of hand hygiene. V5 did not document the medication administration immediately after administering the medication to each of the 6 residents who received the pills from the unlabeled medication cups. On 11/20/24 at 1:10 PM, V11, LPN stated that she does not pre-pour resident medications and that she administers medications to the residents one at a time so she can check the medications against the MAR (Medication Administration Record). V11 stated it is not the facility procedure to pre-pop medications for the residents. V11 stated that she performs hand hygiene before and after each resident during medication administration. On 11/20/24 at 1:43 PM, V1, Administrator stated that the facility nurses are not supposed to pre-pour medications and that the nurses should be performing hand hygiene before and after each resident. 44967 On 11/19/24 at 9:32 AM, V9, LPN, was seen passing meds to R8 while eating breakfast, there was no hand hygiene seen done before or after meds given. On 11/19/24 at 11:25 AM, V9 was seen passing meds to R48, with no hand hygiene done prior to or after meds given. On 11/19/24 at 11:33 AM, V9 was seen transferring a resident to the dining room, then went back to give meds to R171 with no hand hygiene prior to giving R171 meds. V9 gave R171 Gabapentin 100 MG X 2 (200 MG). On 11/20/24 at 12:45 PM, C-Hall medication cart was inspected with V9. Upon opening the cart, a unlabeled medicine cup with three miscellaneous pills was seen sitting in the top drawer. V9 stated I know exactly whose those are, they are for (R168) I popped them out and put them in the cup and took them to her, and she did not want to take all of her morning meds, so I have been holding them for her. She just told me she wants them now. I did document that they were already given this morning. Also in the med cart was an Basaglar Insulin pen with no name or date on it. There were miscellaneous pills in sections of the top drawer: Amoxicillin 250 MG X 2, Zofran 4 MG X 4, Zofran 8 MG X 1, Cefdinir 300 MG X 1, Glipizide 5 MG X 1, and Doxycycline 100 MG X 1. A Tuberculin (TB) Vial 5 ML was in the top drawer open with no open date and box indicated to be stored in the refrigerator. V9 stated Yes, that TB is supposed to be in the fridge and dated when opened. It is used for all residents and staff. On 11/20/24 at 1:45 PM, V9 stated I did just give (R168) her medications and I amended the Medication Administration Record (MAR) to reflect this. On 11/21/24 at 10:55 AM, V17, LPN, stated I usually put the med cart in the middle of the hallway and will prepare each resident's meds one by one. I will then walk the cup of meds to the resident and watch them take them. I never prepare multiple residents at the same time. If a resident refuses or only wants to take part of the meds, I would let the DON know and then waste those meds not taken. I never leave the cup of meds at the bedside for the resident to take on their own. The facility's Storage of Medications policy, undated, documented Purpose: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Procedure: 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. 2. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 5. Hazardous drugs are clearly marked and stored separately from other medications. 6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. 7. Mediations requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly. 8. Schedule II-V controlled medications are stored in separately locked, permanently affixed compartments. Access to controlled medication is separate from access to non-controlled medications. a. Controlled medications that are part of a single unit dose distribution system may be stored with non-controlled medications when the supply is minimal, and shortages are readily detectable. The facility's Medication Administration policy, undated, documented Orders: 1. Do not give any medication without a physician's order. 2. Before a medication is crushed, make sure the rug is allowed to be crushed. 3. Six Rights of Medication Administration a. Right Drug b. Right Guest c. Right Time d. Right Dose e. Right Form f. Right Route. Preparation: 1. Medication Administration Record (MAR) must always be used when giving any medication. 2. Timing must be appropriate. This includes one hour before and after scheduled times: at least 30 minutes prior to meals if medication is ordered or scheduled before meals; one hour after meals if medication is scheduled after meals; with the meal if ordered this way by the physician. 3. Read the label and compare to the MAR. It continues Administration of Oral Medications: 1. Identify the guest by either looking at their photo or asking them to verify their identity. 2. Take blood pressure or pulses before administration of medications, as order by the physician. 3. Answer any questions that the guest may have regarding their medications. 4. Administer the medications with at least 4 oz of water. 5. Observe the guest swallow the medication. 8. document the medication immediately after giving the medication. Best Practices: Be aware of your time window for passing medications. Ensure hand hygiene between guests. Observe the guest take their medications unless they self-administer. Do not administer medications from unlabeled container or if label is not legible.

Based on Interview, Observation, and Record Review, the facility failed to provide complete and timely incontinent care for 4 of 5 residents (R11, R48, R176, R27) reviewed for incontinent care in the sample of 44. The findings include: 1. R11's Facesheet, undated, documents R11 was admitted to the facility on [DATE] with diagnosis of Internal right knee prosthesis, Sepsis, Encephalopathy, Type 2 Diabetes Mellitus (DM), Parkinson's disease, Depression, and Benign prostatic hyperplasia (BPH), Overactive bladder, and Dementia. R11's Care Plan, dated 11/11/24, documents At risk for falls related to weakness, impaired mobility, balance, age. R11 is alert and oriented with confusion at times related to dementia. R11 has had falls in the past 6 months/year, but number is unknown. Interventions: Toilet after meals, educate wife to notify staff when leaving, bed and chair alarm, fall risk assessment on admit and per protocol, keep personal items and frequently used items within reach, encourage to call for assistance as needed, assist to toilet upon request, fall risk. It continues R11 has an Activities of Daily Living (ADL) deficit. Interventions: R11 requires assist of two with transfers and 1-2 with ADL's. R11 has a bed/chair alarm, and the bed is in low position. There are no other interventions for fall precautions seen in R11's room. R11's Minimum Data Set (MDS), dated [DATE], documents R11 has a moderate cognitive impairment and requires partial/moderate assistance from staff for ADLs. R11 is occasionally of both bowel and bladder. On 11/20/24 at 10:00 AM, R11 sitting in recliner with Intravenous (IV) antibiotic running into left upper arm Peripheral Inserted Central Catheter (PICC) line. R11 had t-shirt on and no pants, only an incontinence brief which appeared to be saturated. R11 has his wife V4, and visitors in the room with him. R11 was seen with a folded bath blanket across his lap and kept pulling it up to cover himself with it. V4 was visibly upset and in tears. V4 stated she arrived to the facility around 9:00 AM this morning and found R11 like this. V4 stated that R11 wanted to use the restroom and she put the call light on, and a Certified Nursing Assistant (CNA) came in and stated she couldn't get R11 up until the nurse disconnects his IV and that the CNA let the nurses know. V4 stated R11's IV pump had been going off for at least 30 minutes and they still have not gotten anyone in the room to assist R11. V9, Licensed Practical Nurse (LPN), was notified and stated she was not able to disconnect R11's IV due to the PICC line and that it had to be a Registered Nurse (RN). V13, RN, entered to disconnect R11's IV. V14, CNA, entered to assist R11 to restroom. V14 stood and walked to restroom to use toilet and upon standing, R11's incontinence brief dropped to the floor due to being so heavy and saturated with urine, and R11's chair alarm did not go off. V14 held R11's brief up while R11 walked to the restroom and was assisted to the toilet. R11 stated he thought he was going to try and have a bowel movement. On 11/20/24 at 10:13 AM, after R11 used the toilet, V7, CNA, and V14, CNA, assisted R11 from the toilet to the shower to get cleaned. No checking or wiping of R11 buttocks/anal area was seen done after R11 stood from toilet and assisted to the shower. A slight amount of feces noted on some toilet paper in the toilet from R11 attempting to wipe himself prior to getting up. On 11/20/24 at 10:20 AM, V13, RN, stated that she was the one who got R11 out of bed and to his chair this morning to start his IV antibiotic. V13 stated she did not perform incontinent care at that time. On 11/20/24 at 10:25 AM, V7, CNA, stated that she normally gets R11 out of bed and to the shower early morning and she cleans him up at that time. V7 stated when she walked in, the nurse had already gotten R11 up to a chair and she could not get him up or to the toilet with the IV infusing. V7 stated she did not do incontinent care on R11 this morning. On 11/21/24 at 9:20 AM, V14, CNA, stated I round on my residents every two hours and provide peri-care at that time if needed. I change my gloves when they are visible soiled and when going from dirty to clean areas. On 11/21/24 at 10:45 AM, V2, Director of Nurses (DON), stated I would expect the staff to provide timely and complete incontinent care, including proper cleaning of the peri-area by retracting foreskin in an uncircumsized male. I would expect the staff to change their gloves when soiled and when going from dirty to clean areas, and to do hand hygiene before, in between glove changes, and after care provided. 2. R48's Facesheet, undated, documents R48 was admitted to the facility on [DATE] with diagnosis of Rhabdomyolysis, Neuropathy, Constipation, Depression, Hypertension, and Falls. R48's Care Plan, dated 11/12/24, documents R48 has an ADL deficit. Interventions: Assist to bedpan/toilet upon request and per mobility kardex instruction. It continues R48 has potential for skin impairment. R48's MDS, dated [DATE], documents R48 is cognitively intact and is dependent on staff for toileting. R48 is occasionally incontinent of urine and always continent of bowel. On 11/20/24 at 12:58 PM, V6, CNA, and V14, CNA, provided incontinent care to R48. A basin of soapy water with a few washcloths, a package of wipes, and linen were on the bedside table. R48's incontinent brief was unfastened and tucked between R48's legs. V14 used a disposable wipe to wipe R48's left groin, R48 was rolled to his right side showing a large bowel movement (BM). V14 used a wet washcloth to wipe R48's anal area and using the same soiled gloves, obtained another wet washcloth from the basin of water, contaminating the clean water with feces soiled gloves. V14 used the bath blanket under R48 to wipe more feces off his buttocks, then tucked it under him. V14 continues to grab wet wipes from the package and wet washcloths from the basin of water with soiled gloves on. R48 was rolled to his back and cream applied to his groins and testicles. There was no cleaning of R48's penis, including retracting the foreskin, at any time. V14 applied a clean incontinence brief to R48. 3. R176's Facesheet, undated, documents R176 was admitted to the facility on [DATE] with diagnosis of Atherosclerotic Heart Disease (ASHD), Non-ST Elevation MI (NSTEMI), Abdominal Aortic Aneurysm, Congestive Heart Failure (CHF), Atrial Fibrillation, Cerebral Infarction, Major Depressive Disorder, Anxiety Disorder, and Emphysema. R176's Care Plan, dated 10/11/24, documents R176 has an ADL deficit. Interventions: Assist to bedpan/toilet upon request and per mobility kardex instructions. R176's MDS, dated [DATE], documents R176 is cognitively intact and is dependent on staff for toileting. On 11/19/24 at 1:30 PM, V6, Certified Nursing Assistant (CNA), and V8, CNA, performed incontinent care on R176. Only supplies brought in was a pack of wipes, a clean incontinence pad, and a new incontinence brief. V6 held R176 while V8 performed incontinent care. Soiled brief unfastened and tucked between R176's legs. V8 got a wipe from the package and wiped R176's right groin, left groin, then down middle of her vagina. V6 then rolled R176 over to her right side, V8 used the same soiled gloves and obtained more wipes from the package, wiping R176's anal area with feces. V8 grabbed more wipes out of the package several times using the same soiled gloves to clean R176's anal area, and then buttocks. V8 then doffed her gloves, washed her hands, and donned new gloves, then put a clean incontinence pad on bed, wiped A&D ointment on R176's buttocks/anal area, then put new brief on R176. R176's buttocks and anal area appeared reddened with V8 stating that R176 had a yeast infection all over and was using Nystatin cream and it is getting better now. There was no drying of R176 during peri-care or before applying a clean incontinent brief. 49494 #4) R27's face sheet, undated, documented R27 has diagnoses of dementia, hemiplegia and hemiparesis secondary to a cerebrovascular accident, atherosclerotic heart disease, anxiety, and neuromuscular dysfunction of bladder. R27's MDS dated [DATE], documented R27 is severely cognitively impaired. R27's MDS, dated [DATE], documented R27 is incontinent of bowel and bladder and requires extensive assistance with ADLS. On 11/19/24 at 1:19 PM V15 CNA was observed as she entered R27's room with a sit to stand lift. V15 did not perform hand hygiene upon entering R27's room. V15 then placed the lift sling under R27. V15 then exited the room without performing hand hygiene. V15 then returned to R27's room along with V16 CNA. V15 nor V16 performed hand hygiene prior to transferring R27 from wheelchair to bed with the sit to stand lift. V15 and V16 then washed their hands and donned gloves. V15 then removed R27's pants and urine saturated disposable brief. V15 then cleansed R27's inner thighs and then cleansed R27's penis without cleansing the urethra region nor scrotum. V15 nor V16 dried R27's frontal region. V15 and V16 then rolled R27 onto his right side. V15 cleansed R27's buttocks and then placed a new adult brief on R27. V15 did not dry R27's buttock. V15 stated that she forgot to bring any towels into the room. R27's buttock appeared reddened. V15 nor V16 applied barrier cream on R27's buttock. V15 then covered R27 up while wearing the same disposable gloves that was used during incontinent care. V15 and V16 then removed their gloves and exited R27's room without performing hand hygiene. The facility's Incontinent/Perineal Care policy, undated, documented Purpose: It is the policy of the facility to provide incontinent/perineal care for the guests as indicated by the guest's condition and ability to provide self-care. Perineal care will cleanse the perineum and prevent infections and odors. Incontinent care will include all skin surfaces exposed to urine and/or feces. Procedure: Use the following procedure when providing perineal care to a guest while in bed. Explain the procedure to the guest. Assemble any necessary equipment to the bedside. (No rinse cleanser, washcloths and towels. Provide privacy to the guest. Wash your hands and put on gloves. Expose the perineal area and drape the guest to avoid any unnecessary exposure. Moisten the washcloth with warm water and no rinse cleaner. Cleanse the area, wiping from front to back to avoid the spread of germs. Cleanse al skin areas that have been exposed to urine and/or feces. Repeat cleansing, if necessary, using each cloth only once. Pat dry. Apply protective barrier cream or ointment if the guest is incontinent and/or susceptible to moisture. If the guest has a catheter, cleanse the catheter from the meatus down the catheter about 4 inches. Separate the labia for females. If uncircumcised male, retract the foreskin gently. Remember to pull foreskin back after the procedure. Remove and discard soiled gloves after completing perineal care and prior touching anything clean (sheets, blankets, etc.). Wash your hands. Position and cover the guest for comfort. Ensure the call light is within reach of the guest. Remove any dirty linen or trash. The Facility's Hand Hygiene Policy, undated, documents Purpose: The facility considers hand hygiene the primary means to prevent the spread of infection. Procedure: 2. All employees shall follow the hand hygiene procedures to help prevent the spread of infection to other employees, guests and visitors. 5. Employees must wash their hands for at least fifteen seconds using soap and water under the following conditions: when hands are visibly soiled (soap and water), before and after direct guest contact for which hand hygiene is indicated by acceptable professional practice, before and after assisting guests with meals, before and after assisting a guest with personal care, before and after assisting a guest with toileting.

Based on interview and record review, the facility failed to develop and implement a comprehensive care plan for 3 of 15 residents (R14, R18, R35) reviewed for care plans in a sample of 44. Findings include: 1.) R14's face sheet, undated, documented R14 has diagnoses including major depressive disorder and anxiety disorder. R14's physician orders document orders for buspirone 15 mg 1 tab bid (two times per day) for anxiety disorder with a start date of 6/4/24 and an order for citalopram 10 mg daily for depression with a start date of 6/4/24. R14's care plan, dated 11/17/24, does not address R14's diagnoses of major depressive disorder and anxiety disorder. The facility also failed to address R14's need and orders for the prescribed psychotropic medication nor does R14's care plan document any care approaches/interventions for R14's diagnoses of depression and anxiety. 2.) R18's face sheet, undated, documented R18 has diagnoses including vascular dementia and altered mental status. R18's physician progress note, dated 10/25/24, documented vascular dementia, mild, with mood disturbance. This physician progress note documented HPI (History of Present Illness) [AGE] year-old female being seen today for nursing home follow-up. She has had 1 hospitalization this year which was to local hospital at the beginning of April for altered mental status. At this time, it was ultimately felt to be likely due to her untreated sleep apnea. Patient continues to be noncompliant with her CPAP and diet restrictions for weight loss. It continues, nursing staff report that in the evenings the patient becomes very agitated, verbally fights with staff, and refuses care. SLUMS (mental exam) done on 10/13/24 was a 12/30 indicating dementia. R18's care plan, dated 11/18/24, does not address R18's diagnoses of dementia nor does it document any care approaches for R18's dementia diagnosis. 3.) R35's face sheet, undated, documented R35 has diagnoses including traumatic subdural hemorrhage, anemia, anxiety, and atherosclerotic heart disease. R35's progress note, dated 10/15/24 at 7:15 AM documented writer placed call to local hospital ER (emergency room ), RN (Registered Nurse) currently overseeing R35 stated that resident is currently seeing plastics for hematoma on left forearm and will call facility if resident will be discharged or admitted . R35's fall/event investigation, dated 10/14/24, documented investigation of R35's arm injury concluded R35 bumped her left forearm while propelling self in wheelchair causing the arm injury. R35's weekly skin progress note dated 10/29/24 at 2:16 PM documented writer saw resident today for weekly skin check and obtained the following information. Large wound to LFA (left forearm) measuring 8.3 cm x 5.2 cm x 0.5 cm. Wound bed is red. Packed with NS (normal saline), dry dressing, and kerlix. Ace wrap from fingers to above elbow. Guest is getting skin graft done on 10/31/24. R35's local hospital patient discharge plan, dated 10/31/24, documented R35 had a split thickness skin graft surgical procedure to left forearm secondary to a hematoma. R35's care plan, dated 10/20/24, documented Problem: Potential for skin impairment related to impaired mobility. Guest admits with scattered bruising to BUE (bilateral upper extremities) in various stages of healing and scar to abdomen. 9/26/23 S/T (skin tear) lower left arm. 11/13/23 S/T to lower left arm. 11/13/23 S/T healed. 10/16/23 S/T left lateral elbow. 10/23/23 S/T healed. R35's care plan does not document anything regarding R35's arm injury that occurred on 10/14/24 nor does it address any skin care approaches/post-surgical care for R35's left arm skin graft. The facility also failed to care plan the root cause of R35's arm injury that occurred on 10/14/24 nor did the care plan document any new interventions to prevent R35 from developing any new skin impairments. The facility's Care Plan policy, dated 11/14/16, documented Policy: An individualized person centered care plan, consistent with resident rights that includes measurable objective and time tables to assist the resident to attain or maintain the resident's highest practicable physical mental and psychosocial needs, is to be developed by the interdisciplinary team for each resident within 7 days after completion of the comprehensive assessment. It continues, the person centered care plan identifies the services that are to be furnished to attain or maintain the resident practicable physical, mental and psychosocial well-being, as well as services that would otherwise be required but are not provided due to the resident's exercise of rights including the right to refuse treatment. The care plan is designed to: incorporate identified problem areas, incorporate identified problem areas, incorporate risk factors associated with identified problems; build on resident strengths/needs; reflect resident goals for admission, care and treatment; reflect treatment goal time tables and objectives; outcomes; identify professional services that are responsible for each element of care aide in prevention or reduction of decline in resident functional status.

Based on Interview, Observation, and Record Review, the facility failed to provide and implement safety measures to prevent a resident from falling, failed to complete a Fall Risk Assessment after a fall for 1 of 8 residents (R11) reviewed for falls in the sample of 44. Findings include: R11's Facesheet, undated, documents R11 was admitted to the facility on [DATE] with diagnosis of Internal right knee prosthesis, Sepsis, Encephalopathy, Type 2 Diabetes Mellitus (DM), Parkinson's disease, Depression, and Benign prostatic hyperplasia (BPH), Overactive bladder, and Dementia. R11's Care Plan, dated 11/11/24, documents At risk for falls related to weakness, impaired mobility, balance, age. R11 is alert and oriented with confusion at times related to dementia. R11 has had falls in the past 6 months/year, but number is unknown. Interventions: Toilet after meals, educate wife to notify staff when leaving, bed and chair alarm, fall risk assessment on admit and per protocol, keep personal items and frequently used items within reach, encourage to call for assistance as needed, assist to toilet upon request, R11 is a fall risk. It continues R11 has an Activities of Daily Living (ADL) deficit. Interventions: R11 requires assist of two with transfers and 1-2 with ADL's. R11 has a bed/chair alarm, and the bed is in low position. There are no other interventions for fall precautions seen in R11's room. R11's Minimum Data Set (MDS), dated [DATE], documents R11 has a moderate cognitive impairment and requires partial/moderate assistance from staff for ADLs. R11 is occasionally of both bowel and bladder. The Facility's Fall Log, dated 5/19/24 through 11/19/24, documents R11 had a fall on 11/3/24 at 12:15 PM. Description: Was on the floor in his room. R11's Nursing Note, dated 11/3/24 at 12:21 PM, documents Guest was in his room sitting in bedside chair his wife left the room and closed the door when she returned the guest was on the floor and the alarm was sounding the bedside table was pushed out of the way and the w/c (wheelchair) was pushed towards the door and guest was on his bottom and legs out in front of him, guest is able to move all extremities without any discomforted, guest voiced that he needed to go to the bathroom, staff helped him up and placed in the w/c and was taken to the bathroom to get cleaned up after he was inc. (incontinent) of BM (bowel movement), writer took off the old dressing and checked his knee, all staples intact no open area to incision large amount of drainage noted on old dressing, area cleaned and new dressing applied, Dr. call a nurse was called and fall was reported, the wife here and is aware and looked at the knee manager on call aware. On 11/18/24 at 10:25 AM, V4, R11's Wife, stated (R11) has fallen once getting out of bed himself, and he had bleeding to his leg from the fall. (R11) has a bed/chair alarm that is about the only thing I am aware of for fall precautions. I was told that if I leave (R11's) room, I have to leave the door open so they know he is by himself. R11's Admission Fall Assessment, dated 10/29/24, documents R11 is a fall risk. There is no other fall assessment completed in R11's medical record, even after his fall on 11/3/24. R11's Fall Investigation, dated 11/3/24, documents Root Cause: Wife had been visiting and left without notifying staff and had closed door. Guest attempted to self transfer. staff did not hear alarm with door closed. Guest had been incontinent as well. Intervention(s): Educate wife to notify staff when leaving, toilet after meals - offer. On 11/20/24 at 10:00 AM, R11 sitting in recliner with Intravenous (IV) antibiotic running into left upper arm Peripherally Inserted Central Catheter (PICC) line. V14, CNA, assisted R11 to stand and walk to the restroom to use toilet. Upon R11 standing, his chair alarm did not go off and was not visible in his chair. R11's alarm pad was seen lying on his bed. On 11/20/24 at 10:55 AM, V4, R11's wife, stated (R11's) alarm is still on his bed and is not in his chair with (R11). V4 demonstrated this by sitting on R11's bed and getting up and the alarm went off. V4 stated They are supposed to put the alarm in his chair when they get him up. On 11/20/24 at 12:25 PM, V14, CNA, stated It makes sense to me, if a resident has a bed alarm and gets up to a chair, that alarm should be placed in his chair as well. On 11/25/24 at 10:40 AM, V2, Director of Nursing (DON), stated I would expect the staff to transfer the bed alarm to the chair when getting a resident up to a chair when that resident requires an alarm for fall precautions. A Fall Risk Assessment should be completed after every fall. The Facility's Falls Policy, undated, documents Purpose: To identify interventions related to the guest's specific risks and causes to try to prevent the guest from falling and to try to minimize complications from falling. Procedure: 4. The licensed nurse is responsible for completing a Fall Risk Assessment following a fall as well as identifying and implementing relevant intervention(s) to try to minimize serious consequences of falling.

