Every finding on record at St Marks Living

Based on observation, interview, and document review, the facility failed to ensure dishwashing sanitization temperatures for 1 of 1 dishwashers had been appropriately monitored to prevent the risk of foodborne illness. This had the potential to effect all 30 residents residing in the facility. Findings include:During the initial kitchen tour on 6/15/26 at 10:14 a.m., dietary director (DD)-D stated the dishwasher sanitized dishes with heat. Observed a piece of paper on a clipboard in the dishwasher room titled dishwasher with June 2026, written on top. The form had six columns indicating wash and rinse temperatures for each meal service: 6:00 a.m., 12:30 p.m., and 5:30 p.m. All of the wash temperatures indicated 160 degrees Fahrenheit (F). All of the rinse temperatures indicated 150 - 175 degrees F. (Required temperatures for wash are 150-165 degrees F and rinse is 180 degrees F). The rinse temperature was never documented as having reached 180 degrees F. In addition, out of 43 possible entries to document temperatures three times a day, 16 spaces were blank.During an interview and observation on 6/15/26 at 12:55 p.m., observed dietary aide (DA)-A using the dishwasher to clean silverware from the noon meal. DA-A stated wash temperature should be 160 degrees F and rinse 180 degrees F. With dishwasher in operation the wash gauge only reached 132 degrees F and rinse reached 170 degrees F. Despite DA-A having run multiple racks through the dishwasher, neither wash nor rinse temperatures had reached required temperatures. During an interview on 6/15/26 at 1:02 p.m., with DD-D reviewed the June dishwasher temperature log. DD-D acknowledged no rinse temperatures were documented as reaching 180 degrees F. DD-D admitted she didn't monitor the logs and could not say how long the required temperatures had not been reached. DD-D stated dishwasher vendor representative (VR)-E had been there on 6/8/26, and his service visit report indicated required temperatures had been reached.During document review, additional dishwasher logs for March, April and May 2026, were reviewed. Out of three months, only one time was the required rinse temperature of 180 degrees F reached. The logs did not include what the required temperature parameters were and what staff should do if not met.During record review, the vendor report titled Service Visit Report dated 6/8/26, indicated representative VR-E had checked all chemical titrations and temperatures. The report indicated the wash temperature had reached 160 degrees F and the rinse temperature had reached 180 degrees F, yet the dishwasher log for that day did not reflect rinse temperatures of 180 degrees F.During an interview on 6/15/26 at 2:46 p.m., DD-D stated her and maintenance director (MD)-A had been working with the dishwasher, and it had taken running five loads without pausing in between to get the rinse temperature up to 180 degrees F.During an interview on 6/15/26 at 4:29 p.m., DD-D stated the kitchen would switch to paper plates and bowls until the dishwasher temperatures could be corrected and use the 3-compartment sink to wash and sanitize silverware and cups.During an interview on 6/15/26 at 5:45 p.m., VR-E had arrived on-site and had looked at the dishwasher. VR-E stated the dishwasher would hit 180 degrees F, but staff would have to run five loads through to get to that temperature. VR-E stated one of the five heating elements in the booster was out and would have to order a new one which might take three weeks to get. When asked about his service visit on 6/8/26, VR-E stated he had been able to get the required temperatures by running racks through five times. DD-D had not been informed of this, nor did the written Service Visit Report indicate that. Further, VR-E stated he had been aware on 6/8/26, a heating element in the booster was out, but had not ordered a replacement part. During a telephone interview on 6/16/26 at 9:43 a.m., with vendor manager (VM)-F, concerns were expressed about dishwashing rinse temperature, VR-E's service visit on 6/8/26, and the lack of communication with DD-D about findings (having to run the dishwasher five times to reach a rinse temperature of 180 degrees F and being aware the booster needed a new heating element and replacement part not ordered). VM-F stated he had been informed by VR-E and a part had been ordered today. In the meantime, they would find the part within the district and get it replaced today or tomorrow (6/16/26 or 6/17/26).During an interview on 6/16/26 at 9:53 a.m., with DD-D and administrator, both acknowledged the importance of DD-D monitoring dishwasher temperatures, ensuring staff education, and providing staff with written guidance of what temperatures needed to be and what to do if not met. During an interview on 6/16/26 at 10:59 a.m., the director of nursing (DON) and interim DON stated the facility had no incidences of food borne illness.During a telephone interview on 6/16/26 at 3:43 p.m., registered dietician (RD)-G was unaware of dishwasher temperatures not meeting required temperatures. RD-G stated her contract with the facility indicated kitchen audits upon request but had not been asked to do an audit in quite a while. RD-G stated it was necessary for required temperatures to be reached in order to properly sanitize dishes to prevent health risks to residents. Facility Ware Washing policy dated March 2021, indicated all flatware, serving dishes and cookware would be cleaned, rinsed and sanitized after use. The dish machine would be checked routinely to assure proper functioning and appropriate temperatures for cleaning and sanitizing. Run machine until proper temperatures were reached. Record temperatures. Facility Kitchen Food Safety and Sanitation Audit, undated, indicated dishwasher temperatures at 140 degrees F wash and180 degrees F rinse. (It should be noted, 140 degrees F for wash does not meet CMS (Centers for Medicare & Medicaid Services) requirements.

Based on interview and document review, the facility failed to ensure ongoing surveillance for infections, ongoing review of surveillance data, and documentation of follow-up activity and response. This practice had the potential to affect all 30 residents residing in the facility. In addition, based on observation and interview, the facility failed to ensure a glucometer (a small portable device used to measure the amount of glucose in a drop of blood) used on multiple residents, had been disinfected after use on 1 of 1 resident (R17), revewed for infection control practices. Findings include: SURVEILLANCE Review of the facility infection control binder provided 6/15/26, did not include line listing, mapping, or surveillance data for tracking and monitoring infections in the facility. During interview on 6/16/26 at 3:30 p.m., registered nurse (RN)-A stated she was new, had just started yesterday, and was hired to be the infection preventionist. RN-A stated she had searched the prior infection preventionist's office and was unable to locate any infection control tracking, data, surveillance, or mapping documents. During interview on 6/16/26 at 3:32 p.m., interim director of nursing (IDON) stated the prior infection preventionist had left on short notice and they had just replaced her with RN-A. IDON stated she was unable to find any evidence of surveillance or tracking of infections and had not implemented a new method. IDON stated she knew it was a problem and planned to start the program from scratch. IDON had her infection preventionist certificate and planned to have RN-A acquire hers as well. IDON further stated the infection prevention program was not up to her standards and needed to be improved. Facility policy on infection control and prevention was requested but not received. GLUCOMETER CLEANING: R17's face sheet received on 6/17/26, included diagnosis of diabetes. R17's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R17 had diabetes and had received insulin injections in the last 7 days or since admission. R17's physician orders dated 6/3/26, indicated to check blood glucose per device daily at random times, one time a day every 3 day(s). R17's care plan dated 6/12/26, indicated R17 was at risk due to complications of diabetes, and to perform blood sugars per glucose monitor as ordered. During an observation on 6/16/26 at 8:11 a.m., licensed practical nurse (LPN)-C entered R17's room with a small, two-sided plastic tote with handle to obtain a fingerstick glucose. LPN-C removed the glucometer from the tote, obtained the blood sugar, then put the glucometer back into the tote on top of unused needles, without disinfecting it. LPN-C set the tote at the nurses station and sat down to document in the electronic medical record. During an observation on 6/16/26 at 8:25 a.m., observed LPN-C helping pass breakfast trays, then returned to the nurses station. Glucometer not disinfected. During an interview on 6/16/26 at 10:15 a.m., LPN-D stated LPN-C had left at 10:00 a.m., and LPN-D had not used the glucometer since coming on duty at 10:00 a.m., nor would she need to. During a telephone interview on 6/16/26 at 10:22 a.m., LPN-C admitted she did not disinfect the glucometer after use on R17 – stated she didn't think to and knew she should have disinfected it with a disinfectant wipe to prevent transfer of germs. LPN-C stated the glucometer was used for multiple residents and she had not used it after R17, but acknowledged another nurse could have. During an interview on 6/16/26, at 10:45 a.m., the director of nursing (DON) was informed of findings. The DON expected nursing staff to disinfect glucometers after use to prevent transmission of infection, and called the transitional care unit to ask staff to disinfect the glucometer and the contents of the tote. Facility Glucometer Disinfection policy, undated, indicated the purpose was to prevent cross-contamination and the transmission of infectious diseases during blood glucose monitoring by ensuring proper disinfection. If a glucometer was shared among residents, it must be cleaned and disinfected according to manufacturer recommendations between each use. After testing, disinfect the glucometer before use on another resident using an approved disinfectant wipe. Thoroughly wet all external surfaces of the glucometer and follow the disinfectant manufacturer's required contact time (typically 1–2 minutes or as directed). Allow the glucometer to air dry completely before reuse.

Based on interview and document review, the facility failed to implement a process for antibiotic review to determine appropriate indications, dosage, duration, trends of antibiotic use and resistance. This had the potential to affect all 30 residents residing in the facility.Findings include:Review of the facility infection control binder provided on 6/15/26, indicated no antibiotic tracking for correct indications, dosage, duration, resistance, and no 72-hour time-outs (a check that the resident is on the right antibiotic) to review cultures and verify correct antibiotics or resistance to prescribed antibiotics.During interview on 6/16/26 at 3:30 p.m, registered nurse (RN)-A stated she was new to the facility, had been hired to be the infection preventionist, and had not had time to start working on an antibiotic stewardship program. RN-A further stated she was unable to find any documents from the prior infection preventionist to show that antibiotic usage was being tracked and monitored.During interview on 6/16/26 at 3:32 p.m., interim director of nursing (DON) stated the prior employee in charge of antibiotic stewardship had left on short notice. Interim DON was unable to find any evidence of tracking of antibiotic usage for correct dosage, duration, resistance, or that 72-hour time-outs were being completed to ensure proper antibiotic use. Interim DON stated she was aware this was a problem at the facility and would need to get the program restarted. Interim DON stated this was an area that needed improvement and that antibiotic usage should be monitored to ensure residents are getting the correct treatment and prevent worsening of symptoms.Facility policy on antibiotic stewardship was requested but not received.

Based on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment for residents residing in Golden Oak Hall resulting in numerous large, dark stains throughout the hallway carpeting. This had the potential to affect all 20 residents who resided on the Golden Oak Hall. In addition, the facility failed to repair gaps in an exterior service door allowing the potential for rodents to enter the building. This had the potential to affect all 30 residents who resided in the facility. Finding include: CARPETING On 6/16/26 at 4:00 p.m., observation of the Golden Oak Hall resident hallway revealed multiple dark brown to gray discolorations and stains embedded throughout the carpeted surface. Several stains measured approximately 1 to 3 feet in diameter and were irregularly shaped with darkened edges and concentrated areas of discoloration. The stains were distributed throughout the hallway and were readily visible from a distance due to the contrast between the stained areas and the surrounding carpet. The carpeting appeared worn and soiled, with numerous spots giving the appearance of repeated liquid spills that had penetrated the carpet. Multiple overlapping stains created a large area of visible discoloration extending across a significant portion of the walking path. On 6/16/26 at 4:08 p.m., the interim director of nursing (IDON) observed the hallway carpeting on the Golden Oak Hall and stated the carpet had been shampooed approximately two weeks earlier. The IDON confirmed the carpet was stained and stated, It does not look good, and further stated the carpet needed to be replaced. On 6/16/26 at 4:09 p.m., nursing assistant (NA)-A, NA-B, and NA-C stated the carpet stains throughout Golden Oak Hall were an ongoing concern and not a recent occurrence. NA-A, NA-B, and NA-C stated the carpeting had been shampooed a couple of weeks earlier and confirmed numerous stains remained visible throughout the hallway. NA-A, NA-B, and NA-C stated a beverage cart routinely sits in the hallway and spills occur in the area. NA-B confirmed the condition of the carpeting observed was consistent with its typical appearance and that the staining had been present for an extended period of time. On 6/16/26 at 4:29 p.m., the maintenance director (MD)-A confirmed the carpets in the Golden Oak halls were not clean and acknowledged the appearance and condition of the carpets did not provide a homelike environment. MD-A stated the carpeting was a concern and reported attempts had been made to clean the carpet; however, the staining worsened during humid conditions. On 6/16/26 at 4:49 p.m., the administrator stated the carpeting in the Golden Oak Hall had not been adequately maintained and needed replacement. The administrator stated a professional carpet company evaluated the carpeting the previous fall and indicated replacement was needed. The administrator stated maintenance staff shampooed the carpet approximately three weeks earlier, but the carpeting again appeared heavily stained. The administrator further stated moisture, spills, and coffee spills were contributing factors and acknowledged spills were not always addressed immediately. The administrator stated the carpeting does not look good or homelike, confirmed awareness of the condition, and agreed the carpeting should be replaced. Facility Quality of Life: Home Environment Policy dated 8/25, indicated:The agency/facility will ensure that each patient/resident resides in an environment that is safe, clean, comfortable, and supportive of dignity, independence, and overall quality of life. The home environment shall promote well-being and enable the individual to perform activities of daily living to the highest practicable level. Purpose: To establish guidelines for assessing, maintaining, and improving the patient/resident's home or living environment to promote safety, support independence, maintain comfort, and comply with regulatory standards. Policy Guidelines1. Ensure environmental safety (lighting, temperature, fall prevention). 2. Maintain cleanliness and sanitation. 3. Promote a homelike atmosphere. Assessment Requirements: Environment must be assessed on admission, periodically, and with changes in condition. Intervention and Follow-Up: Address hazards promptly, report unresolved issues, and involve appropriate resources. SERVICE DOOR During the initial kitchen tour on 6/15/26 at 10:14 a.m., with dietary director (DD)-D, observed the double service entrance door that exited the building near the kitchen to the dumpsters outside. The metal door had a gap where the two doors met and was visible by the amount of daylight coming through. DD-D stated the facility had mice in the past and had switched to a different pest control company. DD-D stated she would talk to maintenance director (MD)-A about fixing the door. Resident council meeting minutes dated 3/16/26 and 4/20/26, indicated: Rodents - Pest Control has been called. During an interview on 6/15/26 at 2:45 p.m., family member FM-A stated she had observed mice in R5's room within the last month. FM-A stated the facility had been notified and addressed the issue. During an interview and observation on 6/16/26 at 4:10 p.m., with DD-D and MD-A, observed the gap in the service door. MD-A stated he had been aware of it but didn't know how he could fix it and a new door would be expensive. During an interview on 6/16/26 at 615 p.m., the administrator had been made aware of the gap in the service entrance door and had talked to MD-A about the need to replace it. Facility policy was requested and not received.

Based on interview and document review, the facility failed to ensure accuracy of the Minimum Data Set (MDS) assessment for 1 of 5 residents (R6), reviewed for unnecessary medications, when the MDS did not reflect opioid (a narcotic pain medication) and diuretic (increases urine production) medications R6 had been receiving. Findings include:R6's face sheet received on 6/17/26, included diagnoses of Parkinson's disease, high blood pressure, congestive heart failure (the heart muscle is too weak to pump blood efficiently), and was receiving hospice care. R6's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated moderate cognitive impairment, clear speech, could understand and be understood, required substantial assistance or was dependent on staff for activities of daily living. The MDS, section N for medications, did not include the diuretic and opioid medications R6 had been receiving. The section for diuretics and opioids had been signed off as completed by the MDS nurse on 6/10/26. R6's orders indicated the following:--Ordered on 10/10/25, a diuretic: furosemide oral tablet, 30 mg (milligrams) by mouth two times a day for edema (swelling caused by excess fluid trapped in body tissue).--Ordered on 5/11/26, an opioid: fentanyl transdermal patch 72-hour, 12 MCG/HR (micrograms per hour), apply 1 patch transdermal one time a day every 3 days for pain. R6's MAR (medication administration record), indicated R6 received furosemide twice a day in May and June 2026, and fentanyl patch every third day since ordered in May 2026. R6's care plan dated 3/5/26, indicated congestive heart failure and to administer diuretic medication as ordered and to monitor for side effects and effectiveness every shift. Care plan with revised date of 3/2/26, indicated R6 was at the end stage of life and was utilizing hospice services and would be comfortable. During an interview on 6/16/26 at 3:53 p.m., the director of nursing reviewed R6's orders, MAR and MDS and stated diuretic and opioid medication should have been checked-marked on the MDS indicating R6 had been receiving those medications at the time of the quarterly review. The DON indicated they did not have a policy on accuracy of MDS as it was the expectation the RAI (resident assessment instrument) manual directions were followed.

Based on observation, interview, and document review, the facility failed to follow physician orders during a dressing change and failed to assess and document the condition of finger wound during weekly skin assessments for a non-pressure skin condition for 1 of 2 residents (R1) reviewed for non-pressure skin In addition, based on interview and document review, the facility failed to ensure physician orders were carried out for 1 of 1 residents (R3) reviewed for unnecessary medications, when a physician was not informed of elevated blood sugar levels.Findings include: DRESSING CHANGE/ WOUND ASSESSMENT R1's significant change in status Minimum Data Set (MDS) assessment dated [DATE], indicated cognitively intact, setup or clean up assistance with eating, partial/moderate assistance with oral hygiene, substantial/maximal assistance with dressing, personal hygiene and dependent with toileting hygiene and diagnoses included Cerebral Palsy (disease of the developing brain and nervous system that leads to abnormal muscle tone, movement and posture), and rash and other nonspecific skin eruption. R1's care plan dated 4/1/26, indicated R1 was at risk for skin infections due to frequent refusal of showers and interventions included monitor for signs and symptoms of skin infection: redness, warm to touch, drainage, or pain. R1's Wound Care provider note dated 5/19/26, indicated wound Location: right index finger: wash hands, remove old dressings, cleanse wound bases with acetic acid (must be refrigerated after opening, discard remainder after one week), paint wound base with Betadine (if wound starts to feel mushy or has drainage underneath, contact wound clinic for debridement), cover with soft dry gauze, change dressing daily R1's treatment administration record (TAR) dated 6/1/26-6/30/26, indicated: start date 3/23/26 weekly skin assessment-document under assessments every day shift every Wednesday; start date 5/19/26, right index finger: cleanse wound beds with acetic acid. Paint with betadine. (If wound starts to feel mushy or has drainage underneath, contact Wound Clinic for debridement), cover with soft dry gauze, change dressing daily, every evening shift for wound care. R1's skin assessments indicated: 5/18/26, right hand 2nd digit TX (treatment) in place, continues with wound on right hand 2nd digit. Tx orders in place. 5/20/26, continues with wound on right hand 2nd digit. Tx orders in place. 5/21/26, continues with wound on right hand 2nd digit. Tx orders in place. 5/27/26, continues with wound on right hand 2nd digit. Tx orders in place. Nail missing, finger red. 6/2/26, documentation did not include finger assessment 6/3/26, buttocks generalized, moisture associated skin damage (MASD) 6/9/26, buttocks generalized, moisture associated skin damage (MASD) On 6/15/26 at 5:16 p.m., R1 was seated in a wheelchair in the dining room and R1's right second finger was observed with a bandage covering the tip of the finger. On 6/15/26 at 5:44 p.m., licensed practical nurse (LPN)-A stated R1 had daily dressing change orders for the finger. LPN-A stated they completed earlier today (6/15/26) and included removal of the bandage and application of acetic acid. LPN-A confirmed Betadine had not been applied because they did not believe it was part of the order. LPN-A then reviewed the physician order in the electronic medical record (EMR) and acknowledged Betadine was included in the order and should have been applied during the dressing change. LPN-A stated she had only viewed part of the order and did not realize Betadine was required. LPN-A further stated Betadine had not been applied during dressing changes the previous week. LPN-A stated R1's finger should have been included in weekly skin assessments and staff would be expected to document the condition of the finger during those assessments. On 6/15/26 at 5:51 p.m., LPN-A was observed to complete dressing change of R1's right index finger and found Betadine in R1's room and applied the Betadine and gauze to R1's. LPN-A stated Betadine should be applied according to the physician's order. On 6/15/26 at 6:29 p.m., interim director of nursing (IDON) and DON stated R1's weekly skin assessments were completed on 5/24/26, 5/27/26, 6/3/26, and 6/9/26. IDON confirmed not all the skin assessments included an evaluation of the R1's finger wound. IDON stated she would expect R1's finger to be assessed and documented during skin checks to determine whether the condition was improving or worsening. IDON further stated she would expect Betadine to be applied during dressing changes because it was included in the physician's order. On 6/16/26 at 3:45 p.m., LPN-B stated weekly skin assessments should include an assessment of R1's finger wound and documentation was expected describing the appearance of the finger to determine whether the condition was improving or worsening over time. Facility Skin Assessment Policy dated 1/25, indicated Policy to conduct comprehensive skin assessments for all residents to prevent, identify, and manage skin integrity issues, including pressure injuries, wounds, infections, and other dermatologic conditions.Purpose: To establish guidelines for assessing, documenting, and managing residents' skin conditions to promote skin health, prevent complications, and ensure timely interventions. Procedure:1. Initial Skin Assessment A comprehensive skin assessment shall be conducted upon admission by a licensednurse. Assessment findings shall be documented in the resident's medical record, noting any existing wounds, pressure injuries, bruises, rashes, or other abnormalities. If skin integrity issues are identified, appropriate interventions shall be implemented immediately, and the physician and interdisciplinary team shall be notified.2. Routine Skin Assessments Daily Observations: CNAs shall observe residents skin during routine care (bathing dressing, repositioning) and report concerns to the charge nurse. Weekly Skin Checks: RNs or LPNs shall perform full-body skin assessments on high-risk residents (e.g., those with limited mobility, incontinence, or a history of pressure injuries). Comprehensive Assessments: Skin integrity shall be reassessed at least quarterly or upon significant change in condition.4. Wound Care Management Any new or worsening wounds shall be assessed and documented, including size, depth, color, drainage, and signs of infection. The wound care team or physician shall be consulted for appropriate treatment plans. Wound care treatments shall be performed as prescribed and documented in the resident's record.5. Documentation and Reporting All skin assessments, findings, and interventions shall be documented in the resident's electronic health record (EHR). Any significant skin changes shall e reported to the physician, family, and interdisciplinary team.6. Staff Training All nursing staff shall receive annual training on skin assessment, wound care, and pressure injury prevention. New employees shall be oriented on this policy and proper skin assessment techniques.Compliance and Quality Assurance: The facility's Quality Assurance Committee shall review skin integrity trends and outcomes to improve resident care. Audits of skin assessments and documentation shall be conducted periodically to ensure compliance with this policy. ELEVATED BLOOD SUGAR LEVELS R3's face sheet received on 6/17/26, included diagnosis of diabetes mellitus (metabolic disease, causing high blood sugar levels). R3's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, speech clear, was understood and able to understand. R3 required substantial staff assist or was dependent on staff for activities of daily living. R3's care plan with revised date of 5/9/23, indicated R3 was at risk for complications related to diabetes mellitus; diabetes medication and/or insulin as ordered and blood sugars per glucose monitor as ordered. R3's physician orders all dated 3/5/26, indicated the following with each order including to notify the provider if blood sugar (BS) over 400 mg/dl (milligram per deciliter): --Insulin Aspart FlexPen Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Aspart) Inject 23 unit subcutaneously one time a day. Notify provider if BS (blood sugar) less than 100 or over 400. --Insulin Aspart FlexPen Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Aspart) Inject 25 unit subcutaneously one time a day. Notify provider if BS less than 100 or over 400. --Insulin Aspart FlexPen Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Aspart) Inject 27 unit subcutaneously one time a day. Notify provider if BS less than 100 or over 400. --Insulin Aspart FlexPen Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 0 - 179 = 0; 180 - 219 = 2 units; 220 259 = 4 units; 260 - 299 = 6 units; 300 - 339 = 8 units; 340 - 379 = 10 units; 380 - 399 = 12 units; 400+ = 15 units, call provider. During record review, R3's blood sugar readings over 400 mg/dl included: 5/25/26 at 12:52 p.m. and 12:58 p.m., 479 mg/dl 5/29/26 at 7:41 p.m., 410 mg/dl 5/30/26 at 10:54 a.m. and 11:51 a.m., 424 mg/dl 5/31/26 at 8:12 p.m., 426 mg/dl 6/1/26 at 5:17 p.m., 447 mg/dl 6/1/26 at 9:38 p.m., 427 mg/dl 6/5/26 at 8:32 p.m., 420 mg/dl 6/8/26 at 8:30 p.m., 498 mg/dl 6/10/26 at 11:34 a.m., 416 mg/dl 6/10/26 at 5:01 p.m., 402 mg/dl 6/11/26 at 3:35 p.m., 437 mg/dl 6/11/26 at 5:19 p.m., 473 mg/dl 6/11/26 at 8:00 p.m., 4:39 mg/dl 6/13/26 at 8:07 p.m., 430 mg/dl 6/16/26 at 8:21 p.m., 448 mg/dl During an interview on 6/16/26 at 8:48 a.m., license practical nurse (LPN)-C stated nurses would know when a provider wanted to be notified of a low or high blood sugar if it was included in an order. In addition, LPN-C stated a nurse could also [NAME] over an electronic order in the MAR (medication administration record). LPN-C hovered over R3's insulin order in the MAR and it indicated a sliding scale, and if blood sugar was 400+, give 15 units and notify provider. LPN-C looked in progress notes and of the blood sugars greater than 400 ml/dl, a provider was notified of the BSs over 400 mg/ml on 6/1/26, and 6/11/26, but not the other 10 dates. During an interview on 6/16/26 at 3:36 p.m., with the director of nursing (DON) and interim DON (IDON), informed of findings of blood sugars over 400 mg/dl and provider not informed. IDON stated this had been a problem; they had done some nurse education in spring 2026, on notifying providers on changes in condition, and when orders indicated they wanted to be notified. After reviewing the electronic medication record, neither the DON nor the IDON could verify with certainty the providers were informed of the blood sugars over 400 mg/dl (other than 6/1/26 and 6/11/26). Facility Compliance with Physician orders policy dated 8/2025, indicated the purpose was to ensure all physician (or authorized provider) orders were accurately received, documented, communicated, and implemented in a timely and safe manner to promote optimal resident care and compliance with regulatory standards. All nursing staff must follow physician orders precisely as prescribed. Orders must be verified, documented, and executed promptly unless contraindicated or unclear, in which case clarification must be obtained before implementation.