The facility failed to provide Oxygen (O2) to a resident requiring O2 to maintain an O2 Saturation above 92%, to administer the correct O2 dose per physician order, and to change and date the humidified water bottle for 2 of 3 residents (R170, R175), reviewed for respiratory care in the sample of 44. The findings include: 1. R170's Facesheet, undated, documents R170 was admitted to the facility on [DATE] with diagnosis of Congestive Heart Failure (CHF), Neoplasm of esophagus, Malnutrition, Hypertension, Atherosclerotic Heart Disease, and Atrial Fibrillation. R170's Care Plan, dated 11/15/24, documents R170 requires hospice related to gastroesophageal cancer with (local hospice). Interventions: Notify Hospice when there is any change in condition, administer drugs as needed for palliation. R170's Care Plan does not mention R170 on oxygen (O2) or requiring oxygen. R170's Minimum Data Set (MDS), dated [DATE], documents R170 has a moderate cognitive impairment and is dependent on staff for all ADLs. On 11/18/24 at 10:00 AM, R170 was seen lying in bed on O2 at 2 Liters (L)/Nasal Cannula (NC) with humidity bottle attached, half full, and not dated. There is no sign posted (No Smoking/Oxygen in Use) indicating that R170 is on oxygen. On 11/19/24 at 9:12 AM, R170 asleep in bed, O2 on at 1.5 L/NC with the long NC tubing lying on the floor and appears coiled up in a pile, and was not on R170. The humidified bottle of water was just short of half full and was not dated. R170's Electronic Medical Record, under Vitals, dated 11/19/24 at 9:42 AM, documents O2 Saturation 90%. Oxygen Use: No. Respirations: 20 per minute. On 11/19/24 at 12:00 PM, R170 still asleep in bed with his O2 NC lying on the floor with O2 on at 1.5 Liters per minute (LPM). On 11/20/24 at 9:55 AM, R170 lying in bed with O2 at 1.5L/NC and appears to be same bottle of water which is now quarter full, and not dated. On 11/21/24 at 9:10 AM, R170 lying in bed with O2 on at 1.5 L/NC, the water humidifier bottle remains less then quarter full of water and not dated, appears to be the same bottle he has had since beginning of survey observation. R170's Physician Order (PO), dated 11/14/24, documents Oxygen at 1-5 LPM (liter per minute) PRN (as needed) via nasal cannula to maintain oxygen saturations above 92%. May increase liter flow an additional 2 liters as needed. If saturation level is not maintained, call physician. R170's PO, dated 11/14/24, documents Change oxygen tubing and humidifier bottle weekly. Once A Day on Wed. 2. R175's Facesheet, undated, documents R175 was admitted to the facility on [DATE] with diagnosis of Pneumonia, Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), and Obstructive Sleep Apnea (OSA). R175's Care Plan, dated 11/13/24, documents R175 has potential for acute signs/symptoms (s/s) of respiratory distress related to lung disease: COPD, OSA. Wears Bipap Hours Sleep (HS). O2/2L NC. Interventions: Change O2 tubing and humidifier as ordered/needed, Respiratory medications as ordered. Monitor for side effects. R175's MDS, dated [DATE], documents R175 is cognitively intact and requires partial/moderate assistance from staff for bathing, and dressing, needs supervision for transfers. On 11/19/24 at 9:23 AM, R175 sitting in wheelchair with 4 liters of Oxygen (O2) per NC on, R175 stated he is only supposed to be on 2 L/NC and not 4. There is no sign posted (No Smoking/Oxygen in Use) indicating that R175 is on oxygen. On 11/19/24 at 11:55 AM, R175's still has his O2 on at 4 L/NC. R175's PO, dated 10/24/24, documents Oxygen at 2 LPM continuously via nasal cannula to maintain oxygen saturations above 92%. May increase liter flow an additional 2 liters as needed. If saturation level is not maintained, call physician. R175's PO, dated 10/24/24, documents Change oxygen tubing and humidifier bottle weekly. Once a day on Wed. R175's Electronic Medical Record, under Vital Signs, dated 11/19/24 at 9:56 AM, documents O2 Saturation: 92%. Oxygen Use: No. Respirations: 22 per minute. R175's Electronic Medical Record, under Vital Signs, dated 11/18/24 at 19:04 PM, documents O2 Saturation 99%. Oxygen Use: Yes - Liter flow - 2. Respirations: 17 per minute. On 11/21/24 at 10:47 AM, V2, Director of Nursing (DON), stated The nurses are responsible for changing the humidified bottles for oxygen use weekly and they should be dating them when a new bottle is started. If a resident has a physician order to maintain an O2 sat above a certain number, then I would expect the staff to make sure the resident has his oxygen on and to adjust the oxygen as needed and per physician order. On 11/21/24 at 10:55 AM, V17, LPN, stated If a resident is on oxygen, I know the water bottle is supposed to be hooked up. I am not sure when to change the water bottle or the tubing. I would ask my DON and she would let me know. The Facility's Oxygen Administration Policy, undated, documents The purpose of this procedure is to provide guidelines for oxygen administration. The following equipment and supplies will be necessary when performing the administration of oxygen: 1. Portable oxygen cylinder. 2. Nasal Cannula or mask, as ordered by the physician. 3. Humidifier bottle if utilizing an oxygen concentrator. 4. No Smoking/Oxygen in Use sign. Procedure: 6. Place the Oxygen in Use sign on the outside of the room entrance door. Close to the door. 9. Place appropriate oxygen device on the guest (mask or nasal cannula). 10. Adjust the delivery device so that it is comfortable to the guest and the proper flow of oxygen is being administered.

Based on interview and record review, the Facility failed to re-evaluate the need for psychotropic medications for 2 or 6 residents (R19 and R6) reviewed for unnecessary medications, in the sample of 44. Findings include: 1. R19's Physician Order Report dated 10/21/2024-11/21/2024 documents R19 was prescribed alprazolam 0.5 milligrams (mg) BID (twice a day) as needed on 10/18/2024 and does not have an end date. 2. R6's Care Plan dated 3/14/2024 documents R6 requires hospice care related to senile degeneration of brain. (Hospice) to coordinate care. R6's Physician Order Report documents R6 was prescribed lorazepam 0.5 mg every four hours as needed on 3/21/2024 and does not have an end date. On 11/21/2024 at 8:34 AM, V2, Director of Nursing (DON) stated she is aware orders for psychotropic medications should be re-evaluated and the orders be re-written every 14 days. V2 stated she was not aware the same rules apply for hospice residents. As of 11/25/2024 at 10:40 AM, the Facility still had not provided a policy that addresses unecessary/psychotropic medications.

Based on observation, interview and record review, the Facility failed to follow their Facility Policy regarding tube feeding administration for 1 of 2 residents (R31) reviewed for enteral tube feeding, in the sample of 44. Findings include: On 11/18/2024 at 12:08 PM, there was a bottle of enteral tube feeding, with 200 milliliters remaining and a bag of water with 100 ml remaining, hanging without a date or time of when the feeding was opened. On 11/29/2024, at 9:32 AM, there was a bottle and water that had been spiked and was undated and no time to indicate when it was opened. R31's Physician Order Report dated 11/6/2024 documents, Monitor TF (Tube Feeding) through night to ensure it is still running. Replace bottle as needed and restart feeding. On 11/21/2024 at 8:32 AM, V2 Director of Nursing (DON) stated there should be a date and time to indicate when the tube feeding was opened. The Facility's Tube Feeding Management Protocol undated, documents, Purpose: to outline the nursing management of guests receiving continuous or intermittent enteral tube feedings via gastrostomy, duodenostomy, or jejunostomy tubes. Tube feeding are utilized to meet the nutritional needs when normal oral intake is altered or contraindicated. It further documents, Replace container/tubing/syringe every 24 hours. Discard unused or open container of feeding formula.

Based on interview and record review, the facility failed to ensure residents have services to provide a safe discharge from facility to home for 1 of 3 (R3) reviewed for orientation for discharge in the sample of 4. This failure resulted in R3 being discharged to home alone although the facility had assessed her as needing 24-hour care. This resulted in R3 having the inability to administer her medications as needed, having multiple falls requiring Emergency Medical Care, hospital admission, and subsequent readmission to facility on [DATE]. The findings include: R3's Face Sheet, undated, documents R3 was originally admitted to the facility on [DATE] and was discharged home on [DATE]. R3's Electronic Medical Record, documents R3's diagnoses includes Cerebral infarction, Anemia, Urinary Tract Infections (UTI), Hyperlipidemia, Hypothyroidism, Major depressive disorder, Anxiety disorder, Hypertension (HTN), Chronic Obstructive Pulmonary Disease (COPD), Arteriosclerotic Heart Disease (ASHD), Falls, Osteoarthritis, and Scoliosis. R3's Fall Assessment, dated [DATE], documents R3 is a High Fall Risk. R3's Minimum Data Set (MDS), dated [DATE], documents R3 is cognitively intact and required substantial/Maximal assistance with moving from sitting to standing, transfers, toilet transfers. R3's MDS documented she need partial to moderate assistance for walking at least 150 feet in a corridor. R3's Care Plan, initiated on [DATE], documented Discharge Planning- (R3) lived at home alone with help from her caregivers and home health therapy. Her family lives out of town and unable to help. She would like to return back home with her cat. The Interventions, dated [DATE], documented Identify probably services needed; Identify support system; Referrals as needed for post discharge. R3's Care Plan documented she was at risk for falls related to weakness, impaired mobility, balance, and age. On [DATE] at 9:05 AM, V6, Licensed Practical Nurse (LPN), stated When we are discharging a resident to home, I believe Social Service gets everything set up for home care. The day of discharge, we will go over the medications with the resident along with discharge instructions and send them home with everything. On [DATE] at 10:35 AM, V10, Social Service, stated (R3) did not have any local family. I believe her aunt lived out of state. R3's insurance had cut her off as of [DATE], and (R3) was discharged . I had everything set up for her. She already had Help at Home visits on Mondays through Fridays set up, so we were keeping that going. I also had Home Health set up and the nurse was going to be there within 48 hours. We could not keep her here. She would have received a bill and she said she could not pay that bill. What were we supposed to do? I understand that she would have been home by herself for the weekend, and that is not right, but there was nothing we could do. On [DATE] at 12:10 PM, R3 stated When I was discharged from the facility before, I thought they had Home Health set up for me. I already had most of the equipment I need at home from my husband, who died a few years ago, but what I really need was someone to come to my home and help me. I would have been afraid to go home without someone coming to help me. On [DATE] at 12:25 PM, V9, Licensed Social Worker (LSW) at (local hospital), stated I was familiar with (R3's) situation at home because I spoke with her at the hospital prior to her being discharged . (R3) had no family to assist her and was very concerned about her cat at home. I got ahold of (V11, pet sitter) who owns the (Animal Rescue Center), and she was willing to care for her cat until she made it back home. (R3) was discharged to (Facility) for rehab and when they discharged her, (V11) was the one who picked her up from the facility and took her home. (V11) called me back and stated that (R3) could hardly transfer herself from chair to chair or walk across the house to get needed items, like food and drinks. Home Health was set up, but from I understood, it was not going to happen for a couple of days after she was home. When she got home, there was a large bag of medications and (R3) said she wasn't sure which ones to take or when. This is what the concern was, she was going to be by herself for a couple of days and no one was able to help her. On [DATE] at 1:40 PM, V2, Director of Nursing (DON), stated (R3) had the right to go home and not stay here. She fell at home but that was more than 48 hours after discharge, so the Home Health nurses should have been doing something with her. I understand that she was sent home with no one to care for her for 48 hours, but she wanted to go home. The nurses went over the medications with (R3), and she had discharge instructions about her medications to take with her, and most of them she was already on at home, so probably understood when to take them. On [DATE] at 2:10 PM, R3 stated I don't have any friends or family anymore. My sister is really all I have, and she is in her 70's and lives in Florida. I did not feel safe going home from here, but I didn't have any other options. I figured therapy would not be doing anything with me over the weekend, anyway, so why not just go home. It was scary, so I just did the least amount of activity to stay safe. (V11) came and got me and took me home and got me settled inside, then she left. When I got home, I had all the medications in a bag and was confused what was what. I already had some pills in little plastic containers that I knew what they were, so I just took them until the nurse came in and figured it out. The nurse didn't show up until Monday. I live in a mobile home and get around the best I can by using a walker and holding onto furniture. I fell twice after I got home and both times, I had to use my emergency button and call 911. They showed up and took me to the ER (emergency room ). This next time I get discharged , I'm going to go live with my husband's family, they are getting me a room set up to live with them. On [DATE] at 2:41 PM, V11, R3's pet sitter/ride home, stated I work for the (Animal Rescue Center), and we have an agreement with (local hospital) for when patients are hospitalized and have no one to watch their pets, we go take care of their pets for them. (V9, Social Worker) called me and asked me to take care of (R3's) cat and that is how I got involved. I was in contact with (R3) about her cat, while she was in the facility, so when she was getting ready to be discharged , she called me and said the facility was going to charge her $150 to take her home and she couldn't afford that, so I went and got her. When we got to her home, it was disheveled and very difficult to walk around her house. When we got her in her house, she was so weak she could hardly do anything. I could not leave her like that, but I could not stay with her all night either. The facility called in prescriptions for her medications, so my friend went and picked them up and paid for them, then stopped and picked up some food and brought it back for her. I ended up calling (R3's) niece and explained what was going on to her and I believe she did come see (R3) at some time and ended up texting me and told me that (R3) needs twenty-four-hour care and should not be living by herself. On [DATE] at 4:00 PM, V1, Administrator, stated I would expect Social Service to plan and arrange a safe discharge for all residents, including appropriate home care and DME (Durable Medical Equipment) as resident requires. R3's Social Services Note, dated [DATE] at 2:00 PM, documents Social Service Discharge Planning: Insurance set the guest a discharge date for [DATE]nd. Writer made the guest aware and let her know that she does have the option to appeal it. She said she does not want to appeal it and signed the NOMNC (Notice of Medicare Non-Coverage). Writer asked if she wanted home health therapy, and she said yes. Writer let her know she will set up Advanced home health. Writer asked if she needed caregivers, and she said yes. Writer let her know she will send her referral to Senior Services. She said thank you. Writer asked if she needed any equipment, and she said no. Writer let her know that family would have to pick her up. She said she does not have anyone in town. Writer let her know she will call a local Transport Company transport and see if they could take her home. She said OKAY. R3's Social Service Note, dated [DATE] at 2:16 PM, documents Social Service Discharge Planning: writer sent the guest's referral to (Home Health Agent) with (Home Health Company #1 Name) home health. Writer faxed the guest's referral to agency to assist with Senior Services for caregivers. R3's Social Service Note, dated [DATE] at 3:05 PM, documents Social Service Discharge Planning: Advanced home health is unable to accept. Writer emailed the guests referral to (Home Health Agent) with (Home Health Company #2 Name) home health. R3's Social Service Note, dated [DATE] at 1:16 PM, documents Social Service Discharge Planning: the guest let therapy know she now needs a walker. Writer submitted for a 2 wheeled walker through (Medical Equipment Company) online portal. R3's Physical Therapy (PT) Note, dated [DATE], documents Response to Session Interventions: Good, some goals met, recommend home health and ,d+[DATE] care and to continue at home at WC level and ambulate with assistance only. R3's Physical Therapy Discharge Note, dated [DATE], documents Discharge Recommendations: Recommend senior services, home health to follow, ,d+[DATE] care and a two wheeled walker. R3's Social Service Note, dated [DATE] at 12:56 PM, documents Social Service Discharge Summary: (R3) discharged to home with help from a friend. AXO (alert and oriented). Follow up with PCP (primary care physician). Follow up with (Home Health Company #1) home health and help at home. Patient unable to pay for DME at this time will use her four wheeled walker at home. Belongings were sent home with the guest. R3's Social Service Note, dated [DATE] at 3:33 PM, documents Social Service Discharge Planning: writer called Dr. office and let them know that the guest discharged today, and the NP (Nurse Practitioner) would like a follow up in a week. Writer asked if she would call the patient with the appointment. She said she will give the message to the nurse. R3's Hospital Record, dated [DATE], documents [AGE] year-old female presenting after a fall. Patient was here yesterday with same complaint. She had x-ray hips and CT (cat scan) of the pelvis yesterday which were unremarkable. She also had a UA (urinalysis) that showed findings of UTI, but this was not treated since patient was reportedly asymptomatic. Since then, culture has grown >100,000 E coli. She had another fall today; says she is not eaten since yesterday morning because she has not been able to get up at home. Yesterday she refused ECF (extended care facility) placement. Today she is saying she still has bilateral hip pain, but it has not changed since yesterday. She has some complaints of rib pain and right arm pain which she says have been going on for some time. R3's Hospital Record/OT (Occupational Therapy) Note, dated [DATE], documents Safety concerns: home access, lives alone, Patient is unsafe to live independently at home at this time. Will require (at a minimum) 24 hour assist at home. OT recommends ECF (extended care facility) stay following discharge. Problem list: impaired activity tolerance, impaired balance, impaired safety awareness, difficulty with bed mobility, difficulty with transfers, difficulty with activities of daily living, difficulty with instrumental activities of daily living, Frequent falls. R3's Nurse's Note, dated [DATE], documented The guest is a [AGE] year-old female admitted on [DATE]th following repeated falls. R3's Care Plan, dated [DATE], documents R3 has an ADL (Activities of Daily Living) deficit. Interventions: transfer/mobility per therapy recommendations, provide set up for meals as needed, assist with hygiene as needed, encourage oral care BID (twice daily) as needed, assist to bedpan/toilet upon request, provide physical assistance for dressing as needed. The facility's Discharge Planning Policy, dated [DATE], documents To ensure appropriate discharge planning and communication of necessary information to a continuing care provider if indicated. The facility's Addendum to the Transfer/Discharge Policy, dated [DATE], documents The facility will provide and document sufficient preparation and orientation to residents to ensure a safe and orderly transfer or discharge from the facility. The orientation will be provided in a form and manner that the resident understands.

Based on observation, record review and interview, the facility failed to timely obtain pressure ulcer treatment orders from a physician, perform routine skin assessments, routinely monitor and assess pressure ulcers, and develop pressure ulcer prevention interventions for seven of eight residents reviewed (R4, R5, R7, R11, R12, R3, R9) for pressure ulcers in a sample of 13. These failures resulted in R4 developing a Stage 4 pressure ulcer on the coccyx, which became infected, led [MEDICAL CONDITION] and R4's subsequent death on [DATE]; R5 developing a Stage 4 pressure ulcer on the coccyx, which became infected and required hospitalization ; R7 developing a deep tissue injury to the calf after staff failed to routinely assess R7's skin while using a leg immobilizer, prolonging his admission; R11 developing a Stage 3 pressure ulcer on the right heel and a Stage 2 pressure ulcer on the left heel; R9 having a Stage 2 coccyx wound that progressed to a Stage 3; and R12 having a pressure ulcer on the Right Ischium that progressed from a Stage 2 pressure ulcer to a Stage 3 pressure ulcer. These failures resulted in Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at Severity Level 2, while they monitor the implementation of their new policies and procedures and the inservicing of staff. Findings include: The Immediate Jeopardy began on [DATE] when the facility failed to ensure R4 received timely and appropriate treatment of [REDACTED]. R4's pressure ulcer became infected, which led [MEDICAL CONDITION]. R4 expired on [DATE], due [MEDICAL CONDITION] from the infected coccyx wound. The State Agency informed the V1 (Administrator) and V2 (Director of Nursing) of the Immediate Jeopardy on [DATE] at 12:30 p.m. On [DATE] at 6:30 pm, the Immediate Jeopardy was removed, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility policy, titled Pressure Injury Prevention (no date), documents, Purpose: To prevent avoidable pressure injuries. Procedure: 1. personal care associates to inspect skin daily during care. Pay particular attention to bony prominence's. Report new skin irregularities to the nurse via a STOP and Watch. 2. Keep the skin clean and dry. Cleanse the skin with mild soap and water or a facility approved perineal cleanser after each incontinent episode and at routine intervals. Avoid very hot water. 3. Apply moisturizers to keep skin subtle. Apply moisturizers after bathing, thus reducing dryness. 4. Protect the skin from exposure to excessive moisture with a barrier product in order to reduce the risk of pressure damage. 5. Avoid massage over bony prominence's and reddened areas. 6. Avoid friction and shearing by using proper positioning, transferring and turning techniques. 7. Avoid positioning the guest directly onto medical devices, such as tubes, drainage systems or other foreign objects. 8. Do not leave guests on the bedpan longer than necessary. 9. Encourage adequate intake of calories and fluids. 10. Reposition guests frequently or as often as they will allow. 11. Utilize positioning devices to keep bony prominence's from direct contact with one another. Discourage use of ring or donut shaped devices. The edges of these devices create areas of high pressure that may damage tissue. 12. Float heels as guest will allow. Synthetic sheepskin pads, cutout ring, or donut-type devices should not be used to elevate heels as these products have been shown to have limitations. When floating heels, ensure that the heels are free of the surface of the bed. 13. Avoid positioning directly on the trochanter. 14. Use lifting devices to move guests in bed whenever possible. 15. Maintain the head of the bed at the lowest degree of elevation possible (consistent with the guest's medical condition). 16. Apply pressure-redistributing mattresses to the guest beds and wheelchairs as guest allows. 17. Keep linens as wrinkle free as possible. On [DATE], at 3:30 pm, V2 (Director of Nursing) stated the facility does not have any written policies or procedures related to the management of pressure ulcers/wounds once they develop, but they do have the expectation that staff will do daily skin checks, assess and measure any pressure ulcer on a weekly basis, document those findings, notify the physician of any observed changes and implement appropriate interventions to prevent pressure ulcers from worsening or new ones developing. On [DATE], at 2:29 pm, V14 (Certified Wound Specialist/Nurse Practitioner) stated the facility has an ongoing problem with the management of pressure ulcers and wounds. V14 stated the facility does not have a definitive wound protocol, and no one is developing a treatment plan for the residents who have pressure ulcers present on admission. V14 stated she has seen wound dressings on residents that have not been changed for three days. V14 stated patients are leaving this facility worse than when they came in. On [DATE] at 10:03 am, V3 (Wound Nurse/Registered Nurse) stated he started in that position late [DATE]. V3 stated the previous Wound Nurse had already left when he started, so he was given instruction by V2 (Director of Nursing). V3 stated he was told by V2 that wounds needed to be assessed weekly and within 24 hours of a residents admission and guided him on the computer program, but the remainder was trial and error. V3 stated that the facility did not have any written protocols for wound management, so he went forward with his position based on his experience working in a burn center. V3 stated if a resident is admitted with a Stage 1 or Stage 2 pressure ulcer, they will initiate a foam dressing and repositioning without a physician's orders [REDACTED]. There is no set guidance. We often don't call the physician (for orders) until the wound is a Stage 3. 1. The electronic medical record documents R4 was admitted to the facility on [DATE], following surgical repair of a Right Femur Fracture, for inpatient Physical and Occupational Therapy, and planned to discharge back to home. Nursing Notes, dated [DATE] at 4:11 am, document R4 had a pressure ulcer measuring 4.0 cm x 3.3 cm on her coccyx. R4's admission physician orders [REDACTED]. A Plan of Care, dated [DATE], documents R4 was determined to be Very high risk for skin breakdown (related to) impaired mobility, occasional incontinence. admitted with pressure wound to coccyx, (right) leg surgical wound and (bilateral upper extremity) bruising. A Braden Scale for Prediction of Pressure Sore Risk, dated [DATE], documents R4 was determined to be at moderate risk for the development of pressure ulcers, and instructs staff to do the following interventions: conduct a Braden risk assessment upon admission and weekly for four weeks, observe during care for any signs of breakdown, pressure reducing mattress on bed, pressure reducing wheelchair cushion when in wheelchair, preventative skin care as indicated, and treatment as ordered to the right lower extremity surgical wound. The initial Plan of Care for R4 does not instruct staff to turn and reposition R4, off-load pressure to the coccyx, or administer a treatment to the coccyx wound. An Admission Nursing Assessment, dated [DATE], documents R4 has an unstageable pressure ulcer with scant serosanguinous drainage. A Treatment Administration Record (TAR) for [DATE], documents the facility obtained an order to treat R4's coccyx wound on [DATE], four days after the wound was first noted to be present. The [DATE] TAR documents staff started treating R4's coccyx wound by covering it with a comfort foam dressing, which was to be changed every other day. On [DATE], R4's Plan of Care was updated with the intervention of treatments as ordered to coccyx, but still failed to indicate R4 needed to off-load pressure to the coccyx area or turn and reposition. A [DATE] Minimum Data Set assessment, documents R4 needs the physical assistance of ,[DATE] staff for bed mobility and transfers. The electronic medical record documents R4's weight had decreased from her admission weight of 105.6 pounds, down to 100.6 pounds on [DATE], and then decreased again on [DATE] to 98.8 pounds. The Progress Notes document R4 did not have another wound assessment until [DATE], nineteen days after the initial wound assessment of [DATE]. The [DATE] Progress Note documents R4's coccyx wound as being a Stage III the medial coccyx and measuring 5 cm x 2 cm (no depth measured), and the presence of a new Stage II pressure ulcer on the right medial buttock, measuring 1 cm x 1.5 cm. On [DATE], a physician's orders [REDACTED]. On [DATE] at 10:03 am, when V3 was questioned regarding R4's treatment orders for the coccyx wound not changing between [DATE] and [DATE], after the wound had progressed and an additional wound developed, V3 indicated he had implemented that treatment order and didn't call the physician. V3 did state he referred R4 to the wound clinic for evaluation, which she did go to on [DATE]. On [DATE], a Wound Care History and Physical by V14 (Certified Wound Specialist/Nurse Practitioner), documents the following: The patient is an [AGE] year-old female that was referred to the Wound Center from the Bridge Care Suites. I was notified approximately one week ago that the patient had a wound 'that might need to be seen.' I had the (facility) refer her to the wound clinic at that time. She has been at the Bridge since approximately the beginning of August after a [MEDICAL CONDITION]. She has a past medical history of [REDACTED]. I did speak to her son, who is her Power of Attorney, over the phone quite extensively about her history. She currently lives alone. However, at discharge he plans to have her live with him. I have also suggested that (extended care facility) placement would be appropriate. She does need 24 hour care. When the patient presented today, there is just a foam border dressing covering her wound and that was it. She is in a wheelchair with a cushion that was flat. She has Left Buttock Stage II pressure ulcer that was debrided using a scalpel. Her coccyx wound is very extensive and has large amounts of slough. I am able to feel the bone with palpation, as well. The Bridge is unable to tell me if she came with this wound or how long it has been there. I have been seeing her under Medical Directorship for rehabilitation related to her recent [MEDICAL CONDITION]. I was informed of this wound one week ago on [DATE]. The wound was debrided of some slough using a scalpel. The wound is going to require multiple debridements. The Wound Care History and Physical documents R4's coccyx wound as a Stage 4 Pressure Ulcer, measuring (length) 5.2 cm, (width) 3.0 cm and (depth) 3.2 cm, with purulent, yellow drainage, large amount of necrosis, and bone exposed. The Wound Care History and Physical documents R4's Left Buttock Stage II Pressure Ulcer as (length) 3.0 cm by (width) 0.5 cm by (depth) 0.1 cm. The Wound Care History and Physical documents, Impression and Plan: I would like her to get and x-ray of the sacral and coccyx area to rule out any osseous destruction. The wound should be cleaned twice daily with soap and water and Dakin's moistened gauze packed into the wound, then covered with a foam border dressing. Xeroform should be applied to the left buttocks pressure ulcer. She needs to get a offloading cushion for her wheelchair. She should only be up for meals. She should be turned and repositioned every 1 hour from side to side. Will add Med Pass (nutritional supplement) 90 cc (three) times per day for extra protein supplement for wound healing. The Treatment Administration Record (TAR) for [DATE], documents the nursing staff performed the treatment to R4's coccyx wound on [DATE], in the morning and in the afternoon, as ordered by V14 the day prior. The [DATE] TAR documents the treatment to R4's coccyx wound was only performed in the morning on [DATE], and not in the afternoon, due to the Dakin's solution being unavailable. The [DATE] TAR, documents on [DATE], R4 developed pain in the coccyx area that she rated a 5 on a scale of ,[DATE]. All previous pain assessments in the [DATE] TAR document R4's pain level at a 0 on a scale of ,[DATE]. The electronic medical record fails to document that staff notified the physician on [DATE] of R4's sudden onset of coccyx pain. The [DATE] TAR documents on [DATE] that R4 had increased pain, rated at a 7 on a scale of ,[DATE]. Progress Notes, dated [DATE] at 10:50 am, document R4 was complaining of severe discomfort to back and to coccyx. Order received for Tylenol 650 mg (milligrams) q (every) 6 (hours). The Progress Notes then document at 11:51 am, R4 was complaining of nausea and abdominal discomfort, with [MEDICATION NAME] 4 mg every four hours being ordered. At 12:30 pm, the Progress Notes document, Note (V4's) mental and physical condition had declined. (V4) is unable to answer simple yes and no questions, (V4) is awake but will not respond to name. (V4) is unable to talk to Son, via telephone. (V4) drank one Ensure for breakfast, refused (morning) meal. Spoke with (V4's) Son who would like his Mother sent to (Hospital) for evaluation. (V14) contacted and order received to send to (Hospital) for evaluation. Progress Notes document at 12:50 pm on [DATE], V4 was transported via ambulance to the Hospital. Hospital Emergency Department records, dated [DATE], document V4 arrived with agonal breathing, no blood pressure or pulse and CPR (Cardiopulmonary Recusitation) was initiated, as R4 was a Full Code. Hospital Emergency Records document CPR was unsuccessful and V4 was pronounced dead at 2:10 pm. R4's Death Certificate documents the following under cause of death: 1. [MEDICAL CONDITION] with [MEDICATION NAME] Faecium and Escherichia Coli, 2. Sacral Decubitus Ulcer and [MEDICATION NAME], 3. [MEDICAL CONDITION] due to a fall. Additionally, the Death Certificate documents Neglect as a significant condition contributing to R4's death. A Medical Pathology Report, by V21 (Medical Doctor/Pathologist), dated [DATE], documents After consideration of the circumstances surrounding (R4's) death, review of available medical history and records, and after the postmortem examination with ancillary studies, the death of this [AGE] year old female (V4), is [MEDICAL CONDITION] with [MEDICATION NAME] Faecium and Escherichia Coli in the blood, due to a sacral decubitus ulcer with [MEDICATION NAME] bacterial odor and [MEDICATION NAME] with microscopic [MEDICAL CONDITION], and [MEDICAL CONDITION] due to a fall with surgical repair. A significant factor in her death based upon the coroner investigation information and the autopsy findings is neglect. On [DATE] at 2:29 pm, V14 (Certified Wound Specialist/Nurse Practitioner) stated she did see R4 as a patient during her admission to the facility, as she is [MEDICATION NAME] under the facility's Medical Director. V14 stated she saw R4 on a frequent basis, because the staff felt R4 was declining, but staff did not inform her of R4's coccyx wound until approximately one week before V14 saw R4 as a patient at the Wound Clinic. At that time, staff had simply requested a referral to the Wound Clinic and no treatment orders, making her assume appropriate wound care orders were already in place. V14 stated when she did see R4 at the facility, she was always sitting up in her wheelchair. According to V14, when she saw R4 at the wound clinic, she first noted R4 was very thin and frail and was sitting on a flat cushion in her wheelchair, not a pressure reduction cushion. V14 stated she was mortified when she first saw R4's coccyx wound, as it had obvious tunneling to the bone, and stated the wound was nasty, nasty. V14 stated the foam dressing that was in place when R4 presented to the Wound Clinic was not an appropriate treatment for [REDACTED]. V14 stated when she removed the foam dressing, the wound stunk and had copious amounts of drainage. V14 stated that the treatment of [REDACTED]. V14 stated the treatment started on [DATE] (foam dressing changed every two days) would not have been an appropriate treatment for [REDACTED]. V14 also stated R4's weight loss was not addressed timely, as V14 was who initiated the nutritional supplement order on [DATE], which was two weeks after the significant weight loss occurred. V14 concluded that the facility should have obtained a treatment order for R4's coccyx wound on the day she was admitted ([DATE]), implemented a turning and repositioning program, assessed the wound on a weekly basis, and utilized a actual pressure reduction cushion in her wheelchair. V14 stated, if the facility had implemented all of the basics of wound management upon R4's admission, they could have prevented R4's wound from developing into a Stage 4, along with the development of the Stage 2 on the buttock. According to V14, if the facility did not follow the instructions she provided on [DATE] regarding wound care and the need to change R4's coccyx dressing twice per day, it could lead to the wound getting infected because R4's wound had significant drainage. On [DATE] at 12:51 pm, V15 (Coroner) stated he observed R4 in the emergency room shortly after she expired on [DATE]. V15 stated (R4) was in bad shape, enough for me to recommend an autopsy by (V21). V15 stated that it was he and V21's opinion that poor/lack of wound care led to R4's [MEDICAL CONDITION] and the deterioration of R4's wound was something that could have been avoided with proper treatment. 2. The electronic medical record documents R5 was admitted to the facility on [DATE] for Physical and Occupational Therapy following surgical repair of a left femur fracture. The [DATE] admission Progress Note, simply documents R5's buttocks as red and identifies a surgical incision. A Plan of Care, developed [DATE], documents R5 as very high risk for skin breakdown (related to history) of pressure wound (right) buttocks, Stage 2 pressure wound (left) buttock and coccyx, impaired mobility, occasional bladder incontinence. On [DATE], Progress Notes document R5 has a Stage 2 pressure ulcer on medial left buttock, measuring 2.0 x 3.0 cm, and described as open with bright red scant drainage, and Stage 2 pressure ulcer on the medial coccyx, measuring 1.0 x 0.5 cm, described as open and bright red, with both being covered by a foam dressing. R5's [DATE] admission physician's orders [REDACTED]. On [DATE], Progress Notes documents R5's buttock wounds had progress to a 5.0 x 2.0 cm unstageable pressure ulcer on the right medial buttock and a 2.0 x 1.0 Stage 3 pressure ulcer on the medial buttock, with V3 (Wound Nurse) documenting the wounds were covered with foam dressing. V3 also documented the skin surrounding both pressure ulcers as being red, so zinc cream was applied to the area. There is no documentation that V3 notified R5's physician that the wounds progressed, on [DATE]. R5's Plan of Care was updated on [DATE], documenting R5 now had a unstageable right buttocks pressure ulcer and a Stage 4 pressure ulcer to the medial buttock with the added intervention of encourage/assist to turn/reposition frequently. On [DATE], Progress Notes document V26 (Licensed Practical Nurse) contacted V3 over concerns about R5's pressure ulcers and V3 advised her to continue to apply zinc to the areas and cover them with a foam dressing until he could see the wounds [DATE]. There is no documented evidence that V3 assessed R5 on [DATE]. On [DATE], the Treatment Administration Record (TAR), identifies the first scheduled wound care for R5's pressure ulcers, 17 days after the wounds were first identified upon admission. The [DATE] TAR instructs staff to cleanse (R5's) bottom and apply foam dressing daily; however, there is no corresponding physician's orders [REDACTED]. R5's Progress Notes on [DATE], by V3 (Wound Nurse), document, (Right) medial buttock/ medial buttock expanding/joining stage 3 (pressure ulcer) with areas of eschar, covered with [MEDICATION NAME], physician/ wound consult needed, Blisters has callused on bilateral heels, guest instructed to keep heels off bed, redness surrounding PU on buttocks, zinc paste applied. The following Progress Note, on [DATE], documents V17 attempted to contact V27 again regarding R5's pressure ulcers. The next documentation regarding R5's pressure ulcers is a Progress Note dated [DATE] by V17, indicating another call was placed to V27 wanting a referral to the Wound Clinic for R5. Progress Notes document on [DATE] at 9:27 am, the facility decided to send R5 to the emergency room for evaluation of her coccyx wounds. Hospital Admission records, dated [DATE], document, [AGE] year old female (R5) brought to the emergency room today from (rehabilitation) center with the complaints of increased lower back and left hip pain. She has a recent history of left intertrochanteric femur fracture status [REDACTED].[MEDICAL CONDITION] secondary to infected sacral decubitus ulcer. The Hospital Admission record documents the reason for admission as infected Sacral Decubitus Ulcer with the bone exposed. The Hospital History and Physical documents the sacral wound was debrided by Plastic Surgery and R5 was treated with IV (intravenous) [MEDICATION NAME] for wound infection. On [DATE], a Hospital physician progress notes [REDACTED]. On [DATE] at 9:22 am, V17 (Licensed Practical Nurse) stated she was trying to reach V27, who was R5's Primary Care Physician for several days, because she knew R5 needed to be seen by the Wound Clinic for the pressure ulcer on her coccyx. V17 stated the wound was not getting better, but getting worse and in need of treatment. V17 stated the facility can always fall back on their own Medical Director if they are unable to reach a resident's Primary Care Physician and need treatment orders, but V17 stated she did not do so in this situation. On [DATE] at 2:29 pm, V14 (Nurse Practitioner) stated the facility always has the option of reaching out to herself or the Medical Director for orders related to the care of any resident admitted to the facility. V14 stated she nor the Medical Director were ever notified that R5 had a pressure ulcer, let alone that it was progressing to a Stage 4 wound. V14 stated the facility should have obtained appropriate treatment orders for R5's wound at the time of her admission and notified either herself or the Medical Director as soon as the wound started worsening. 3. The electronic medical record document R7 was admitted to the facility on [DATE] for inpatient Physical and Occupational therapy following a Left [MEDICAL CONDITION]. Hospital Discharge instructions, dated [DATE], document R7 has a left leg immobilizer that he is to wear at all times. Progress Notes, dated [DATE], document Wound Nurse found DTI (Deep Tissue Injury) on (R7's) posterior left calf from leg brace. (V14-Wound Nurse) assessed area and has ordered [MEDICATION NAME] to area and sheepskin in between leg and brace. Removed center metal plate that caused injury and she has ordered to keep brace off while in bed until return call from (Orthopedic Doctor's) office. A Weekly Skin Check, dated [DATE], documents R7's Deep Tissue Injury as 6.5 cm x 1.5 cm, and that R7 was referred to the wound clinic. On [DATE], documentation in a Nurse Practitioner Nursing Home Note indicates V14 examined R7 at the facility for a routine visit. The [DATE] Nursing Home Note documents, I'm seeing the patient today for follow-up at the Bridge Care Suites. He had a fall which resulted in a left distal femur fracture. (R7) is a [AGE] year old male with past medical history of [REDACTED]. Patient had ORIF of left distal femur on [DATE]. He was made non-weight bearing and places in a leg immobilizer. The leg immobilizer has since caused a deep tissue injury to his left posterior calf area. The wound is currently unstable. Wound bed does have some loss. Today when I examined, it was very saturated. Surrounding skin shows signs of maceration. Drainage is serosanguinous. A Wound Clinic note, dated [DATE], documents R7's left calf wound measured 6.9 cm x 3.7 cm x 0.7 cm and required a wet to dry dressing with Dakin's solution daily. A subsequent Wound Clinic note, dated [DATE], documents R7's left calf wound measured 6.3 cm x 2.7 cm x 1.0 cm and now required a [DEVICE] to promote healing. On [DATE] at 11:00 am, R7's wound care was completed by V3 (Wound Nurse). V3 removed the old dressing and released the suction from the [DEVICE], making the wound on the left calf fully visible. R7's wound was 5.0 cm by 2 cm and 0.1 cm deep. At that time, V3 stated R7's wound developed a few days after he was admitted , when (R7's) leg brace was not removed for a few days, per an order. On [DATE] at 3:10 pm, V14 (Nurse Practitioner) stated R7 developed a very large deep tissue injury from his leg immobilizer. V14 stated she observed the wound on [DATE] after it was identified. V14 stated she recalled staff at the facility were under the impression that R7's leg could not be taken out of the immobilizer at all, when he was first admitted . V14 stated the hospital discharge orders were not clear in their instruction regarding the immobilizer, but staff should have clarified those orders. V14 stated R7 should have had a skin assessment once per shift during cares, especially if they have a device on their body. V14 stated routine skin checks would have caught the deep tissue injury earlier and the wound could have been prevented. On [DATE] at 2:40 pm, V32 (Orthopedic Nurse) stated, even though R7's hospital discharge orders said for R7 to utilize the immobilizer to the left leg at all times, it is assumed staff will be doing skin checks at a minimum of every shift, as that is basic nursing care. On [DATE] at 1:10 pm, R7 was lying in bed with a [DEVICE] attached to his left outer calf. R7 stated that he got the wound to his leg shortly after he was admitted to the facility when his leg was in a brace for a few days straight. On [DATE] at 3:15 pm, R7 stated he has pain in his leg, mostly from the constant suction of the [DEVICE]. R7 stated the pain and suction often keeps him up at night. R7 stated he tried to go home to his wife once, but had to come back to the facility for care. R7 stated he would have been home a by now, but the wound has kept me here. 4. The electronic medical record documents R11 was admitted to the facility for Physical and Occupational Therapy following a left femur fracture. The Progress Notes, dated [DATE], document upon R11's admission heels soft placed on pillow off the bed. A Plan of Care dated [DATE], documents R11 is at risk for skin breakdown due to impaired mobility and instructs staff to perform preventative skin care as needed, utilize a pressure reduction wheelchair cushion and mattress, observe during care for signs of breakdown, and conduct weekly Braden Risk skin assessments for the first four weeks. On [DATE], Progress Notes document staff observed a skin flap on R11's right heel and nursing staff applied skin prep to the area. On [DATE], R11's Treatment Administration Record. the following treatments were initiated by V20 (Previous Wound Nurse): 1. Skin Prep to Right Heel twice per day for popped blister and 2. Apply foam dressing to Deep Tissue Injury on Left Heel every three days. A Weekly Wound Pressure Injury Report documents R11's Left Heel Wound measured 1.0 cm x 1.0 cm on [DATE]. R11's electronic medical record does not contain any documented information regarding either of R11's heel wounds, until 16 days later, on [DATE]. A Skin Assessment, by V3 (Wound Nurse) documents on [DATE] that R11 now has the following: 1. A unstageable wound to the right heel, with heavy purulent drainage, measuring 2.5 cm by 4.0 cm and 2. A Stage 2 Pressure Ulcer to the left heel, measuring 2.5 cm by 4.0 cm. It was not until that time, that pressure reduction interventions for R11's heels were implemented. V3 documented on [DATE] in the Progress Notes that R11 needed to be referred to the Wound Clinic, heel cushions were ordered and R11's wound treatment was changed to a daily treatment, rather than every three days. R11's Plan of Care during his admission from [DATE] through [DATE] was never updated to identify R11 had skin impairment on the bilateral heels or with pressure ulcer prevention interventions. On [DATE], at 11:45 am, V3 (Wound Nurse) stated when he first observed R11's bilateral heel wounds on [DATE], they had progressed to the point that they required a daily wound treatment, due to the amount of drainage from the right heel. On [DATE] at 11:50 am, V2 (Director of Nursing) stated she had no explanation as to why staff failed to complete the necessary skin assessments for R11's bilateral heel wounds on [DATE] or the week following. On [DATE] at 3:10 pm, V14 (Nurse Practitioner) stated she observed R11's heel wounds for the first time at the Wound Clinic (on [DATE]) and R11's heels needed to be debrided. V14 stated she was unaware that R11 had wounds of that nature, as R11 was admitted to the facility with no skin issues. V14 stated that routinely off loading R11's heels, when they were found to be soft upon admission, could have prevented the wounds from developing. 4. R3's nursing notes dated [DATE] document R3 was admitted on [DATE] [MEDICAL CONDITIONS], diabetes, hypertension and [MEDICAL CONDITION] with [MEDICAL TREATMENT]. R3 was admitted with a 1 x 1 cm open skin area to his left foot on left side and a partially amputated right foot. This note states these wounds need to be evaluated by the wound nurse. There is no further wound assessments until [DATE] when a weekly pressure injury report and weekly skin assessment documents a left foot Stage 1 pressure sore 1 x 1 cm and a right heel DTI (deep tissue injury) measuring 4 x 2.5 cm with a wound bed black and purple. R3's physician orders [REDACTED]. 1 left foot pressure ulcer. R3's next weekly skin assessment dated [DATE], 15 days later, documents R3 has a right heel DTI with no measurements or assessment. Blanching redness noted to buttock, cream used. R3's weekly skin assessment dated [DATE], 21 days later, documents R3 has a DTI to