Based on observation, interview and document review the facility failed to ensure safe transfers with a sit-to-stand mechanical lift and/or total body mechanical lift for 2 of 3 residents (R4 and R9) reviewed for falls/safety. The facility's failure resulted in immediate jeopardy (IJ) for R4 when staff were observed to use the wrong size harness for sit-to-stand mechanical lift transfer after a previous fall from sit-to-stand lift on 12/21/25 which resulted in minor injuries. In addition, the facility failed to comprehensively investigate/analyze falls for root cause, implement appropriate interventions to prevent and/or reduce the risk for future falls for 1 of 3 residents (R3) reviewed for falls/safety. The IJ began on 2/25/26, when nursing assistant (NA)-C and NA-D had to be stopped from using the wrong harness size according to R4's care plan and the failed to follow manufacturer's instructions to tighten the harness torso strap to ensure safety putting R4 at likelihood for serious harm/injury or death. The administrator and director of nursing (DON) were notified of the immediate jeopardy on 2/26/26 at 6:08 p.m. The immediate jeopardy was removed on 3/2/26 at 2:30 p.m., but non-compliance remained at the lower scope and severity level D, which indicated no actual harm with the potential for more than minimal harm that is not immediate jeopardy. Findings include: R4's face sheet dated 2/27/26, identified diagnoses of heart failure, chronic kidney disease, neoplasm (cancer) of the pancreas, diabetes, osteoarthritis, and history of falling. R4's admission Minimum Data Set (MDS) dated [DATE], indicated R4 did not have cogntive impairment, had no behaviors, no rejection of care, no range of motion limitations on upper or lower extremities, was dependent for sit to stand, and was dependent on staff for chair to bed transfer. Additionally, R4 had a fall in the last month prior to facility admission, had a fall within the last 2-6 months since admission with no injury, and had one fall since admission with injury. R4's Morse Fall Scale (a tool used to determine risk of falling) dated 12/18/25, identified R4 as a high-risk for falling due to weakness and history of falling. R4's Therapy Recommendation form dated 12/18/25, identified R4 needed assistance of two staff with the sit-to-stand mechanical lift for all transfers with large harness due to needing cues for hand placement. R4's fall focus care plan dated 12/27/25, identified R4 was at risk for falls related to history of falls before and after admission. Goal to be free from falls. Interventions dated 12/18/25 as follows: -Call light within reach. Encourage use of call light for assistance as needed. -Ensure resident is wearing appropriate footwear (non-skid socks or rubber soled shoes) during transfer, ambulation and/or mobilizing in wheelchair. -In the event of fall, resident will need assistance of two staff with a total mechanical lift and a large sling. -Routine safety checks. -Follow facility fall protocol. R4's Activity of Daily Living (ADL) focus care plan initiated on 12/18/25, identified R4 had an ADL self-care performance deficit related to weakness, history of stroke, cancer of the pancreas, and diabetic with neuropathy (damage to the nerves resulting in pain, numbness, tingling, or weakness especially in the hands and feet). Goal to improve current level of function in ADLs. Interventions dated 12/19/25 directed staff for toilet use: R4 required assistance from two staff for all transfers with a sit to stand mechanical lift and for transfers R4 required assistance from two staff members for all transfers. R4's nurse aide resident care sheet dated 12/21/26, identified R4 needed assist of two staff with the sit-to-stand mechanical lift with a large harness. During an interview on 2/25/26 at 7:45 a.m., trained medication aide (TMA)-B explained staff would use the therapy recommendation or the paper care sheet (not the care plan or kardex (abbreviated care plan)) to determine what size harness a resident required when using the sit-to-stand lift. R4's progress note dated 12/21/25 at 1:56 p.m., identified the nurse was called to R4's room and found that R4 had fallen from the sit-to-stand mechanical lift. R4 was lying on the floor with his feet still on the sit-to-stand with the leg strap still buckled and his head resting on the recliner. Isolated incident care plan was not followed by nursing assistant and was transferred by one person using the sit-to-stand mechanical lift. Noted a friction bruise that was reddish in color under left armpit from the sling. R4 was changed to a total mechanical lift until therapy can re-assess. Educated staff on importance of following care plan and two staff for cares and transfers. R4's record did not identify the size of sling used and not evident a comprehensive assessment was completed to determine sling size for the full body mechanical. Additionally, the care plan was not revised to include intervention(s) for R4 falling asleep in the lift. R4's fall incident report dated 12/21/25 at 12:23 p.m., identified R4 had a witnessed fall from the sit-to-stand mechanical lift. Writer witnessed the patient lying on the floor with his feet still in the sit-to-stand mechanical lift with leg strap still buckled, head propped up on the footrest of the recliner, which was down at the time. Resident description was that R4 felt weak and let go of the sit-to-stand mechanical lift and his arms went up and he fell. R4's Fall Root Cause Analysis and Witness Statement form dated 12/21/25, identified R4 was supposed to have two staff members for all transfers with the sit-to-stand however, according to witness statement the nursing assistant attempted transfer by herself from wheelchair to the recliner while R4 fell asleep during transfer and fell. R4 felt weak and arms went up when he let go of the sit to stand mechanical lift and fell. During an interview on 2/26/26 at 11:06 a.m., nursing assistant (NA)-E stated on 12/21/26, R4 had asked for a brief change and wanted to be transferred from his wheelchair to his recliner. NA-E stated she was aware R4 needed two staff to transfer using the sit-to-stand mechanical lift, so she had requested assistance over the walkie talkie but did not get a response. NA-E stated she had not verified R4's care plan/care sheet and/or therapy sheet to see what size sit-to-stand harness R4 was supposed to use. NA-E stated with conviction she was 100% positive she used an extra-large [XL] harness to transfer R4, because R4 was the only resident using the sit to stand lift in that unit and staff kept the sling at all times on the lift. NA-E then proceeded to transfer R4 by herself. NA-E stood R4 in the sit-to-stand mechanical lift, performed pericare as R4 stood up, pulled R4's pants back up, and then turned and then pushed the lift towards the recliner. Once in front of the recliner R4 began to fall asleep, he let go causing him to slip completely out of the lift harness onto the ground. Review of the facility investigation notes identified NA-E was not contacted until 12/22/25 by an unknown staff member. On 12/22/25 NA-E stated she was aware R4 needed assist of two staff with the sit to stand lift, but other staff were busy, so she needed to get R4 cleaned up and moved. NA-E informed DON she had checked R4's care plan and verified harness size (notes did not identify what size harness NA-E used at the time of the transfer), attached the harness and buckled R4's feet and decided to then lift R4 up in the lift. NA-E cleaned and changed R4's pad and then was going to transfer R4 to the recliner but when NA-E was positioning R4 near the recliner, R4 slipped out, fell to the ground. R4 told NA-E he had fallen asleep and she then called the nurse. During an interview on 2/26/26 at 12:02 p.m., licensed practical nurse (LPN)-C stated on 12/21/25 at around 12:30 p.m. she had been called to R4's room by NA-E over the walkie talkie to report R4 had fallen from the lift. Upon entering R4's room she found R4 sitting on the floor in front of his recliner with both of his legs still resting on the lifts' foot plate with the calf strap still buckled. The harness was still connected to the lift with the torso strap still buckled; the harness was connected to the lift appropriately. LPN-C had not verified that R4's harness was the correct size after the fall, I did not even think to check. LPN-C explained she thought R4 fell out of the lift because NA-E had not cinched the torso strap tight so when R4 let go he slipped completely out of the harness. LPN-C further stated R4 had pain in his left shoulder for some time after the fall which was treated with pain cream. During an interview on 2/26/26 at 12:44 p.m., the Director of Nursing (DON) stated she was notified on 12/21/25 that R4 had fallen from the sit to stand lift. Following the notification, the DON immediately removed NA E from the work schedule. She reported attempting to interview NA E shortly after the incident but was unable to reach her at that time. DON returned to the facility later that afternoon, inspected the lift and harness, and noted no apparent defects. She reported she was not aware that an XL harness had been used during the transfer; she believed a large sling had been used but had no documentation verifying the harness size at the time of the fall. DON interviewed NA E on 12/22/25. During that interview, NA E reported she had transferred R4 alone and did not utilize a second staff member as required by policy and the resident's care plan. NA E had stated that R4 fell asleep during the transfer, released her hold on the equipment, and subsequently slipped out of the sling. DON reported she did not recreate the incident with NA E to determine the cause of the fall and did not have documentation of any post incident inspection of the lift or harness. DON kept NA E off the schedule until NA E completed a repeat competency test on the safe use of mechanical lifts. DON reported conducting multiple competencies and audits on NA E only and acknowledged she did not perform audits or provide additional staff education regarding adherence to care plans for any other staff members. DON stated she did not believe improper lift use was a systemic issue and therefore limited education and competency review to NA E. R4's progress note dated 12/22/25, identified R4 was complaining left shoulder was sore. R4 pointed to left shoulder and had an ache and with range of motion (ROM) had pain. R4 was seen by nurse practitioner virtually and no x-ray ordered. R4's nurse practitioner note dated 12/22/25, identified R4 was seen due to pain in left shoulder following a fall from the sit-to-stand mechanical lift on 12/21/25. Physician order for Voltaren (pain cream)1% gel; Apply 2 g topically 4 (four) times a day. May also apply 2 grams four times a day as needed (shoulder pain). R4's Medication Administration Record (MAR) reviewed 12/23/25 through 1/5/26 identified Voltaren cream had been applied to R4's left shoulder 14 times. R4's care plan revised on 2/24/26, identified R4 required assistance from two staff using sit-to-stand mechanical lift. R4's resident care guide reviewed on 2/25/26, identified R4 needed assist of two staff with sit-to-stand mechanical lift with a large harness. During an observation and interview on 2/25/26 at 9:31 a.m., NA-C and NA-D entered R4's room to assist R4 with transfer from bed to shower chair. NA-D brought in a sit-to-stand mechanical lift with a harness draped over the top of the lift. NA-D stated R4 was the only resident on the wing that used the sit-to-stand lift and that his (XL) harness was draped over the lift. NA-D stated twice the XL was the correct size for R4. NA-C and NA-D then sat R4 at the edge of the bed and placed the XL harness behind R4's back. Surveyor intervened and asked NA-C and NA-D to verify that the XL harness size was the correct size to use with R4. Neither NA-C nor NA-D had a resident care guide that identified R4's correct harness size. NA-D left the room to find out the correct harness size R4 was supposed to use and returned to R4's room with a large harness. NA-D stated she verified R4's resident care guide and it identified R4 was to use a large harness not an XL. NA-D stated she had to go to another wing in the building to find the correct harness size for R4, because the size was not in R4's unit. Registered nurse (RN)-A then entered R4's room and stated R4 had been assessed by therapy and was suppose to be using a large harness, RN-A stated R4's care plan/kardex did not identify harness size , but the resident care guide did specify the correct size and staff should be checking in all places to verify they are using the correct harness. NA-C and NA-D then placed the large harness behind R4's back, applied the loops, provided cues to have proper hand placement to R4, attached the leg and torso strap, had R4 stand. As R4 stood, NA-C nor NA-D cinched the torso strap. Surveyor intervened to instruct NA-C and NA-D to cinch the torso strap as R4 stood. NA-C stated she was aware the torso strap needed to be cinched as a resident stands up, but must have just overlooked doing it. NA-C stated a resident could fall out of the lift if this is not done each time they stand up and she should have made sure this was done. NA-C and NA-D stated they had not received any re-education on the proper use of mechanical lifts nor following care plan since their initial orientation. During an interview on 2/25/26 at 10:30 am., director of nursing (DON) verified R4's care plan/Kardex did not identify R4's harness size staff are supposed to use during a transfer with a sit to stand lift. DON stated R4 was supposed to be using a large harness and it had been identified on the resident care sheet, but should have been added to the care plan/Kardex. DON stated staff were supposed to use the Kardex and/or resident care guides to verify correct harness size prior initiating a transfer with the lifts. During an interview on 2/26/26 at 4:26 p.m., medical director (MD) stated any resident being transferred using a mechanical lift without a care plan and/or policy followed for use of the mechanical lift had the likelihood to cause serious harm, serious injury, or even death in the event the resident falls from the mechanical lift. R9 R9's face sheet dated 3/1/26, identified R9 had diagnoses of heart failure, chronic respiratory failure, and chronic kidney disease. R9's Significant Change MDS dated [DATE], identified R4 was cognitively intact, had no behaviors, no rejection of care, had impairment of range of motion on both lower extremities, used a wheelchair, was dependent for chair/bed to chair transfers. R9's Mechanical Lift Sling/Harness Sizing assessment dated [DATE], identified R9 needed a large sling for the total mechanical lift. R9's ADL focus care plan dated 5/21/25, identified R9 had a self-performance deficit related to weakness, chronic respiratory failure, and schizophrenia. Goal to maintain current level of functioning. Interventions as follows for transfers: -EZ stand harness size large (R9 did not use an EZ stand lift); Total mechanical lift sling: (was left blank). Dated 2/27/26. -Transfer: The resident requires total dependence on two staff for transferring via total mechanical lift with an XL sling. Dated 1/8/26. R9's Kardex reviewed on 3/2/26 at 10:00 a.m., identified R9 needed a XL sling for with the total mechanical lift, however, this conflicted with the assessment dated [DATE] that identified R9 required a large sling. During an interview on 3/2/26 at 10:14 a.m., DON reviewed and verified R9's care plan/Kardex conflicted with the assessment dated [DATE]. DON confirmed R9 had been measured and assessed for proper sling size on 2/27/26, determined he needed a large sling verses an XL sling. DON was not aware R9's care plan/Kardex had not been updated to reflect the correct sling size of a large sling. During an observation and interview on 3/2/26 at 10:39 a.m., R9 was seated in wheelchair on top of mechanical lift sling that was in color with green trim. Trained medication aide (TMA)-C entered R9's room and stated that she was unable to verify what size R9's sling by the tag, due to the sizing being washed off. TMA-C stated a tan sling with green trim would be an XL sling. TMA-C then walked to a mechanical lift, identified the sling color with the coding sizing chart on the front of the lift that indicated a green trim sling was indeed an XL sling. TMA-C then verified on R9's Kardex that R9 was supposed to be in a large sling and not an XL sling during transfers using the total mechanical lift. TMA-C stated, R9 could have fallen out of that sling, and we are lucky he did not. During an interview on 3/2/26 at 11:03 a.m., DON stated NA-D informed her that she had not transferred R9 using the correct sling size, NA-D had only verified the sling size by using the paper nurse aide care guide. DON explained using the sling that was too large could have caused R9 to fall out of the sling during a transfer. DON and TMA-C then removed the incorrect sling out from under R9 and placed the correct size sling in R9's room to be used for the next transfer. DON stated R9's care plan had been amended to remove any XL sling off his care plan and the paper care sheets removed off the floor to ensure staff were checking the same place to verify correct sling sizes for any residents that need to transferred using any mechanical lift. The immediate jeopardy that began on 2/25/25 was removed on 3/2/26 at 2:30 p.m., when it was verified, the facility implemented the following: - The facility has identified all those that use a sit to stand. The facility has assessed each resident and the size of harness needed. The facility educated each member of the nursing staff that will or had potential to use the sit to stand. - R4 and all residents using mechanical lifts were assessed for: Proper transfer method Correct sling/harness size Care plan accuracy. - Sling/harness size was verified for each resident through: Therapy documentation Direct measurement Manufacturer guidelines Care plan accuracy. -Systemic Corrections Policy Review Mechanical lift transfer policy reviewed and updated to: Require sling/harness size documented in care plan and Kardex. Require 2-assist transfers when indicated. Require staff verification of sling size prior to transfer. Require cinching of waist/middle straps before elevation. Documentation Care plans updated to specifically identify: Type of lift Assist level. Sling/harness size. Kardex updated to match care plan. Care sheets updated to match the care plan -Education All licensed nurses and other certified individuals: Manufacturer recommendations Proper sling application Proper strap placement and cinching When sit-to-stand lifts are contraindicated. Always following care plan Education included: In-service training Hands-on demonstration Return competency validation. Competency Quiz Review of the facility's Mechanical Lift Policy dated 12/25, identified it is the policy to lift and move a resident safely without causing serious injury to staff or residents. Procedure as follows: -All mechanical lifts require two staff for operation. -All staff will be trained on proper lift use prior to operating mechanical lifts. -Lifts will be inspected per manufacturer's recommendations. -Lift slings are inspected by nursing prior to use and by laundry when washed. -Inspections will be audited and reviewed and monthly safety meetings. R3 R3's face sheet dated 2/27/26, identified diagnoses of malignant neoplasm of the brain, heart failure, and osteoporosis. R3's significant change MDS dated [DATE], identified moderate cognitive impairment, no behaviors, no rejection of care, used a walker and wheelchair, needed partial/moderate assistance for transfers, had one fall with no injury and one fall with injury since admission. R3's fall focus care plan initiated on 1/9/26, identified R3 was at risk for falls related to limited mobility, communication issues, and weakness. Goal to be free from falls. Interventions as follow: -Follow facility fall protocol. -Routine safety checks. Start date 1/9/26. -Anticipate and meet the resident's needs. Start date 1/9/26. -PT evaluate and treat as ordered. Start date 1/9/26. -Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter/remove any potential causes if possible. Educate resident/family/caregivers/interdisciplinary team (IDT) as to causes. Start date 1/9/26. -Be sure the residents' call light is within reach and encourage the residents to use it for assistance as needed. The resident need prompt response to all requests for assistance. R3's fall incident report dated 2/10/26 at 1:40 p.m., identified R3 had an unwitnessed fall in the bathroom after being assisted by a family member and being alone for a minute. R3 attempted self-transfer and fell on her buttocks. Family member assisted R3 off the floor and reported the fall to staff. R3's Incident Root Cause Analysis Worksheet dated 2/10/26, identified problem that R3 was left unattended while in the bathroom. Root cause of fall was left blank. There was no indication of a comprehensive analysis to identify potential causal factors. R3's fall focus care plan was revised on 2/11/25 to encourage family members not to transfer resident and to ask for staff for assistance. R3's fall incident report dated 2/18/25 at 1:50 a.m., identified R3 was on the bathroom floor with her walker located outside of the bathroom door. Predisposing physiological factors of weakness, gait imbalance, drowsy. Predisposing situation factors of ambulating without assist devices. R3's fall incident report did not identify an immediate intervention to mitigate the risk of further falls. R3's Incident Root Cause Analysis Worksheet dated 2/18/26, identified a problem that R3 self-transfers at times without a walker. Root causes of fall identified as brain cancer, weakness, and self-transfers. Although the analysis idetentified potential causal factors, there was no indication of a comprehensive analysis that determined associated interventions that would decrease the risk or prevented falls based on the causal factors that were identified. R8's care plan revised on 2/19/26 directed staff to place dycem (anti-slip) mat placed in seat of wheelchair, however, it could not be determined the rational for placement of the dycem based on the identified causal factors of the fall that were identified on the causal analysis worksheet. R3's fall incident report dated 2/20/26, identified R3 had an unwitnessed fall in her room at 8:05 a.m. R3 was found on the floor lying next to her bathroom. R3 had independently walked to the bathroom by herself and lost her balance. R3's fall incident report did not identify an immediate intervention to mitigate the risk of further falls. R3's Incident Root Cause Analysis Worksheet dated 2/20/26, identified R3 was found outside of her bathroom on the floor, visual checks every 30 minutes cannot be done when nursing assistants in rooms providing care (R3's record did not identify 30-minute checks had ever been initiated). Had an inquiry about adding an ultra-low bed. In review of R3's record although a potential cause was identified there was no indication 30-minute checks had ever been initiated. Additionally even though R3's care plan had been revised 2/25/26 (5 days after the fall) directed staff to check and change every two hours and offer bedpan if the R3 chose, there was no corresponding comprehensive assessment that identified how the frequency and type of toileting program was determined. During an interview on 2/27/26 at 1:16p.m., DON stated R3's falls had been discussed during the IDT daily meetings, however, had not had a comprehensive causal analysis done for each fall to ensure that person-centered interventions were put in place for each fall. DON indicated toileting was the root cause of her falls and should have been addressed before 2/25/26 Review of the facility's Falls-Clinical Protocol dated 2/26, identified the following: Cause Identification 1. For an individual who has fallen, the staff and practitioner will begin to try to identify potential causes within 24 hours of the fall. Often, multiple factors contribute to a falling problem. 2. If the cause of a fall is unclear, or if a fall may have a significant medical cause such as a stroke or an adverse drug reaction (ADR), or if the individual continues to fall despite attempted interventions, a physician will review the situation and help further identify causes and contributing factors. After a fall, the physician should review the resident's gait, balance, and current medications that may be associated with dizziness or falling. Many categories of medications, and especially combinations of medications in several of those categories, increase the risk of falling. 3. The staff and physicians will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable.