Based on record review and interview, the facility failed to develop policies related to wound management, notify the physician of pressure ulcers, neglected to provide pressure ulcer treatment in accordance with physician's orders [REDACTED]. These failures resulted in R4 developing a Stage 4 pressure ulcer on the coccyx, which became infected, led [MEDICAL CONDITION] and R4's subsequent death on [DATE] and R5 developing a Stage 4 pressure ulcer on the coccyx, which became infected and required hospitalization . These failures resulted in Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at Severity Level 2, while they monitor the implementation of their new policies and procedures and the inservicing of staff. Findings include: The Immediate Jeopardy was identified on [DATE] at 12:30 pm. The Immediate Jeopardy began on [DATE] when the facility failed to ensure R4 received timely and appropriate treatment of [REDACTED]. R4's pressure ulcer became infected, which led [MEDICAL CONDITION]. R4 expired on [DATE], due [MEDICAL CONDITION] from the infected coccyx wound. The V1 (Administrator) and V2 (Director of Nursing) was notified of the Immediate Jeopardy on [DATE] at 12:30 p.m. The facility's Abuse Prevention Program ([DATE]), defines Neglect as, the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain or mental anguish. Neglect means a facility's failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness. The facility policy, titled Notification and Significant Change of ondition Policy (no date), documents, Purpose: To ensure that the facility immediately informs the guest; consult with the guest's physician; and notify, consistent with his or her authority, the guest representative when there is: An accident or incident involving the guest which results in injury and has the potential for requiring physician intervention; A significant change in the guest's physical, mental, or psychosocial status (Deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications); Life threatening conditions are such things as a [MEDICAL CONDITION] or stroke. Clinical complications are such things as development of a pressure injury, onset or recurrent periods of [MEDICAL CONDITION], symptoms of a urinary tract infection, or onset of depression; A need to alter treatment significantly or commence a new form of treatment to deal with a problem. The policy later documents, The physician will be contacted immediately for any emergencies regardless of the time of day. Non-emergency notifications may be made the next morning during normal business hours if the situation occurs on the late evening or night shift. This applies to any day of the week, including holidays. If the physician cannot immediately be reached in an emergency, the Medical Director will be contacted. If that physician cannot be reached, the Director of Nursing or the Charge Nurse can make arrangements for Transportation to the Emergency Department. In a non-emergency situation, the physician will be called unless he/she has left an alternate name to call. If after two attempts, there is no response to the calls, the Medical Director will be contacted. Each attempt will be charted as to the time the call was made, who was spoken to, and what information was given to the physician. On [DATE], at 3:30 pm, V2 (Director of Nursing) stated the facility does not have any written policies or procedures related to the management of pressure ulcers/wounds once they develop, but they do have the expectation that staff will do daily skin checks, assess and measure any pressure ulcer on a weekly basis, document those findings, notify the physician of any observed changes and implement appropriate interventions to prevent pressure ulcers from worsening or new ones developing. On [DATE], at 2:29 pm, V14 (Certified Wound Specialist/Nurse Practitioner) stated the facility has an ongoing problem with the management of pressure ulcers and wounds. V14 stated the facility does not have a definitive wound protocol, and no one is developing a treatment plan for the residents who have pressure ulcers present on admission. V14 stated patients are leaving this facility worse than when they came in. V14 stated she is often not notified of wounds that staff find when residents are admitted and/or if wounds progress. V14 stated she has come into the facility to assess residents and will find they have a treatment on their wound that is three days old, when it should be changed every day. V14 stated that a simple protocol for nursing staff to follow for wound management would be beneficial, because wounds are not always being monitored on a weekly basis, which is a standard of care, and basic pressure reduction interventions are not always being implemented for residents in a timely manner. V14 stated she has seen treatments on residents that are not treatments that she or the Medical Director would have ordered, as they are not within the parameters of the standard of practice for wound care. On [DATE] at 10:03 am, V3 (Wound Nurse/Registered Nurse) stated he started in that position late [DATE]. V3 stated the previous Wound Nurse had already left when he started, so he was given instruction by V2 (Director of Nursing). V3 stated he was told by V2 that wounds needed to be assessed weekly and within 24 hours of a residents admission and guided him on the computer program, but the remainder was trial and error. V3 stated that the facility did not have any written protocols for wound management, so he went forward with his position based on his work experience; however, V3 stated he is not Wound Certified. V3 stated if a resident is admitted with a Stage 1 or Stage 2 pressure ulcer, they will initiate a foam dressing and repositioning without a physician's orders [REDACTED]. There is no set guidance. We often don't call the physician (for orders) until the wound is a Stage 3. 1. The electronic medical record documents R4 was admitted to the facility on [DATE] following surgical repair of a Right Femur Fracture, and planned to discharge back to home. Nursing Notes, dated [DATE] at 4:11 am, document R4 had a pressure ulcer measuring 4.0 cm x 3.3 cm on her coccyx. R4's admission physician orders [REDACTED]. A Plan of Care, dated [DATE], documents R4 was determined to be Very high risk for skin breakdown (related to) impaired mobility, occasional incontinence. admitted with pressure wound to coccyx, (right) leg surgical wound and (bilateral upper extremity) bruising. A Braden Scale for Prediction of Pressure Sore Risk, dated [DATE], documents R4 was determined to be at moderate risk for the development of pressure ulcers, and instructs staff to do the following interventions: conduct a Braden risk assessment upon admission and weekly for four weeks, observe during care for any signs of breakdown, pressure reducing mattress on bed, pressure reducing wheelchair cushion when in wheelchair, preventative skin care as indicated, and treatment as ordered to the right lower extremity surgical wound. The initial Plan of Care for R4 does not instruct staff to turn and reposition R4, off-load pressure to the coccyx, or administer a treatment to the coccyx wound. An Admission Nursing Assessment, dated [DATE], documents R4 has an unstageable pressure ulcer with scant serosanguinous drainage. A Minimum Data Set assessment, dated [DATE], documents R4 required the extensive assistance of two staff for bed mobility (turning from side to side). A Treatment Administration Record (TAR) for [DATE], documents the facility initiated a treatment R4's coccyx wound on [DATE], four days after the wound was first noted to be present. The [DATE] TAR documents staff started treating R4's coccyx wound by covering it with a comfort foam dressing, which was to be changed every other day. On [DATE], R4's Plan of Care was updated with the intervention of treatments as ordered to coccyx, but still failed to indicate R4 needed staff assistance to off-load pressure to the coccyx area or turn and reposition. The Progress Notes document R4 did not have another wound assessment until [DATE], nineteen days after the initial wound assessment on [DATE]. The [DATE] Progress Note documents R4's coccyx wound as being a Stage III the medial coccyx and measuring 5 cm x 2 cm (no depth measured), and the presence of a new Stage II pressure ulcer on the right medial buttock, measuring 1 cm x 1.5 cm. On [DATE], a physician's orders [REDACTED]. On [DATE] at 10:03 am, when V3 was questioned regarding R4's treatment orders for the coccyx wound not changing between [DATE] and [DATE], after the wound had progressed and an additional wound developed, V3 indicated he had implemented that treatment order and didn't call the physician. V3 did state he referred R4 to the wound clinic for evaluation, which she did go to on [DATE]. V3 did not have an explanation as to why R4's coccyx wound did not have a documented assessment for 19 days, and concluded that the standard of practice for wound assessments would be to measure them weekly (ideally on the same day of the week). On [DATE], a Wound Care History and Physical by V14 (Certified Wound Specialist/Nurse Practitioner), documents the following: The patient is an [AGE] year-old female that was referred to the Wound Center from the Bridge Care Suites. I was notified approximately one week ago that the patient had a wound 'that might need to be seen.' I had the (facility) refer her to the wound clinic at that time. She has been at the Bridge since approximately the beginning of August after a [MEDICAL CONDITION]. She has a past medical history of [REDACTED]. I did speak to her son, who is her Power of Attorney, over the phone quite extensively about her history. She currently lives alone. However, at discharge he plans to have her live with him. I have also suggested that (extended care facility) placement would be appropriate. She does need 24 hour care. When the patient presented today, there is just a foam border dressing covering her wound and that was it. She is in a wheelchair with a cushion that was flat. She has Left Buttock Stage II pressure ulcer that was debrided using a scalpel. Her coccyx wound is very extensive and has large amounts of slough. I am able to feel the bone with palpation, as well. The Bridge is unable to tell me if she came with this wound or how long it has been there. I have been seeing her under Medical Directorship for rehabilitation related to her recent [MEDICAL CONDITION]. I was informed of this wound one week ago on [DATE]. The wound was debrided of some slough using a scalpel. The wound is going to require multiple debridements. The Wound Care History and Physical documents R4's coccyx wound as a Stage 4 Pressure Ulcer, measuring (length) 5.2 cm, (width) 3.0 cm and (depth) 3.2 cm, with purulent, yellow drainage, large amount of necrosis, and bone exposed. The Wound Care History and Physical documents R4's Left Buttock Stage II Pressure Ulcer as (length) 3.0 cm by (width) 0.5 cm by (depth) 0.1 cm. The Wound Care History and Physical documents, Impression and Plan: I would like her to get and x-ray of the sacral and coccyx area to rule out any osseous destruction. The wound should be cleaned twice daily with soap and water and Dakin's moistened gauze packed into the wound, then covered with a foam border dressing. Xeroform should be applied to the left buttocks pressure ulcer. She needs to get a offloading cushion for her wheelchair. She should only be up for meals. She should be turned and repositioned every 1 hour from side to side. Will add Med Pass (nutritional supplement) 90 cc (three) times per day for extra protein supplement for wound healing. R4's Plan of Care related to skin impairment was still not updated with any new pressure ulcer prevention interventions, and remained the same plan of care that was developed for R4 upon admission. The Treatment Administration Record (TAR) for [DATE], documents the nursing staff performed the treatment to R4's coccyx wound on [DATE], in the morning and in the afternoon, as ordered by V14 the day prior. The [DATE] TAR documents the treatment to R4's coccyx wound was only performed in the morning on [DATE], and not in the afternoon, due to the Dakin's solution being unavailable. The [DATE] TAR, documents on [DATE], R4 developed pain in the coccyx area that she rated a 5 on a scale of ,[DATE]. All previous pain assessments in the [DATE] TAR document R4's pain level at a 0 on a scale of ,[DATE], with no pain medication administered. The electronic medical record fails to document that staff notified the physician on [DATE] of R4's sudden onset of coccyx pain. On [DATE] at 2:29 pm, V14 (Certified Wound Specialist/Nurse Practitioner) stated she would expect staff to contact herself or the Medical Director if a resident experiences a sudden onset of pain/increased pain in a wound. The [DATE] TAR documents on the morning of [DATE], R4 had increased pain, rated at a 7 on a scale of ,[DATE]. Progress Notes by V31 (Registered Nurse), dated [DATE] at 10:50 am, document R4 was complaining of severe discomfort to back and to coccyx. Order received for Tylenol 650 mg (milligrams) q (every) 6 (hours). The Progress Notes then document at 11:51 am, R4 was complaining of nausea and abdominal discomfort, with [MEDICATION NAME] 4 mg every four hours being ordered. At 12:30 pm, the Progress Notes document, Note (V4's) mental and physical condition had declined. (V4) is unable to answer simple yes and no questions, (V4) is awake but will not respond to name. (V4) is unable to talk to Son, via telephone. (V4) drank one Ensure for breakfast, refused (morning) meal. Spoke with (V4's) Son who would like his Mother sent to (Hospital) for evaluation. (V14) contacted and order received to send to (Hospital) for evaluation. Progress Notes document at 12:50 pm on [DATE], V4 was transported via ambulance to the Hospital. Hospital Emergency Department records, dated [DATE], document V4 arrived with agonal breathing, no blood pressure or pulse and CPR (Cardiopulmonary Recusitation) was initiated, as R4 was a Full Code. Hospital Emergency Records document CPR was unsuccessful and V4 was pronounced dead at 2:10 pm. R4's Death Certificate documents the following under cause of death: 1. [MEDICAL CONDITION] with [MEDICATION NAME] Faecium and Escherichia Coli, 2. Sacral Decubitus Ulcer and [MEDICATION NAME], 3. [MEDICAL CONDITION] due to a fall. Additionally, the Death Certificate documents Neglect as a significant condition contributing to R4's death. A Medical Pathology Report, by V21 (Medical Doctor/Pathologist), dated [DATE], documents After consideration of the circumstances surrounding (R4's) death, review of available medical history and records, and after the postmortem examination with ancillary studies, the death of this [AGE] year old female (V4), is [MEDICAL CONDITION] with [MEDICATION NAME] Faecium and Escherichia Coli in the blood, due to a sacral decubitus ulcer with [MEDICATION NAME] bacterial odor and [MEDICATION NAME] with microscopic [MEDICAL CONDITION], and [MEDICAL CONDITION] due to a fall with surgical repair. A significant factor in her death based upon the coroner investigation information and the autopsy findings is neglect. On [DATE] at 2:00 pm, V31 (Registered Nurse) stated she could easily recall R4 because of her coccyx wound, stating it was very sizable, you could put your fist in it and described it as having an odor with a lot of slough (dead tissue). V31 stated the morning of [DATE], it was not passed on to her from the night shift nurse that R4 had complaints of increased pain in the coccyx wound. V31 stated R4 was alert when she came on shift the morning of [DATE], but not as alert as in the days prior. V31 stated R4 had complained that morning of increased pain in her coccyx and nausea, so she did call the physician to request an order for [REDACTED]. V31 stated she received a phone call at the nurses station from R4's Son, who was concerned because R4 was not making any sense. V31 stated she went to check on R4, who she described as very slow to respond. V31 did not do any kind of nursing assessment on R4 at that time, but called R4's Son back and asked him what he wanted her to do with R4. V31 stated she gave R4's Son the option of her trying to manage R4 at the facility by increasing her fluids or sending R4 to the emergency room . V31 stated R4's Son requested she send R4 to the emergency room . On [DATE], V34 (Family/Power of Attorney) stated on the morning of [DATE], he called the facility to speak to R4. V34 stated he knew immediately something was wrong with her (R4) and described hearing R4 moaning and screaming on the phone. V34 stated R4 sounded like she was in distress and was not making any sense, so he hung up and called the nurses station. V34 stated the nurse he spoke with told him R4 was just dehydrated and that she would try to get fluids into R4, but he asked they send R4 to the hospital. V34 stated R4 died either on the way to the hospital or as soon as she arrived. V34 stated he was in shock, as they had been planning on R4 discharging to his home. V34 stated he was unaware of how severe R4's coccyx wound had become, until he received a call from V14 on [DATE], and V14 told him she was mortified at the condition my Mom was in. On [DATE] at 2:29 pm, V14 (Certified Wound Specialist/Nurse Practitioner) stated she did see R4 as a patient during her admission to the facility, as she is [MEDICATION NAME] under the facility's Medical Director. V14 stated she saw R4 on a frequent basis, because the staff felt R4 was declining, but staff did not inform her of R4's coccyx wound until approximately one week before V14 saw R4 as a patient at the Wound Clinic. At that time, staff had simply requested a referral to the Wound Clinic and no treatment orders, making her assume appropriate wound care orders were already in place. V14 stated when she did see R4 at the facility, she was always sitting up in her wheelchair. According to V14, when she saw R4 at the wound clinic, she first noted R4 was very thin and frail and was sitting on a flat cushion in her wheelchair, not a pressure reduction cushion. V14 stated she was mortified when she first saw R4's coccyx wound, as it had obvious tunneling to the bone, and stated the wound was nasty, nasty. V14 stated the foam dressing that was in place when R4 presented to the Wound Clinic was not an appropriate treatment for [REDACTED]. V14 stated when she removed the foam dressing, the wound stunk and had copious amounts of drainage. V14 stated that the treatment of [REDACTED]. V14 stated the treatment started on [DATE] (foam dressing changed every two days) would not have been an appropriate treatment for [REDACTED]. V14 also stated R4's weight loss was not addressed timely, as V14 was who initiated the nutritional supplement order on [DATE], which was two weeks after the significant weight loss occurred. V14 stated R4 was a small and frail appearing woman, with bony prominence's visible and a low BMI (Body Mass Index), so nutritional supplements should have been started as soon as weight loss occurred. V14 concluded that the facility should have obtained a treatment order for R4's coccyx wound on the day she was admitted ([DATE]), implemented a turning and repositioning program, assessed the wound on a weekly basis, and utilized a actual pressure reduction cushion in her wheelchair, as this is a standard of practice for wound management. V14 stated, if the facility had implemented all of the basics of wound management upon R4's admission, they could have prevented R4's wound from developing into a Stage 4, along with the development of the Stage 2 on the buttock. According to V14, if the facility did not follow the instructions she provided on [DATE] regarding wound care and the need to change R4's coccyx dressing twice per day, it could lead to the wound getting infected because R4's wound had significant drainage. On [DATE] at 12:51 pm, V15 (Coroner) stated he observed R4 in the emergency room shortly after she expired on [DATE]. V15 stated (R4) was in bad shape, enough for me to recommend an autopsy by (V21). V15 stated that it was he and V21's opinion that poor/lack of wound care led to R4's [MEDICAL CONDITION] and the deterioration of R4's wound was something that could have been avoided with proper treatment. 2. The electronic medical record documents R5 was admitted to the facility on [DATE] for therapy following surgical repair of a left femur fracture. The [DATE] admission Progress Note, simply documents R5's buttocks as red and identifies a surgical incision. A Plan of Care, developed [DATE], documents R5 as very high risk for skin breakdown (related to history) of pressure wound (right) buttocks, Stage 2 pressure wound (left) buttock and coccyx, impaired mobility, occasional bladder incontinence. On [DATE], Progress Notes document R5 has a Stage 2 pressure ulcer on medial left buttock, measuring 2.0 x 3.0 cm, and described as open with bright red scant drainage, and Stage 2 pressure ulcer on the medial coccyx, measuring 1.0 x 0.5 cm, described as open and bright red, with both being covered by a foam dressing. R5's [DATE] admission physician's orders [REDACTED]. On [DATE], Progress Notes documents R5's buttock wounds had progressed to a 5.0 x 2.0 cm unstageable pressure ulcer on the right medial buttock and a 2.0 x 1.0 Stage 3 pressure ulcer on the medial buttock, with V3 (Wound Nurse) documenting the wounds were covered with foam dressing. V3 also documented the skin surrounding both pressure ulcers as being red, so zinc cream was applied to the area. There is no documentation that V3 notified R5's physician that the wounds progressed, on [DATE]. R5's Plan of Care was updated on [DATE], documenting R5 now had a unstageable right buttocks pressure ulcer and a Stage 4 pressure ulcer to the medial buttock with the added intervention of encourage/assist to turn/reposition frequently. On [DATE], Progress Notes document V26 (Licensed Practical Nurse) contacted V3 over concerns about R5's pressure ulcers and V3 advised her to continue to apply zinc to the areas and cover them with a foam dressing until he could see the wounds [DATE]. There is no documented evidence that V3 assessed R5 on [DATE]. On [DATE], the Treatment Administration Record (TAR), identifies the first scheduled wound care for R5's pressure ulcers, 17 days after the wounds were first identified upon admission. The [DATE] TAR instructs staff to cleanse (R5's) bottom and apply foam dressing daily; however, there is no corresponding physician's orders [REDACTED]. R5's Progress Notes on [DATE], by V3 (Wound Nurse), document, (Right) medial buttock/ medial buttock expanding/joining stage 3 (pressure ulcer) with areas of eschar, covered with Mepelix, physician/ wound consult needed, Blisters has callused on bilateral heels, guest instructed to keep heels off bed, redness surrounding PU (pressure ulcer) on buttocks, zinc paste applied. The following Progress Note, on [DATE], documents V17 (Licensed Practical Nurse/Nurse Manager) attempted to contact V27 again regarding R5's pressure ulcers. The next documentation regarding R5's pressure ulcers is a Progress Note dated [DATE] by V17, indicating another call was placed to V27 wanting a referral to the Wound Clinic for R5. Progress Notes document on [DATE] at 9:27 am, the facility decided to send R5 to the emergency room for evaluation of her coccyx wounds. Hospital Admission records, dated [DATE], document, [AGE] year old female (R5) brought to the emergency room today from (rehabilitation) center with the complaints of increased lower back and left hip pain. She has a recent history of left intertrochanteric femur fracture status [REDACTED].[MEDICAL CONDITION] secondary to infected sacral decubitus ulcer. The Hospital Admission record documents the reason for admission as infected Sacral Decubitus Ulcer with the bone exposed. The Hospital History and Physical documents the sacral wound was debrided by Plastic Surgery and R5 was treated with IV (intravenous) [MEDICATION NAME] for wound infection. On [DATE], a Hospital physician progress notes [REDACTED]. On [DATE] at 9:22 am, V17 (Licensed Practical Nurse/Nurse Manager) stated she was trying to reach V27, who was R5's Primary Care Physician for several days, because she knew R5 needed to be seen by the Wound Clinic for the pressure ulcer on her coccyx. V17 stated the wound was not getting better, but getting worse and in need of treatment. V17 stated the facility can always fall back on their own Medical Director if they are unable to reach a resident's Primary Care Physician and need treatment orders, but V17 stated she did not do so in this situation. On [DATE] at 2:29 pm, V14 (Nurse Practitioner) stated the facility always has the option of reaching out to herself or the Medical Director for orders related to the care of any resident admitted to the facility. V14 stated she nor the Medical Director were ever notified that R5 had a pressure ulcer, let alone that it was progressing to a Stage 4 wound. V14 stated the facility should have obtained appropriate treatment orders for R5's wound at the time of her admission and notified either herself or the Medical Director as soon as the wound started worsening. On [DATE], a facility wide skin evaluation was completed on all residents in the facility. All pressure areas identified were measured and assessed, with an update provided to the physician, along with the current treatment order. Any new orders received will be documented and treatment will be initiated. All residents with pressure ulcers will also be communicated to the Registered Dietitian for evaluation of nutritional needs. A Wound Care Policy/Procedure will be developed and implemented by [DATE] and Licensed staff will be inserviced to this specific policy. This particular policy will include wound assessment criteria, including wound length, depth, stage (if applicable), drainage, odor, color, wound bed description. These assessments will be done on admission, weekly thereafter, or if a change is noted. The wound response to treatment will also be addressed. The physician will made aware of any deterioration of said wound. Licensed nurses will be inserviced by end of day on [DATE], by V1/V2. All Nurses will be inserviced prior to being scheduled to work at the facility. The staff inservicing will include: 1. Abuse/ Neglect policy. 2. Admissions assessment, with emphasis on pressure areas, wounds and current measurements. 3. Physician admission orders [REDACTED]. 4. Policy for physician notification and resident change of condition. 5. Wound status is to be included in the care plan to reflect current status of the resident. 6. Pressure areas are to be measured upon admission and weekly thereafter, as part of weekly wound assessment. Audits will be performed by V1, V2, and Nurse Managers on residents identified with pressure areas on a daily basis for 1 month, then twice a week for one month, and then weekly for one month to ensure that the wound monitoring, assessment and treatment is current with regard to wound status and physician treatment orders. Audits will be performed daily on admission orders [REDACTED]. All Certified Nursing Assistants will be inserviced on pressure ulcer prevention measures and reporting changes to the licensed nurse, by [DATE]

Based on observation, record review and interview, the facility failed to notify the physician of pressure ulcers either identified upon admission, at onset or with progression, for five of eight residents (R4, R5, R3, R9, R12) reviewed for pressure ulcers, in a sample of 13. These failures resulted R4 and R5, both admitted pressure ulcers on the coccyx, going without physicain's ordered treatments and progressing to a Stage 4 infected wounds requiring debridement. Findings include: The facility policy, titled Notification and Significant Change of Condition Policy (no date), documents, Purpose: To ensure that the facility immediately informs the guest; consult with the guest's physician; and notify, consistent with his or her authority, the guest representative when there is: An accident or incident involving the guest which results in injury and has the potential for requiring physician intervention; A significant change in the guest's physical, mental, or psychosocial status (Deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications); Life threatening conditions are such things as a [MEDICAL CONDITION] or stroke. Clinical complications are such things as development of a pressure injury, onset or recurrent periods of [MEDICAL CONDITION], symptoms of a urinary tract infection, or onset of depression; A need to alter treatment significantly or commence a new form of treatment to deal with a problem. The policy later documents, The physician will be contacted immediately for any emergencies regardless of the time of day. Non-emergency notifications may be made the next morning during normal business hours if the situation occurs on the late evening or night shift. This applies to any day of the week, including holidays. If the physician cannot immediately be reached in an emergency, the Medical Director will be contacted. If that physician cannot be reached, the Director of Nursing or the Charge Nurse can make arrangements for Transportation to the Emergency Department. In a non-emergency situation, the physician will be called unless he/she has left an alternate name to call. If after two attempts, if there is no response to the calls, the Medical Director will be contacted. Each attempt will be charted as to the time the call was made, who was spoken to, and what information was given to the physician. On 10/22/20 at 10:03 am, V3 (Wound Nurse/Registered Nurse) stated if a resident is admitted with a Stage 1 or Stage 2 pressure ulcer, they will initiate a foam dressing and repositioning, but the facility does not require a physician's orders [REDACTED]. There is no set guidance. We often don't call the physician (for orders) until the wound is a Stage 3. V3 confirmed that there is no written standing orders by a physician for wound care that the facility utilizes. On 10/22/20 at 2:29 pm, V14 (Nurse Practitioner/Certified Wound Care Specialist) stated if a resident has a pressure ulcer or deep tissue injury upon admission to the facility and does not have treatment orders, or if a wound deteriorates, the Physician or herself should be notified for appropriate wound care orders. 1. The electronic medical record documents R4 was admitted to the facility on [DATE], following surgical repair of a Right Femur Fracture, for inpatient therapy. Nursing Notes, dated 7/25/20 at 4:11 am, document R4 had a pressure ulcer measuring 4.0 cm x 3.3 cm on her coccyx. R4's admission physician orders [REDACTED]. A Treatment Administration Record (TAR) for July 2020, documents the facility initiated a treatment to R4's coccyx wound on 7/28/20, four days after the wound was first noted to be present. The July 2020 TAR documents staff started treating R4's coccyx wound by covering it with a comfort foam dressing, which was to be changed every other day. The Progress Notes document R4's next wound assessment on 8/12/20, and R4's coccyx wound had progressed to a Stage III on the medial coccyx measuring 5 cm x 2 cm (no depth measured), and identified a new Stage II pressure ulcer on the right medial buttock, measuring 1 cm x 1.5 cm. On 8/13/20, a physician's orders [REDACTED]. On 10/22/20 at 10:03 am, when V3 was questioned regarding R4's treatment orders for the coccyx wound not changing between 7/25/20 and 8/12/20, after the wound had progressed and an additional wound developed, V3 indicated he had implemented those treatment orders and didn't call the physician. V3 did state he referred R4 to the wound clinic for evaluation, which she did go to on 8/17/20. On 10/22/20 at 2:29 pm, V14 (Certified Wound Specialist/Nurse Practitioner) stated she did see R4 as a patient during her admission to the facility, as she is [MEDICATION NAME] under the facility's Medical Director. V14 stated she saw R4 on a frequent basis, because the staff felt R4 was declining, but staff did not inform her of R4's coccyx wound until approximately one week before V14 saw R4 as a patient at the Wound Clinic. At that time, staff had simply requested a referral to the Wound Clinic and no treatment orders, making her assume appropriate wound care orders were already in place, but they were not. V14 stated when she saw R4 on 8/17/20 at the Wound Clinic, the treatment that was on R4's coccyx was not an appropriate treatment for [REDACTED]. V14 indicated, had she or the Medical Director been notified of R4's wounds, they could have ordered appropriate treatments and possibly prevented the wound's progression. On 8/17/20, a Wound Care History and Physical by V14 (Certified Wound Specialist/Nurse Practitioner), documents the following: When the patient presented today, there is just a foam border dressing covering her wound and that was it. She is in a wheelchair with a cushion that was flat. She has Left Buttock Stage II pressure ulcer that was debrided using a scalpel. Her coccyx wound is very extensive and has large amounts of slough. I am able to feel the bone with palpation, as well. The Bridge is unable to tell me if she came with this wound or how long it has been there. I have been seeing her under Medical Directorship for rehabilitation related to her recent [MEDICAL CONDITION]. I was informed of this wound one week ago on August 10, 2020. The wound was debrided of some slough using a scalpel. The wound is going to require multiple debridements. The Wound Care History and Physical documents R4's coccyx wound as a Stage 4 Pressure Ulcer, measuring (length) 5.2 cm, (width) 3.0 cm and (depth) 3.2 cm, with purulent, yellow drainage, large amount of necrosis, and bone exposed, and the Left Buttock Stage II Pressure Ulcer as (length) 3.0 cm by (width) 0.5 cm by (depth) 0.1 cm. 2. The electronic medical record documents R5 was admitted to the facility on [DATE] for therapy. On 7/23/20, Progress Notes document R5 has a Stage 2 pressure ulcer on medial left buttock, measuring 2.0 x 3.0 cm, and described as open with bright red scant drainage, and Stage 2 pressure ulcer on the medial coccyx, measuring 1.0 x 0.5 cm, described as open and bright red, with both being covered by a foam dressing. R5's 7/22/20 admission physician's orders [REDACTED]. On 7/30/20, Progress Notes documents R5's buttock wounds had progressed to a 5.0 x 2.0 cm unstageable pressure ulcer on the right medial buttock and a 2.0 x 1.0 Stage 3 pressure ulcer on the medial buttock, with V3 (Wound Nurse) documenting the wounds were covered with foam dressing. V3 also documented the skin surrounding both pressure ulcers as being red, so zinc cream was applied to the area. There is no documentation that V3 notified R5's physician that the wounds progressed, on 7/30/20. On 8/05/20, Progress Notes document V26 (Licensed Practical Nurse) contacted V3 over concerns about R5's pressure ulcers and V3 advised her to continue to apply zinc to the areas and cover them with a foam dressing until he could see the wounds 8/06/20. There is no documented evidence that V3 assessed R5 on 8/06/20. On 8/07/20, the Treatment Administration Record (TAR), identifies the first scheduled wound care for R5's pressure ulcers, 17 days after the wounds were first identified upon admission. The August 2020 TAR instructs staff to cleanse (R5's) bottom and apply foam dressing daily; however, there is no corresponding physician's orders [REDACTED]. There is no documented evidence that the facility attempted to contact the Medical Director or V14 (Nurse Practitioner) when V27 failed to respond to their messages left regarding R5. R5's Progress Notes on 8/10/20, by V3 (Wound Nurse), document, (Right) medial buttock/ medial buttock expanding/joining stage 3 (pressure ulcer) with areas of eschar, covered with Mepelix, physician/ wound consult needed, Blisters has callused on bilateral heels, guest instructed to keep heels off bed, redness surrounding PU (pressure ulcer) on buttocks, zinc paste applied. The following Progress Note, on 8/10/20, documents V17 attempted to contact V27 again regarding R5's pressure ulcers. The next documentation regarding R5's pressure ulcers is a Progress Note dated 8/12/20 by V17, indicating another call was placed to V27 wanting a referral to the Wound Clinic for R5. Progress Notes document on 8/12/20 at 9:27 am, the facility decided to send R5 to the emergency room for evaluation of her coccyx wounds, with still no notification to the facility's Medical Director or Nurse Practitioner. Hospital Admission records, dated 8/12/20, document, [AGE] year old female (R5) brought to the emergency room today from (rehabilitation) center with the complaints of increased lower back and left hip pain. She has a recent history of left intertrochanteric femur fracture status [REDACTED].[MEDICAL CONDITION] secondary to infected sacral decubitus ulcer. The Hospital Admission record documents the reason for admission as infected Sacral Decubitus Ulcer (Stage 4) with the bone exposed. On 10/22/20 at 9:22 am, V17 (Licensed Practical Nurse) stated she was trying to reach V27, who was R5's Primary Care Physician for several days and made multiple attempts that are not documented, because she knew R5 needed to be seen by the Wound Clinic for the pressure ulcer on her coccyx. V17 stated the wound was not getting better, but getting worse and in need of treatment. V17 stated the facility can always fall back on their own Medical Director if they are unable to reach a resident's Primary Care Physician and need treatment orders, but V17 stated she did not do so in this situation. On 10/22/20 at 2:29 pm, V14 stated the nursing staff or V3 (Wound Nurse) never contacted her or the Medical Director for any wound care orders or regarding R5's wound deteriorating. V14 stated the staff should be immediately contacting her or the Medical Director if a residents Primary Care Doctor is not responding to their concerns. 3. R3's nursing notes dated 2-16-20 document R3 was admitted on [DATE] [MEDICAL CONDITIONS], diabetes, hypertension and [MEDICAL CONDITION] with [MEDICAL TREATMENT]. R3 was admitted with a 1 x 1 cm open skin area to his left foot on left side and a partially amputated right foot. This note states these wounds need to be evaluated by the wound nurse. There are no further wound assessments until 2-24-20 when a weekly pressure injury report and weekly skin assessment documents a left foot Stage 1 pressure sore 1 x 1 cm and a right heel DTI (deep tissue injury) measuring 4 x 2.5 cm with a wound bed black and purple. R3's physician was not notified nor were orders obtained for R3's right heel DTI until 2-25-20 and no orders for R3's Stage 1 left foot pressure ulcer. R3's next weekly skin assessment dated [DATE], 15 days later, documents R3 has a right heel DTI with no measurements or assessment. Blanching redness noted to buttock, cream used. R3's weekly skin assessment dated [DATE], 21 days later, documents R3 has a DTI to the right heel that is unchanged (no measurements given). Stage 2 pressure ulcer to coccyx measuring 1 x 2 cm, foam dressing applied, surrounding area is a Stage 1 pressure ulcer. On 10-23-20 at 11:20 am, V28, Nurse Anesthetist stated on 3-29-20, R3 had open pressure ulcers to his buttocks, back and penis. There is no documentation that R3's physician was notified of the open areas to R3's back, penis or newly developed State 2 pressure ulcer. On 10-21-20 at 9:00 am. V2 DON/Director of Nursing verified there was no initial physician's orders [REDACTED]. There is no documentation related to a back wound before 4-7-20 and no documentation of physician notification for the open area to R3's penis. On 10-21-20 at 2:30 pm, V14 NP (Nurse Practitioner) stated when R3's pressure ulcer advanced from a Stage 1 to a Stage 2, she should have been notified and new orders for treatment obtained. R3's right heel DTI should have been measured weekly and an order obtained for treatment. The supplement Nepro should have been ordered earlier to help with wound healing. V14 had no knowledge of the open area to R3's penis or back. 4. R12's physician order [REDACTED]. This POS has no initial wound care orders except to follow hospital discharge orders. R12's Wound admission note dated 9-4-20 includes a left medial buttock Stage 2 pressure ulcer measuring 7 x 2.5 cm (centimeter), medial coccyx Stage 2 pressure ulcer measuring 2 cm linear and a right medial buttock Stage 2 pressure ulcer measuring 7 x 4 cm all covered with [MEDICATION NAME]. R12's 9-10-20 Weekly wound assessment documents the same plus redness in high moisture areas of buttock. R12's 9-15-20 and 9-22-20 Weekly wound assessment document a Stage 2, 2 x 2cm pressure ulcer to the left and right medial buttocks, and a large Stage 1 reddened pressure ulcer to the coccyx buttocks area. R12's 9-29-20 and 10-5-20 Weekly skin assessments documents wound progression to a Stage 2 medial buttock 6 x 4cm covered with [MEDICATION NAME]. R12's nursing note dated 10-13-20 document R12 pressure on buttock has worsened and V14, NP (Nurse Practitioner) was notified. There is no assessment/description of the area given at this time. V14 NP note date 10-14-20 documents Stage III pressure ulcer to right ischium Orders left to turn and reposition every 2 hours and Dakins treatment to the wound once a day or twice a day if large amount of drainage is present. R12's physician's orders [REDACTED]. There is no order for R12's right ischium pressure ulcer until 10-13-20 after R12's pressure ulcer had increased from a Stage 2 to a Stage 3. On 10-21-20 at 2:30 pm, V14, Nurse Practitioner stated she should have been notified earlier for care and treatment of [REDACTED]. V14 stated she was not notified of R12's pressure areas until 10-13-20 when she was notified by the facility to evaluate R12's wounds. R12's right ischium had progressed to a Stage 3 pressure ulcer. V14 stated R12's wound progression may have been prevented if she had been notified earlier for treatment. 5. On 10-21-20 at 11:30 am R9 had a 3.5 cm (centimeter) x3cm x 3.75cm open pressure ulcer to his left buttock. R9's progress notes document R9 was admitted on [DATE] with a [MEDICAL CONDITION] hip with open areas to coccyx, and inner buttocks, with dark area in center small amount of drainage. R9's 9-2-20 and 9-11-20 weekly skin check noted the following pressure ulcer areas: Unstageable pressure ulcer medial coccyx, 2.5cmx2cm, dark eschar, 7x3cm open pressure injury area around the unstageable pressure ulcer, covered with [MEDICATION NAME], Stage 2 right medial buttock, [MEDICAL CONDITION], Stage 2 left medial buttock, [MEDICAL CONDITION] and Stage 1 right lateral heel, .5x2.5cm. All these wounds were covered with a [MEDICATION NAME] (foam) dressing. R9's physician order [REDACTED]. R9's weekly wound assessment note dated 9-16-20 documents R9 has an unstageable 7 x 3cm pressure ulcer to the coccyx area, a Stage 3 to the coccyx area measuring 3 x 3cm on which a [MEDICATION NAME] dressing was applied. A Stage 1 to the right heel remains open to air. Redness noted to R9's medial buttock. R9's wound clinic note dated 9-21-20 documents R9 has a 4.5 x 5 x1.6 cm pressure ulcer to the sacrum. New orders received for wet to dry dressing changes two times a day until a wound vac can be placed. On 10-22-20 at 10:00 am, V3, Wound Nurse, stated he was not completing most of R9's wound assessments and could not accurately track R9's wounds as the documentation of location is confusing. V3 stated V14, NP at wound clinic should have been notified sooner regarding R9 pressure ulcers. On 10-21-20 at 2:30 pm, V14 NP (Nurse Practitioner/Certified Wound Nurse), stated R9's sacral wound has become much worse. V14 stated she was not notified for a consult until R9's sacral wound worsened to a Stage 3. V14 stated she should have been notified when an unstageable ulcer and Stage 2 pressure ulcers worsened so appropriate treatment could have been provided.