Based on observation, interview, and document review the facility failed to ensure residents at risk for or with pressure ulcers received ongoing comprehensive assessment, individualized reassessment of pressure-relief effectiveness, and revised interventions necessary to prevent deterioration and support healing for 3 of 3 residents (R10, R4, R9) reviewed for pressure ulcers. This resulted in actual harm for R10 who had facility acquired stage 2 pressure ulcer on left sacral region (buttock) that deteriorated to a stage 3 pressure ulcer. Findings include: Pressure Ulcer/Injury (PU/PI) is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury occurs because of intense and/or prolonged pressure or pressure in combination with shear. Stage 2 Pressure Ulcer: Partial thickness skin loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink, or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis, intertriginous dermatitis (inflammation of skin folds), medical adhesive related skin injury, or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Ulcer: Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration: Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Moisture Associated Skin Damage: inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, sweat, wound drainage, saliva or mucus. R10's face sheet dated 3/3/26, identified diagnoses of multiple sclerosis, diabetes, heart failure, neurogenic bladder and bowel, and chronic kidney disease. R10's quarterly Minimum Data Set (MDS) dated [DATE], identified R10 was cognitively intact, no behaviors, no rejection of care, had impairment on both lower extremities, used a wheelchair, dependent to roll left and right, dependent for transfers, at risk for pressure ulcers, had no unhealed pressure ulcers, no venous/arterial ulcers, had moisture associated skin damage (MASD); used pressure reducing device for chair and bed, was not on a turning and repositioning program, had application of non-surgical dressings other than feet; and application of ointments/medications other than feet. R10's Braden Scale for Predicting Pressure Sore Risk dated 9/18/25, identified R10 was at moderate risk for developing pressure ulcers due to being slightly limited to respond to pressure-related discomfort; skin is occasionally moist; being chairfast; being very limited with mobility; having a problem with friction and shear. Interventions to elevate heels off bed, pressure reducing mattress on bed, pressure reducing pad in chair, turn and reposition while in bed. R10's Activity of Daily Living (ADL) focus care plan dated 9/4/21, identified R10 had a self-care deficit related to multiple sclerosis (MS) and MS complications. Goal to be clean and well groomed. Interventions as follows: -Transfers: dependent on two staff (dated 5/14/25). -Bed mobility: dependent on staff for repositioning and turning in bed (dated 12/16/25). R10's skin integrity focus care plan revision date of 12/16/25, identified R10 had potential/actual impairment to skin integrity with fragile skin related to limited mobility and moisture associated skin damage (MASD). Goal to be free of any skin related infection. Interventions as follows: -Elevate heels off bed (dated 11/24/21). -Skin barrier cream/ointment to protect skin as needed (dated11/24/21). -Pressure reducing pad while in chair (dated 6/21/24). -Have resident lay down one hour every shift to relieve pressure off peri area. Start 4/11/25. -Avoid pulling buttocks open with care and treatment (dated 9/24/25). -Nutrition supplements as ordered for wound healing (dated 9/24/25). -Provide peri care two times per shift on days and evening (dated 9/24/25). -Reposition every hour while in chair (dated 9/24/25). -Turn and reposition while in bed every two hours (dated 9/24/25). Review of R10's Skin Assessments dated 9/19/25, 9/26/25, 10/3/25, 10/10/25, 10/24/25 (completed 14 days after last assessment) identified R10 had redness to bottom/skin breakdown on each of the assessments. R10's assessments did not identify location, measurements, wound type, nor any other wound characteristics. R10's physician orders identified the following: -Wound left buttocks: wash per facility protocol, pat dry, apply zinc oxide (a medical cream to treat skin irritations) ointment twice daily for 14 days; after 14 days apply barrier cream to wound until resolved twice daily. Start date 8/15/25 with end date of 11/19/25. R10's Skin assessment dated [DATE], identified left buttocks had healing popped blisters. Mepilex (foam dressing) had been applied. No other wound characteristics including measurements, wound integrity, and location on the buttock were included. R10's record did not identify a corresponding physician order for the treatment of the foam dressing. However, physician order dated 11/8/25 directed alternating pressure air mattress; a full 30 degrees turns side to side every 2 hours while in bed; reposition every hour while in bed; cushion to chair -such as ROHO (air filled pressure-relief cushion) when in wheelchair; elevate heels while in bed. R10's Skin assessment dated [DATE], identified a stage two pressure ulcer on left buttocks measuring 2.0 cm x 1.0 cm. R10's assessment did not identify any description of the wound characteristics. Corresponding progress note included a situation, background, assessment, and response (SBAR) had been sent to physician indicating R10 had a stage 2 pressure ulcer on left buttocks that measured 2.0 (cm) x 1.0 cm with partial thickness loss of skin, skin was pink, had a moist wound bed with fragile surrounding skin. No further characteristics was identified. R10's record reviewed 11/14/25 through 11/16/25 did not include an order for wound care treatment for the identified stage 2 pressure ulcer. R10's nurse practitioner note dated 11/17/25, identified R10 had a stage 2 pressure ulcer on her left buttocks that continue to be open despite nursing care. R10 used a ROHO cushion but unfortunately the ROHO was placed backwards. R10's physician orders dated 11/17/25, included the following: -Left buttocks wound to wash with wound cleanser, scrub the wound bed, apply Duoderm Signal (a name brand dressing that signals when it is time to be changed) dressing to wound bed, change every 3rd day or as needed if dressing peels off. Start date 11/17/25. -Apply zinc oxide twice daily to skin surrounding left buttocks wound to act as barrier for incontinence. Do not scrub the zinc oxide off but reapply twice a day for incontinence. Start date 11/17/25. R10's Skin Assessments dated 11/21/25, 11/28/25, and 12/5/25, identified R10 had a stage two pressure ulcer on left buttocks measuring 2.0 cm x 1.0 cm (which was the same measurement of wound for each assessment). R10's assessments did not any other wound characteristics except being marked as improving. R10's Braden Scale for Predicting Pressure Sore Risk dated 12/10/25, identified R10 was at moderate risk for developing pressure ulcers due to being slightly limited to respond to pressure-related discomfort; skin is occasionally moist; being chairfast; being very limited with mobility; having a problem with friction and shear. Interventions as follows: -Elevate heels off bed. -Pressure reducing pad while in chair. -Pressure reducing mattress on bed. -Skin barrier cream/ointment to protect skin as needed. -Turn and reposition while in bed every 2 hours. R10's nurse practitioner nursing home visit note dated 12/13/25, included an order to discontinue all prior wound buttocks wound treatments and new order for buttocks wound treatment of zinc barrier cream mixed with collagen powder twice daily and as needed for incontinence. The visit note did not include wound status and/or characteristics. R10's Skin Assessments dated 12/12/25, 12/19/25, 12/26/25, 1/2/26, and 1/9/26, identified R10 had a stage two pressure ulcer on left buttocks measuring 2.0 cm x 1.0 cm (which was the same measurement of wound for each assessment). R10's assessments did not any other wound characteristics except being marked as improving. R10's Skin Assessments dated 1/17/26 indicated no change to the size of the stage two pressure ulcer on the left buttock since 11/14/25. The assessment identified the stage 2 ulcer with measurements 2.0 cm x 1.0 cm., marked as improving. No other wound characteristics were included. R10's nurse practitioner (NP) note dated 1/21/26, identified R10 was seen for wound care management. R10 had a stage 3 pressure ulcer on left buttocks near the crease. Original size was 1.7 cm x 1.0 cm x 0.2 cm with current size of 2.0 cm x 3.6 cm x 0.1 cm. Edges distinct and epithelization. Wound bed with granulation and epithelization. Minimal serous (clear and watery) drainage. Tender and not odor present. Periwound with blanchable erythema. Identified current physician orders as wash per facility protocol, pat dry, apply foam dressing, change every 3rd day and as needed for rolling/soiling. Do not apply barrier cream with collagen powder to wound. -Zinc powder with collagen powder on other perianal wounds twice daily and as needed. -Do not scrub or wash barrier cream off when soiled. -Encourage repositioning every 2 hours while in bed to offload pressure. -During the day encourage R10 to lay down for at least 60 minutes at a time to offload pressure at least twice daily. If R10 does not want to lay down at least verify R10 is clean and dry and reposition in wheelchair. In review of R10's record between 11/14/25 when the stage 2 pressure ulcer was first identified through 1/21/26 when the NP identified the ulcer had deteriorated to a stage 3 , there was no indication the existing pressure relieving interventions were evaluated for effectiveness, and no new interventions were added . Additionally, R10's record did not include a comprehensive assessment that identified R10's skin tolerance to pressure over time; it could not be ascertained how every two-hour positioning schedule first initiated on 9/24/25 (prior to ulcer development) was appropriate or effective. R10's physician order dated 1/22/26 directed for other sacral wounds apply zinc barrier cream mixed with collagen powder twice daily and as needed. Do not apply where dressing for left buttocks wound cut. The transcribed order did not direct the application of the foam dressing changed every 3rd day. Review of R10's January and February 2026 TAR included the physician order that had been transcribed without the foam dressing. The TARs indicated R10's wound treatments were completed without using the foam dressing according to transcribed order. R10's Skin assessment dated [DATE], 1/30/26, 2/6/26, 2/13/26, 2/20/26, and 2/27/26 did not identify the correct staging of the ulcer according to the nurse practitioner instead the assessment identified a healing stage 2 pressure ulcer to left buttocks measuring 2.0 cm x 1.0 cm indicating the wound remained the same size since first identified on 11/14/25. The assessment did not include any wound characteristics. In review of R10's record between 11/15/25 through 2/27/26 revealed R10's record did not include weekly comprehensive skin assessments and even though the TAR directed wound monitoring for any wounds for changes was completed (denoted by check marked boxes) and treatments were completed according to orders (denoted by check marked boxes) that were transcribed, there was no documentation of wound status and characteristics. R10's nursing home nurse practitioner note dated 2/28/26, identified R10's pressure injury stage 3 to left sacral region had resolved. During an interview on 3/2/26 at 12:18 p.m., R10 was in her room seated in her wheelchair. R10 explained she had a sore on her bottom but believed it was getting better. R10 stated when she was in bed, staff did come in at night to reposition her every 2 hours. R10 explained in the morning once she got up for the day, she spent most of her time in her electric wheelchair that could lean back this helps me get off my bottom. R10 then used her controls on her wheelchair to lean back in her chair 45-degree angle which although redistributed the amount of weight from R10's bottom did not completely offload all of her weight from her bottom. R10 stated sometimes she could not tell if her bottom was getting sore because of her MS, this may be why I got a sore on my bottom. R10 further stated staff did not come into her room to give her direction to reposition while in her chair, so she tried to remember to do it herself, but sometimes forgets. R10's wheelchair had a ROHO cushion on it with the words FRONT on the front of the cushion. R10 stated that the aides had put this wording on the front of the cushion, because staff kept putting the cushion in her chair backwards. R10 stated if her cushion was backwards her bottom worse if not placed correctly. R10 was unaware how long ago the wording was added to the cushion. During an interview on 3/2/26 at 12:34 p.m., trained medication aide (TMA)-C stated R10's wheelchair allowed her to reposition herself in her chair if she felt the need to get off her bottom. TMA-C was unaware R10 was supposed to be repositioned every hour in her chair and was not sure if staff were supposed to remind R10 to reposition in her chair. During an interview on 3/2/26 at 12:38 p.m., nursing assistant (NA)-D stated was she responsible for caring for R10 today but was unaware R10 was supposed to lay down in bed for one hour and was unaware R10 needed to be repositioned every hour while in her wheelchair. NA-D stated once R10 was in her recliner she would notify staff when she wanted to be checked and changed. During the day R10 spent the majority of the time in her wheelchair and did not like to lay in her bed. R10's electric wheelchair reclined to different positions which R10 would do that herself, however, staff did not track how often R10 repositioned. NA-D was not able to articulate how R10's chair was able to take pressure off her bottom. NA-D further explained R10's the chair reclining would not be considered offloading her bottom; R10 would have to be completely off her bottom. During an interview on 3/2/26 at 12:40 p.m., licensed practical nurse (LPN)-C stated R10's left buttocks wound had not had an order for a foam dressing since 1/21/26, the wound has been treated with mixing collagen powder with zinc oxide twice a day even though the physician order directed the use of one. LPN-C explained this order should have been clarified with the nurse practitioner before it had been removed off of the orders. LPN-C indicated even though the treatment order was not followed, R10's wound had been healing. During an interview on 3/2/26 at 3:07 p.m., registered nurse manager (RN-NM) stated R10's pressure ulcer on her left sacral region was facility acquired and developed on 11/14/25. RN-NM reviewed R10's skin assessments from 1/22/26 through 2/27/26 and believed the assessments were inaccurate with measurements since R10's left buttocks pressure ulcer as healed on 2/28/26. RN-NM also identified R10's weekly skin assessments were not considered comprehensive. RN-NM was unaware the pressure ulcer was first identified as a stage 2 pressure ulcer and then had deteriorated to a stage 3 pressure ulcer. RN-NM stated R10 was supposed to be turned and repositioned every 2 hours in bed and every hour in her wheelchair R10 has MS and is not able to feel when she may be having buttocks pain RN-NM was now aware that direct care staff were relying on R10 to reposition herself when she was in her wheelchair. RN-NM explained R10's every 2-hour turning and repositioning was given as an order by the nurse practitioner; RN-NM was not aware if the frequency was appropriate or effective. During an interview on 3/2/26 at 11:05 a.m., director of nursing (DON) stated she was unaware R10's pressure ulcer on her left buttocks had deteriorated to a stage 3 pressure ulcer on 1/21/26. R10's wound staging should have been identified as stage 3 since 1/21/26 remained at stage 3 until the wound had been determined it had healed. On 3/2/26 at 1:05 p.m. and 3:45 p.m., attempted to contact R10's nurse practitioner responsible for her pressure ulcer care, however, did not get a return phone call. R4 R4's face sheet dated 2/27/26, identified diagnoses of heart failure, chronic kidney disease, neoplasm (cancer) of the pancreas, diabetes, osteoarthritis, and history of falling. R4's admission Minimum Data Set (MDS) dated [DATE], identified R4 was cognitively intact, had no behaviors, no rejection of care, no range of motion limitations on upper or lower extremities, need substantial/maximum assistance for rolling side to side, was dependent for sit to stand, dependent for chair to bed, at risk for pressure ulcers, no unhealed pressure ulcers, had MASD, treatments of pressure reducing device in chair and bed, application of nonsurgical dressings and ointments. R4's ADL focus care plan revised on 12/27/25, identified R4 had a self-care deficit related to weakness, history of stroke, cancer of the pancreas and liver, and diabetes with neuropathy (a type of nerve damage that happens with diabetes). Goal to improve current function in ADLs. Interventions as follows: -Bed mobility extensive assistance of two staff to turn and reposition in bed. -Partial assistance of two staff with a sit to stand mechanical lift for transfers. R4's skin integrity focus care plan revised on 1/7/26, identified R4 had a potential/actual impairment to skin integrity with old scarring from previous pressure injuries on bilateral buttocks related to incontinence of urine and stool. Goal to free from skin related infection. Interventions as follows: Wound/Skin treatment as ordered (date 12/18/25). -Use a draw sheet of lifting device to move resident (date 12/18/25). -lotion dry skin areas as necessary (date 12/18/25). -Skin barrier cream/ointment to protect skin as needed (date 12/18/25). -Pressure relieving/reducing pad while in chair (date 12/18/25). -Pressure reducing mattress on bed (date 12/27/25). -Assist with offload every two hours in bed and chair (date 12/27/25). R4's nursing home visit nurse practitioner note dated 12/22/25, identified R4 had been admitted with a wound to left buttocks (the note did not identify type of wound nor wound characteristics including measurements). The note included orders to cleanse wound with wound cleanser, pat dry, apply small amount of Iodosorb (antimicrobial gel directly to open wound area, cover with dry gauze and secure with foam dressing. R4's progress note dated 1/19/26, identified a situation, background, assessment, response (SBAR) was sent to physician that wound to buttocks in now open and bleeding. Buttocks has keloid skin to the right and skin tags that had an open area and the left had an open area as well. Asked for new treatment for the wound. The note did not include any further description of the wound. R4's physician orders dated 1/20/26, identified order to buttocks wounds as follows: -Wash per facility protocol and pat dry. Cover with silicone bordered foam dressing and change every 3rd day and as needed for rolling or getting soiled. (Start date 1/20/26 through 2/9/26). -Buttocks wounds peel dressing back to assess wound once daily. Start date 1/20/26 through 2/9/26) R4's Skin assessment dated [DATE], identified R4 had non-blanchable redness to the right buttocks near the gluteal cleft and bilateral buttocks had red/purple discoloration that was blanchable. Left buttocks had 1.2 cm x 1.2 cm open area. Corresponding progress note dated 2/3/26 included R4's bottom was starting to look macerated with non-blanchable redness noted to the right buttocks near the intragluteal cleft. R4's nursing home nurse practitioner note dated 2/6/26, identified a stage 2 pressure injury to the left medial buttocks and incontinence associated dermatitis. Pressure ulcer had three small open wounds on the left buttocks close together measuring 1.0 cm x 1.0 cm x 0.1 cm. More proximal (center of the body) on the left buttocks measures 1.5 cm x 1.0 cm x 0.1 cm. Edges attached and open. Wound bed denuded (loss of top layer of skin), fragile, and non-blanchable erythema. Minimal bloody drainage and tender with no odor. Periwound fragile and pink. Ulceration had gotten larger. Treatment orders as follows: -Wash buttocks wound per facility protocol, pat dry, cover with silicone bordered foam dressing, peel back daily to assess daily and change every 3rd day and as needed rolling/soiling. R4's Skin assessment dated [DATE], identified R4 had thick scar tissue with 1.2 cm x 1.2 cm open wound to the left buttocks, with red/purple discoloration that is blanchable. Treatment orders in place. The assessment did not include further description of the wound nor address the second wound as identified by the NP. R4's Skin assessment dated [DATE], identified R4's left buttocks had thick scar tissue with 1.2 cm x 1.2 cm open wound to left buttocks. Bilateral buttocks had red/purple discoloration that was blanchable. Identified as healing. No further description was included. Review of R4's record from 2/14/26 through 2/25/26 did not include a comprehensive wound assessment had been completed of R4's buttock wounds. During an observation and interview on 2/25/26 at 10:10 a.m., R4 was lying in a bed on top of a deflated air mattress that had been unplugged. There was no other barrier between the metal bedframe and the plastic material of the mattress. NA-C and NA-D entered R4's room, NA-D stated R4's air mattress was totally deflated and must have been unplugged by accident. NA-D was unsure how long R4's mattress had been unplugged or when the last time R4 had been turned and repositioned in bed. NA-D then plugged R4's air mattress back in the outlet. R4 was assisted by NAs to stand up using a sit-to-stand lift exposing the back of R4's incontinent brief which had a silicone foam dressing stuck on the right side. NA-D stated, How did that get there?, it is supposed to be on his wound on his bottom. As NA-D removed R4's brief an open wound was observed on R4's right buttock that was approximately 2.0 cm x 1.0 cm in size. The wound had uneven edges and was macerated (white, soft, wrinkled skin due to excessive moisture). Base of the wound was pink and R4 denied pain in the area. R4's bilateral buttocks had thick skin that was light brown (hyperpigmentation) in color with no redness or purple noted. NA-D stated R4 was going to get a shower, then the nurse would check his skin and apply a new dressing. During an interview on 2/25/26 at 10:45a.m., RN-B stated she had been told earlier that R4 had a new open area on his right buttocks and needed to put a dressing on it. RN-B explained that by R4's air mattress being deflated for an unknown time this could cause injury to R4's bottom. RN-B indicated she was not responsible for completing the comprehensive wound assessments, the nurse managers completed them. R4's Skin assessment dated [DATE], identified R4 had moisture associated skin damage (MASD) to left buttocks measuring 2.5 cm x 1.0 cm; stage 2 pressure injury to right buttocks measuring 2.5 cm x 1 cm; and bilateral deep tissue injury measuring 9.0 cm x 8.0 cm. Wound identified as worsening. Assessment did not identify any further details of the pressure injury. R9 R9's face sheet dated 3/1/26, identified diagnoses of heart failure, chronic respiratory failure, and chronic kidney disease. R9's significant Change MDS dated [DATE], identified R9 had intact cognition, had no behaviors, no rejection of care, had impairment of range of motion on both lower extremities, used a wheelchair, was dependent for chair/bed to chair transfers, was at risk for developing pressure ulcers, had one stage 2 pressure ulcer, R9's Braden Scale for Predicting Pressure Sore Risk dated 1/26/26, identified R9 was moderate risk for developing pressure ulcers due to being slightly limited in sensory perception, being occasionally moist, chairfast, completely immobile, problem with friction/shear. R9's ADL focus care plan revised on 5/21/25, identified R9 had a self-care deficit related to weakness, respiratory failure, and kidney failure. Goal to maintain current level of function. Interventions as follows: -Transfers: dependent with assist of two staff using a full body mechanical lift. -Bed mobility: dependent with one to two staff for repositioning and turning in bed. R9's pressure ulcer focus care plan dated 5/21/25, identified R9 had potential for pressure ulcer development related to history of ulcers and immobility. Goal to have intact skin. Interventions as follows: -Assist of two staff to turn and reposition every 2 hours in bed and chair, more often as needed or requested. Pressure relieving mattress on bed (dated 2/16/19). -Pressure reducing device on wheelchair (dated 12/16/19). -Lay resident down between meals and prop to either side using pillows to fully offload buttocks. If refused report to the nurse (dated 1/28/26). -May leave lift sling under due to discomfort with removing and replacing. Skin checks increased to twice per week (dated 1/28/26). R9's Skin assessment dated [DATE], identified left buttocks wound with an open area that measured 0.5 cm x 0.5 cm, no drainage, center is red in color. Mepilex dressing applied. The assessment did not include any other characteristics. R9 nurse practitioner nursing home visit note dated 1/13/26, identified R9 had been having severe pain in buttocks for past 3 weeks with pain relieved by lying flat in bed. Stage 2 pressure ulcer on left buttocks identified. Treatment orders to wash per facility protocol, pat dry, cover with silicone bordered foam dressing, change every 3rd day and as needed and frequent repositioning and offloading pressure. In review of R9's record despite the order for frequent repositioning/offloading there was no indication of a comprehensive assessment to determine the frequency of repositioning nor evident the care plan was revised with a change from every two hour positioning which was identified as an intervention on 2/16/19. Review of R9's Skin Assessments dated 2/3/26 through 2/21/26 indicated the measurements of the left buttock wound remained the same. The assessments each identified a wound with an open area that measured approximately 1.3 cm x 0.75 cm. Area cleansed and patted dry, skin prep and bordered foam dressing applied on each assessment. The assessments did not include any other wound description or characteristics. R9's Skin assessment dated [DATE], indicated the wound to the left buttock had deteriorated. The assessment included the wound had an open area, wound bed appears superficial, pink/red in color, no drainage, measures 2.5 cm x 3.0 cm. New bordered foam dressing applied. The assessment did not include any other wound description or characteristics. R9's Weekly Wound/Complex Wound Observation Tool dated 2/27/26, identified R9 had a stage 2 pressure ulcer on left buttocks that measured 0.8 cm x 1.6 cm with no depth. Wound was acquired while in the facility. - During an interview on 3/2/26 at 12:40 p.m., LPN-C stated R9 was turned and repositioned every 2 hours while in bed and the chair, which he allows. R9's wound on his left buttock has been improving with turning and repositioning and treatments. LPN-C further explained that the skin assessments that were done on bath days were not comprehensive assessments because many of them were completed by LPN's and not an RN. LPN-C was unsure which registered nurses was responsible for the assessments and staging of a wound. During an interview on 2/26/26 at 2:06 p.m., Minimum Date Set Coordinator Registered Nurse (MDS-RN) stated she had noticed a while ago that residents with pressure ulcers had not had a weekly comprehensive wound assessment of their wounds completed and had informed her concern to upper management, but continued to notice that the comprehensive assessment have not been completed. During an interview on 3/2/26 at 3:07p.m., RN-NM stated she had not been performing any comprehensive assessments of residents with pressure ulcers and was not aware that a registered nurse needed to complete the comprehensive assessment each week. RN-NM explained she had not been given directions to be responsible for completing the wound assessment for the residents with pressure ulcers; the only direction she received to ensure the weekly bath skin assessments by the floor nurses. RN-NM further explained she had not received any wound assessment education and without having this education she would not feel comfortable performing the assessments also RN-NM believed that any staff could assess the wounds and was not aware a registered nurse would need to complete the assessment to ensure it was correct and appropriate treatments and pressure reducing measures were in place. During an interview on 3/2/26 at 11:05 a.m., director of nursing (DON) stated registered nurse manger (RN-NM) had been assigned the responsibility of ensuring the weekly pressure ulcer assessments were being completed. DON explained when she started reviewing wound documentation she realized the weekly skin bath audits were completed however, not the comprehensive wound assessments. Any resident with pressure ulcers should have had a weekly comprehensive registered nurse (RN) assessment of the wounds to ensure the appropriate treatment and pressure prevention measures were in place. The comprehensive assessment should have included: type of wound, location, date acquired, staging, length, width, depth, description of wound base, edges, and drainage. DON reviewed R10, R4, R9's record and identified no RN weekly comprehensive wound assessments had been completed since identification of the pressure ulcers and they should have been completed. DON explained the purpose of the comprehensive assessment being done by an RN would be to ensure the pressure ulcers are assessed for healing and/or deterioration and to ensure proper pressure relieving measures/treatments are in place. Review of the facility's Prevention and Treatment of Skin Breakdown Policy undated, identified it was the policy of the facility to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care. Procedure as follows: Skin Ulcer Data Collection & Assessment sheets are used for pressure, stasis, arterial and neuropathic ulcers. Data is provided by the floor nurse or nurse manager on resident's bath day. RN assesses the information and writes a progress note detailing the wound appearance, treatment, and healing progress. Treatment orders to be followed as MD prescribes, measurements of wounds only need to be documented weekly. If wound worsens consecutively for 2-3 weeks a note to the MD is sent with request for new orders. Prevention of Pressure Ulcers A. Braden Scale* and Comprehensive Risk Data Collection form (which includes a skin audit) will be done: Upon admission Weekly for the first 4 weeks post admission, Quarterly, and With a change in status (i.e., pressure ulcer development, change in mobility, continence status, Change in cognition, nutrition, etc.). Please see Policy and Procedure for Braden Scale & Comprehensive Risk Data Collection in the Forms and Care Plans section for instructions. A. Turning and Repositioning Observation (capturing turning & repositioning). Pressure is the primary cause of pressure ulcers. An effec[

Based on interviews and document review the facility failed to ensure that 1 of 1 resident (R1) was free of a significant medication error by not observing the rights of medication administration. This caused actual harm for R1 when she was administered another resident's medications became unresponsive and had to be hospitalized for hypotension and acute kidney injury. In addition, based on observation and interview the facility failed to ensure appropriate correction measures after R1's medication errors to decrease the risk or reduce the risk of significant medication errors and could have prevented or reduced the risk additional medication errors that were not significant for 2 of 2 residents (R12, R5) observed during medication pass. Findings include: R1's face sheet dated 2/27/26, identified diagnoses of heart failure, transient cerebral ischemic attacks (mini strokes), and use of anticoagulants (blood thinners). R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had moderate cognitive impairment, no behaviors, no rejection of care, diagnosis of renal insufficiency, renal failure, or End Stage Renal Disease, and took an anticoagulant. R1's physician orders identified the following: -Midodrine (a drug used to treat orthostatic hypotension and increase blood pressure) 5 mg three times per day related to orthostatic hypotension. Do not take if systolic blood pressure (top blood pressure) if greater than 150. -Vitamin D (supplement) tablet 50 micrograms (mcg) one time per day. -Pantoprazole (drug to reduce stomach acid) 40 milligram (mg) one time per day. -Apixaban (blood thinner) 5 mg by mouth one time per day. -Rosuvastatin (drug to treat high cholesterol) 20 mg one time per day. -Calcium carbonate (supplement) 1500 mg 2 tablets two times per day. R1's Medication Error incident report dated 2/13/26, identified R1 had been given R2's medications inadvertently at 7:32 a.m. R1 became unresponsive and had to be sent to the emergency department for evaluation. The investigation notes identified the medications that R1 received included: Atorvastatin 40 mg (milligrams-lipid/cholesterol management), Clopidogrel 75 mg, (antiplatelet-increases risk for bleeding) Duloxetine 30mg, (antidepressant) Empagliflozin 10 mg (diabetic management), Famotidine, (reduces stomach acid) Lamotrigine 100mg (anticonvulsant/mood stabilizer), Losartan 25 mg (treats hypertension) Metoprolol 25 mg (treats hypertension/heart rate control) Potassium 20 mEq,(treats low potassium) and Torsemide 20 mg (diuretic and hypertension) R1's progress note dated 2/13/26 at 7:35 a.m., identified nurse was called over the walkie talkie by trained medication aide (TMA) to inform this nurse that R1 had been given another resident's medication by mistake. Nurse called the on-call physician and informed the medications R1 received and was instructed to monitor resident for any adverse reactions to any of the medications. R1's progress note dated 2/13/26 at 9:20 a.m., identified nurse was called into R1's room by nursing assistant because R1 became unresponsive. R1 was lying with eyes closed, did not respond to verbal commands. Sternal rub (a painful stimulation technique to assess a level of consciousness) done and did get some facial grimace. Blood pressure 137/82 (normal blood pressure is under 120/80) and heart rate 92 (normal heart rate is 60-100), respirations 18 (normal respirations 12-18), oxygen saturations 97% (normal oxygen saturations are 95-100%). Ambulance called and R1 sent to emergency department (ED). R1's emergency department (ED) note dated 2/13/26, identified R1 was seen in the ED after becoming unresponsive after receiving another resident's medications at 7:35 a.m. A list of medications that was administered was as follows: Atorvastatin 40 mg, Clopidogrel, 75 mg, Duloxetine 30mg, Empagliflozin 10 mg, Famotidine, Lamotrigine 100mg, Losartan 25 mg, Metoprolol 25 mg, Potassium 20 milliequivalent (mEq), and Torsemide 20 mg. R1 had become somnolent (sleepy) and not acting herself at the nursing home so was sent to ED for evaluation. Blood pressure on admission to the ED was 133/59. Blood urea nitrogen (lab value to evaluate kidney function) slightly up trending. R1's blood pressure at 10:58 a.m., decreased to 97/48 millimeters of mercury (mm/Hg) and one liter of fluid bolus initiated. R1 was admitted for monitoring for hypotension and resolution of a mild acute kidney injury. R1's hospital progress note dated 2/14/26, identified diagnoses of accidental drug ingestion, hypotension secondary to accidental drug ingestion, blurry vision secondary to accidental drug ingestion, and orthostatic hypotension. On 2/14/26 she endorsed blurry vision which the note identified this could be a side effect of the medication of the low blood pressures. R1's hospital Discharge summary dated [DATE], identified R1 had been hospitalized 2/13/26 through 2/17/26 after being inadvertently administered another patient's medications at a skilled nursing facility. On presentation R1 was somnolent (sleepy and or drowsy) and did not follow commands, had a single episode of hypotension that responded to intravenous (IV) fluids. Laboratory evaluation revealed an acute kidney injury with a creatinine elevated to 1.36 milligram/deciliter (mg/dl). The medication error of receiving medications not prescribed to R1 and was admitted for close monitoring of hemodynamics and renal (kidney) function. R1 experienced symptomatic orthostatic hypotension with dizziness and blurry vision on standing, required ongoing conservative management including compression wraps, abdominal binder, hydration, and gradual titration of midodrine to 10 mg three times per day. R1's acute kidney injury resolved with IV fluids and avoidance of nephrotoxic agents (medication that cause kidney damage). R1 was discharged on 2/17/26 to another skilled nursing facility. During an interview on 2/24/26 at 4:06 p.m., trained medication aide (TMA)-A stated she was agency staff and had worked a handful of times at the facility. She had not worked with R1 before and had not seen R1 before. During the day shift on 2/13/26, TMA-A prepared R2's medications, verified R2's picture in the electronic health record (EHR), identified R2's room number, however, TMA-A entered R1's room instead. TMA-A did not verify the room number prior to entering R1's and then entered R1's room to administer the medications. TMA-A then proceeded to administer R2's medications to R1. When TMA-A attempted to give R1 an inhaler R1 stated, I don't take an inhaler., TMA-A realized her error. TMA-A left R1's room and verified on the EHR that she had mistakenly given R2's medications to R1. TMA-A immediately called the nurse to inform them of error and took R1's vital signs. TMA-A stated she did not follow the rights of medication administration to ensure the correct resident received the correct medications. TMA-A further stated she had not had orientation on medication pass or any previous education on rights of medication administration at this facility. During an interview on 2/24/26 at 1:44 p.m., licensed practical nurse (LPN)-B stated she had been notified by TMA-A on 2/13/26 around 7:30 a.m., that R1 received R2's medications. LPN-B stated she immediately came to the unit to check on R1. R1's vitals were stable; however, she was concerned about getting the wrong medications. LPN-B stated, I don't even know how TMA-A made that kind of error and told her she should have verified she was giving the medications to the right resident. LPN-B further stated if TMA-A had performed her rights of medication administration she would have not made the mistake. During an interview on 2/25/26 at 1:04 p.m., medical director (MD) stated she considered R1's medication error that occurred on 2/13/26 to be considered a significant error. MD further stated R1 becoming hypotensive and developing an acute kidney injury was likely caused by getting medication that were not prescribed to her. Staff should have followed the rights of medication administration for all residents to ensure safe medication administration utilized. During an interview on 2/20/26 at 4:04 p.m., director of nursing (DON) stated she had been informed 2/13/26 at 8:00 a.m., that R1had inadvertently received R2's medications at 7:30 a.m. DON stated she instructed the nurse to monitor and ensure the physician had been informed of R1's medication error. The nurse had informed DON that R1 was doing fine and she was being monitored. DON then arrived at the facility around 8:45 a.m. to 9:00 a.m. Shortly after the DON arrival she was notified that R1 had become unresponsive. DON then immediately went to R1's room where R1 was found lying in bed and not responding to verbal commands. R1's vitals had been taken and were stable, but continued to not respond, so DON sent R1 to the ED for evaluation. DON stated R1's medication error occurred because the rights of medication administration had not been followed by TMA-A and the wrong medication was given to the wrong resident. R1 was admitted for observation, but did not return to the facility, so she did not know the outcome. TMA-A had told DON that as she prepared R2's medications, believed she had entered R2's room, however after administering R1 all of R2's pills, she had tried to offer R1 an inhaler, when R1 stated that was not her medication. TMA-A then told her she realized she had given medications to the incorrect resident and notified the nurse immediately. DON then sent TMA-A home and stated she had provided verbal education to the staff that was working on the rights of medication administration, however, did not have any documentation of her education provided. DON stated the facility then began competency testing of the staff that administered medication to ensure that the rights of medication were being followed. During an interview on 2/24/26 at 12:56 p.m., TMA-D stated he had recently had education and competency testing provided by one of the LPNs to ensure he know how to pass medications correctly. He did not recall exactly what kind of education he had received. TMA-D was able to name five of the seven rights of medication administration, however, was not aware of right rationale or right documentation being part of the rights of medication administration. During an interview on 2/24/26 at 2:11 p.m., TMA-B stated she had recently received education on the rights of medication administration and had competency done by the administrator. TMA-B stated she did not recall exactly what the education was about, but believed it was just about how the process of doing the medication pass correctly and making sure we are doing all of the steps correctly. During an interview on 2/24/26 at 4:52 p.m., administrator stated she was not a licensed nurse, however, had completed some of the staff medication administration competencies and education even thought she had not had any formal training on medication administration or the rights of medication administration to be able to determine if staff were deemed competent doing a medication pass. During an interview on 2/24/26 at 4:52 p.m., DON stated she had not performed any of the medication administration training or competencies done with staff. She had a few staff deemed competent by a registered nurse, but most of the staff had been completed by the administrator (who was not a licensed nurse nor had any education on medication administration) or by a licensed practical nurse. DON stated the competencies/education that had been completed by administrator, or the LPNs would not be considered valid, due to those staff not having the capability to determine competency of the staff or provide education. DON stated the staff that were responsible for medication administration should have had their competencies and/or education done by a registered nurse only. R12's face sheet dated 2/27/26, identified diagnoses of heart failure and gastroesophageal reflux disease. During an observation and interview on 2/25/26 at 7:52 a.m., registered nurse (RN)-B prepared medications for R12 by verbalizing and comparing the order to the medication package label. RN-B walked to R12 and verified R12's identity with name and date of birth and compared image of R12 in the electronic health record (EHR). RN-B then informed R12 what each medication was and then handed R12 a liquid oral antifungal in a small cup, instructed R12 to swish the medication in his mouth then spit the medication out. RN-B then realized the medication was supposed to be a swish and swallow versus a swish and spit. RN-B stated she must have misread the order as a swish and spit verses a swish and swallow and this would be a medication error. RN-B stated she had a kind of audit done recently by the administrator while she passed medication to ensure she was doing them correctly. RN-B did not recall getting any recent education on the rights of medication administration. R5's face sheet dated 2/27/26, identified diagnoses of heart failure, Parkinson's disease, and dementia. R5's quarterly MDS dated [DATE], identified R5 had intact cognition, no behaviors, took an antianxiety medication, and received hospice services. R5's physician orders dated 1/30/26, identified an order for Lorazepam (anti-anxiety) give 1 mg three times per day for anxiety. R5's Medication Error Incident Report dated 2/21/26, identified R5 received an extra dose of Lorazepam at 4:45 p.m. During an interview on 2/26/26 at 2:28 p.m., TMA-C stated she had a recent medication pass audit and competency test given by the administrator along with education on the rights of medication administration. However, despite the education she had made a medication error on 2/21/26 when she gave R5 a extra dose of Lorazepam on 2/21/25. TMA-C explained she had thought R5 had orders for an as needed dose but did not verify R5's physician orders prior to administering the dose of Lorazepam on 2/21/26 at 4:45 p.m. TMA-A stated she should have ensured the rights of medication administration were done prior to administering R5's medication, and if she had followed the rights of medication administration she would not have made R5's medication error. TMA-C recited the rights of medication and identified R5's medication error was the result of not administering the right dose of medication. TMA-C indicated she has continued to pass medications even though she had not received any re-education since the error was made on 2/21/26. TMA-C explained the DON would be providing education on a later date. During an interview on 2/25/26 at 2:59 p.m., DON stated R5's medication error on 2/21/26 was due to TMA-C not performing the rights of medication not being followed and therefore an error happened that had the potential of being a significant error in certain residents. DON stated she had not given TMA-C formal re-education on the rights of medication administration but was planning on doing it soon. Review of the facility's Administering Medications Policy dated 2/26, identified the following: -The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the residents include: a. checking identification band; b. checking photograph attached to medical record; and c. if necessary, verifying resident identification with other facility personnel. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on interview and document review the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee identified, investigated, analyzed, and responded high risk issues related to a falls, medication errors, and pressure ulcers by developing and implementing action plans for process improvement. This deficient practice had the potential to affect all 36 residents that resident in the facility. Findings include:SEE F689: Based on observation, interview and document review the facility failed to ensure safe transfers with a sit-to-stand mechanical lift and/or total body mechanical lift for 2 of 3 residents (R4, R9) reviewed for falls/safety. The facility's failure resulted in immediate jeopardy (IJ) for R4 when staff were observed to use the wrong size harness for sit-to-stand mechanical lift transfer after a previous fall from sit-to-stand lift on 12/21/25 which resulted in minor injuries. In addition, the facility failed to comprehensively investigate/analyze falls for root cause, implement appropriate interventions to prevent and/or reduce the risk for future falls for 1 of 3 residents (R3) reviewed for falls/safety. SEE F760: Based on interviews and document review the facility failed to ensure that 1 of 1 resident (R1) was free of a significant medication error by not observing the rights of medication administration. This caused actual harm for R1 when she was administered another resident's medication became unresponsive and had to be hospitalized for hypotension and developed an acute kidney injury. SEE 686: Based on observation, interview, and document review the facility failed to monitor, comprehensively assess, develop, and implement individualized interventions to prevent/mitigate the risk of pressure ulcers to prevent deterioration for 3 of 3 residents (R10, R4, R9) reviewed for pressure ulcers. This resulted in actual harm for R10 who developed a stage 2 pressure ulcer on her sacrum that deteriorated to a stage 3 pressure ulcer.Review of QAPI data from May 2025 through January 2026 identified across all months the facility consistently collected and reported data related to falls, pressure ulcers, and medication errors; however, the documents did not address or include root cause analysis, prioritization of high-risk or recurring issues, development of performance improvement projects, implementation of corrective actions, and monitoring of interventions for effectiveness. Quality documents included the following:May 2025: 5 falls; 3 residents with stage 3 pressure ulcer with no documentation if facility acquired or admitted with; no documentation of medication errors. No documented discussion or action plans.June 2025: No fall data documented; 2 residents with Stage 1 pressure ulcers with no documentation if facility acquired or admitted with; one medication error. No documented discussion or action plans.July 2025: 6 falls with no injury; 2 pressure ulcers (Stage 1 and Stage 2) with no documentation of facility acquired or admitted with; no medication errors. No documented discussion or action plans.August 2025: 8 falls (1 with injury); 1 healed facility acquired pressure ulcer.September 2025: 9 falls with one with injury. Comment added that one fall with major injury/hip fracture; 2 pressure ulcers (Stage 1 and unstageable/DTI), no indication if facility acquired.; one medication error. No documented discussion or action plans.October 2025: 7 falls; no pressure ulcer data; one medication error. No documented discussion or action plans.November 2025: 8 falls (1 with injury); 3 pressure ulcers (Stage 1, Stage 2, unstageable/DTI), no indication if facility acquired; one medication errors No documented discussion or action plans.December 2025: 7 falls (1 with injury); spreadsheet did not identify that the fall with injury involved a mechanical lift; pressure ulcers; no medication errors. No documented discussion or action plans.January 2026: 8 falls (no injury); 3 Stage 2 pressure ulcers and 1 unstageable/DTI; no indication if facility acquired; no medication errors. No documented discussion or action plans.During an interview on 2/26/26 at 4:26 p.m., medical director (MD) stated she was part of the QAPI committee and attends the meetings monthly. MD was unaware of any current action plans that had been put in place by the committee to ensure falls, wounds, or medication errors had been addressed. During an interview on 3/2/26 at 4:39 p.m., administrator stated the facility's QAPI committee meets monthly to bring forward data such as wounds, falls, and medication errors. The facility had identified a current issue in each of these areas after review of incident reports and wound documentation, however, had not created an action plan to improve quality in any of the areas but only reviewed the data. The administrator stated she was the QAPI committee chairperson who would be responsible for ensuring adverse outcomes are identified, a discussion with the committee, and action plans put in place to attempt/reduce further adverse outcomes. Administrator explained that the QAPI committee had not taken any minutes regarding any discussions during the last four quarters, so therefore had not had any discussion from previous months to review, analyze, and respond to the issues brought forth in the QAPI meetings. The administrator stated, The facility does a great job collecting data, however, does not do a great job with what we do with the data.Review of the Review of the facility's Quality Assessment and Assurance/Quality Assurance Performance Improvement (QAA/QAPI) Plan dated 11/25/25, identified the following:The purpose of QAPI in our organization is to take a proactive approach to continually improve the way we care for and engage with our residents, caregivers and other partners so that we may realize our mission. To do this, all employees will participate in ongoing QAPI efforts which support our mission. Feedback, Data Systems, and Monitoring: -The facility will put in place systems to monitor care and services, drawing data from multiple sources. Feedback systems will actively incorporate input from staff, residents, families, and others as appropriate. It will include using performance indicators to monitor a wide range of care processes and outcomes and reviewing findings against benchmarks and/or goals the facility has established for performance. It also includes tracking, investigating, and monitoring adverse events every time they occur, and action plans implemented through the plan, do, study, act (PDSA) cycle of improvement to prevent recurrences.Performance Improvement Projects:-The QAPI team at St. Mark's Living will review our sources of information to determine if gaps or patterns exist in our systems of care that could result in quality problems; or if there are opportunities to make improvements. -Based on the result of the review of information, the QAPI team will prioritize opportunities for improvement, taking into consideration the importance of the issues (high risk, high frequency, and/or problem prone). The QAPI team will determine which problems will become the focus for a performance improvement project (PIP).

Based on interview and document review, the facility failed to notify a physician for a change of condition for 1 of 3 residents (R3) who had a syncopal episode. Findings include:R3's diagnoses list dated 4/10/26 included pneumonia, acute respiratory failure, chronic heart failure, chronic kidney disease, atrial fibrillation, and syncope.R3's admission Minimum Data Set (MDS) dated [DATE] indicated no cognitive deficits.R3's health status note dated 4/4/26 at 9:09 a.m., trained medication assistant (TMA)-A reported on 4/3/26 R3 had passed out for a few seconds during a transfer. A nurse was notified and evaluated R3. In review of R3's record there was no indication the physician was notified. R3's care plan dated 3/26/26 indicated on 4/6/26 R3's transfer status was changed to assist of two for all transfers due to possible vagal response.During an interview on 4/10/2026 at 11:30 a.m., TMA-A stated on 4/3/26 she placed a gait belt on R3 then assisted him to a standing position. Upon rising, R3 started to lean forward, then went limp so TMA-A lowered him back into his recliner. After he sat down, his eyes opened, and he said hi. TMA-A immediately called for assistance over the walkie talkie. Licensed practical nurse (LPN)-A, LPN-B and registered nurse manager (RN-NM) responded to the call for assistance. During an interview on 4/10/2026 at 11:39 a.m., LPN-A stated on 4/3/26 at change of shift, TMA-A requested assistance in R3's room. LPN-A responded with LPN-B and RN-NM. R3 was alert when LPN-A entered the room. Because it was the end of her shift, LPN-A left the room with LPN-B and RN-NM caring for R3. LPN-A stated a provider should be updated any time a resident had a change in condition.During an interview on 4/10/2026 at 2:52 p.m., LPN-B stated on 4/3/26 she responded to a call for assistance in R3's room. When she entered, R3 was alert and following commands. LPN-B stated she did not check vital signs, did not update the provider and did not complete a nursing note because there was a lot going on that shift. LPN-B stated a note should be written and a provider should be updated any time a resident had a change in condition. During an interview on 4/10/2026 at 11:46 a.m., RN-NM stated on 4/3/26 she responded to a request for help in R3's room. When RN-NM entered R3's room, R3 was alert and LPN-B was obtaining vital signs. R3 had not had an episode like that before at the facility. RN-NM stated there was no nurse's note about the event on 4/3/26 and no indication in the chart the provider had been notified. RN-NM stated a provider should be updated any time a resident had a change in condition. During an interview on 4/10/2026 at 11:05 a.m., director of nursing stated the provider should have been notified about the event the day it occurred because it was a significant change from R3's baseline. During an interview on 4/10/2026 at 9:51 a.m. medical doctor (MD) stated she learned of R3's dizziness episode on 4/8/26 through asking routine questions during rounds at the facility. MD would have wanted to be notified right away following the episode. The Change of Condition policy dated 2/2026 instructed to notify the physician in the event of a status change.

Based on interviews and document review the facility failed to maintain a complete, accurate and readily accessible medical record was maintained for 1 of 1 (R1) resident reviewed for significant medication error. Findings include: R1's face sheet dated 2/27/26, identified diagnoses of heart failure, transient cerebral ischemic attacks (mini strokes), and use of anticoagulants (blood thinners).R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had moderate cognitive impairment, no behaviors, no rejection of care, diagnosis of renal insufficiency, renal failure, or End Stage Renal Disease, and took an anticoagulant.R1's progress note dated 2/13/26 at 7:35 a.m., identified nurse was called over the walkie talkie by trained medication aide (TMA) to inform this nurse that R1 had been given another resident's medication by mistake. Nurse called the on-call physician to inform of the medications had R1 received and was instructed to monitor residents for any adverse reactions to any of the medications.R1's Medication Error incident report dated 2/13/26, identified R1 had been given R2's medications inadvertently at 7:32 a.m. R1 became unresponsive and had to be sent to the emergency department for evaluation. R1's progress note dated 2/13/26 at 9:20 a.m., identified nurse was called into R1's room by nursing assistant because R1 became unresponsive. R1 was lying with eyes closed, did not respond to verbal commands. Sternal rub (a painful stimulation technique to assess a level of consciousness) done and did get some facial grimace. Blood pressure 137/82 (according to the Mayo Clinic normal blood pressure is under 120/80) and heart rate 92 (according the Mayo Clinic a normal heart rate is 60-100), respirations 18 (according to the Mayo Clinic normal respirations 12-18), oxygen saturations 97% (according to the Mayo Clinic normal oxygen saturations are 95-100%). Ambulance called and R1 sent to emergency department (ED). During an interview on 2/24/26 at 1:44 p.m., licensed practical nurse (LPN)-B stated she had been working on 2/13/26 when R1 received R2's medication. LPN-B stated she had taken R1's vital signs multiple times during her assessments after the medication error, however, did not enter the vital signs in R1's electronic health record (EHR) or any assessments LPN-B had completed on R1. During an interview on 2/24/26 at 4:52 p.m., director of nursing (DON) stated LPN-B should have included each set of vital signs values along with assessments in R1's EHR that she had completed to ensure R1's record was complete and accurate. DON explained that her expectation would be for all licensed staff to ensure the documentation was complete prior to the end of their shift. DON added, If it is not documented, then it was not done. Review of the facility's Charting and Documentation Policy dated 3/26, identified that all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record.Policy Interpretation and Implementation as follows:The following information is to be documented in the resident medical record:Objective observations.Medications administered.Treatments or services performed.Changes in the residents' condition.Events, incidents, or accidents involving the resident; andProgress toward or changes in the care plan goals and objectives.2. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.3. Entries may only be recorded in the resident's clinical record by licensed personnel (e.g., RN, LPN/LVN, physicians, therapists, etc.) in accordance with state law and facility policy. Certified nursing assistants may only make entries in the residents' medical chart as permitted by facility policy.4. Documentation of procedures and treatments will include care-specific details, including:the date and time the procedure/treatment was provided.the name and title of the individual(s) who provided the care.the assessment data and/or any unusual findings obtained during the procedure/treatment.how the resident tolerated the procedure/treatment.whether the resident refused the procedure/treatment.notification of family, physician, or other staff, if indicated; andthe signature and title of the individual documenting

Based on observation, interview and document review, the facility failed to monitor the concentration of sanitizer used in the 3-compartment sink to ensure proper sanitation for cleaning pots and pans. This had the potential to affect all 36 residents who were served food from the kitchen. Findings include: During observation and interview on 3/31/25 at 11:35 a.m., with dietary assistant (DA)-A, 3 sinks were being used to clean pots and pans. DA-A stated the pots and pans rarely if ever go thru the dishwashing machine. DA-A indicated they aren't currently testing the concentration of the sanitizer or checking temperatures of water used for washing. DA-A stated they change out the chemicals and is not sure if the contract company completes maintenance on the system or not. The chemical used for sanitizing dishes stated Sunburst on the container. During observation 3/31/25 at 6:21 p.m., C-B filled the 3 sink system to wash pots and pans. C-B stated they check the concentration of the sanitizer each time they wash the pots and pans and showed the [NAME] Sticks (all were sealed in individual packs) used but did not check the concentration of the sanitizer sink. During an observation and interview on 4/1/25 at 8:50 a.m., with dietary manager (DM)-A, 3 compartment sink was filled with water and sanitizer solution and dishes had just been washed and were sitting on the counter, still wet. DM-A stated they don't check temperatures of the water and use cold water for the sanitizing solution. DM-A stated staff should be checking the concentration of the sanitizing solution each time the sink is filled using the tape found above the sinks. DM-A checked the current concentration using sanitizer test strip tape and correct concentration (200 parts per million) was noted. DM-A stated they do not document these checks or temperatures and has no documentation to support this is being completed. During interview 4/2/25 at 7:26 a.m., cook (C)-B indicated they wash, rinse and sanitize the pots and pans in the three sink system. C-B stated contact time for leaving pots and pans in sanitizer is 1 minute. Facility Cleaning Dishes/Dish Machine policy dated 2010, included all flatware, serving dishes and cookware will be washed, rinsed and sanitized after each use. Dish machines will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitation. The policy did not include instructions for use for the 3 sink system for cleaning pots and pans but did include scrub pots and pans with a non-metallic scouring pad when necessary and rinse in the sink.