Based on observation, interview and record review the facility failed to implement effective interventions and provide increased supervision to prevent falls for 2 of 3 residents (R1, R2) reviewed for falls in the sample of 3. This failure resulted in R2 falling and obtaining a fractured fibula (lower leg bone). Findings include: On 11/20/19 at 10:00 AM, R2 was in her room sitting in her wheelchair, attempting to get up by herself. Surveyor turned R2's call light on and told V11, Certified Nurse Aide (CNA) R2 was trying to get up by herself. On 11/21/19 at 9:40 AM, R2 was in her room, sitting in her wheelchair, her call light was not within reach. The call light was approximately 4 feet behind her on her bedside table. Surveyor told V7 CNA (R2) could not reach her call light and V7 went into room and put the call light next to R2 and asked R2, Who wheeled you into the room? R2 stated, I don't know. R2's Face Sheet, undated, documents R2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R2's Minimum Data Set, dated dated [DATE], documents R2's has moderately impaired cognition. The MDS documents R2 requires extensive assistance (resident involved in activity, staff provide weight-bearing support) of two staff person physical assistance for transfers, bed mobility and dressing. R2's MDS documents she requires extensive assistance of one staff person for personal hygiene. R2's Care Plan, dated 9/23/19, Problem: At risk for falls related to weakness, impaired mobility, balance, age, cardiovascular disease and history of falls prior to admit. High sided mattress as she swings her legs outside the bed. The Care Plan documents Approach: Therapy as ordered for mobility. Keep personal items and frequently used items within reach. High sided mattress on bed to define bed boundaries. Fall risk assessment on admit and per protocol. Encourage to call for assistance as needed-easy operation touch light. Call don't fall sign in room as a reminder to call for assist prior to getting up. R2's Progress Note dated 9/25/19 at 4:55 PM documented Guest found on floor next to bed sitting on bottom. The Note continued Reviewed, with family present, importance of using call bell for assist before getting up. Guest verbalized understanding. R2's Care Plan approach, dated 9/25/19 documented Keep bed in lowest position when in bed, adjust height of bed as needed for care. When requested, the facility was unable to provide a documented fall investigation for R2's fall on 9/25/19. R2's Progress Note, dated 9/26/19 at 2:45 AM documented Guest found trying to get out of bed again without assist earlier despite high sided mattress placed on bed prior to HS (at night) and bed low to ground. The Note documented R2 would be monitored closely and was on frequent bed checks. R2's Progress Note, dated 9/27/19 at 4:43 AM documented Guest found sitting on bottom next to bed on routine Q (every) 30min rounding. The Note documented Guest cannot comprehend that she is not to get out of bed without help Guest cannot comprehend use of the call light for assistance. R2's Care Plan Approaches, dated 9/27/19 documented Keep in supervised areas as much as possible, 30-minute checks in room. Check for need to toilet at least every 2 hours on odd hours and as needed. Frequent rounding to check on needs. When requested, the facility was unable to provide a documented fall investigation for R2's fall on 9/27/19. R2's Progress Note, dated 9/29/19 at 3:55 PM documented Had unwitnessed fall at 0100 (1:00 AM). Stated she was trying to get out of bed to look out of the window to see the thunderstorm. Pt (Patient) was not able to confirm or deny head injury. Upon assessment, no sign of head or extremity injury. The Note documented she was transferred with a gait belt back to bed with assistance of two staff persons. R2's Progress Notes for Fall on 9/29/19 document, Had another fall on 9/29/19 at 5:05 AM. When asked why she got up she said she didn't want to bother us by calling and she needed to go to the bathroom but repeatedly denied needing to void when she was rounded on. Patient hit her head pretty hard as the sound of her falling was heard from the hallway and she was found with her head under the wheelchair. Upon assessment, she had a pretty big closed head injury at the back of her head and her right ankle had become 3+ [MEDICAL CONDITION]. Right ankle was painful to the point where it became non-weight bearing related to pain. The Note documented R2 was sent to local emergency department. R2's Progress Note, dated 9/29/19 at 11:00 AM documented R2 returned from the hospital and all diagnostic tests were negative. The Progress Note documented Guest encouraged to please call for assistance, do not try to get up alone for any reason. R2's Progress Note, dated 9/29/19 at 5:24 PM, documented Writer sitting at desk charting at this time, heard 'thud' and call out for help upon arriving to (resident's room) guest is found on the floor once again on her back. Informed writer that she hit her head once again and that 'things were spinning currently. The Note documented R2's bed was in the low position, high side mattress was in place, touch call light was in place. The Note documented that R2 was once again informed she should not try to get up alone and the danger of the doing this without help and R2 voiced understanding. R2's Care Plan Approaches, dated 9/29/29, documents, Encourage activities of interest, assist in providing items. House calls. Do not leave unattended in bathroom. When requested, the facility had no documented investigation R2's falls occurring on 9/29/19. There was no documentation the facility assessed R2 for the need for increased supervision. R2's Progress Note, dated 10/1/19 at 6:45 AM documented R2 had multiple falls and sustained a bruise to the back of her head and was complaining of right foot pain. The Note documented the right foot was swollen and bruised. Progress Note at 8:51 AM documented V10, R2's Physician ordered an x-ray. R2's X-ray results, dated 10/3/19 documented she had a right fibular (leg) fracture. R2's Progress Note, dated 10/09/19 at 6:10 AM, documents 0610 found guest laying sideways on the side of the bed. Able to move extremities. Has bilat (bilateral) redness to her knees. The Note documented V10 was notified and ordered x-ray of both knees. R2's Progress Note at 2:05 PM documented the x-ray results showed no fractures. When requested, the facility had no documented investigation of R2's fall occurring on 10/9/19. R2's Progress Note, dated 10/20/19 at 10:37 AM documented Nurse and CNAs (Certified Nurse's Aides) rounded on pt (patient) every 30 mins (mins) to an hour because of Hx of multiple falls. Reminded multiple times to call for needs. Rounded at 0300 (3:00 AM) and CNA found her on the floor in the bathroom. Pt did not attempt to call out for help. R2's Fall Event investigation, dated 10/20/19 documented the root cause of R2's falls as confusion: resident self transferred to bathroom. The Interventions listed on this Investigation was frequent safety checks. The Investigation did not document how often frequent checks should be conducted to prevent R2 from falling in the future. R2's Care Plan Approaches, dated 10/20/19 documented Frequent safety checks. R2's Progress Note dated 11/5/19 documented Guest is (full body mechanical lift) to and from bed this shift, does continue to try to reposition self in chair and trying to get out of bed when in low position. The Note documented will continued to encourage guest to use this and not try to get up w/o (without) assistance. R2's Progress Note, dated 11/19/19 at 4:08 PM documented Guest was observed on the bedroom floor in a sitting position against her wall. When requested, the facility did not have a documented investigation of R2's fall on 11/19/19. R2's Progress Note, dated 11/20/19 at 7:59 AM documented guest found on the floor in her room next to the bed near her window. R2's Progress Note, dated 11/20/19 at 11:35 PM documented On rounding, guest found in bathroom on toilet. Had apparently ambulated in there independently. Assisted back to bed, tried to re-orient her to her surrounding but she remains pleasantly confused. The Note documented will continue frequent rounding on guest. The note did not document how often frequent rounds were to be conducted. On 11/21/19 at 3:10 PM, V2 Director of Nurses (DON) was asked if R2's interventions were working for her, V2 agreed they were not. The facility Policy and Procedure for Falls, not dated, documents in part, Purpose: To identify interventions related to the guest's specific risks and causes to prevent the guest from falling and try to minimize complications from falling. The Procedures documented #4. The licensed nurse is responsible for completing a fall risk assessment following a fall as well as identifying and implementing relevant interventions to try to minimize serious consequences of falling. #5. The licensed nurse will complete a Fall Event as well as a Progress Note in the Electronic Medical Record, which provides as much information regarding the fall as possible. The Procedures continued #7. If falling occurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. #8. If the underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature of the falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. 2. Current Resident Face Sheet, for R1, documents R1 was admitted to the facility on [DATE]. R1's [DIAGNOSES REDACTED]. R1's Care Plan, dated 10/25/19, documents, At risk for falls r/t (related to) weakness, impaired mobility, balance, dementia, [MEDICAL CONDITION], age, self-transfer attempts. The Care Plan Approach documents Encourage to call for assistance as needed. MDS for R1, dated 10/31/19, documents R1's cognition is moderately impaired and needs assistance of 1 staff for transfers and ambulation. R1's Progress dated 10/30/2019 at 10:53 PM documents (R1) was standing in his doorway. fell . He has two sm (small) skin tears & another one an inch long on his right hand. Fall Event Investigation for R1 dated 10/30/19, documents, Root Cause: confusion/weakness. self transferring. Interventions: Triangle call light (push pad), encourage to call for assistance On 11/20/19 at 2:07 PM, R1 was sitting in his room in his recliner next to the left side of his bed. The call light push pad was on the far right side of R1's bed, not within R1's reach. On 11/21/19 at 9:40 AM, R1 was sleeping in his room in his wheelchair positioned on the right side of his bed. R1's call light push pad was on the far left side of R1's bed. The push pad call light was on the far left side of R1's bed, not within R1's reach. On 11/20/19 at 2:07 PM, when R1 was asked where his call light push pad was, R1 stated, I don't know, I was looking for it. When asked what you would do if you needed something and no call light push pad was within reach, R1 stated, I guess yell for help. The push pad call light was not within R1's reach. On 11/21/19 at 10:05 AM, R1 was awake and sitting in his wheelchair next to the right side of his bed and the call light push pad remained on the far left side of R1's bed. When R1 was asked if he could reach his call light push pad, R1 stated, Probably not. R1 started reaching across his bed trying to touch the call light push pad and after several attempts, R1 attempted to stand up from his wheelchair to reach the call light push pad. R1 was instructed not to stand up from the wheelchair. The push pad call light was not within R1's reach. On 11/20/19 at 2:08 PM, V8 CNA, and V9, CNA, entered R1's room and when informed R1's call light was not within his reach, V8 and V9 stated, I wonder who put him in his chair? On 11/21/19 at 2:45 PM, V2, Director of Nurses, (DON), stated, I would expect the call light to be within the reach of resident.

[NAME] Based on interview and record review, the facility failed to ensure that wounds were assessed, monitored and treated according to physician's orders for 1 of 3 residents (R3) reviewed for wound care in a sample of 5. This failure resulted in deterioration of leg wounds for R3 requiring hospitalization . Finding include: 1. Hospital Discharge Records dated 8/24/19 document R3's [DIAGNOSES REDACTED]. The Hospital Course documents a wound care team was consulted for non-healing vascular ulcers and R3 was initially seen by V11 (Vascular Surgeon) who recommended amputation versus revascularization. The Record documented when a second consult was done by V12, (Vascular Surgeon) he recommended at least initially good wound care and pressure offloading. The note continued to document that R3 was then discharged to an extended care facility on 8/24/19. Hospital Discharge orders reflected no leg wounds treatments but did have [MEDICATION NAME] Topical lotion to be applied two times daily as needed for dry skin. The Facility's Admitting Progress Note, dated 8/24/19, at 4:01 PM, entered by V6, Licensed Practical Nurse (LPN) documents (R3) has Vascular wounds to Bilateral Lower Legs that are wrapped at the time-CDI (clean, dry, intact), R (right) Heel wounds with [MEDICATION NAME] covering-CDI, minimal [MEDICAL CONDITION] to legs. This initial note does not include any specifics about R3's wounds on admission including size and condition of wounds. There was no documentation that the facility contacted V12 for treatment orders for R3's vascular wounds to his bilateral lower legs. A Clinical Documentation - Admission Nursing Assessment, dated 8/24/19 at 1:02 PM, created by V6 in the electronic medical record (EMR) is totally blank including the areas for any type of skin condition and for the Integumentary system or skin in general. There was no documentation a thorough skin assessment was completed upon R3's admission. R3's Initial Care Plan, dated 8/24/19, identifies R3's problem as Vascular wounds to legs. R3's Care Plan interventions dated 8/24/19 include Repair cream as ordered - see TAR (Treatment Administration Record), Observe during care for any signs of breakdown, and preventative care as indicated. The Care Plan had no information regarding the treatments for R3's vascular wounds. R3's Progress Note, dated 8/26/2019 at 1:45 AM, written by V7 documents (Off-loading) boots in place bilaterally. Bilat (bilateral) lower legs dressings intact. Did secure them with stockinette earlier. Incontinent. Again, this Progress Note doesn't include any wound information including size and condition of R3's wounds and what treatment was done for R3's leg wounds during this time. The (MONTH) 2019 TAR documents no treatments were done to R3's legs being done from admission on 8/24/19 until 8/28/19 and documents no [MEDICATION NAME] Cream applied at all. R3's Wound Care Note dated 8/27/19 signed by V8 Facility Nurse Practitioner (NP), ordered Wash legs daily with saline, apply [MEDICATION NAME] (a dressing which prevents air from reaching the wound by using mesh gauze impregnated with a petroleum blend formula) to all open wounds including necrotic calves, L (left) heel, bilateral toes then wrap with Kerlix (gauze), then apply (off-loading) boots. This was three days after R3's initials admission to the facility. On 8/28/2019 at 2:23 AM, V7 documents R3 to be on every 2hr (hour) bed checks. Guest has removed (off-loading) boots and dressings unraveled. Attempted to re-secure the dressings without waking guest, as he is now sleeping soundly. There was no documentation V7 applied a new dressing to R3's wounds. At 5:48 AM, V7 documents Guest had kicked off most of his lower leg wraps. Secured with tube sleeve. On 8/28/2019 at 4:02 PM, V4 RN/Wound Nurse entered the first skin assessment done on R3 since admission. The report documented Scattered necrotic areas are noted on bilateral lower legs, L heel and all toes. All are clean and dry. (Off-loading) boots are in place at present but guest removes them frequently. All remaining skin is clear and intact. Today's Braden score indicates he is at risk for pressure injury. Pressure reducing mattress and WC (wheelchair) cushion are in place, turning and repositioning are scheduled. Dietary consult is ordered for nutritional support. There was no further assessment on R3's leg wounds such as size, depth, color, drainage, etc. at the time of this wound assessment. The Emergency Note dated 9/1/19 documents R3 was admitted after a change in condition. The ER Note documented Family was also concerned that he was not getting adequate wound care on his lower extremities as directed by (V12). On 9/11/19 at 12:00 PM, V5, LPN, stated V5 stated she never did his leg treatments because whenever she was here, the care giver did them, so she never actually saw his leg wounds. On 9/11/10 at 9:00 AM, V4, Facility Wound Nurse/RN stated R3 was admitted on [DATE] which was a Saturday and she saw him for the first time the following Wednesday, 8/28/19. V4 stated she did not measure the wounds due to them being all over. V4 stated she didn't remember seeing him after that. V4 stated R3's legs were covered with necrotic areas when she saw him and agreed that there is no prior admission assessment in the record. V4 stated the admitted nurse is supposed to assess all wounds and do a skin check for a baseline following up with the physician for wound treatment orders. V4 states she suspects treatments were not done as ordered. She stated she removed the dressing she applied (the dressing had the date and her initials on it) from the previous week. V4 stated she understood R3 had an order for [REDACTED]. On 9/11/19 at 1:33 PM, V8, Nurse Practitioner (NP), stated R3's leg dressings were hanging off both legs and he had no dressings on his feet or heels when she saw him on 8/27/19. V8 stated the dressings were dry kerlix and he had numerous necrotic areas on the front/back of both legs and on his toes. V8 stated R3 also did not have his protective boots on when she entered the room. V8 stated she is concerned that treatments were not done as ordered because she's taken off dressings that are up to three days old (dressings are dated) when they should have been changed daily. V8 stated she would expect the nurse to clean and redress the wounds instead of rewrapping them if the dressings were no longer intact. V8 stated she would have expected the nurses to call for treatment orders immediately following admission since he didn't seem to have orders sent with him from wound care which would just be standard practice of care and would have expected them to assess all wounds upon admission for a baseline. B. Based on interview and record review, the facility failed to perform on-going assessments, monitor, recognize a change of condition and timely notify a physician of pertinent information for one of one resident (R3) reviewed for a change of condition in the sample of 5. Finding include: On 8/28/2019 at 1:32 PM, V9, Licensed Practical Nurse (LPN), documents she Held B/P (Blood Pressure) medications in the AM due to blood pressure 102/48 and rechecked it 98/40 (normal blood pressure range is 120/80). There was no documentation the physician had been notified of his blood pressure being low. There was no documentation the facility was monitoring R3's blood pressure after this. R3's Progress Note, dated 9/1/19 at 6:04 AM, written by V10, Registered Nurse (RN), documents Pt (patient) had a big diarrhea episode HS (hour of sleep). V10 documented R3 struggled to swallow HS medicine, so she gave him his pills one at a time. V10 documented that R3 was able to successfully consume medication after big pills were broken in half and instructed to swallow with force. Made AM shift nurse aware that pt had massive diarrhea episode x (times) 1 and that speech therapy needed to do a swallow eval (evaluation) AM 09/01. There was no documentation V10 notified the physician of R3's diarrhea and/or condition change of R3 having difficulty swallowing his medications. R3's Progress Report, dated 9/1/19 at 3:23 PM, written by V5, LPN, documents Does take all medications crushed w/o (without) difficulty swallowing. Lung sounds are clear, bowel sounds are present x 4. Guest has refused to get out of bed during this shift today informs writer that he just does not feel well, currently having loose stools and staff continue to check and change frequently to prevent further skin and scrotal breakdown. V5 documented Son did request that personal home care assistant come in and assess both areas and make decision on what should be done. Will await return call from son. Continent of urine, incontinent of bowel, abdomen is soft, non-distended. Vital signs: 97.0 (temperature; normal 98.6), 90 (pulse), 20 (respiration), 122/60 (blood pressure). Resting in room with call light in reach. Will monitor. Again, there is no documentation V5 assessed R3's complaints of not feeling well, having loose stools or having difficulty taking his medications and notified the physician of R3's significant change in condition. R3's Progress Note, dated 9/1/19 at 6:00 PM, written by V5 noted R3's physician was called with a message left due to condition change and guest is being sent to hospital due to change in mental status. R3's Progress Noted, dated 9/1/19 at 6:08 PM, documents Guest continues to decline at this time. Family informed (son) really does not wish to have father sent out at this time, believes he will be fine for the rest of the evening. Writer informs son that guest condition continues to decline and should be evaluated. Call made to (V2, Director of Nurses/DON)), at this time, informed that guest continues to decline and that he is being sent out due to diarrhea, decrease in fluid intake this shift, color pale gray, not responding to staff unable to get temp, pulse 76 blood pressure 82/50. Medics First called at this time to transport to (local Hospital). An entry dated 9/2/19 at 6:09 AM by V10 documents R3 was admitted to the hospital with [REDACTED]. diff), and urinary tract infection [MEDICAL CONDITION]. The Hospital History and Physical (H&P), dated 9/1/19 documented R3 [MEDICAL CONDITION] secondary to UTI and [MEDICAL CONDITION] diarrhea upon arrival. The H&P continued to document R3 presented in the emergency room (ER) with diarrhea, dehydration and poor nutrition. The H&P documented the family were concerned R3 had poor nutrition and decreased oral intake and was having diarrhea about 3-4 days ago. The H&P documented R3 was given IV fluids and had good response to the treatment but was admitted . On 9/11/19 at 12:00 PM, V5, LPN, stated she was told in report the morning of 9/1/19 that R3 had diarrhea. V5 stated she saw R3 for the first time on 9/1/19 around 9:00 AM and that she noted a condition change then as he was unable to take whole medications and she had to crush them. V5 stated she wanted to call the physician, but the son insisted on R3's home care giver coming in and checking him out first. V5 stated R3 continued to decline as the day progressed and finally she just told the family that she was going to send him out for evaluation. On 9/11/19 at 12:25 PM, V15, Certified Nurse Aide (CNA), stated she was working on 9/1/19 and remembered R3 being incontinent of stools. V15 stated R3 didn't want to get out of bed but family was here and did anyway On 9/11/19 at 1:33 PM, V8, Nurse Practitioner (NP), stated she did not see R3 after 8/27/19 and was not contacted regarding his change of condition at all. The facility policy/procedure entitled Notification and Significant Change of Condition Policy undated documents the purpose as to ensure that the facility immediately inform the guest; consult with the guest's physician; and notify, consistent with his or her authority, the guest representative when there is: a significant change in the guest's physical, mental, or psychological status and/or the need to alter treatment significantly.

Based on observation, interview, and record review the facility failed to assess pain immediately, administer physician ordered narcotic pain medications, and failed to implement non-pharmacological pain interventions for four of five residents (R2, R3, R4, and R10) reviewed for pain in the sample of 11. These failures resulted in R2 and R3 experiencing excruciating head pain and abdominal pain for numerous hours, resulting in nausea/vomiting. These failures also prevented R2 from attending physical and occupational therapy. Findings include: The facility's undated Pain Management policy documents, All guests will receive the best level of pain control that can safety be provided in order to prevent unrelieved pain. Pain is whatever the experiencing person says it is, existing whenever he/she says it does. Self-report is the preferred indicator of pain. Pain relief is the alleviation of pain or reduction in pain to a level of comfort that is acceptable to the guest and is demonstrated by a decrease in the guest's pain scale rating. Licensed Staff will screen for the presence of pain at least every shift. It is the responsibility of the licensed nurse to reassess pain intensity once a sufficient time has elapsed for the pharmacological treatment to reach peak effect,Your nurses and personal care associates will come by regularly to see how you are feeling. Request the pain medicine as soon as you start to have pain and report unrelieved pain after being medicated. The longer you wait the worse the pain gets, the harder it is to control. We will evaluate your use of the medications and help you learn how to use them in the most effective manner to treat your pain. As a partner in your health care, your caregivers will depend on you to tell them how you feel. Based on you own comfort level, your health worker will make a pain management plan. Rating your pain: While in the facility you will be ask you to rate your pain. A pain scale has a face that you can point to that will show us how much pain you are feeling. A zero indicates no pain. A six indicates distressing, miserable pain. An eight indicated intense, dreadful, horrible pain. A ten indicated worst possible, unbearable, excruciating pain (crying face). Will ask what type of pain you are having and what works for you. Treating pain consists of medications, cold packs, exercise, ultrasound, and therapy. 1. On 8-26-19 from 9:10 AM to 9:30 AM R2's call light was on. At 9:30 AM V10 (Certified Nursing Assistant/CNA) answered R2's call light. R2 informed V10 that she needed a pain pill for a migraine and nausea. V10 proceeded to turn R2's call light off and reported to V5 (Licensed Practical Nurse/LPN) that R2 was requesting a pain pill and was nauseated. On 8-26-19 at 9:35 AM, R2 was lying in the dark with a wet towel on her head and over her eyes. R2 stated, I had been waiting for over 40 minutes to have my call light answered. I have an excruciating headache and stomach ache and need a pain pill. On 8-26-19 at 10:50 AM R2's call light was on and V10 answered immediately. R2 complained of feeling nauseated to her stomach. V10 turned off R2's call light and informed V5 of R2 complaining of nausea. On 8-26-19 from 9:40 AM to 11:10 AM V5 proceeded to administer medications to other residents (R3, R4, R5, and R6). On 8-26-19 at 11:10 AM (one hour and fourty minutes after requesting pain medication) V5 entered R2's room to give R2 routine morning medications. During this time, R2 was crying and had to request a pain pill from V5. R2 stated that she was having severe pain to the abdomen and head and requested a Tylenol #3 for the pain. V5 administered Tylenol-[MEDICATION NAME] #3 300-30 mg (milligrams) one tablet to R2. On 8-26-19 at 1:20 PM R2 was lying in bed with a basin containing vomit that was sitting on her abdomen. R2 stated at this time, The nurse has not come back and checked on my pain. My migraine was so bad that I am vomiting now. If I get my pain medication quickly then I do not vomit. My head pain is still excruciating. I have complained to the supervisors before about getting my pain medications timely and nothing has really improved. I cannot even do therapy today because my pain was so bad. I need to be able to do therapy to get my skilled stay covered here by my insurance. The facility did nothing for me to try and control my pain. On 8-27-19 at 8:50 AM, R2 was lying in bed. R2 stated, The nurse did not check on me yesterday after getting my pain pill. My migraine was terrible. The next nurse that came on gave me something around 9:00 PM. I needed something to help before that to keep the migraine away. R2's Minimum Data Set ((MDS) dated [DATE] documents R2 is cognitively intact. This same MDS documents R2 has frequent pain that effects sleeping at night. R2's current physician's orders [REDACTED]. These same POS's document the following orders: [MEDICATION NAME] 200 mg (milligrams) two tablets every four hours as needed for pain. [MEDICATION NAME] 25 mg one tablet every six hours for nausea. Tylenol-[MEDICATION NAME] #3 300-30 mg one tablet every six hours for migraine headaches. Assess pain every shift. Skilled Occupational Therapy (OT) six times a week and Skilled Physical Therapy (PT) seven days a week. R2's Pain assessment dated [DATE] documents R2 rating of intensity of pain at a eight with a seven indicating severe pain that is horrible/intense. This same assessment documents interventions: [MEDICATION NAME], Cold, Relaxation Techniques, and Rest. R2's current Pain Plan of Care documents, Problem: Potential for pain due to weakness, recent surgery, intrahepatic bile [MEDICAL CONDITION], migraines, and [MEDICAL CONDITION]. Goal: Pain medication will be effective by guest indicating effectiveness within 30 minutes of being medicated. Approach: Pain assessment upon admit and per protocol. Pain medication as ordered. Reposition as needed/desired for comfort. R2's PT Daily Treatment Note dated 8-26-19 documents, Attempted to see (R2) twice today. (R2) states that she is having a migraine and stomach pain. (R2) has puked this morning. Pain is an 'eight' on 0-10 scale. Nursing aware. Patient refused to participate in skilled therapy. R2's OT Daily Treatment Note dated 8-26-19 documents, Guest was approached multiple times today, however complained of nausea/migraine. The patient declined to sit on the edge of the bed due to reports that she might get sick. The patient is limited due to nausea/migraine. 2. On 8-26-19 from 9:10 AM to 9:28 AM R3's call light was on. At 9:28 AM V10 answered R3's call light. R3 informed V10 that she needed a pain pill for a migraine and nausea. V10 proceeded to turn R3's call light off, answered R2's call light, and then reported to V5 (Licensed Practical Nurse/LPN) that R3 was requesting a pain pill and was nauseated. On 8-26-19 at 10:10 AM, R3 stated, My light was on for 40 minutes before a CNA answered it. I told the CNA I needed a pain pill. I have a bad headache and stomach ache. My headache is a 'seven' on a 0-10 scale. It takes forever to get pain pills here. At this time R3 was holding her right hand on her head and had tears in her eyes. R3's room was dark. On 8-26-19 at 10:20 AM, V5 entered R3's room with R3's scheduled morning medications. R3 at that time noticed V5 did not bring in a pain pill. R3 stated, My migraine is killing me! I need a pain pill. I am nauseated. V5 responded to R3 by stating, You have been out of your [MEDICATION NAME] since last night and you have nothing else ordered for pain. I will have to try and get the [MEDICATION NAME] ordered in a little bit. V5 then administered a [MEDICATION NAME] 8 mg for R3's complaints of nausea. On 8-26-19 at 11:45 AM R3 put the call light on, again. V10 answered the call light and R3 stated that she needed the nurse because she was in pain. V10 proceeded to inform V5 immediately that R3 was in pain. On 8-26-19 at 1:30 PM, R3 stated, I still have not gotten a pain pill. I am nauseous from my headache. My pain is a 'nine' on a 0-10 scale and excruciating. I need a pain pill now! On 8-26-19 at 2:12 PM, V6 (CNA) reported to V5 that R3 was still needing a pain pill. On 8-27-19 at 9:00 AM, R3 was sitting on the edge of the bed eating breakfast. R3 stated, I did not get my pain pill until after midnight yesterday. My head was pounding with a migraine. The migraine was debilitating. I ended up vomiting that night. I should have never had to go without my pain medication. The staff did nothing for me to try to help my migraine. R3's MDS dated [DATE] documents R3 is cognitively intact. R3's current POS documents R3 has the [DIAGNOSES REDACTED]. These same POS's document the following orders: [MEDICATION NAME]-[MEDICATION NAME] 7.5/325 mg one every four hours as needed for chronic pain. [MEDICATION NAME] 2.5 percent cream topically to affected areas as needed for pain. Assess pain every shift. R3's current Pain Plan of Care documents, Problem: Potential for pain due to weakness, [MEDICAL CONDITIONS], Ostoearthritis, sciatica, low back pain, and migraines. Goal: Pain medication will be effective as guest indicating effectiveness within 30 minutes of being medicated. Approach: Pain assessment upon admit and per protocol. Pain medications as ordered. Reposition as needed/desired for comfort. R3's Pain Assessment Section Pain Symptoms dated 8-15-19 is incomplete and does not address how often R3 has pain. This same assessment documents R3's pain is usually severe pain that is horrible/intense, constant/persistent, and [MEDICATION NAME] used for the pain are usually effective. This assessment also documents that no other non-pharmacological interventions are used to manage R3's pain. R3's MAR indicated [REDACTED]. 3. On 8-26-19 at 9:15 AM, R4 was lying in bed and stated that she had a headache. R4 stated, I asked for Tylenol for a headache and haven't got it yet. My call light was on for 30 minutes before the CNA finally answered it. My headache is a 'seven' on a 0-10 scale. On 8-26-19 at 9:53 AM V5 administered two Tylenol tablets 325 mg orally to R4. On 8-26-19 at 11:00 am, R4 requested a [MEDICATION NAME] from V5. R4 stated, The Tylenol is not helping and my headache is getting worse. V5 replied to R4 that R4 needed to wait at least one half hour. I need to do (administer medications) to two other residents first. V5 told R4 that she needs to Hang in there. R4's MDS dated [DATE] documents R4 is cognitively intact. R4's current POS document R4 has the [DIAGNOSES REDACTED]. This same POS documents the following orders: [MEDICATION NAME] (Tylenol) 325 mg two tablets every six hours as needed for pain. [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg one to two tablets every four to six hours as needed for pain (not to exceed eight tablets daily). Assess pain every shift. R4's current Pain Plan of Care documents, Problem: Potential for pain and weakness due to right hip pain, left patella fracture, and restless leg syndrome. Goal: Pain medication will be effective by guest indicating effectiveness within 30 minutes of being medicated. Approach: Ice as ordered. Pain assessment upon admit and per protocol. Pain medication as ordered. Reposition as needed. R4's MAR indicated [REDACTED]. This same MAR indicated [REDACTED]. R4's MAR indicated [REDACTED]. 4. On 8-27-19 at 10:20 AM R10 was lying in bed. R10 stated, I have had open heart surgery, Ostoearthritis, and [MEDICAL CONDITION]. I have severe pain, unless I get a pain pill ([MEDICATION NAME]) every six hours. I will put on my call light to ask for pain medicine 20 minutes early, because I know it will take at least that long to get my light answered. I usually have to wait at least another hour to two hours after the call light is answered to get my pain medicine. I start to get excruciating pain that goes from my back down my legs. Today I waited for my call light to get answered for over an hour this morning because I wanted a [MEDICATION NAME]. R10's current POS documents R10 has the [DIAGNOSES REDACTED]. This same POS documents the following orders: [MEDICATION NAME] 5 mg one tablet every four hours as needed. [MEDICATION NAME]-[MEDICATION NAME] 37.5-325 mg every two tablets every six hours as needed for pain. R10's current Pain Plan of Care documents, Problem: Potential for Pain due to Dorsalgia, Cervical Disc Disorder, and Lumbar Disc Degeneration. Goal: Pain medication will be effective as guest indicates effectiveness within 30 minutes of being medicated. Approach: Pain assessment upon admit and per protocol. Pain medication as ordered. Reposition as needed. R10's Pain assessment dated [DATE] documents R10 has moderate pain daily that is constant. This same assessment documents [MEDICATION NAME] are used to manage pain. On 8-26-19 at 1:38 PM, V5 stated, (V10) reported to me that (R2, R3, and R4) needed pain medications between 9:00 and 9:28 am. I got the wrong room number for one resident. I would not expect a resident to lay in pain for any length of time. I usually don't have that many residents needing pain medications. I should have assessed all three resident's pain before giving other residents all of their medications. (R3) does not have anything else prescribed for pain. I did go back and tell (R4) to wait on her pain medication. I should not have made (R4) wait for [MEDICATION NAME]. I should not have documented that (R4's) Tylenol was effective for the pain. That was an error on my part. On 8-28-19 at 3:05 PM V15 (R3's Physician) confirmed that R3 should not have had to with stand excruciating pain from morning until night time on 8-26-19, or go without pain control. On 8-27-19 at 12:30 PM, V2 (Director of Nursing) stated, A nurse should have accessed R2's pain as soon as possible and give R2 her pain medication. The nurse should have went to the three residents (R2, R3, and R4) first to do an assessment, find out what the pain is, have the resident rate the pain, and find out what medication she had to offer before continuing a medication pass. The nurse should have evaluated (R2) and (R3) before continuing a medication pass with the other residents. No residents should experience excruciating pain. (R3) should not have to go without the [MEDICATION NAME] for pain.

Based on observation, interview, and record review the facility failed to acquire medications from the pharmacy and acquire a controlled substance refill request from the physician for three of five residents (R1, R2, and R3) reviewed for medication availability in the sample of 11. These failures resulted in R2 experiencing distressing, miserable pain for over 24 hours and R3 experiencing on a pain is a 'nine' on 0-10 scale and excruciating pain for 15 hours. Findings include: The undated Acquiring Medications policy states Purpose To ensure that routine and emergency medications are provided to the guests and Procedure 1. To order new medications, staff is to enter the medication into the electronic medical record. The order is transmitted to the pharmacy via ePrescription (electronic prescription). Prescriptions for controlled substances must be faxed to the pharmacy. If the eprescription fails, a message will be sent via the message system in the electronic record. The order must be re-sent to the pharmacy in order for the medication to be sent to the facility. At times the facility is unable to obtain controlled substances due to an issue with a prescription. In this case, the physician/on call physician will be contacted in an attempt to obtain the script. If the facility is not successful in obtaining a valid script for the medication, the guest or responsible party may be allowed to bring in a personal supply of the medication and If both of these attempts to fill the medication fail, the Medical Director will be notified and the Medical Director may fill a short script until a valid script can be obtained by the prescribing physician. The facility's undated Pain Management policy documents, Rating your pain: While in the facility you will be ask you to rate your pain. A pain scale has a face that you can point to that will show us how much pain you are feeling. A zero indicates no pain. A six indicates distressing, miserable pain. An eight indicated intense, dreadful, horrible pain. A ten indicated worst possible, unbearable, excruciating pain (crying face). 1. On 8-26-19 at 1:20 PM R2 was lying in bed with a basin containing vomit, sitting on her abdomen. If I get my pain medication quickly then I do not vomit. I have complained to the supervisors and filed a grievance about getting my pain medications and nothing has really improved. I went almost two days without Tylenol #3 and was having a terrible migraine and was miserable. R2's current physician's orders [REDACTED]. These same POS's document the following orders: [MEDICATION NAME] 200 mg (milligrams) two tablets every four hours as needed for pain. [MEDICATION NAME] 25 mg one tablet every six hours for nausea. Tylenol-[MEDICATION NAME] #3 300-30 mg one table every six hours for migraine headaches. Assess pain every shift. R2's Grievance Form dated 8-19-19 documents, (R2) states that she does not have her pain medication, specifically Tylenol #3,when needed. According to nursing, they (nursing) have had some issues with receiving the prescription for (R2's) Tylenol#3, and therefor (R2) has missed a dose. R2's Controlled Drug Record dated 8-16-19 documents the pharmacy sent four [MEDICATION NAME]/[MEDICATION NAME] 300-30 mg tablets on 8-16-19. This same record documents the last dose of [MEDICATION NAME]/[MEDICATION NAME] 300-30 mg was administered on 8-19-19 at 12:25 AM. R2's Controlled Drug Record documents R2 did not receive more [MEDICATION NAME]/[MEDICATION NAME] 300-30 mg tablets until 8-21-19. R2's Medical Record and Pharmacy Records do not include and documentation of a refill request being sent to pharmacy for R2's [MEDICATION NAME]/[MEDICATION NAME] 300-30 mg on 8-19-19 or 8-20-19. R2's Pain assessment dated [DATE] at 7:00 PM to 8-20-19 at 7:00 PM documents R2's pain level at a six indicating R2 was experiencing distressing, miserable pain while out of the [MEDICATION NAME]/[MEDICATION NAME] 300-30 mg. 2. On 8-26-19 at 9:10 AM, R3 requested a pain pill from V10 (CNA) for nausea and a migraine. V10 immediately reported to V5 (Licensed Practical Nurse/LPN) that R3 was requesting a pain pill and was nauseated. On 8-26-19 at 10:10 AM, R3 stated, I have a bad headache and stomach ache. My headache is a seven on a 0-10 scale. At this time R3 was holding her right hand on her head and had tears in her eyes. R3's room was dark. On 8-26-19 at 10:20 AM, V5 entered R3's room with R3's scheduled morning medications. R3 stated, My migraine is killing me! I need a pain pill. I am nauseated. V5 responded to R3 by stating, You have been out of your [MEDICATION NAME] since last night and you have nothing else ordered for pain. I will have to try and get the [MEDICATION NAME] ordered in a little bit. On 8-26-19 at 11:45 AM R3 put the call light on, again. V10 answered the call light and R3 stated that she needed the nurse because she was in pain. V10 proceeded to inform V5 immediately that R3 was in pain. On 8-26-19 at 1:30 PM, R3 stated, I still have not gotten a pain pill. I am nauseous from my headache. My pain is a 'nine' on a 0-10 scale and excruciating. I need a pain pill now! On 8-27-19 at 9:00 AM, R3 was sitting on the edge of the bed eating breakfast. R3 stated, I did not get my pain pill until after midnight yesterday. My head was pounding with a migraine. The migraine was debilitating. I should have never had to go without my pain medication. R3's current POS documents R3 has the [DIAGNOSES REDACTED]. These same POS's document the following orders: [MEDICATION NAME]-[MEDICATION NAME] 7.5/325 mg one every four hours as needed for chronic pain. [MEDICATION NAME] 2.5 percent cream topically to affected areas as needed for pain. Assess pain every shift. R3's Controlled Drug Record documents 29 tablets of [MEDICATION NAME] 7.5/325 mg were delivered to the facility on [DATE]. This same Controlled Drug Record and R3's MAR indicated [REDACTED]. R3's Medical Record dated 8-16-19 to 8-25-19 has no evidence documented of R3's physician being notified of the need for a refill request prescription for the [MEDICATION NAME]/[MEDICATION NAME] 7.5/325 mg before administering the last dose on 8-25-19 at 1:10 PM. The facility's Pharmacy Records do not include evidence of a Controlled Substance refill request form being sent to the facility or to R3's Physician. R3's Progress Notes dated 8-26-19 at 10:26 AM and 1:27 PM and signed by V5, documents V5 left a message with V15's office requesting R3's [MEDICATION NAME]/[MEDICATION NAME] 7.5/325 mg. R3's Progress Notes dated 8-26-19 at 2:28 PM and signed by V5, document V5 left a message for V18 (R3's Oncologist) requesting [MEDICATION NAME]. R3's Progress Notes dated 8-25-19 to 8-26-19 do not include any documentation of V2 or V14 (Medical Director) being notified of the need to get a short script to fill R3's [MEDICATION NAME]/[MEDICATION NAME] 7.5-325 mg. On 8-28-19 at 3:05 PM V15 (R3's Physician) stated, The facility should have got ahold of a physician to reorder (R3's) [MEDICATION NAME] before (R3) ran out on Monday (8-26-19). V15 confirmed that R3 should not have had to with stand excruciating pain from morning until night time on 8-26-19, or go without pain control. On 8-28-19 at 1:40 PM, V2 (Director Of Nursing) stated, I was not notified of R2 running out of her Tylenol #3 on 8-19-19 or R3 not having her [MEDICATION NAME] on 8-26-19. I should have been told so I could have notified the Medical Director (V14) to try and get the medication prescriptions. On 8-29-19 at 9:10 AM, V19 (Pharmacist) stated, A refill request was sent on 8-23-19 for (R3's) [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 mg, but the facility never had the physician fill out the controlled substance refill form that is required before the pharmacy can send the medication out. The facility ordered (R3's) Tylenol #3 on 8-15-19 and the pharmacy sent four tablets on 8-15-19. The facility did not request any more refills for (R3's) Tylenol #3 until 8-20-19. 3. On 8-26-19 at 11:45 AM R1 stated, It took a long time to get pain medication there (the facility). I would suffer with Heartburn and Diarrhea sometimes for hours. The heartburn would cause me severe chest pain. I had diarrhea the whole time I was at the facility and would not get a pill for the diarrhea. The diarrhea caused me to have stomach pain continuously. I made my daughter take me home because I was not getting good care at the facility. The Physician order [REDACTED]. R1's Minimum (MDS) data set [DATE] documents R1 is cognitively intact. R1's Nurses Note dated 8/3/19 at 2:15 am documents (R1) has reportedly had some diarrhea stool and complained of heartburn on previous shift. Will notify MD (Medical Doctor) office in the am (morning) or oncoming shift. R1's Nurses Note dated 8/4/19 at 4:00 am documents (R1) Wants order for heartburn and diarrhea. R1's Nurses Note dated 8/5/19 at 5:36 am documents (R1) wants order for heartburn and diarrhea. R1's Medical Record dated 8/3/19 through 8/7/19 does not document that a physician was notified of R1's request for heartburn medication until 8/8/19. R1's Medical Record dated 8/3/19 through 8/13/19 does not document that a physician was notified of R1's request for diarrhea medication until 8/14/19. R1's Nurses Note dated 8/8/19 at 3:54 PM documents Call made to (V16 Physician's) office. and (R1) would like to have PRN (as needed) Tums (Heartburn Medication) order. Awaiting return call. R1's Nurses Note dated 8/13/19 at 5:06 am documents (R1) had diarrhea this shift and wanted doctor called for anti-diarrhea medication. AM shift nurse made aware that (R1) had one episode of vomiting 8/12 (19) HS (bedtime). V17's (Licensed Practical Nurse) Progress Note dated 8/14/19 at 9:57 AM documents Called placed to (V16) to get an order for [REDACTED].>R1's Progress Note signed by V5 (Licensed Practical Nurse) and dated 8/14/19 at 3:26 PM documents Writer rec'd (received) N.O. (new order). [MEDICATION NAME] and [MEDICATION NAME] PRN. R1's Physician order [REDACTED]. R1's Medication Administration Record [REDACTED]. On 8/29/19 V5 stated V5 remembered taking the telephone order for the [MEDICATION NAME] for R1 and stated V5 must have taken the order for [MEDICATION NAME] at the same time. V5 reviewed R1's physician order [REDACTED]. On 8/28/19 at 1:40 PM, V2 Director of Nurses could not provide documentation that V16 was notified of R1's request for heartburn medication before 8/8/19 or that V16 was notified of R1's request for anti diarrhea medication before 8/14/19. V2 stated V2 would expect staff to have notified R1's Physician (V16 ) of R1's requests for medication within 24 hours. V2 confirmed that when the orders for [MEDICATION NAME] and [MEDICATION NAME] were received they were not entered into the Electronic Medical Record so the medications did not appear on the Electronic Medication Administration Record [REDACTED]. On 8-29-19 at 9:10 AM, V19 (Pharmacist) stated, (R1's) [MEDICATION NAME] and [MEDICATION NAME] was never ordered from the pharmacy.