Based on interview and document review, the facility failed to submit accurate and/or complete data for staffing information, based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed (Quarter 1, 2024), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS.This deficient practice had the potential to affect all 36 residents residing in the facility. Findings include: The CMS payroll-based journal (PBJ) staffing data report indicated the following: Failed to have RN hours four or more days within the quarter: 10/12/24, 10/13/24, 10/26/24, 10/27/24, 11/9/24, 11/10/24, 11/23/24. Failed to have licensed nursing coverage 24 hours/day on the following dates: 10/4/24, 10/6/24, 10/13/24, 10/19/24, 10/26/24, 10/27/24, 11/2/24, 11/9/24, 11/10/24, 11/14/24, 11/15/24, 11/16/24, 11/17/24, 11/23/24, 11/24/24, 11/28/24, 11/29/24, 12/7/24, 12/8/24, 12/22/24 and 12/25/24. On 4/2/25 at 9:17 a.m., staffing specialist (SS)-E, stated she was responsible for the nurse staff schedules. SS-E stated the staff schedule ensured a licensed nurse was scheduled each shift (days, evenings, and nights) and 24 hours every day with a minimum of one registered nurse (RN) every 24 hours. SS-E indicated she has always been able to cover licensed nurses staffing for above required hours but they sometimes have to mandate staff stay to cover the shift until a replacement can be found. The DON has had to cover portions of the shift also due to last minute call ins. On 4/1/25 at 9:34 p.m., the administrator stated the facility uploads the payroll information from their automated payroll system to the PBJ staffing site except the contracted staff who are manually entered. The administrator indicated in June 2024, the facility had a change in their payroll system and have been having issues with the information uploading to the PBJ site correctly. The administrator indicated they had to manually enter all their hours for July, August and September as none of their data would transfer. The administrator indicated they are working with the new payroll system staff to correct this problem. The administrator added once information is uploaded to PJB you can not go in and manually correct it, which they would have done once they noted the issue with some data not uploading. Review of timecards for the above dates was completed. All dates reviewed for lack of RN coverage were verified to have an RN on duty at least 8 hours per day. Review of above dates for licensed staff 24 hours per day were verified to have licensed staff 24 hours per day on site. Schedules and time cards were verified and accurate. A request for a facility policy for payroll based journal was requested and not received.

Based on interview and document review, the facility failed to implement a process for antibiotic review in order to determine appropriate indications, dosage, duration, trends of antibiotic use and resistance. This had the potential to affect any residents who had infections requiring antibiotic use. Finding include: On 4/1/25 at 2:16 p.m., during an interview with registered nurse (RN)-E also identified as infection preventionist, stated she tracked and documented infections and antibiotics use on a software program they started using in January 2025. Prior to this, the facility lost their electronic tracking system in June 2024 and she was not documenting on a tracking form, just notes jotted down. Upon request, to review the previous year data, RN-E indicated she could attempt to get the notes, but it likely wouldn't make sense. Review of monthly antibiotic use data available for January 2025 to March 31, 2025 included: if acquired in house or present on admission, resident, unit/room number, infection onset date, type of infection, infection site, organism, medication, provider, isolation if used, outcome, and date infection resolved. Review of the data indicated 6 of 7 urinary tract infections (UTI) treated with antibiotics did not include culture results and analysis of antibiotic treatment. In addition to the 6 UTI infections, one infection was listed as bacterial cystitis and one infection with diagnosis as unknown. These 2 infections were also treated with antibiotics and did not include culture results and analysis of antibiotic treatment. On 4/1/25 at 2:20 p.m., during interview, RN-E stated they have trouble getting cultures completed or results reported when patients go to the emergency department (ED). RN-E stated they are working with the local ED about other issues, but have not discussed the lack of cultures being completed on urine specimens, wounds and other infections being treated with antibiotics. RN-E stated she has not discussed this issue at quality assurance and improvement meetings at this time and stated she didn't have a lot of communication with the previous medical director. RN-E confirmed they do not know if the resident is placed on the correct antibiotic since no cultures are being completed. RN-E also confirmed they are not tracking overall infection rates or catheter associated urinary tract infections. RN-E confirmed antibiotic time outs are not occurring at this time. On 4/2/25 at 10:11 a.m., the director of nursing (DON) stated they are having issues with cultures on urines and other specimens being completed and confirmed it is rare when they actually get a culture completed. The DON confirmed continued issues with the local ED department but the facility has not addressed the lack of cultures at this time. The DON stated she would expect the antibiotic stewardship program to follow the policy and procedure which includes time outs for antibiotic use. Facility Antibiotic Stewardship policy dated 2/14/25, included: -The facility will maintain an antibiotic stewardship program with the mission of promoting the appropriate use of antibiotics to treat infections and reduce possible adverse events associated with antibiotic use .This policy including procedure section will be reviewed yearly to ensure that all objectives and conditions are being met to streamline procedures and algorithms, and to identify opportunities for enhancement. - Antibiotic time out will be used at 72 hours after antibiotic initiation or first dose in the facility. Each resident will be reassessed for consideration of antibiotic need, duration, selection and de-escalation potential. At this time, laboratory testing results, response to therapy, resident condition and facility needs will be considered. Completion of an antibiotic time-out must be recorded in the resident record. -Microbiologic specimen submission guidelines to be completed per Loeb algorithm. -First-line treatment recommendations: Prescriber's will base treatment recommendations on the following factors: Likely UTI cite, culture and antibiotic sensitivity data, and patient specific factors including age, sex, prior antibiotic use, allergy history, current drug therapy, renal function and presence of urinary catheter. -What will be measure and tracked: Antibiotic starts, compliance and use of antibiotic time-outs, antibiotic use and days of therapy, record-keeping protocol compliance, use of antibiotic time-outs and compliance with urine culture specimen submission guidelines. -Antibiotic use data will be complied monthly and reviewed by the consulting pharmacist. Consulting pharmacist and the infection preventionist interpret the monthly data, define any necessary action steps and compile information for the monthly tracking report.

Based on observation, interview and document review the facility failed to ensure a comprehensive care plan was developed to include of post-traumatic stress disorder (PTSD) triggers and interventions for 1 of 1 resident (R25) who had a diagnosis of PTSD. R25's admission Minimum Data Set (MDS) assessment dated [DATE], indicated moderately impaired cognition, feeling down, depressed or hopeless nearly every day, dependent on staff for personal hygiene, dressing, toileting, utilized a walker and wheelchair, diagnoses included psychotic disorder and post-traumatic stress disorder (PTSD), and antipsychotics were received on a routine basis. R25's care plan dated 2/28/25, indicated medications daily for PTSD, psychosis, monitor/record occurrence of target behaviors: worried expression, verbalization of worries. monitor/record target behaviors: restlessness, wandering, pacing, exit seeking, unable to sit still to rest, administer psychotropic medications as ordered by physician, monitor for side effects and effectiveness every shift, monitor/document/report as needed any adverse reactions of psychotropic medications: unsteady gait, tardive dyskinesia, (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideation, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person, consult with pharmacy, medical doctor (MD) to consider dosage reduction when clinically appropriate at least quarterly, discuss with MD, family ongoing need for use of medication, review behaviors/interventions and alternate therapies attempted and their effectiveness. R25's annual Care Area Assessment (CAA) dated 2/12/25, triggered for Psychosocial Well-Being R25's mood interview indicates the presence of little interest or pleasure in doing things, when assessed, the resident was asked if he had little interest in doing anything, and he stated yes for 2-6 days, has been feeling down for 12-14 days due to everything happening to him, trouble falling asleep at night for 2-6 days and feeling tired for 2-6 days due to being unable to sleep at night, history of delusional disorders and unspecified psychosis. R25's Psychosocial assessment dated [DATE], indicted sometimes traumatic events in a person's life can have an effect on how we heal from illnesses or react to certain situations now, would you like to discuss interventions that may help address these concerns, response indicated no. On 3/31/25 at 1:58 p.m., R25 stated he had PTSD and some things that triggered his PTSD were flashbacks of his mom getting beat up, staff that were not patient, when staff made him wait a long time for help, voices and loud noises across the hall at night. On 3/31/25 at 7:01 p.m., registered nurse (RN)-B stated R25 had brain trauma and was not sure if R25 had a diagnosis of PTSD. On 3/31/25 at 7:04 p.m., R25 was laying in bed and stated he mainly stays in his room all day and will leave his room to go to therapy appointments, does not like to participate in group activities. R25 further stated I am in this hole all day long, and I wish people would come and talk and visit. R25 stated there is a list of activities to do, but I don't want to do those. R25 stated nobody comes to visit with me unless they are checking my catheter bag and stated wished people that worked here would come visit with me and not ignore me, because I feel like I am just staring and talking to a wall all day. On 4/1/25 at 9:18 a.m., RN-A, known as the nurse manager, stated R25's PTSD triggers were expected on his care plan. RN-A stated R25's care plan discussed PTSD medications and side effects of medications, and confirmed R25's care plan lacked the PTSD triggers and interventions. RN-A stated she completed residents' assessments, and stated the director of nursing was responsible for updating the care plans. On 4/1/25 at 9:59 a.m., social services (SS)-A stated the MDS coordinator was responsible for updating the care plans. On 4/1/25 at 11:51 a.m., SS-A stated she visited and with R25 and will use the trauma assessment for triggers and interventions on R25's care plan related to PTSD. On 4/1/25 at 12:40 p.m., the director of nursing (DON) stated the admission nurse was responsible for completing the care plan at the time of resident's admission. Facility Care Plans, Comprehensive Person-Centered policy dated 3/11/20, indicated: The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment The comprehensive, person-centered care plan will: Include measurable objectives and timeframe's; Describe the services that are to be furnished to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being; Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; Describe any specialized services to be provided as a result of PASARR recommendations; Include the resident ' s stated goals upon admission and desired outcomes; Include the resident ' s stated preference and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such a desire; Incorporate identified problem areas; Incorporate risk factors associated with identified problems Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. No single discipline can manage an approach in isolation. The resident ' s physician (or primary healthcare provider) is integral to this process. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident ' s problem areas and their causes, and relevant clinical decision making. When possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms or triggers. Care planning individual symptoms in isolation may have little, if any, benefit for the resident. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). Assessments of residents are ongoing and care plans are revised as information about the residents and the residents ' conditions change. The Interdisciplinary Team must review and update the care plan: When there has been a significant change in the resident ' s condition; When the desired outcome is not met; When the resident has been readmitted to the facility from a hospital stay; and At least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observation, interview and document review, the facility failed to ensure physician orders were followed for pressure ulcer (PU) wound care for 1 of 1 resident (R2) reviewed for pressure ulcers. Findings include: R2's facesheet printed on 4/3/25, included diagnoses of palliative care, Alzheimer's disease, and pressure ulcer sacral region. R2's annual Minimum Data Set (MDS) assessment dated [DATE], indicated severe cognitive impairment, dependency on staff for all activities of daily living, and two unstageable pressure ulcers. R2's care area assessment (CAA) dated 2/25/25, triggered secondary to actual pressure ulcers. Contributing factors included mobility impairment, actual pressure ulcers, cognitive loss, incontinence, and pain. Risk factors included pain, wound infection, and fluid deficit risk. R2's physician orders dated 3/31/25, included: --LEFT HIP: cleanse pressure injury with wound cleanser. Pat dry. Open and sprinkle Flagyl (an antibiotic) 375 mg (milligrams) capsule to wound base with dressing change. Pack with moistened packing strip. Apply foam border dressing to cover. Change daily and prn, every night shift for wound care (possible wound infection) AND as needed for wound care. --COCCYX: cleanse wound with wound cleanser. Open and sprinkle 1 Flagyl 375 mg capsule on wound bed. Pack with moistened packing strip. Apply foam border dressing to cover. Change daily and PRN if soiled every night shift for Wound Care AND as needed for Wound Care R2's care plan with revised date of 6/8/23, indicated R2 was at risk for pressure ulcer formation related to her bowel/bladder incontinence, low weight/bony prominence's, and decreased mobility. Care plan intervention dated 3/31/22, indicated staff would provide treatments as ordered for sacrum and right hip. During an observation on 4/2/25 at 1:09 p.m., with licensed practice nurse (LPN)-A, viewed R2's pressure wounds to her sacrum and left hip. LPN-A stated dressing changes were done daily on the night shift. LPN-A removed the foam dressing from the left hip, had a scant amount of serosanguinous drainage on it and measured 8.0 centimeters (cm) x 5.5 cm. LPN-A reapplied a foam dressing to the wound. LPN-A removed the dressing from the sacral PU, and it had a moderate amount of serosanguinous drainage on it and measured 3.0 cm x 3.5 cm, no redness or bone visible. LPN-A reapplied a foam dressing to the wound. During record review after observing the wounds and dressing changes, noted the physician order indicated both wounds were to be packed with saline moistened packing strips. When LPN-A removed the dressing that had been applied by the night shift nurse, there were no packing strips observed either in or on the wounds or on the dressings she removed, nor did LPN-A place moistened packing strips in the wounds as ordered by the physician when she replaced the dressings. During an interview on 4/2/25 at 2:02 p.m., registered nurse (RN-A) who was also the nurse manager stated she was not aware of the order to pack R2's wounds with moistened packing strips, stating she would need to look at the order. After reviewing the order, RN-A verified the ordered included packing strips to both wounds. Together with RN-A, went to R2's room to see if there were packing strips and saline available and there was, but no disposable sterile tweezers to use to pack the wounds. RN-A stated that would be necessary to pack the wounds. RN-A admitted she did not oversee wound care orders, observe wounds or dressing changes -- only if asked to by nursing staff. During an interview on 4/2/25 at 2:10 p.m., RN-C who was R2's hospice nurse stated hospice was in charge of wound management for R2. RN-C stated the order for wound care with saline moistened packing strips was not a new order, but it had been modified several times. Looking at previous hospice orders, RN-C stated the wound orders for hip and sacrum, including packing both wounds with moistened packing strips started on 1/31/25. During an interview on 4/2/25 at 2:27 p.m., the director of nursing (DON) joined the conversation with RN-A and RN-C and stated the process of informing nurses of new orders depended on the time of the day and whether the HUC (health unit coordinator) or a nurse entered the provider orders into the EMR. In any case, the DON stated the orders were on the TAR (treatment administration record) and nurses were expected to review them before going into a residents room. The DON stated the nurse who changed the dressing on the night shift and who did not follow physician orders for packing the wounds with saline moistened packing strips, was RN-D. The DON stated she would contact her about it. During a telephone interview on 4/2/25 at 2:34 p.m., with LPN-A, and with the DON and RN-A present, LPN-A admitted she forgot to use the packing strips to pack R2's wounds when she changed the dressing with the surveyor observing. LPN-A stated before she ended her shift, she changed the dressings and packed the wounds. In addition, LPN-A stated when she changed the dressing, she sprinkled the Flagyl on top of the packing strip, to which RN-A stated, the order was for the Flagyl to be sprinkled on the wound bed (not on top of the packing strips). During an interview on 4/2/25 at 3:07 p.m., the DON stated she called and left a message for RN-D who changed the dressing on the night shift on 4/2/25. In addition, the DON stated she had been planning to ask hospice to provide wound management training and would now get it scheduled. In a follow-up via email on 4/3/25 at 2:37 p.m., RN-D confirmed to the DON she had changed R2's dressing during the night on 4/2/25, and did not read R2's wound care orders carefully, and therefore did not pack the wounds with moistened packing strips as ordered by the physician. Facility Dressing Change/General Wound Care policy with review date of 4/2025, indicated all dressing changes would be performed by licensed nursing staff in accordance with provider orders, evidence-based practice, infection control protocols, and resident specific care plans. All dressing changes would be documented in the residents medical record. Steps included: Verify orders by checking the most current provider order for dressing change frequency, type of dressing, and any special instructions.

Based on observation, interview and document review, the facility failed to provide services to maintain and prevent loss of range of motion (ROM) for 1 of 2 residents (R7) reviewed for limited ROM. Findings include: R7's facesheet printed on 4/3/25, included diagnoses of multiple sclerosis (MS), osteoporosis, diabetes and heart disease. R7's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R7 was cognitively intact, had clear speech, could understand and be understood. R7 was dependent upon staff for most ADL's and did not walk. The MDS did not indicate that R7 was in a restorative nursing program. R7's orders dated 5/9/23, indicated PT evaluation. R7's care plan dated 8/4/21, indicated R7 had an alteration in musculoskeletal status related to history of MS, would remain free of complications or discomfort related to MS, and would have range of motion (active or passive) with am/pm (morning and evening) care daily. R7's care plan dated 11/24/21, indicated R7 had limited physical mobility related to MS with referrals to PT and OT, and to monitor/document/report PRN (as needed) any signs and symptoms of contractures forming. During an interview on 3/31/25 at 1:12 p.m., R7, who was sitting in her electric wheelchair stated she was not able to walk or move her legs, and stated she did not receive passive ROM to them. R7 stated leg exercises had only been done when she was in rehabilitation therapy and was no longer in therapy. R7 stated she would like leg exercises to keep her joints limber, adding .but I know the nurses are busy. During an interview on 4/1/25 at 11:51 a.m., physical therapy aide (PTA)-G, provided a paper document titled Therapies Restorative Care Program. The document indicated R7 had started active PT on 9/3/24, and was discharged from therapy on 10/21/24, with the following restorative nursing recommendations: --Leg lifts 10 reps (repetitions), R LE PROM (right lower extremity passive range of motion) --Kick outs, 10 reps, L LE AAROM to AROM with gentle knee stretch (left lower extremity active, assisted range of motion to active range of motion) --R ankle PROM (right ankle passive range of motion) --L LE AROM (left lower extremity active range of motion) During an interview on 4/1/25 at 11:58 a.m., PTA-G stated she had filled out the Therapies Restorative Care Program form for R7 after R7 had completed physical therapy. PTA-G stated the intent of the form was for nursing to continue the recommendations after R7 was discharged from therapy. PTA-G stated the form was given to the health unit coordinator (HUC)-D and a copy was placed in the restorative nursing binder on the nursing unit. PTA-G stated she also demonstrated to nurses and nursing assistants how to do the exercises since R7 could not do them on her own. PTA-G stated she could not recall if the document was given to the HUC or placed in the binder for sure, but that was their process. PTA-G could not recall which nurse and/or NA she demonstrated the exercises for R7. The Therapies Restorative Care Program form did not indicate who the form was routed to or when. During review of the restorative nursing binder, located at the nurses station, the binder was titled, Occupational and Physical Therapy Resident Updates. The only document in the binder for R7 was not related to restorative nursing. During an interview on 4/1/25 at 2:28 p.m., nursing assistant (NA)-B stated R7 did not receive restorative nursing services. NA-B stated if a resident received restorative nursing services, it would be noted on the TASK list in the electronic medical record (EMR). Review of the TASK list in the EMR for R7 indicated: RESTORATIVE: T-Band pulleys 3x/week. There was nothing on R7's TASK list regarding restorative ROM to her legs. During an interview on 4/02/25 at 9:33 a.m., the director of nursing (DON) and registered nurse (RN)-A, were shown the Therapies Restorative Care Program form for R7, and both stated they had never seen the form before .specifically for R7. RN-A stated therapy would usually place these forms on her desk and then she would add it to the NA care sheets. The DON stated when this recommendation from therapy would have been received in September 2024, R7 would have been able to participate in the recommended ROM exercises. Both the DON and NA-A stated had they received the recommendations, they would have initiated them, but neither could recall receiving it. A restorative nursing policy was requested and not received. In an email follow-up on 4/3/24, the DON indicated they did not have a restorative nursing policy.

Based on observation, interview and document review the facility failed to assess and follow provider orders for removal of an indwelling urinary catheter as soon as possible to restore urinary continence for 1 of 1 resident (R25) reviewed for catheter care. Findings include R25's admission Minimum Data Set (MDS) assessment dated [DATE], indicated moderately impaired cognition, indwelling urinary catheter, dependent on staff for personal hygiene, dressing, toileting, utilized a walker and wheelchair, diagnoses included benign prostatic hyperplasia (enlarged prostate), psychotic disorder, post-traumatic stress disorder, retention of urine, and history of falling. The MDS indicated a toileting program (e.g., schedule toileting, prompted voiding, or bladder training) had not been attempted. R25's care plan dated 2/28/25, indicated R25 had a catheter d/t (due to) urinary retention, catheter care and treatment per current orders, monitor/record/report to MD (medical doctor) for s/sx (signs/symptoms) UTI (urinary tract infection): pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns, position catheter bag and tubing below the level of the bladder monitor and document intake and output as per facility policy. Urology office visit note dated 2/28/25, physician assistant (PA)-C recommend a void trial when due for catheter exchange, if R25 is not able to pass a voiding trial, should continue with his indwelling catheter including routine care and monthly exchanges, if R25 requires chronic catheter, should be seen in one year for follow-up, if catheter able to be removed, should return in three months for follow-up. R25's treatment administration record dated 3/1/25-3/31/25, indicated change Foley collection bag weekly and as needed every Saturday. R25's physician orders, care plan, and progress notes lacked evidence of an order for monthly catheter exchange or voiding trial, and R25's record lacked appropriateness of continued catheter use or justification of continued use. On 3/31/25 at 7:04 p.m., R25 was observed with urinary catheter bag attached to the bed rail. R25 stated he came to the facility with the catheter. R25 stated staff had not offered or attempted to remove the catheter since he was admitted to the facility. R25 stated he recently saw a doctor about the catheter and stated the doctor discussed the facility would attempt to remove the catheter. R25 stated removal of the catheter had not been attempted, and he wished the catheter was removed. On 3/31/25 at 7:09 p.m., registered nurse (RN)-B stated R25 was admitted with a urinary catheter and was not aware if a voiding trial had been attempted. RN-B stated she was not aware of any provider orders for urinary catheter removal and stated the nursing assistants take care of the catheter and stated she had never completed a catheter exchange for R25. On 4/1/25 at 8:39 a.m., the director of nursing (DON) stated when a resident returns from a provider appointment the health unit coordinator (HUC)-A was responsible to enter orders into the electronic medical record (EMR) the resident returned with from the provider visit. The DON stated if the resident did not return with hard copy orders, the HUC was responsible to obtain the orders from the provider or look into resident's provider's EMR from the provider visit. The HUC then was responsible to print the orders, enter the orders in the facilities EMR, and give the orders to RN-A (nurse manger) to double check the orders. On 4/1/25 at 9:18 a.m., RN-A, also known as the nurse manager, stated R25 saw urology last month, and confirmed the 2/28/25, urology provider note indicated a voiding trail attempt at the next catheter change. RN-A confirmed R25's orders failed to indicate a monthly catheter exchange or voiding trail was entered into R25's EMR. RN-A further confirmed R25 had not had a monthly catheter exchange since admitted to the facility on [DATE], and confirmed a voiding trail had not been attempted per the provider order on 2/28/25. RN-A stated she would not have known about the R25's voiding trial order or the catheter exchange order was missing if the state agency (SA) had not brought urology order to the attention of the facility. RN-A stated monthly exchanges of R25's catheter were expected and she assumed were done routinely by nursing staff. RN-A stated the process for entering orders included the HUC-A obtained the resident orders from the provider visit, entered the orders into the EMR, and the orders get placed in the nursing station for the floor nurse to double check the resident order, and the HUC was to verbally tell her (RN-A) of any new resident orders. RN-A stated she was not made aware of any new orders from R25's 2/28/25, urology visit. RN-A confirmed the voiding trial order and catheter exchange order was missed and not placed in the EMR as expected. RN-A confirmed R25 was expected to have had voiding trial ordered and completed. RN-A stated the current process for entering and confirming orders was not working. On 4/1/25 at 9:47 a.m., HUC-A stated her role was to ensure all forms of provider orders including, physical written forms and electronic visits were printed, entered in the resident's EMR, scanned to the EMR, placed into the nursing station for the nurse to double check the entered orders, and verbally make RN-A aware of new orders. HUC-A stated the orders were not initialed, dated or reviewed by the nurse prior to scanning the order into the EMR. HUC-A stated she was responsible to ensure R25's 2/28/25, urology orders were entered and confirmed R25's voiding trail or monthly catheter exchange was not entered into the EMR as expected. HUC-A stated the order for a catheter exchange was not double checked by a nurse since it was not a pharmaceutical order. HUC-A stated she was not sure if RN-A had been made verbally aware of the R25's new urology orders. On 4/1/25 at 12:40 p.m., the DON confirmed R25's 2/28/25, provider order for trial of catheter removal was expected entered the day or the next day after R25's appointment to be assessed as soon as possible for removal of the catheter to help restore continence. The DON confirmed R25's order for catheter trial removal was not entered into the EMR as expected and trial of the urinary catheter was not attempted as ordered by the provider. On 4/2/25 at 7:36 a.m. R25 was lying in bed and stated his catheter was removed last night and stated he was urinating with no problems or concerns. R25 further discussed having the catheter out was nice and he wished he could have had it [catheter] out sooner. Facility Indwelling Catheter Policy dated 1/25, indicated: 2. Change the drainage bag and connection tubing bimonthly. 3. Residents with chronic in-dwelling catheters should have Foley catheter replaced according to Physician's order. Documenting in Resident's chart: 1. Identification and documentation of clinical indications for the use of a catheter; as well as criteria for the discontinuance of the catheter when the indication for use is no longer present. 2. Documentation of the involvement of the resident/representative in the discussion of the risks and benefits of the use of a catheter, removal of the catheter when criteria or indication for use is no longer present, and the right to decline the use of the catheter. Facility Policy titled Electronic Health Record (EHR) Maintenance and Documentation Policy dated 3/25, indicated: All resident documents, including admission forms, assessments, progress notes, physician orders, laboratory results, provider visits, hospital visits and care plans, must be uploaded into the EHR promptly, if it is not otherwise charted in the EHR. Health unit coordinator is responsible for this. Health unit coordinator will obtain the necessary records from the visit and give them to the nurse manager to look over, initial, and date. The HUC will then upload necessary information into the EHR. Authorized personnel must ensure scanned or electronically uploaded documents are legible, properly indexed, and accurately linked to the correct resident record. The facility will utilize automated interfaces where possible to reduce manual data entry errors. Paper records, when necessary, must be scanned into the EHR within 24 hours of receipt. Staff must verify that uploaded documents have been successfully saved and associated with the correct resident profile. If the paper documents are provider or hospital visits or orders, they must be initialed and dated by nurse manager to show that we have seen them before scanning them in.

Based on interview and document review, the facility failed to assess trauma history and identify potential triggers for 1 of 1 resident (R25) who had a diagnosis of post-traumatic stress disorder (PTSD). Findings include: R25's admission Minimum Data Set (MDS) assessment dated [DATE], indicated moderately impaired cognition, feeling down, depressed or hopeless nearly every day, dependent on staff for personal hygiene, dressing, toileting, utilized a walker and wheelchair, diagnoses included psychotic disorder and post-traumatic stress disorder (PTSD), and antipsychotics were received on a routine basis. R25's care plan dated 2/28/25, indicated medications daily for PTSD, psychosis, monitor/record occurrence of target behaviors: worried expression, verbalization of worries. monitor/record target behaviors: restlessness, wandering, pacing, exit seeking, unable to sit still to rest, administer psychotropic medications as ordered by physician, monitor for side effects and effectiveness every shift, monitor/document/report as needed any adverse reactions of psychotropic medications: unsteady gait, tardive dyskinesia, (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideation, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person, consult with pharmacy, medical doctor (MD) to consider dosage reduction when clinically appropriate at least quarterly, discuss with MD, family ongoing need for use of medication, review behaviors/interventions and alternate therapies attempted and their effectiveness. R25's annual Care Area Assessment (CAA) dated 2/12/25, triggered for Psychosocial Well-Being R25's mood interview indicates the presence of little interest or pleasure in doing things, when assessed, the resident was asked if he had little interest in doing anything, and he stated yes for 2-6 days, has been feeling down for 12-14 days due to everything happening to him, trouble falling asleep at night for 2-6 days and feeling tired for 2-6 days due to being unable to sleep at night, history of delusional disorders and unspecified psychosis. R25's Psychosocial assessment dated [DATE], indicted sometimes traumatic events in a person's life can have an effect on how we heal from illnesses or react to certain situations now, would you like to discuss interventions that may help address these concerns, staff indicated that R25's response was no. On 3/31/25 at 1:58 p.m., R25 stated he had PTSD and some things that triggered his PTSD were flashbacks of his mom getting beat up, staff that were not patient, when staff made him wait a long time for help, voices and loud noises across the hall at night. On 3/31/25 at 6:55 p.m., nursing assistant (NA)-A stated R25 would become anxious and agitated when he talked about family and she would try to verbally diffuse the situation. On 3/31/25 at 7:01 p.m., registered nurse (RN)-B stated R25 had brain trauma and was not sure if R25 had a diagnosis of PTSD. On 3/31/25 at 7:04 p.m., R25 was laying in bed and stated he mainly stays in his room all day and will leave his room to go to therapy appointments, does not like to participate in group activities. R25 further stated I am in this hole all day long, and I wish people would come and talk and visit. R25 stated there is a list of activities to do, but I don't want to do those. R25 stated nobody comes to visit with me unless they are checking my catheter bag and stated wished people that worked here would come visit with me and not ignore me, because I feel like I am just staring and talking to a wall all day. On 4/1/25 at 9:18 a.m., RN-A, known as the nurse manager, stated R25's PTSD triggers were expected on his care plan. RN-A stated R25's care plan included PTSD medications and side effects of medications, and confirmed R25's care plan lacked the PTSD triggers and interventions. RN-A stated she completed residents' assessments, and stated the director of nursing was responsible for updating the care plans. RN-A stated the social services role is new to the facility and not sure if social services had assessed R25 for PTSD and triggers. RN-A stated R25 went to appointments outside of the facility for mental health. RN-A stated the provider notes were not returned or shared with the facility. RN-A stated the notes would be helpful in the care of R25's PTSD and trauma informed care. On 4/1/25 at 9:47 a.m., health unit coordinator (HUC)-D stated she made R25's mental health appointments and gave R25 paperwork to bring to the appointments. HUC-A stated R25 did not return with paperwork from the appointments, and she had not called to get information regarding the appointments. HUC-D stated she was responsible to ensure resident information was returned to the facility and was expected to call if notes were not received. HUC-A stated the notes would be important for nursing to review and care for R25. On 4/1/25 at 9:59 a.m., SS-A stated she was responsible for the residents trauma assessments. SS-A stated prior to the end of February 2025, she was not aware if trauma assessments were completed. SS-A confirmed R25 did not have a trauma assessment completed upon admission and confirmed R25 had a PTSD diagnosis. SS-A stated she had not heard that R25 had any concerns with behavior or mood, and stated she would expect nursing to make her aware of behavioral concerns, and if concerns then she would go talk with R25. SS-A stated the MDS coordinator was responsible for updating the care plans. On 4/1/25 at 11:26 a.m., during a follow up interview R25 was in his room lying in bed and stated he went to a therapist and a therapist came to talk to him once a week. R25 stated the social worker at the facility had not been in to talk to him. R25 stated it would be nice if someone who worked at the facility came in and talked to me about my feelings and had conversation with me about how I am doing. On 4/1/25 at 11:33 a.m., the activities director (AD)-A stated R25 does not want to do group activities, and does physical therapy, radio, and television. AD-A stated she occasionally goes and visits with R25, however could not remember when she last visited with him and had no documentation of one on one visits with R25. On 4/1/25 at 11:51 a.m., SS-A stated she visited and with R25 today and he expressed he was glad to talk to her. SS-A stated she completed the trauma checklist that had not been done and will use the trauma assessment for triggers and interventions on R25's care plan related to PTSD. On 4/1/25 at 12:40 p.m., the director of nursing (DON) stated a trauma assessment was expected to be completed upon admission. The DON stated she was unaware who was responsible for resident's trauma assessments. The DON stated she was not aware of R25 having a PTSD diagnosis, and stated the admission nurse was responsible for completing the care plan at the time of resident's admission, and the DON updated care plans when needed. The DON stated social services was expected to round with residents and discuss any concerns. The DON stated trauma assessments were important to identify any potential triggers and guide resident care. Facility Trauma Informed policy dated 8/15/24, indicated: Purpose: To guide staff in appropriate and compassionate care specific to individuals who have experienced trauma. Nursing staff are trained on screening tools, trauma assessment and how to identify triggers associated with re-traumatization. Develop an organizational culture that supports trauma-informed care. Include trauma-informed care as part of the QAPI plan, so that needs and problem areas are identified and addressed. As part of the comprehensive assessment, identify history of trauma or interpersonal violence when possible. Identifying past trauma or adverse experiences may involve record review or the use of screening tools. Utilize trained and qualified staff members who have established a rapport with the resident to assess him or her for previous trauma. Interact with all residents and visitors in a manner that is welcoming and kind, without being intrusive. Reduce or eliminate unnecessary stimuli (noise, lighting, unwanted or sudden physical contact, etc.).

Based on interview and document review, the facility failed to properly insert an indwelling urinary catheter and failed to assess and monitor for complications following insertion for 1 of 3 (R1) residents reviewed for catheters. This resulted in harm for R1 when the catheter balloon was improperly inflated in the urethra causing perforation within urethra, hospitalization for hematuria (blood in urine), and a urinary tract infection. The facility implemented immediate corrective action, so the deficient practice was issued at past non-compliance. Findings include: R1's face sheet dated 2/21/25, identified retention of urine, diabetes mellitus, and chronic kidney disease. R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 was admitted on [DATE], had an indwelling catheter, and diagnosis of retention of urine. R1's care plan focus dated 12/3/24, identified R1 had a catheter due to benign prostatic hyperplasia (BPH). Care plan goal was resident will be/remain free from catheter-related trauma with interventions. Interventions for catheter included: care and treatment per current orders; position catheter and tubing below the level of the bladder; and monitor/record/report to MD for signs and symptoms of urinary tract infection. R1's physician orders dated 12/28/24, identified order for catheter exchange: 16F (French) and 10 milliliters (ml) balloon. Exchange monthly and as needed. Review of facility's Standing Orders for Skilled Nursing Facilities dated 10/17/23, identified under care of indwelling catheter: -Do not irrigate. -Change catheter as needed for leaking or decreased urinary output using similar-sized catheter. -Change catheter and tubing prior to obtaining sample for urinalysis/urine culture. -May attach leg bag when patient is out of bed; reattach to straight drainage when in bed. R1's progress note dated 1/24/25 at 5:26 p.m., indicated R1's catheter was flushed with 60 cubic centimeters (cc) of normal saline with good return and color was yellow and clear. R1 had been having issues with the catheter leaking around the urethra. Nurse to call this evening and see if we can change it to a larger sized and a bigger balloon. R1's record did not identify a catheter assessment for placement and did not include a physician order to flush R1's catheter. R1's progress note dated 1/24/25 at 9:53 p.m., identified R1 was complaining of urine leaking out of his catheter. Director of nursing (DON) asked nurse to contact on call doctor tonight. Order received for 18fr catheter. Nurse passed this message along to next shift nurse as well. R1's outside medical record dated 1/24/25 at 9:28 p.m., identified nursing home called due to R1 had chronic leakage to size 16cc catheter and physician advised to try size eighteen. Facility's electronic health record (EHR) did not identify this physician order. R1's progress note dated 1/25/25 at 5:50 a.m., included this nurse was told by p.m. nurse ok to place 18fr indwelling catheter due to leaking. A 18fr placed at 4:30 a.m., with no return at this time. The note further indicated although there was no physician order to flush the catheter, R1's Catheter flushed for patency. The progress note did not identify if catheter placement was checked, did not address how R1 tolerated the catheterization procedure, and did not identify what the catheter was flushed with and how much. R1's progress note dated 1/25/25 at 1:35 p.m., identified R1 had 400cc of straight bright red blood noted in catheter bag after having catheter changed at 5:00 a.m., and had been experiencing pain. The progress note also included Report stated that after she placed the catheter, did not get any return and we were to watch him closely. Around 9:00 a.m., there was 200 cc of urine with a few clots and pink tinge to it. R1 was sent to emergency department (ED) at 1:30 p.m. due to the frank blood and pain. R1 was also on Eliquis (blood thinning medication) R1's record dated 1/25/25 was reviewed between 5:50 a.m. and 1:35 p.m. identified although the progress note at 1:35 p.m. indicated R1 had been experiencing pain as a result of the catheterization, there was no indication of completed assessments and ongoing monitoring of urinary output/catheter placement/patency, and R1's pain. R1's emergency department (ED) note dated 1/25/25, indicated since R1 had a urinary catheter change with a larger size catheter, there has been blood in the urine collection bag. Additionally R1 had discomfort in lower abdomen and the tip of penis. Patient stated underwent catheter placement with a larger catheter and stated procedure was very painful and feels like he needs to urinate but was unable to do so. On physical exam noted purulence (the state of containing or forming pus) present at the urethral meatus (external opening of the penis) with blood collecting through the urinary catheter and collection bag. An ultrasound of the bladder at bedside showed 600cc in the urinary bladder with no evidence of rupture (normal bladders can hold 400-600 cc's; urge to urinate usually starts when the bladder contains around 200 to 300 cc). Significant leukocytosis (elevated white blood cells) noted at 23,000 (normal for male is 5,000 to 11,000). A computed tomography (CT) scan of abdomen and pelvis revealed the catheter balloon inflated within the penile urethra. Urology consulted and reported R1 sustained perforation within the urethra and had staff placed a curved coude catheter and recommended admission to hospital due to concerns for urosepsis (severe and life-threatening infection that occurs when a urinary tract infection spreads to the bloodstream). R1's outside medical record discharge summary dated 1/28/25, identified R1 was hospitalized [DATE] to 1/28/25 for a displaced chronic foley catheter leading to hematuria (blood in urine) and urinary tract infection. R1 was placed on intravenous antibiotics and switched to oral antibiotics due to E.Coli seen in the urine cultures. R1's outside medical record dated 2/10/25, identified R1 was seen by urology for hematuria. Recently during catheter replacement the catheter balloon was inflated within the urethra that caused significant hematuria. Recommended continuation of the catheter due to history of retention to protect his kidneys. During an interview on 2/20/25 at 10:10 a.m., family member (FM)-A stated on 1/25/25 she had met R1 in the ED and R1 had reported to her that when the nurse inserted the catheter that morning it had been very painful. During an interview on 2/20/25 at 9:50 a.m., LPN-A stated she had worked the overnight shift 1/24/25 into 1/25/25. LPN-A explained she was told by the nurse before her that an order for 18fr was to be placed. Around 4:30 a.m., LPN-A placed the 18 fr catheter and did not get any urine return. Around 5:50 a.m., LPN-A flushed the catheter, it was patent, and R1 did not complain of pain with insertion or after the insertion. LPN-A indicated she did not check placement and there was not an order to flush the catheter. During an interview on 2/20/25 at 11:19 a.m., nursing assistant (NA)-B stated on the day of 1/25/25, R1 was complaining of pain from his catheter and he was not very good. That morning, R1 had told NA-B, I would have rather been dead when she [LPN-A] put the thing in me. NA-B explained she had not been informed there had not been any urine return after R1's catheter insertion and had not been directed to monitor his output. NA-B indicated had she been made aware there had been no urine output when the catheter was inserted that morning, she would have watched him more closely that day. During an interview on 2/20/25 at 12:14 p.m., trained medication aide (TMA)-A worked the day shift on 1/25/25 and was told by LPN-A that when R1's catheter was changed earlier there was no urine return and staff were to watch him closely. Around 7:30 a.m., TMA-A observed what appeared to be 200 cc's urine in the tubing with blood clots. TMA-A replaced the overnight collection bag with the leg bag at which time R1 had complained of pain on the tip of his penis. TMA-A notified registered nurse (RN)-C that R1 was having output. TMA-A could not differentiate if the fluid in the collection bag was urine or fluid that was used for flushing the catheter. TMA-A stated RN-C looked at R1 after she had notified her, but did not recall if she had assessed him. TMA-A explained R1 had not complained of any further pain and she had not check the collection bag until around 1:30 p.m. when a nursing assistant informed her of bright red blood in the bag. TMA-A called RN-C over the walkie talkie to come and evaluate R1. RN-C called the ambulance to take R1 in for evaluation. R1 was complaining of pain when the emergency management service (EMS) came. During a follow up interview at 4 p.m., TMA-A stated it could have been the flush she observed in the tubing and not urine. TMA-A stated she did a set of vitals before R1 left, but did not enter them into the chart and was unsure if RN-C performed any assessment before the ambulance arrived. During an interview on 2/20/25 at 4:45 pm., RN-C stated in report on 1/25/25 she was told by LPN-A that an 18fr catheter had been placed in R1 earlier that morning with no urine return so the catheter was flushed and R1 was to be monitored. RN-C stated she did observe him around 7:00 a.m.-8:00 a.m., after being told by TMA-A he had blood clots in the tubing. R1 had been lying in bed and did not complain of any discomfort. RN-C stated she did not do a comprehensive assessment on R1, or bladder scan him. During an interview on 2/20/25 at 2:30 p.m., RN-B reviewed R1's records dated 1/25/25 and verified there was no order transcribed for the 18fr catheter, no order to flush the catheter, and no documentation of monitoring the catheter or pain after the catheter was inserted. RN-B indicated the order for the catheter should have been in R1's record, flushes required a physician order, the catheter should have been monitored for patency, and R1's pain should have been monitored. During an interview on 2/20/25 at 1:05 p.m., director of nursing (DON) stated R1 had been having trouble with his catheter leaking prior to the catheter change on 1/25/25. On 1/24/25, R1 had requested to be sent to the ER to be evaluated for his leaking catheter, but she talked with him, and he agreed to try a larger size. DON stated she flushed R1's foley catheter with 60cc of normal saline and instructed the evening shift nurse to call the on-call provider to get an order for a larger catheter. DON interviewed LPN-A on 1/27/25, LPN-A had reported she was unaware she should not have blown up the foley balloon until she got urine return and was unaware of how far to insert a male catheter. DON stated LPN-A did not have any foley insertion competencies prior to her inserting the catheter for R1. DON reviewed R1's record and identified the record did not include assessment. During an interview on 2/21/25 at 9:28 a.m., certified nurse practitioner (CNP) stated if a nurse puts a catheter in a resident and does not get urine return, they should not blow up the balloon. They should have repositioned the catheter, bladder scanned to see if urine in the bladder, took that catheter out and tried a different catheter. During an interview on 2/21/25 at 11:51 a.m., medical director (MD) stated after a catheter is inserted in the bladder and no urine return after insertion the catheter should either repositioned, removed, perform a bladder scan, and should not inflate the bulb until get that urine return. MD stated the facility should have monitored R1 closely and performed bladder scans due to no urine return after insertion. The following corrective actions were verified as implemented prior to the survey: -Beginning 2/3/25 the facility updated the procedure procedure for male and female foley catheter insertion which included. Additionally the facility implemented an on-call nurse to trouble shoot any catheter related problems if they arise. -Beginning on 2/3/25, staff were informed of the policy and on 2/14/25 staff development coordinator completed competency evaluations with licensed staff for all scheduled foley catheter changes and will continue until all licensed staff have shown competency. -Sampled resident records were reviewed from 1/1/25 to 2/21/25 did not identify deficient practices pertaining to catheter management. Review of the facility's Indwelling Catheter Policy dated 1/2025, identified the resident has the right to timely and appropriate assessments of the catheter by nursing staff as ordered and as needed and to maintain care of indwelling catheters in collaboration with the medical director, director of nursing, and current professional standards of practice. Review of the facility's Foley Catheterization Insertion/male procedure dated 2/3/25, identified staff to insert catheter 5-7 inches until resistance met, wait 2-3 seconds and advance catheter for about two inches and drain bladder. If you do not have urine output, slowly advance until urine output is obtained. Once obtained, insert another two inches. Inflate balloon slowly with ordered amount. If resident complains of any pain or pressure when inflating the balloon, stop, deflate the balloon, and advance the catheter another inch. Inflate balloon slowly.