Based on interview and record review, the facility failed to administer medications as ordered to prevent significant medication errors for 2 of 8 residents (R1, R3) reviewed for medications in a sample of 8. This failure resulted in R1 not receiving her insulin as ordered and being admitted to intensive care unit. Findings include: 1. R1's profile page identifies her [DIAGNOSES REDACTED]. R1's Hospital Discharge Medications Orders dated 5/30/19 included the following insulin medication orders [REDACTED] -[MEDICATION NAME] (long acting insulin) [MEDICATION NAME] Pen, 100 units/mil (milliliter) subcutaneous (injection under skin), 10 units one time daily at bedtime. -Humulog (fast acting insulin) 100 units/ml injectable solution before meals and at bedtime per sliding scale (insulin dose based on blood glucose ranges) of 180-220 = give 1 unit of Humulog, 221-260= give 2 units of Humulog, 261-300= give 3 units of Humulog, and blood glucose level above 300 call medical doctor. -[MEDICATION NAME] (Humulog/fast acting insulin) before meals with 10 units with breakfast, 5 units with lunch and 6 units with dinner. R1's Electronic Medical Record (EHR) Progress note, dated 5/30/19 at 4:31 PM entered by V9, Licensed Practical Nurse (LPN) documents R1 being admitted to the facility and was alert/oriented. The next entry into the progress notes is on 5/31/19 at 12:22 PM entered by V4, Registered Nurse (RN) and documents HS (bedtime) blood sugar (reading) administered at (1:30 AM) and was 124. Pt's (patients) nighttime meds (medications) were missed because they did not yet come in from pharmacy. R1's Progress Note continued to document Checked BS (blood sugar) at (7:30 AM) R/T (related to) to malfunctioning glucometer (a device that measures sugar level in blood). Pt. seemed a little bit drowsy upon awakening, BS was 568 at the time. R1's Progress Note documented Spoke with nurse at the physician's office and told her that nighttime [MEDICATION NAME] was not administered because the meds had not arrived from pharmacy. Asked the nurse to clarify the Humulog sliding scale and [MEDICATION NAME] orders. Awaiting call back from doctor to have orders clarified before contacting family. Took the blood sugar again at (10:30 AM) and it was 517. Doctor's order was for a one- time dose of 10 units of [MEDICATION NAME] and a one- time order for Humulog 10 units. Also got an order for [REDACTED]. Will continue to monitor. Passed onto next shift to monitor the blood sugar. The (MONTH) 2019 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. According to R1's Admission physician's orders [REDACTED]. scale order; on 5/31/19, at breakfast, R1 did not receive 10 units of [MEDICATION NAME] and her sliding scale insulin; On 5/31/19, at lunch, R1 did not receive 5 units of [MEDICATION NAME] and her sliding scale insulin. V10 LPN documented in the MAR indicated [REDACTED]. The next entry is later that evening on 5/31/19 at 9:24 PM entered by V10 LPN and documents Phone call to (hospital) at this time, informed that guest is being admitted to the hospital at this time. Prior to this note, there is no information in the clinical record as to what happened or why R1 was sent to the hospital and or what time she transferred out. R1's Hospital Emergency Department (ED) Notes dated 5/31/19 documents R1 was being evaluated at the ED at 1:00 PM and documents caretaker and family present at bedside and note patient to be more confused from her baseline and Lab work in the ED demonstrated DKA (Diabetic Ketoacidosis) with [MEDICAL CONDITION], acidosis, urine [MEDICATION NAME] and elevated [MEDICATION NAME] in the urine with an AG (Argentum) of 20. The note documents R1 was admitted to intensive care unit for the DK[NAME] The website, Mayoclinic.org, defines Diabetic Ketoacidosis as a serious complication of diabetes that occurs when your body produces high levels of blood acids called [MEDICATION NAME]. The condition develops when your body can't produce enough insulin. On 7/11/19 at 9:28am, V10, LPN, stated she walked into the building the morning of 5/31/19 at 7am and R1's granddaughter was here. V10 stated she didn't remember what R1's blood sugar was or even if she was told. V10 stated she documented R1's fall but didn't do any further assessments or anything with her as V4 was still here. V10 stated V4 could have gotten the insulin from the CAPSA but didn't remember giving her any insulin at all that day. On 7/11/19 at 1:06 PM, V4 RN stated on 5/30/19 she didn't do the bedtime blood sugar for R1 until 1:30 AM because she might have been busy doing patient care, answering call lights or such. V4 stated she didn't give any insulin at bedtime. V4 stated she didn't do the 5-7 AM blood sugar until 7:30am due to her having a nonfunctioning glucometer and didn't think about getting a glucometer from one of the other units. V4 stated she didn't ask the other nurses in the building about it either. V4 stated she called V15, R1's Physician, after getting the 568 glucose at 730 AM but didn't get a call back until much later. V4 stated she didn't know at the time that the insulin was available through the CAPSA system (an automated medication dispensing system) and didn't ask any of the other nurses or call the DON regarding it. V4 stated she redid the blood sugar at 10:30 AM and got the 517 level but hadn't heard back yet from the physician. V4 stated the physician did finally call back but she couldn't remember the time and can't remember if she gave R1 the insulin he ordered at the time or not. V4 stated she handed R1 off to the day nurse and didn't know what happened after that. V4 stated she realized that a blood sugar of 568 is a critical level. V4 stated R1's family was present and was concerned with her blood sugar being so high. V4 stated she was here when R1 fell but couldn't describe her demeanor or her cognitive ability during time of the fall or after when the blood sugar was extremely high. V4 was unaware that R1 was admitted to the hospital later that day with ketoacidosis and [MEDICAL CONDITION]. A Resident Grievance Form, regarding R1, undated documents Family reports on 5/31/19 upon visiting guest that she was not acting right and On 6/1/19, the family posted on facility (social media) page that the facility failed to administer insulin in a timely manner which led to high blood sugar of the guest. Upon investigation, her nurse on overnights 5/30/19 did fail to give insulin in a timely manner. This nurse states that the pharmacy had not yet delivered this medication and she was unaware that it could be found in the CAPSA system. On 7/11/19 at 10:44 AM, V2, Director of Nurses, states R1's insulin would have been available from the CAPSA in the building and they also have a back up pharmacy which they could have gotten the medication done. V2 confirmed at 1:50pm on 7/12/19 that no insulin was recorded as being given during R1's stay at the facility and no information was documented as to any details of her discharge. A CAPSA list provided by V2 on 7/11/19 documents R1's Humalog and [MEDICATION NAME] were available for use at the time of R1's admission from the unit available in the facility. On 7/11/19 at 12:25 PM, V14 Pharmacist stated R1's blood sugar of 568 is life threatening and the physician should have been notified immediately. On 7/16/19 at 12:38 PM, V18 LPN/Endocrinologist nurse for V19, Endocrinologist stated V19 would always expect the nurse to follow the physician's orders [REDACTED]. V18 stated V19 manages R1's Diabetes and insulin. The policy/procedure entitled Medication Administration undated documents the MAR must always be used when giving any medication, timing must be appropriate (this includes one hour before and after scheduled times; at least 30 minutes prior to meals in medication is ordered or scheduled before meals; one after meals if medication is scheduled after meals; with the meal if ordered this way by the physician. The Reasons medication may not be given is listed as a. guest is out of facility, b. There is an order to hold them medication, and c. Medication is refused by the guest. The policy/procedure entitled Acquiring Medication undated documents the purpose as to ensure that routine and emergency medications are provided to the guests. The policy documents to order new medications, staff are to enter the medication into the electronic medical record. The order is transmitted to the pharmacy via ePrescriptions. Prescriptions for controlled substances must be faxed to the pharmacy. If the ePresciption fails, a message will be sent via the message system in the electronic record. The policy documents The facility maintains a limited supply of medications in the facility for use during emergency or after-hours situations. The policy documents An emergency supply of medications is also maintained within the facility. Licensed nurse will complete a Request for Removal and fax this request to the pharmacy. Once the fax is sent to the pharmacy will provide the nurse with the code to open the box as well as an authorization code for removal. The policy also documents Licensed nurses may contact the pharmacy 24 hours per day, 7 days per week to order/obtain medications and When delivery of a medication will be delayed or the medication is not or will not be available, the licensed nurse will contract the physician for notification. 2. R3's Hospital History and Physical dated 5/30/19 documents the reason for hospitalization is [MEDICAL CONDITION](rapid heart rate) thought to be [MEDICAL CONDITION] Fibrillation (an irregular and often rapid heart rate that can increase your risk of stroke, heart failure and other heart related complication) with Rapid Ventricular Response (RVR -lower chambers of the heart beat too fast). R3's Medication Discharge Report from the hospital, dated 6/5/19, documents multiple prescriptions including the following: [MEDICATION NAME] (a medication used to treat certain types of serious irregular heartbeat), 200 milligrams (mg), twice daily; [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION] Fibrillation), 125 micrograms (mcg); and [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION]), 50 mcg, 1 tablet every day. The Profile page of R3's electronic record documents admitted [DIAGNOSES REDACTED]. On 7/10/19 at 11:08 AM, V8, R3's wife and Power of Attorney (POA) stated R3 was in the hospital for rapid heart rate and went to the facility for rehabilitation after they adjusted his medication [MEDICATION NAME]. V8 stated it was V7, Nurse Practitioner, who discovered R3's [MEDICATION NAME] and [MEDICATION NAME] wasn't being given as ordered from admission not the facility who made the discovery of initial medication error. On 7/10/19 at 3:15 PM, V7 stated she initially came in to see R3 on 6/12/19 and she always checks current meds with admission orders [REDACTED]. V7 stated she was very concerned because R3 had just been hospitalized for [REDACTED]. V7 stated she immediately went into R3's room to assess him and found his heart rate estimated to be in the 120s resting as he sat in the wheelchair. V7 stated with activity, R3's rate could go as high as 160. When told that R3's vitals were checked every shift from admission to current with the pulse documented as being between 71-82, V7 stated There is no way it would have been that without the [MEDICATION NAME] and [MEDICATION NAME]. V7 stated this medication is significant and harmful in that it caused [MEDICAL CONDITION] puts him at a higher risk for another stroke. V7 stated R3 already had a stroke that left him with left [MEDICAL CONDITION] (paralysis). V7 stated both her and V11, Physician, have talked to V1, Administrator, and V2, Director of Nurse's, about this. V7 stated medication errors in the facility have been a problem for a while and no improvement has been noted. R3's Resident Grievance Form dated 6/12/19 documents the summary of the grievance as follows: Facility does find that there a was a medication error in transcribing medications from his hospital orders to the facility orders. R3's Electronic Health Record (EHR) Progress notes, dated 6/12/19 1:42 PM, documents new orders written by V7 for [MEDICATION NAME] 50mcg and [MEDICATION NAME] 125mcg which were already ordered on admission from the hospital. The Progress note, Late Entry, entered on 6/15/19 at 3:21 PM by V6 Registered Nurse (RN) documents On 6/15/19 writer was putting in data entry of guest admissions orders and overlooked 2 medications [MEDICATION NAME] and [MEDICATION NAME]. My Administrator notified writer that physician is aware of medication errors. The Medication Administration Record [REDACTED]. On 7/10/19 at 11:00 AM, V2 Director of Nursing (DON) stated the facility does not have a policy/procedure on processing admission medication orders and then explained that the admitting nurse enters the medications into the computer and then sends them to the pharmacy. V2 stated there is no check system in place to ensure that the orders are processed properly. V2 stated regarding R3's situation, she did re-educate the nurse, V5 Licensed Practical Nurse (LPN) who made the error, on processing orders correctly. On 7/11/19 at 12:25 PM, V14 Pharmacist stated R3 not receiving the [MEDICATION NAME] with the [MEDICATION NAME] with a history of [MEDICAL CONDITION] with RVR is a bad deal and could be life threatening.

Based on interview, observation and record review, the facility failed to ensure that safety measures including secured side rails, adequate supervision, safe positioning in bed and assistance were implemented to prevent falls from bed for 6 of 9 residents (R3, R4, R5, R7, R8, R9) reviewed for falls prevention in the sample of 9. This failure resulted in R3 falling from bed sustaining Bilateral Subdural Hematomas. Findings include: 1. R3's Admission Sheet identifies her as an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], identifies R3 to have short/long term memory loss with severe cognitive impairment. The MDS documents R3 requires extensive assist of two staff for bed mobility and transfer. The care plan, dated 01/08/18, identifies R3 to have the potential for falls due to weakness, impaired mobility, balance, [MEDICAL CONDITION], age, self-transfer attempts, cognitive deficits and history of falls. The Goal is to have no falls with interventions being: high sided mattress (03/23/18), keep in lowest position (03/23/18), Call don't fall sign in room as a reminder to call for assistance and do not attempt to reposition self, fall risk assessment per protocol, and keep personal items and frequently used items within reach, encourage her to request assistance to reach items if needed all dated 01/08/18. The Care Plan identifies R3 to have been readmitted to the hospital on [DATE] and remains at risk on readmission. On 04/04/18 at 11:45 AM, R3 was in bed with her side rails in up position. She had a scoop mattress, but her bed was not in low position, R3 was lying flat. She had bilateral blackened eyes and bruising down the right side of her face. R3 spoke slowly, but was cooperative as she was rolled to the right by V10 and V11, Certified Nurse Aide (CNA), with no problem. R3's left arm and leg are flaccid. R3 moved her right leg out to the right during bed mobility, but made no attempt to assist staff. The EHR (Electronic Health Record) Progress Notes, dated 03/22/18, entered by V5, Registered Nurse (RN), documents at 2050 (8:50PM), R3 was on the floor left side of bed with her head toward the head of the bed, Range of Motion (ROM) WNL (Within normal limits) noting that R3 was already flaccid on the left side. The note documents R3 to have a hematoma right side of the forehead and after contacting the physician, was sent to the emergency room (ER) for evaluation due to her being on anticoagulants. The progress note documents R3 returned to the facility on [DATE] at 1:30AM with negative X-rays noted. The EHR Progress Notes dated 03/26/2018 at 16:12 (4:16 PM), documents, Called into guest's room by PCA (Personal Care Assistant), guest vomited approximately 150 ml (milliliter) red tinged fluid. Guest c/o (complained of) pain in chest. Called daughter (V12) who would like guest evaluated at ER. (Local Ambulance) called, upon their arrival guest had an additional 250 ml of red tinged fluid. Guest transferred to stretcher and transported via ambulance. The EHR Progress Notes, dated 03/26/2018 at 22:38 (10:38PM), documents, Per ER charge nurse, guest is being admitted to ICU (Intensive Care Unit) for bilat (bilateral) subdural hematoma and GI (gastric-intestinal) bleed. The Progress Notes document R3 returned to the facility on [DATE] and was placed on Hospice. The facility's Event Report documents under Evaluation for the fall on 03/22/18 as It is the conclusion of the facility that R3 slid off bed onto the floor on her left side and a High sided mattress with bed in low position when occupied being implemented as a result. There is no explanation as to how R3 slid off the bed given that she requires extensive assist of two staff for bed and transfer mobility and the investigation fails to reflect where in the bed R3 was just prior to the fall or if the hand rails were up and functional. The Hospital History and Physical, dated 03/26/18, documents R3 to have Extensive bilateral acute subdural hematomas at the cerebral convexities, with smaller acute subdural hematomas in the interhemispheric fissure and along the tentorial leaflets. There may be [MEDICATION NAME] components to the hematoma at the right front convexity. The hematomas are new since prior CT (computed tomography) from 4 days earlier. Largest extra-axial hematoma measures up to 3 cm (centimeters) in depth. There is mild mass effect on the underlying cerebral hemispheres, with 4 mm (millimeters) of leftward shift of the septum pellucid. The impression documented [AGE] year old female with fall 3 days ago, now with large bilateral subdural hematomas. On 04/04/18 at 1:09PM, V12, R3's daughter/Power of Attorney (POA), stated the day before R3 fell , she had thrown her right leg over her left leg, but was unable to turn over due to her being centered in bed. V12 stated she was told that a new staff named V7 (CNA) was taking care of her mother the evening of the fall and did not check on her every hour as she should have. V12 stated she has at times come in and found R3's grab/hand rail on the bed not secured causing it to swing out so she had concerns with that if they are rolling her into it, she would fall. V12 stated R3 had only one other fall at the facility last year during a prior admission when R3 was rolled off the bed during care by a staff member. V12 could not recall the date or the staff member. V12 stated staff, are aware that the rails don't always latch. On 04/04/18 at 1:20PM, V10, CNA, stated she's worked with R3 for the past year off and on and knows she will throw her right leg out of bed on the right side, but has never known her to try to get up unattended. V10 stated the bed rails sometimes won't lock . you have to be sure you check them because they will swing out if you don't lock them. V10 stated she has had to call maintenance a few times to have the rails repaired because they don't secure in place. V10 stated if R3 is centered on the bed, she's not going anywhere. V10 recalled R3 telling her she was looking for her keys when she fell on [DATE], but acknowledged that she is confused. On 04/04/18 at 3PM, V5, RN, who was working when R3 fell on [DATE], stated she had just been in R3's room giving her medication. When asked how R3 was positioned in bed, V5 stated R3 was on her left side, maybe a little too close to the side of the bed. V5 stated she left R3's room after giving her medication and heard her say Ohhhhh. When she went back into the room, R3 was on the floor with her head toward the top of the bed. V5 stated she thinks R3 hit her head on the bedside chest then on the wall. V5 stated she checked her out and got the CNA's (V6 and V7) to help put R3 back in bed. V5 stated when she went to move the side rail out so they could move R3 into the bed with the full body mechanical lift, she noted the rail was not secured in place and swung out easily. V5 stated she did not tell anyone about the rail being unsecured and no one interviewed her about the fall after the occurrence. V5 stated she was unaware of who the last person was to see R3 in bed. V5 stated she wanted R3 to be evaluated due to the fact that she was receiving both [MEDICATION NAME] and [MEDICATION NAME] 4-6 mg, blood thinners. V5 stated she doubted had the rail been secured, that R3 would have fallen from the bed. On 04/04/18 at 2:30PM, V6, CNA, stated if R3 is centered in the bed, she isn't going anywhere. V6 stated she was surprised that R3 fell as she never attempts to get up from bed unattended. V6 stated she recalled R3's prior fall last year and stated a CNA was rolling her over and rolled her out of bed onto the floor. On 04/04/18 at 2:55PM, V7, CNA, that worked the night of R3's fall on 03/22/18, stated she couldn't recall when she had last seen R3, but remembered when they went into the room to help put her back to bed, R3 was lying with her head toward the head of the bed. V7 estimated that it had been at least 2 hours since she had last seen R3 that night. V7 stated she has had trouble getting the bed rails to secure in place at times too. On 04/04/18 at 11:30AM, V9, Care Plan Coordinator, stated she just added the attempts to get up on her own after R3's fall on 03/22/18, adding that she's never known her to do that. V9 stated she revised the care plan to include low bed and scoop mattress after her fall as well. There is no evidence the facility adequately identified the root cause of R3's fall and failed to identify that the side rail was not secured in place at the time. The facility also failed to determine if R3's position in bed was appropriate just prior to the fall. There is no documentation or revision within the care plan that addresses the need of the CNA's to ensure the rails are adequately secured, R3 is properly positioned in the center of the bed and adequate supervision is done. On 04/05/18 at 8:40AM, when asked about the hand rails not securing, V13, Licensed Practical Nurse (LPN), stated she will occasionally have people complain about the bed rails not latching, but never (R3). V13 stated the rails are functional, but have to be latched properly or they will swing out. An Event Report completed by V13, LPN, documents under Notes, 03/22/18 at 23:27 (11:27PM) Guest had a fall from bed, but writer did not witness. Per PCA, guest did not hit her head and slid off the bed on to her knees. Guest knees do show signs of redness from the fall, but skin is intact. All other skin is also intact to her feet. Per family request, X-rays have been ordered for LUE (left upper extremity). The report documents under Evaluation It is the conclusion of the facility that (R3) fell from bed to floor. 2 person assist for bed mobility and high sided mattress to be implemented as a result of the fall. On 04/05/18 at 8:40AM, V13, LPN, stated the CNA, V18, who no longer works at the facility, called her into the room and R3 was on the floor. V13 stated V18 told her she rolled her to her weak side and she rolled out of bed. V13 stated she thought R3 was bottom heavy as she landed on her knees with her head on the bed. V13 stated she fell on her weak side so she couldn't use her hand to grab the rail. V13 remembered both hand rails being up at the time of the fall. There is no evidence the facility identified the root cause of the fall as being improperly positioned prior to rolling her to the side. 2. On 04/05/18 at 9AM, R5 who was identified on 04/04/18 as being interview able by the facility, stated she has had her rails not be secured when she went to use them so she knows better now to make sure they are secured before she grabs them to move herself. 3. On 04/05/18 at 9:17AM, R7 also identified by the facility as interview able on 04/04/18, stated she has had them be loose when she's grabbed them, but the facility has fixed the problem and she hasn't had any other incidences where they weren't secured. 4. On 04/05/18 at 8:55AM, R8's bedrail on her right side was not secured in place. 5. On 04/05/18 at 8:58AM, R9's rails on both sides were not secured, but appeared to be in the correct position. At that time, V17, CNA, was told of the rails not being secured at the time for R8 and R9. V17 stated she didn't know that. At 9:20AM on 04/05/18, V13 stated both R8 and R9 definitely use their side rails for mobility both for bed and transfer and the rails need to be secured at all times. 6. R4's MDS, dated [DATE], identifies him to have no deficits with short term memory, but deficits with long term memory. The MDS also documents R4 to require minimal assist of one staff for bed mobility and transfer. The care plan, dated 08/31/17, documents R4 to have a potential for falls due to weakness, impaired mobility, balance, age and self-transfers. The goal is to improve to a safe level of independence and will have no injuries. Interventions include assist to toilet upon request, Call don't fall sign in room as a reminder to call for assist prior to getting up, encourage to call for assistance as needed, provide reminders, keep personal items and frequently used items within reach and therapy as ordered for mobility. An Event Report, dated 09/13/17 completed at 7:55AM, documents R4 was last seen in his room. The report documents at 3:35AM, R4 was found on the floor at bedside. R4 was sent to the emergency room for evaluation and returned to the facility at 4:15AM with no fractures identified. The Evaluation Note documents, It is the conclusion of the facility that (R4) was found on the floor in room. (R4) attempted to self-transfer from bed to w.c. (wheelchair) without call light usage or staff assist. Verbal staff assist and call re-education given. High sided mattress to bed was the intervention added to the care plan as a result. On 04/04/18 at 1:09PM, V12, daughter, stated her father, R4, had a fall at the facility last year when he went to use his side rail and it wasn't secured. V12 stated she witnessed the rail not being secure the day before he fell . V12 stated R4 said he'd grabbed the rail and it came out causing him to fall. On 04/04/18 at 3PM, V5, RN, stated she had noted R4's stump was scraped and when she asked how it happened, he said the hand rail folded when he grabbed it and he fell out of bed. V5 stated she did not say anything to anyone else about R4's allegation of the unsecured railing. There is no evidence the facility identified an accurate root cause of R4's falls and revised his falls prevention plan to include ensuring secured side rails if R4 was to use them to help him get up or for bed mobility. On 04/05/18 at 12:01PM, V21, Maintenance Supervisor, stated the only thing that is holding the rail secured is a plastic bushing which can act like a screw going up and down causing the pin that holds the railing in place to become misaligned. V21 stated he has never had a railing brake. V21 stated staff has to wiggle the bolt until the pin aligns to fall into the chamber in order for the railing to latch. V21 stated he educates staff when he gets a call that a railing is not working. V21 stated he last checked R3's bed on 03/30/18 and 12/04/17 adding that he does every bed checks quarterly or as needed. On 04/05/18 at 1:20PM, V2, Director of Nurses (DON), stated she was unaware that the staff was having problems with getting the hand rails latched securely and was never told by V12 that R4's fall occurred when his railing was not latched properly. V2 also stated she was unaware that V5, RN, noted R3's railing was unsecured immediately following her fall and that she was positioned too close to the side of the bed. V22, Nurse Practitioner, stated on 04/05/18 at 2:15PM stated the railings at the facility would be to enable residents to get in/out of the bed or to aid be mobility and would assume staff, keep them secured. On 04/05/18 at 4:45PM, V23, Technical Assistant for Bed Company, provided the handbook sheet on the Assist Handle for the bed used in the facility. V23 stated if the Handles were not secured in place, it would be a safety risk and could cause someone harm. The Handbook documents for the Assist Handle Two Position bed - The assist device is intended for use as an aid in entering or exiting the bed sleep area, as well as a stable handle hold during self-positioning within the bed sleep area and under Warnings: Serious Injury or Death, it documents Do not use this assist device until you have verified that it is locked in place. Injury to resident or care giver may result if this procedure is not followed. The facility's undated Fall Management Program policy/procedure documents the program is designed to identify guests at risk for falls, initiate interventions to reduce falls and thus reduce the risk of injury due to falls. Under Policy, it documents Interventions will be implemented according to the guest's need identified during assessment. If a systematic evaluation of a guests fall risk identifies several possible interventions, the staff may choose to prioritize interventions.

Based on observation, interview and record review the facility failed to adequately assess and monitor a wound for decline for 1 of 3 residents (R1) reviewed for wounds in the sample of 15. This failure resulted in R1 having a wound that was not accurately assessed and monitored and increased in size requiring medical and possible surgical intervention. Findings include: The Facility Weekly Pressure Ulcer Report dated 1/9/15 documents R1 had a Stage III pressure ulcer to her right buttock measuring 3 centimeters (cm) by (x) 1.2 cm x 0.4 cm in depth. R1's January 2015 physician's orders [REDACTED]. R1's Treatment Administration Record (TAR) documents E3, (Registered Nurse, RN) did a treatment to R1's right buttocks the morning of 1/15/15. There was no documentation regarding if R1's pressure ulcer had increased in size. On 1/15/15 at 1:30 PM, R1's wound was observed to be much bigger in depth and width than what the facility had assessed on 1/9/14. There was a small amount of pale yellow drainage on the bandage. E3, Registered Nurse (RN) measured the wound and provided the measurement as being 2.5 cm x 2 cm and 2 cm in depth. E3 confirmed the decline and stated it could be tunneling. R1's TAR and Nurse's Notes show no documentation of a decline in the wound. On 1/15/15 at 4:00 PM, E2, Director of Nursing (DON), stated she looked at R1's wound and stated the area on R1's right buttock looks more like an abscess, not a pressure sore. E2 stated she was trying to contact the Wound Clinic. On 1/16/15 at 10:30 AM, R1's wound was again observed with E2, Director of Nurses. E2 stated the dressing had just been changed earlier in the morning as she removed it. R1's wound was draining a tan colored exudate and when E2 pressed on the outer parameters of the wound, a copious amount of drainage came from the wound bed. E2 stated there was a hard knot under the skin on the on the right side of the wound and also acknowledged that the drainage increased when pressure was applied. E2 stated R1 was going to the physician 1/16/15 to have the wound evaluated as they thought it was an abscess. On 1/16/15, at 10:40 AM, E2 stated during interview that the nurses should assess and monitor for change in wounds during treatments to the wound. E2 stated the wound was not a pressure sore but an abscess and confirmed that it had increased in size. Z2, (R1's Physician), was interviewed by telephone on 1/16/15 at 4:26 PM. Z2 stated that he would expect the nurse doing the daily dressing changes to notice a change in the wound and notify the physician. Z2 stated that he had seen R1 on 1/16/15 and he was referring R1 to a plastic surgeon. The facility's Wound Assessment Policy documents that the purpose of the assessment is to document an accurate, ongoing assessment for wounds in the medical record.