Based on interview and document review, the facility failed to follow the Provider Orders for Life Sustaining Treatment (POLST), did not initiate cardiopulmonary resuscitation (CPR) as per the residents wishes for CPR for 1 of 3 resident (R)7 resident reviewed for CPR status. R7 was found without a pulse or respirations and staff did not initiate CPR and R7 expired. This resulted in an Immediate Jeopardy (IJ) for R7. The IJ began on [DATE], at 4:40 a.m. when licensed practical nurse (LPN)-A failed to follow the POLST and did not initiate CPR as per R7's wishes. The administrator and director of nursing (DON) were notified of the IJ on [DATE], at 4:05 p.m. The facility implemented corrective action and the IJ was removed on [DATE], at 4:20 p.m. but non-compliance remained at scope and severity of D, isolated which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R7's five-day Minimum Data Set (MDS) dated [DATE], identified R7 was admitted to the facility on [DATE], was not cognitively impaired, had clear speech, was able to understand others and make herself understood by others. In addition, R7 did not have signs/symptoms of [CONDITION(S)]. R7's POLST dated [DATE], directed in the event of cardiopulmonary arrest, staff would attempt resuscitation and begin CPR. R7's POLST was signed by certified nurse practitioner on [DATE]. During an interview on [DATE], at 1:58 p.m. LPN-A stated nursing assistant (NA)-A assisted R7 to the commode around midnight and was on every two-hour resident safety checks. NA-A observed R7 sleeping at 2:00 a.m. and LPN-A explained at approximately 4:30 a.m. NA-A called on the walkie-talkie and requested help in R7's room. Upon arrival to R7's room NA-A indicated R7 was not breathing. LPN-A stated she assessed for a pulse and respirations and finding none, she left NA-A with R7 and went to get her stethoscope. Upon return, LPN-A listened for an apical pulse and stated R7 had passed away. LPN-A stated she did not know the code status for R7, so she went to the nurse's station a second time to access R7's PointClickCare (PCC) electronic medical record. When LPN-A discovered R7 was full code, she elected to not start CPR because R7 had already passed away. LPN-A obtained a (resident) Death responsibility check list and attempted to call the director of nursing (DON) and the unit nurse manager. She was unable to contact either one of the nursing leaders, so she called 911 and requested a police officer and county coroner but not an ambulance because R7 had already passed away. LPN-A reiterated she did not perform CPR and it was her fault. During an interview on [DATE], at 12:45 p.m. NA-A stated he was making his every two-hour resident safety check and while conducting his observation of R7 at approximately 4:30 a.m. it appeared she was not breathing. Upon touching R7 she felt warm and immediately called the nurse (LPN-A) for assistance. When LPN-A arrived in R7's room, she attempted to find a pulse and was unsuccessful and observed R7 was not breathing. NA-A stated he asked LPN-A if R7 was DNR or full code and LPN-A stated she did not know. LPN-A quickly left R7's room returned with her stethoscope and listened to R7's chest. LPN-A indicated R7 had passed away. NA-A asked if they should start CPR and LPN-A indicated it was too late. During an interview on [DATE], 4:30 p.m. registered nurse (RN)-B stated during end of shift hand-off, LPN-A stated R7 passed away earlier that morning. LPN-A further stated to RN-B R7 was full code but she did not start CPR because she was not going to put R7 through that. She had already passed away. During an interview on [DATE], at 1:05 p.m. director of nursing (DON) stated she was notified of R7's passing at approximately 6:00 a.m. on [DATE]. DON indicated LPN-A had reported to her she had not known R7's code status until she checked PCC, and did not initiate CPR or request an ambulance because R7 was already dead. During a follow-up interview on [DATE], at 11:33 a.m. DON stated during her first interview with LPN-A, LPN-A stated it was too late to start CPR because R7's eyes were fixed and dilated and her lips were blue. LPN-A further stated that R7 was still warm and did not have signs irreversible death. She knew she should have started CPR and takes full responsibility for her lack of action. DON explained her expectation that staff would follow the POLST and start CPR if that is the resident's wishes. LPN-A should have started CPR. The facility policy, Emergency Procedure - Cardiopulmonary Resuscitation, last revised ,d+[DATE], referencing the AHA Guidelines for CPR and Emergency Cardiovascular Care, directed if a resident is found unresponsive and not breathing normally, a staff member certified in CPR/BLS shall initiate CPR. The IJ that began on [DATE], was removed on [DATE], at 4:20 p.m. after the facility-initiated training for all staff on their responsibilities, per American Heart Association guidelines, of how to respond to a resident in suspected cardiac and/or respiratory arrest. Additionally, training included training on the updated Emergency Procedure - Cardiopulmonary Resuscitation policy which directed staff to initiate CPR immediately when there was an unwitnessed arrest or when code status was unknown until EMS arrives or when code status of DNR could be confirmed. Facility staff training that were on duty included CNA's, trained medication assistant, LPN, and RN's, were interviewed to ensure all staff were knowledgeable of their responsibilities and changes to the CPR policy.

Based on observation, interview, and document review, the facility failed to complete comprehensive safe transfer assessments for 9 of 9 residents (R1, R2, R3, R4, R5, R6, R7, R8, and R9), ensure the appropriate sling size was used for safe transfer for 4 of 9 residents (R1, R6, R5, and R8), develop a consistent system for repair of mechanical lifts, and failed to assess staff competency to ensure safe transfers via full body mechanical lifts. The facility's failures resulted in actual falls with injury for 2 of 9 residents (R1, R6) and immediate jeopardy (IJ) situation for (R1). The immediate jeopardy began on 12/31/21, when R1 had a fall from the mechanical lift that resulted in a head strike and a hospital transfer after staff involved in the mechanical lift transfer did not follow manufacturer's recommendations for safe transfers and the facility failed to assess staff were competent to use equipment safely. The administrator and director of nursing were notified of the immediate jeopardy at 12:00 p.m. on 1/7/22. The immediate jeopardy was removed on 1/10/22, but non-compliance remained at scope and severity of E scope and severity level pattern which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1 R1's care plan for transfers dated 7/12/21, included, The resident requires A2 [assist of 2] Hoyer transfers. and did not identify the size of sling appropriate for R1. The care plan for transfer revised on 1/5/22 included, The resident requires A2 [assist of two] Hoyer transfers. Ensure proper sized sling is used, proper placement of sling straps and that Hoyer is functioning properly. The care plan did not identify the size of the sling. R1's care plan revised on 1/6/22, included the aforementioned however, directed staff to use a small sling. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified that R1 had diagnoses that included dementia and R1's cognition was severely impaired. The MDS indicated R1 did not have verbal, physical, and rejection of care behaviors. The MDS also indicated R1 required assistance of two or more staff for transfers. R1's progress note dated 12/31/21, at 5:50 p.m. included, Nurse called to residents' room at 3:10 p.m. by aide, and found resident lying in bed on her back with blood area under her head. She was awake. Aide stated she fell and hit her head on the right hoyer base. Nurse lifted head slightly to see swollen area to back center of head and a dark red spot about 4 inches wide with lighter color surrounding it. Nurse left to call 911 about 3:15 p.m. The note indicated R1 was transferred to the hospital around 3:45 p.m. and the nurse was informed by emergency room nurse that R1 would be discharged back to the facility with no stitches needed. A subsequent progress note at 8:51 p.m. indicated R1 had returned to the facility at 8:45 p.m Facility reported incident dated 12/31/21 at 4:27 p.m. indicated at 3:25 p.m. on 12/31/21, two staff were assisting R1 using a Hoyer (full body mechanical lift) to transfer R1 to the shower chair when the upper left side of the transfer sling slipped from Hoyer and R1 fell towards the ground hitting her head on the leg of the Hoyer. R1 was transferred to the hospital for further evaluation; R1 sustained a bump to the back of her head with a laceration. R1's record lacked evidence of a comprehensive assessment for sling size in accordance with manufacturer's recommendations for safe transfers. During the entrance conference on 1/6/22, at 9:15 a.m. with the director of nursing (DON) and administrator the DON provided a recapitulation of R1's fall from the lift and the facility's investigation and interventions to date. DON stated she immediately received the call from the nurse and immediately began her investigation. DON indicated based on interviews, R1 was being lifted off the bed, the sling started swaying, R1 leaned to the left, R1's upper body then rolled out of the sling which caused R1's head strike on the leg of the lift. DON indicated the head strike resulted in a hematoma to the back of her head with a small laceration and was transferred to hospital for further evaluation and returned later that evening with no new orders. DON indicated the interviews were inconsistent in that nursing assistant (NA)-F stated both aides were in the room at the time of the transfer, however, NA-G stated he was just entering the room as NA-F was lifting R1 off the bed and could not get to R1 before she rolled out of the sling. DON stated she immediately provided both aides verbal education on responsibilities of 2nd person during transfers and verification of the sling loops connected to the lift. DON stated it is required 2 staff are present during hoyer transfers; the second person checks to ensure the sling is positioned correctly and connected to the lift. DON indicated that based on the interviews from staff, staff were not positioned appropriately during the transfer. DON stated the lift and sling were removed from the floor and immediately inspected by maintenance. DON stated maintenance reported a bolt loose on the cradle of the Hoyer and there was a rubber sleeve covering the area which was to be in place as well, rubber stoppers were also not in place on the Hoyer cradle hook ends. DON indicated all the other lifts were inspected the same day. DON indicated the NAs involved had not been tested for competency following the incident, and not all staff had received re-education pertaining to the lift safety, however, the education coordinator was going around doing audits and providing the education. DON stated as part of the facility investigation we verified that the right sling was used. During an observation on 1/6/22, at 9:34 a.m. R1 sat in her wheelchair at a table in a common area. R1 had a swollen area on the back of her head that was approximately 1-2 centimeters in diameter and was raised approximately 0.5 centimeters, the surrounding area was observed to have bruising in various stages of healing. NA-A and NA-B stated R1 was cooperative when in the lift and did not have behaviors. NAs indicated resident care plans identified the sling size they were supposed to use. NA-B stated she had worked at the facility for about 7 months, although she had been shown how to use the lift, she was not tested to ensure competency. NA-A indicated an unawareness of the last time she had received education and/or testing to ensure competency. NAs stated they had not received any re-education within the last two weeks pertaining to lift safety. During an observation on 1/6/22, at 11:01 a.m. the lift and sling that had been removed from the floor was observed with the administration and DON. The size of the sling was identified as a small using the color chart on the lift. DON confirmed the size of the sling as small, and that sling had been used in the incident on 12/31/21. During an observation on 1/6/22, at 12:28 p.m. R1 sat straight in her wheelchair in her room. NA-A and NA-B knocked on R1's door and explained they were going to transfer her to her bed. NAs placed the lift sling underneath R1 as she sat in her wheelchair. R1 was cooperative. NA-A stated the size of the sling was small. NAs hooked the sling loops to the lift, when NA-A pushed the up button on the lift, the lift did not move, the display panel directed to change the battery. NA-A bypassed the warning message by simultaneously pressing the up and down buttons on the lift. R1 was then raised out of her chair, as R1 went up in the air she started leaning to the right side so that her shoulder was not totally supported inside the sling (the sling placement was in the middle of R1's right shoulder.) NA-B stood on R1's right side during the transfer guiding R1 in the sling as NA-B pushed the lift towards the bed. NAs did not stop the transfer to reposition the sling and/or identify the sling was too small for R1. During an interview on 1/6/22, at 2:08 p.m. NA-F confirmed she was involved in R1's lift transfer that resulted in a fall with injury. NA-F stated she was going to transfer R1 from bed to shower chair, had put the sling underneath R1 in bed, and hooked the sling up to the machine. NA-F stated she then called for assistance from NA-G. NA-F indicated once NA-G was in the room he ran the lift, while she stood at the head of the bed. NA-F indicated NA-G had raised R1 up off the bed, as NA-G pulled the lift out from underneath the bed, R1 started to sway, R1 started to lean to left, then suddenly her top half rolled out of the sling. NA-F stated she thought R1's sling was too small because it did not go around her shoulders. NA-F stated DON provided immediate education verbally after the event, had not completed an assigned training module and indicated she had not been audited for competency since the event. During an interview on 1/6/22, at 2:26 p.m. NA-G confirmed he was involved in R1's lift transfer that resulted in a fall. NA-G stated NA-F called for assistance for R1's transfer. NA-G stated ,I opened the door she [NA-F] was lifting her [R1] up. NA-G indicated NA-F had started moving the lift underneath the bed, R1 started to sway as the lift moved out from under the bed, R1 started leaning left and suddenly rolled out of the sling. NA-G stated her upper body was on the floor and her feet were still in the sling. NA-G stated it happened so quick he could not get to her in time. NA-G stated R1 used a small lift sling, It doesn't wrap around her shoulders, it doesn't seem big enough. NA-G indicated the DON had provided verbal education, had not been audited, and was assigned a learning module, however, had not yet completed it. After the IJ was called, the facility completed a comprehensive safe transfer assessment dated [DATE] that identified R1 required a medium sized sling for transfers and not a small. R6 R6's care plan for transfers dated 8/24/21, did not identify the size of sling R6 required for safe transfers. The care plan included, Hoyer assist x2. R6's care plan was revised on 1/6/22, indicated R6 required a medium sling, however, the record did not include an assessment that identified how the medium sling size was determined to be appropriate and safe for R6. R6's progress note dated 9/26/21, at 11:53 a.m. included, Resident had a near miss fall. Two CNA's [certified nursing assistants] were transferring resident from bed to chair using a hoyer lift when the left upper strap came undone. CNA's stated they lowered him to the floor, and resident hit his left shoulder on the hoyer lift leg. CNA's witnessed he did not hit his head. Resident is claiming he did. Assessed for any injuries. No injuries noted. R6's fall care plan dated 9/27/21, included, 9/26/21-Fall during Hoyer transfer, hit left shoulder. NP [nurse practitioner] provided orders for x-rays, education to staff per DON [director of nursing] via 5-minute meeting to review and sign stating A2 mechanical lift transfers must have 2nd person verifying that resident's [sic] is appropriately and safely secure in lift prior to transfer and to ensure slings and straps are correctly positioned. Maintenance to do a safety check on all mechanical lifts and slings. R6's quarterly MDS dated [DATE], indicated R6 had moderate cognitive impairment and did not have behaviors. The MDS identified R6 required assistance from two or more staff for transfers. Facility's Monthly Preventative Maintenance (PM) records were reviewed from September through December 2021. The PM checklist directed to complete wheel inspection and cleaning. Completed forms reviewed from September to December 2021, the forms identified the month in which inspections had been completed but not the date. The forms indicated wheel preventative maintenance had been completed for the month, however, did not identify when the 9/18/21, request for wheel cleaning had been specifically completed. During an interview on 1/7/22, at 3:45 p.m. DON stated the incident was considered a near miss as R6 was lowered to the floor by staff. DON indicated staff visualized a sling loop slipping off the lift. DON indicated after the incident she had provided education of the requirement for having two staff for Hoyer transfers, appropriately attaching sling to lift, and verification of placement. DON stated she had also watched and/or participated in transfers, however, had stopped documenting on 10/11/21. DON indicated she had not assessed residents to ensure proper sling size for residents after the incident. During an interview on 1/9/2022, NA-E stated she had been the second person in the room when the incident happened. NA-E indicated she entered the room and R6's sling had already been connected to the lift by the other NA who was in the room. NA-E stated as R6 was raised into the air, she saw the one sling loop came undone, causing R6 to lean outside the sling. NA-E stated they manually lowered R6 to the floor, and in the process R6 bumped his shoulder on one of the Hoyer legs. NA-E stated, I think the one loop was not latched all the way, I should have made sure the loop was in all the way and verified it. NA-E stated the sling that was used was a medium. During an interview on 1/10/22, at 9:35 a.m. director of maintenance (DM) indicated mechanical lift inspections were completed monthly in accordance with manufacturer's recommendations. DM stated if something was identified during the monthly inspections then it was recorded on the preventative maintenance form. DM indicated direct floor staff were supposed to alert maintenance if there was a concern with the lift and remove it from service. DM indicated if a service request was communicated between monthly checks the issue and fix were not recorded. During an interview on 1/10/22, at 11:11 a.m. DON indicated after the event she had requested for maintenance to look at the lift, however, there was no documentation that had been completed. DON referenced the historical orders on her computer and stated on 9/18/21, she had submitted a high priority ticket; All the EZ stands and Hoyers have hair around the wheels and they are getting hard to push resident on them. Please clean the wheels. DON stated according to the tracking system, the order was set to in-progress on 9/18/21, and as of 9/30/21, the documentation does not indicate this was completed. After the IJ was identified, the facility completed a comprehensive safe transfer assessment dated [DATE], that identified R6 required a large sized sling for transfers and not a medium. R2 R2's care plan for transfers dated 8/4/21, included, The resident requires mechanical lift with (2) staff assistance for transfers; the care plan did not identify R2's sling size. The care plan revised on 1/6/22, directed staff to use large sling. R2's quarterly MDS dated [DATE], indicated R1 had diagnoses that included [CONDITION(S)] and did not have cognitive impairment. The MDS indicated R1 required assistance from two or more staff for transfers. R2's record did not include an assessment that identified how the large sling size was determined to be appropriate and safe for R2. During an observation on 1/6/21, at 11:21 a.m. NA-C walked out of R2's room carrying a lift sling. NA-C stated the sling was an extra large (XL) and was too big for R2 and she was going to get the right size. NA-C indicated the wrong sized sling had not been used today, however, had been used a few times to transfer because R2's sling was in the wash. At 11:23 a.m. R2 stated she had been using a sling that was too large because hers was in the wash. R2 stated staff had only transferred her a couple of times using the XL sling. NA-C and NA-D then safely transferred R2 out of her bed to her wheelchair using the correct size sling. After the IJ was identified, the facility completed a comprehensive safe transfer assessment on 1/7/22 that reflected large sling was appropriate for R2. R3 R3's significant change MDS dated [DATE], identified R3 had diagnoses that included dementia and Alzheimer's disease, was assessed by staff to have severe cognitive impairment, had signs and symptoms of [CONDITION(S)] that were continuously present, and had physical behaviors. The MDS indicated R3 required assistance of two or more staff for transfers. R3's care plan for transfers dated 12/13/21, did not identify a sling size for R6. The care plan included the resident is totally dependent on two staff with Hoyer lift for transfers. She is to have a full body sling used for transfers and it is to stay under her while in her Broda chair. After the IJ was identified, the facility completed a comprehensive safe transfer assessment on 1/7/22 that reflected medium full body sling was appropriate for R3. R4 R4's transfer care plan dated 10/19/21, did not identify a sling size for R4. The care plan included; the resident requires a mechanical lift (Hoyer) with 2 staff assistance for transfers. The revised transfer care plan dated 1/6/22, directed staff to use an extra-large sling. R4's quarterly MDS dated [DATE], indicated R4 did not have cognitive impairment and did not have behaviors. The MDS identified R4 required two or more staff assistance for transfers. After the IJ was identified the facility completed a comprehensive safe transfer assessment on 1/7/22, that reflected that the extra-large sling was appropriate for R4. R5 R5's quarterly MDS dated [DATE], indicated R5 had severe cognitive impairment and did not have behaviors. The MDS identified R5 required assistance of two or more staff for transfers. R5's transfer care plan dated 12/19/2019, indicated R5 required two staff assistance with Hoyer lift and used a small sling size. R5's record did not include an assessment that identified how the small sling size was determined to be appropriate and safe for R5. After the IJ was identified, the facility completed a comprehensive safe transfer assessment on 1/7/22 that identified R5 required a medium size sling for transfers and not a small. R7 R7's admission MDS dated [DATE], identified R7 had diagnoses that included [CONDITION(S)] or [CONDITION(S)] disorders. The MDS indicated R7 had moderate cognitive impairment with signs and symptoms of [CONDITION(S)] that fluctuated, and did not have behaviors. The MDS indicated R7 required extensive assistance from two or more staff members for transfers. R7's Baseline Care Plan for transfers revised on 1/6/22, indicated R7 was a pivot transfer, however, was moved to a Hoyer on 1/6/22, related to decline in condition. The care plan included, Transfer: A2 Hoyer- medium sling. R7's record lacked a comprehensive assessment that identified how the medium sling size was determined to be appropriate and safe for R7. After the IJ was identified, the facility completed a comprehensive safe transfer assessment on 1/7/22 that reflected the medium sling was appropriate for R7. R8 R8's significant change MDS dated [DATE], identified R8 had diagnoses that included dementia and anxiety disorder. The MDS indicated R8 had severe cognitive impairment with fluctuating symptoms of [CONDITION(S)] and had verbal behaviors directed at others. The MDS also identified R8 required assistance of two or more staff for transfers. R8's care plan for transfers dated 10/25/21, identified R8 required a Hoyer lift with two staff assistance; the care plan did not identify a sling size. R8's care plan revised on 1/6/22, included the aforementioned level of assistance and directed staff to use a small sling. R8's record lacked a comprehensive assessment that identified how the small sling was determined to be appropriate and safe for R8. After the IJ was identified, the facility completed a comprehensive safe transfer assessment on 1/7/22, that identified R8 required a medium size sling for transfers and not a small. R9 R9's care plan for transfers dated 11/16/20, indicated R9 required assistance from two staff with Hoyer and a large sling. R9's quarterly MDS dated [DATE], identified R9 had diagnoses that included dementia, Alzheimer's disease, and [CONDITION(S)]. The MDS indicated R9 had moderate cognitive impairment and had behaviors that were not directed toward others. The MDS also identified R9 required two or more staff assistance for transfers. R9's record lacked a comprehensive assessment that identified how the large sling size was determined to be appropriate and safe for R9. After the IJ was identified, the facility completed a comprehensive safe transfer assessment on 1/7/22, that reflected the large sling was appropriate for R9. During an interview on 1/6/22, at 3:08 p.m. education coordinator (EC) stated the lift sheet needed to encompass the shoulders to keep balance, if NAs thought the sling was not fitting appropriately, they should report to the nurse. EC stated she had been out of the facility when the event occurred and had started providing verbal education to remaining staff pertaining to requirement of having 2nd person in the room, proper positioning of the sling, proper placement of lift straps onto the lift, and instructions to provide to residents during transfers on 1/3/22, when she had returned to work. EC indicated not all staff had been provided education and seven regularly scheduled staff were left. EC stated she had not completed audits on staff to ensure competency since the incident on 12/31/21. EC indicated upon hire staff were assigned to learning modules pertaining to mechanical lifts and then were supposed to be competency tested . EC indicated training then is provided annually and as needed. EC indicated after April 2021 competency testing upon new hire orientation was not always completed and there were a few staff who did not receive the training. EC stated she was in the process of doing that now. Review of the facility's training records identified new hires completed the manufacturer's video for the lifts however, testing to ensure competency with safe transfer techniques were not completed for 13 of 13 staff members who were hired after 4/21/21. During an interview on 1/7/22, at 9:31 a.m. licensed practical nurse (LPN)-A stated sling sizes were assessed by therapy or nursing evaluations. LPN-A indicated nurse managers were responsible for assessing and care planning the correct sling size. LPN-A indicated the proper sling size is important to prevent falls and injury. During an interview on 1/7/22, at 10:27 a.m. NA-H indicated R1 was cooperative during transfers and had a tendency to start leaning to her right side when she got tired. NA-H stated she has not been at the facility very long. NA-H stated her training for mechanical lifts included watching videos and watching facility staff. NA-H stated she had not been tested for competency and was going to complete with the education coordinator on 1/10/22. The immediate jeopardy was removed on 1/10/22, at 12:50 p.m. after verification the facility had implemented an acceptable plan of correction that included: 1) Facility developed a safe transfer assessment and provided training on the assessment tool. 2) Comprehensive assessment for sling size were completed for all residents who required mechanical lift for transfers. 2) Care plans for residents who required mechanical lift transfers were updated to reflect appropriate sling size per the comprehensive assessment. 3) All staff were provided with education and competency testing was completed. EZ Way Lift Manufacturer Operator's Instructions included the following: -For safe operation of EZ Way Smart Lift, operators should watch the training video, read through this manual, complete the competency checklist, and practice on fell ow staff members before use with patients. WARNING: For safe operation of the EZ Way Smart Lift, the lift must be used by trained personnel in accordance with the operator's manual, video and training checklist to avoid injury to patient. -As patients do vary in size, shape, weight, and temperament, these conditions must be taken into consideration when deciding which EZ Way sling is suitable for each patient's needs. NOTE! The size/weight designations are merely estimates and basic guidelines. A proper fit will depend on factors other than weight measurements, including the height and girth of the patient. **It is important that no portion of the patient overlap the sides of the sling. -When the battery level becomes low swap the battery with a fully charged battery. NOTE: if the battery indicator reads SWAP BATTERY, the lift will go down but not up. -Competency checklist included the following: Demonstrate proper fitting of sling to the resident, demonstrate proper attachment of sling to lift, and Demonstrate how and when to change battery. -All EZ Way equipment must be maintained regularly by competent staff according to the maintenance checklist provided. Facility policy Ecumen Resident Lift Purchase Policy dated 1/31/2019, included Communities are required to log and track all preventative maintenance and emergency services in TELS

Based on document review and interview, the facility failed to adequately assess and implement new fall prevention interventions to prevent falls for 1 of 3 residents (R1) reviewed for falls in the facility. In addition, the facility failed to communicate fall interventions that were developed for implementation by nursing staff for R1. R1 sustained actual harm when she was found on the floor and sustained a [MEDICAL CONDITION] resulting from the fall. Findings include: R1's [DIAGNOSES REDACTED]. R1's admission Minimum Date Set (MDS) assessment dated [DATE], indicated R1 scored 14 on the Brief Interview for Mental Status assessment, indicating R1 did not have cognitive deficient. The MDS further indicated R1 required extensive assistance with all activities of daily living, including ambulation. R1's care plan included a fall focus initiated 9/1/20, and last revised date on 10/11/20, indicating R1 had an actual fall due to poor balance, poor vision, and unsteady gait. During an interview on 11/2/20, at 12:50 p.m. nursing assistant (NA)-A stated in the event of a fall, nursing staff complete an incident report and it goes to administration. The interdisciplinary team (IDT) will review the fall and create new fall prevention interventions. NA-A further stated, the new fall prevention interventions can be found in the nursing assistant Kardex. Lastly, NA-A stated the Kardex includes interventions from the care plan and what needs to be done to keep the resident from falling. During an interview on 11/2/20, at 12:55 p.m. registered nurse (RN)-A stated after a fall, an incident report must be completed immediately in their Point Click Care (PCC) electronic medical record, in the Risk Management section. RN-A stated once the incident report is completed, it is saved and reviewed by administration and the IDT. The IDT creates new fall prevention interventions which are documented in the care plan. RN-A stated, Whenever new fall prevention interventions are created in the care plan, they pop up upon logging into PCC. This is how I know a new fall prevention intervention was created. Review of R1's falls indicated [REDACTED]. On 9/2/20, at 6:54 a.m. R1 was found on the floor in her room with an abrasion noted to the right forehead. An Incident/Root Cause Analysis was completed and interventions included the resident was added to falling star program, fall mat placed at bedside, low bed placed in room, resident reoriented to room call light and safety measures. Although fall prevention interventions were documented in the Incident/Root Cause Analysis report form, the interventions were not entered into the care plan so licensed and unlicensed staff could view the interventions. Additionally, licensed staff would not be automatically notified of the new interventions and non-licensed do not have access to the Risk Management folder. On 9/2/20, at 4:18 p.m. no details of the fall event were documented however, R1 sustained a hematoma to left forehead. The Incident/Root Cause Analysis was completed and interventions documented resident is on one-to-one visual observation by placing at the nurse's station and in a Broda Chair. Although fall prevention interventions were documented in the Incident/Root Cause Analysis report form, the interventions were not entered in the care plan so licensed and unlicensed staff could view the interventions. Additionally, licensed staff would not be automatically notified of the new interventions and non-licensed do not have access to the Risk Management folder. On 9/9/20, at 6:30 a.m. R1 was observed on the floor beside bed in her room with no injuries documented. The Incident/Root Cause Analysis was not fully completed. Neither the physician nor family were notified of the fall. There are no fall prevention interventions noted in the Incident/Root Cause Analysis report. On 9/10/20, at 2:07 p.m. an Incident/Root Cause Analysis report was initiated but not completed. The details of the incident only documented the resident had no self-attempts to transfers and denied having any pain when asked. No other documentation was filled in on the Incident/Root Cause Analysis report. A progress note dated 10/14/20, at 1:38 p.m. indicated R1 was found on the floor with a small laceration to the right hand. The progress note indicated the fall was reported to hospice, and no other documentation was provided. An Incident/Root Cause Analysis report on the fall was not found. A hospital emergency department admission noted dated 10/14/20, at 8:38 p.m. indicated R1 sustained a left [MEDICAL CONDITION] from a 10/14/20, 1:38 p.m. fall that would require orthopedic surgical intervention. Due to R1's advance age and comorbidities, the orthopedic surgeon and anesthesia indicated it would be safer for R1 to have surgery at a tertiary surgical center so they transferred R1. R1 did not return to the nursing home facility. During an interview on 11/2/20, at 1:45 p.m. the director of nursing (DON) stated after each fall an Incident/Root Cause Analysis is completed and the IDT reviews each fall. She stated the IDT creates new fall prevention interventions and the DON documents the new fall prevention intervention(s) in the care plan. The DON verified fall prevention interventions had not been entered timely due to her current workload and management staffing issues. The DON stated, There just isn't enough time to get all the work done by one person. The DON further explained that due to time-constraints, the facility administrator had created a 5-Minute Meeting document to keep staff up to date on fall prevention interventions. The DON stated that staff are mandated to read the report before each shift, and were expected to initial that they have read the report. During an interview on 11/2/20, at approximately 2:15 p.m. the DON stated, Since care planning was identified as a quality improvement issue, the facility administrator created a fall analysis and follow through Excel spreadsheet. It was completed by 10/27/20, and included the name of the resident and the completion date when the care plan was updated with new fall prevention interventions. Following this interview, it was observed that two residents had been included on the Excel spreadsheet by 10/27/20, and check marks in the completion column indicated these residents had updated fall prevention care plans. However during document review on 11/2/20, when the 5-Minute Meeting documents dated 7/7/20, 7/27/20, 8/10/20, 9/15/20, 9/16/20, and 10/16/20 were reviewed. It was discovered from the six reports, nineteen designated staff were documented on each report who are mandated to read and initial the report. Staff had only initialed completion of reading the document 15 of the 114 opportunities. The facility's policy Assessing Falls and Their Causes last revised 10/2020, directed staff to notify the physician and family after each fall. In addition, the policy indicated a detailed incident report must be completed and submitted to the DON no later than twenty-four hours after a fall, and indicated appropriate fall prevention interventions were to be documented in the resident's chart to prevent future falls. The facility's policy Falls, Clinical Protocol last revised 9/2020, directed staff to document risk factors for falling and to develop pertinent fall prevention interventions. In addition, the protocol indicated staff were to monitor and document an individual's response to interventions to reduce future falls, to address whether the individual continues to fall, and to ensure staff would re-evaluate and consider other interventions. The facility's policy Care Plans, Comprehensive Person-Centered revised 12/2006, directed the IDT to develop and implement a person-centered care plan based on the comprehensive assessment. In addition the care plan was to reflect objective and measurable outcomes, and was to be updated by the IDT whenever there is a significant change or an outcome which is not being met.

Based on observation, interview and document review, the facility failed to ensure resident's were free from abuse, failed to investigate and failed to protect residents from abuse following an allegation of physical abuse by staff. This resulted in an immediate jeopardy (IJ), with risk of serious harm, for 1 of 3 (R1) residents reviewed for allegations of abuse. The IJ began on [DATE], when R1 was noted to have bruising in her perineum and alleged a staff person had hurt her. The IJ was identified on [DATE], and the administrator and the director of nursing were informed of the IJ on [DATE], at 1:46 p.m. The IJ was removed on [DATE], at 10:57 a.m. but non compliance remained at the lower scope and severity level of G, isolated with actual harm. Findings include: A Facility Reported Incident submitted to the State Agency on [DATE], at 7:57 p.m. indicated an allegation of physical abuse occurred on [DATE], at 6:30 p.m. The report included, RN (nurse name) called DON (director of nursing) to inform that when she went to administer resident's (R1) vaginal cream, resident had blood in her pad. Nurse (nurse name) requested assistance and was joined by TMA (trained medication assistant). Both employees reported witnessing scratches on resident's inner thighs and several bruises. Employees asked resident how this occurred and resident reported CNA (certified nursing assistant (NA-1)) 'with the sparkly hair', was rough during cares when she was getting ready for bed. CNA responsible during cares matching physical description was suspended immediately pending investigation. Nurse and TMA cleansed resident, measured wounds, applied cream to wounds which resident reported felt better, and administered [MED] for pain relief. Resident reported she felt safe and was ready for bed. The report further indicated the resident's family member was notified, and the physician would be notified in the morning. The summary indicated the facility would continue to monitor R1's mood/behavior, complete skin checks, treatments, and pain level during investigation. Further, the report indicated the investigation would include interviews with other residents, review of medication and treatment administration records, wound assessments, nursing assistant care sheets, and care plan. R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R1 did not have cognitive impairment, did not have signs and symptoms of [MEDICAL CONDITION], and did not exhibit any behaviors. The MDS indicated R1 required extensive assistance from one staff member for all activities of daily living with the exception of eating. The MDS also indicated R1 did not have impaired skin integrity. R1's facility Admission Record dated [DATE], included [DIAGNOSES REDACTED]. During an interview on [DATE], at 10:33 a.m. R1 was observed seated in her wheelchair in her room. R1 stated she had been back from the hospital for a few days now however, felt much better, but could not recall why she had been in the hospital. When asked if something happened prior to going to the hospital R1 stated, I remember the aide that was not nice. When asked, R1 did not know the NA's name. R1 continued, That aide was never nice to me, she had black braided hair with gold glitter in it, and long fingernails that were curved. When asked why she did not think the NA was nice to her, R1 stated, She (NA-1) transferred me with a mechanical standing lift and was rough with me. The aide put the calf strap on too tight. When I told her it was too tight, she did not listen. R1 also stated she'd had large bruises all the way down her legs to the floor and stated she had thought NA-1 pulled her hair above her left ear. R1 stated then, She (NA-1) was washing down there (vaginal area), really hard. She kept doing it when I told her to stop it, she wouldn't quit. R1 had tears in her eyes, looked down, and would not make eye contact but stated, There wasn't anybody else in the room when she was doing that, I have no witnesses whatsoever. When she was done she (NA-1) kissed me, she was so insistent with herself. I told her to 'get her ass out the door and don't look back'. R1 stated she had reported NA-1 to registered nurse (RN)-A. R1 also stated, That was not the first time that aide treated me roughly. When asked if she had previously reported any issues with the aide, R1 said she thought she had however, could not remember to who. R1 stated, This time I was sick of how she (NA-1) treated me. When she got done washing me, it hurt! R1's physician orders [REDACTED]. R1's Progress note dated [DATE], at 9:04 p.m. indicated the family member had been informed of the allegation of potential abuse. The note indicated the family had been assured NA-1 was no long in the building, and R1 felt safe. Documentation also indicated it had been explained to R1's family that RN-A and the TMA had spent time with R1 to ensure that she was doing okay emotionally felt safe. R1's Skin Assessments dated [DATE] and [DATE], verified R1 had no impaired skin integrity (such as bruises, abrasions, or moisture associated skin damage) anywhere, other than a scab on her left outer foot near the heel noted on the [DATE] assessment. R1's skin assessment dated [DATE], at 7:30 p.m. indicated R1 had pain in peri area and left breast. The skin assessment included: -Right knee (rear) Bruise 1 centimeter (cm) x 1.25 cm -Right lower leg (rear) bruise 2.0 cm x 1.0 cm -Abrasion to peri area (did not specify exact location) 6.0 cm x 1.5 cm -Left breast caught in side rail during transfer (did not describe skin impairment) -Left outer thigh bruise 1.5 cm x 2.0 cm -Left side inner knee (below the 1.0 cm x 1.0 cm) bruise 4.5 cm x 4.5 cm -left side inner knee bruise 1.0 cm x 1.0 cm -Right back upper knee bruise 1.25 cm x 1.25 cm -Right below back knee bruise 2.0 cm x 1.[AGE] cm -Right front side of shin bruise 1.5 cm x 1.0 cm -Right upper thigh bruise 2.0 cm x 2.0 cm R1's nursing progress note dated [DATE], at 5:37 a.m. included, When administering residents morning meds this nurse was doing a skin check for bruises and marks that may not have been previously noted. When this nurse asked resident what happened resident stated, We were talking about racism and she got mad and slapped me three times in the face, my eyes hurt. I then asked what happened to her right knee for it to have so much bruising and resident stated that happened too. R1's behavior progress note dated [DATE], at 10:03 a.m. included: (R1's name) continues to be sad about what happened to her. Able to talk about it and redirect. In the section Details of Behavioral Episode?: Talking about what happened. In the section Potential Causes or Triggers?: Incident that occurred. In the section, List non-pharmacological interventions attempted/effective?: Sat with her (R1) and listened and visited with her in regards to what happened and just small talk. R1's progress note dated [DATE], at 2:48 p.m. indicated R1 had experienced a change in cognition over period of time today, seen by the physician, and determined (R1) should be sent to the emergency room (ER) for further evaluation. A subsequent progress note at 2:50 p.m. indicated R1 had been transferred to the ER via ambulance. Progress note at 6:19 p.m. indicated RN-A had called the hospital to get an update on R1 and had been informed R1 had a sexual assault nurse team collecting evidence and doing an exam. The hospital nurse reported R1 had 3 abrasions inside her labia and bruising to both sides of the peri lips. The note further indicated the hospital inquired if the staff member involved in any incident was male or female and was informed it was a female staff member. R1's progress notes reviewed from ,[DATE]-[DATE], did not identify R1 had been treated for [REDACTED]. During an interview on [DATE], at 10:18 a.m. nursing assistant (NA)-A stated she was very familiar with R1, and worked at the facility full time. NA-A stated R1 used a standing mechanical lift for transfers, had been normally alert and orientated. NA-A stated R1 historically was pleasant and cooperative however, it she felt like she was being ignored or took a long time to answer her call light, she would be more particular when her call light was finally answered. NA-A stated, She (R1) would have you do more things for her or be picky about how things were done. NA-A stated R1 had never made allegations of abuse before. NA-A stated the morning of [DATE], she had washed R1 up and had not noticed any bruises or scratches, and R1 had not complained of any discomfort. NA-A further stated indicated R1 had not complained of vaginal itching and had not seen R1 scratching herself. NA-A stated she thinks she went home around noon that day. NA-A stated she had received a phone call later that evening from registered nurse (RN)-A asking about injuries on R1. NA-A stated the next morning on [DATE], R1 was weepy, would not tell her why, and wasn't conversational. NA-A stated she gave R1 a shower and during the shower R1 seemed better. NA-A verified during the shower she noted R1 had bruises on both her legs everywhere, on the front and back, up and down. NA-A stated she thought R1 bruised easily however, had not seen bruising to that extent on R1. NA-A stated after the shower, R1 was brought back to her bed and laid down on her bed, and RN-A came to her room to do a skin check. NA-A also stated she then saw an injury in R1's peri area that was a couple of centimeters long, and stated she had some redness on the labia and in the groin. During an interview on [DATE], at 10:48 a.m. RN-A stated she worked late on [DATE], and was asked to do R1's [MEDICATION NAME] treatment. RN-A stated R1 was not on a blood thinning medication but when she pulled back the covers she noticed bruises and a mark in the groin area. RN-A said R1 had reported to her She (NA-1) hurt me. RN-A stated the TMA then came into the room and R1 described the NA who hurt her as the one with sparkles in her hair, R1 told RN-A she told the NA-1 to get out of here. RN-A stated R1 did not go into detail about what NA-1 had done other than stating during the transfer NA-1 got R1's breast stuck in the bedside rail. RN-A stated she had immediately called the director of nursing who had instructed her to walk NA-1 out of the building. RN-A stated she kind of remembered NA-1 having long fake fancy fingernails on that evening. RN-A stated R1 was lucid, alert and orientated, and did not have bruises and/or vaginal abrasions before 2:00 p.m. on [DATE]. RN-A stated she had counted 9 bruises and scratches, but the lighting was really bad and had questioned some areas that may have been bruises. RN-A stated she called NA-A to ask if she had seen the injuries earlier in the day, which she had not. RN-A stated she informed family. RN-A stated that night R1 was worried the rough NA (NA-1) was still in the building, was anxious, was provided reassurance that NA-1 was sent home, and eventually R1 settled down. RN-A stated she had not informed the physician on [DATE], of the allegation or of R1's bruises. RN-A stated the next morning on [DATE], she re-examined R1, and had identified the same injuries in better light. RN-A stated R1 continued to report rough treatment and described NA-1 however, later that morning/day she became less lucid and became very confused. RN-A said due to the cognitive changes, the physician saw R1 that afternoon and R1 was sent to the ER for assessment of the mental status change. RN-A stated, That's when the emergency room staff called to ask some clarifying questions about (R1's) bruises/injuries. Further, RN-A stated the family member who had been present at the hospital said R1 had reported to the family she had been raped. During an interview on [DATE], at 11:45 a.m. the medical doctor (MD) stated he had seen R1 the following day for a routine visit and that is when it was brought to his attention there had been an allegation of rough treatment. MD stated he did not do a vaginal exam. MD stated he saw fresh bruises on R1's lower extremities that could have been from an aggressive transfer. MD stated he was also aware R1 had a tendency to scratch her peri area, but could not say the injuries were not caused by someone else, and also stated the injuries could have been caused by sharp nails. When the MD was informed of the size of abrasion, as reported by the facility, the MD stated a scratch that size was not likely to have been self-inflicted. The MD stated R1 often had pain during urination, and stated on [DATE], R1 was sent to the emergency room (ER) related to new onset of confusion, but testing had not revealed the etiology of confusion. R1's hospital record indicated R1 was admitted to the hospital on [DATE], and was discharged back to the nursing home on [DATE]. R1's hospital emergency room record identified R1 had been admitted [DATE] at 2:53 p.m. In the area Reason for Visit, the chief complaint included: Altered mental status (pt (patient) lives at [ENTITY] and was brought in by E[CONDITION] (emergency medical service) for altered mental status. Patient is normally alert and orientated. E[CONDITION] states nursing home reported a possible abuse allegation against the patient as the victim and hx (history) of UTI (urinary tract infection) recently. Pt denies any pain, VS (vital signs) are WNL (within normal limits).). The emergency room physician note dated [DATE], at 4:08 p.m. included, pt was found to have multiple bruises and an abrasion to vagina, when asked, pt stated, 'She (an aide, NA-1) was in a hurry and rough and she has long nails.' The traveling aide whom they believe the patient was talking about was fired and they have an ongoing internal investigation. Patient today also made statements such as 'she slapped me three times in the face.' Pt is unable to give clear account of injuries .At this time it was decided that pt could benefit from admission to the hospital for further work up of [MEDICAL CONDITION], A[CONDITION] (altered mental status) and abuse. The emergency room physician note dated [DATE], at 6:02 p.m. indicated E[CONDITION] reported R1 underwent a harsh bed transfer by a caregiver at the nursing home.there were [MEDICAL CONDITION] on inner labial wall and clitoral hood. I think evaluation by SANE (sexual assault nurse evaluation) staff to better delineate the physical findings . An emergency room nursing note dated [DATE], at 7:23 p.m. included: This nurse spoke to (nurse from nursing home RN-A).According to (RN-A) there was an 'incident' last evening. (RN-A) went further into detail that last evening a travel nurse aide (NA-1) was 'getting rough' with (R1) while doing her cares. She reports the travel aide had long nails and cut a little on patient's perineum are and gave patient bruises on bilateral legs while doing cares. This travel aide was fired immediately and escorted out of the building and (RN-A) stated they opened up a report'. No indication further of what the travel aides name was, if law enforcement was called, and did not state any further injuries to the patient. When nurse, nursing assistant (at ER) were to obtain a urine sample from patient using a straight in and out catheter, after cleaning the area to prepare for the procedure there were abrasions noticed inside the labia (minimum of 3) and what looked like discoloration/bruising outside of the genitalia. ER provider was notified and did an assessment when nurse was told to halt any further urine sample obtained and call daughter for consent to do an exam, to which daughter agreed. The note indicated an exam by SANE nurses was requested and a report was filed with the county. The note further included: Patient doesn't know what happened to her but states its from her husband (who is deceased ).has altered mental status as of today. Further the note indicated RN-A from the facility had informed the ER nurse the resident's allegations were against a female staff. When the ER nurse asked RN-A whether she had examined R1, RN-A had informed the ER nurse she had, and R1 had a small scratch on the outside of the perineum. The ER nurse then told RN-A, while trying to obtain a urine specimen, staff noticed discoloration/bruising outside the perineum and a few abrasions inside of the labia. The not further indicated the ER nurse had notified RN-A the ER staff had reported the incident to the county. Photos, and documentation of the sexual assault nursing evaluation from the ER dated [DATE], at 6:15 p.m. identified the following injuries without measurements: 1) Contusion on right lateral calf 2) Contusion to top of the right shin 3) Contusion on right inner/lower knee 4) Contusion on right inner/upper knee 5) Contusion on right outer/lower knee 6) Left outer foot noted dressing in place 7) Contusion on left center below knee 8) Contusion on left outer posterior knee 9) Contusion on left outer posterior knee 10) Contusion on left outer above knee 11) Contusion on left wrist 12) Right labia majora, raised discolored linear injury 13) Left labia majora, raised discolored linear injury 14) Right posterior medial gluteal fold: linear excoriation, bright red; raised and welted 15) Left posterior medial gluteal fold; linear excoriation, bright red in color, raised and welted 16) Along and inside vaginal wall: small reddened areas circumferential that patient indicates tenderness 17) Labia minora; abrasions 18) Tissue surrounding clitoris; reddened area with superficial tissue injury that patient indicates great tenderness. Sexual assault evaluation note dated [DATE], at 9:22 p.m. included: During exam patient repeats that she was abused, but remains unable to communicate how it occurred. Injuries noted and recorded on bilateral lower extremities. No open areas visualized. Injuries noted and recorded to genital/perineal area. Of note that tissue surrounding these injured areas is clean/dry/intact no maceration noted. Unable to appreciate any identifiable contributing factors such as dry skin/rash and patient denies itching. The note also indicated report and evidence was provided to law enforcement. R1's hospital social worker note dated [DATE], indicated the reason for social worker referral was discharge planning, suspected abuse or neglect. The note included: There was a report of abuse and the appropriate person was notified, spoke with (name of family member) extensively and she wants (R1) to return to the nursing home. The person suspected of abuse is no longer employed. The note indicated R1 would return to [ENTITY]. A police report dated [DATE], indicated a detective went to the hospital on [DATE], to investigate suspicious injuries on R1, and had interviewed SANE nurses. The report included statements from the SANE nurse including: Possible skin injury consistent with abuse on her clitoris, (R1) had abrasions inside of her vulva, (R1) also had abrasions in her vaginal wall. (Name of nurse) stated that these injuries are not consistent with normal injuries that an elderly patient would receive from normal activities. The report also indicated the injuries on R1's body were relatively recent and evidence was collected. The police report did not identify any conclusion of facts, or whether the case was considered resolved or closed. Upon review of the facility's internal Investigative Summary submitted to the State Agency on [DATE], at 4:26 p.m. the facility's Investigative Summary was noted to be inconsistent with hospital documents and other notes in the resident's record. On [DATE] at 1:20 p.m., NA-1 was interviewed regarding the allegation of abuse. NA-1 stated in an angry tone of voice, They investigated it at the facility, I was cleared! They let me come back to work! NA-1 stated the facility had told her they had talked to several people, and had determined the resident involved had previously made allegations about having been abused. NA-1 stated, They told me I was cleared and the allegation was wrong. NA-1 also stated she had worked a 16 hour shift on [DATE], but was no longer working at the facility due to a facility nurse having reported she (NA-1) was mean to her. NA-1 said, The facility ended my contract the next day ([DATE]). During the interview, NA-1 verified she had been suspended on [DATE], and had remained on suspension on ,[DATE], ,[DATE], and [DATE]. When asked to describe what happened on [DATE], NA-1 stated she wore her hair in a braid and during provision of cares, R1 had asked her if she was a thug. NA-1 stated she had transferred R1 to a commode and had washed R1's perineum from behind her while R1 was on the commode. NA-1 stated, I must have wiped her too hard between her legs. She said 'ouch'. NA-1 stated she hadn't meant to wipe R1 to make her sore, but stated when she had looked at R1's perineum, She was a little red. NA-1 said she had then put R1 to bed. When NA-1 was asked whether she had noticed any bruises on R1's legs, or abrasions in R1's perineum area, NA-1 yelled, I didn't do anything wrong, I don't wear nails to work. I keep my nails short when I have to work! NA-1 then verified she had seen bruises, but stated the bruising had looked old. NA-1 also stated that was only the second time she had assisted with R1's cares. During interview with the director of nursing (DON) and administrator on [DATE] at 2:46 p.m., they were asked how they had concluded there had been no abuse or assault to R1, in order to allow NA-1 to return to work Monday [DATE]. The DON stated they'd taken into consideration R1's report of somebody treating her rough, her description of the aide, and her injuries and stated: Once we had looked into all the pieces, which the hospital did as well, it was determined by myself and the hospital staff the scratches were caused by the resident. In addition, the DON stated, The ER nurse had thought the scratches could have been a result of sexual assault so they did a SANE and sexual assault kit. However, the DON stated, The facility staff had not considered that (R1) had been sexually abused because there was no report of that, and we had not seen any physical signs of sexual abuse. The DON reiterated the reason R1 had been transferred to the ER was for evaluation of a change in mental status and decline, which the physician had felt was likely related to [MEDICAL CONDITION] and/or an urinary tract infection.The DON stated, On Thursday [DATE], (R1) had reported (NA-1) was rough with her and we reported it to the State Agency. She (R1) continued to have changes in baseline mental status like seeing things and people that were not there. When the hospital nurse went to insert a catheter for urine specimen they discovered the injuries. The hospital informed us they were going to make a report to the State Agency for physical and sexual abuse, and as a result the police became involved in the investigation. What I was told from the hospital and police, the result from the SANE evaluation and sexual assault kit were unsubstantiated. I was also told from the hospital staff and investigator (family member), the resident had continuously described a different person. The original NA (R1) had reported was black and had sparkle in her hair with long black braids. When she (R1) reported to the investigator she reported it was a short white women with blonde hair that wore a lot of jewelry. No staff members fits that description. The DON further stated that throughout R1's hospital stay it was continuously reported that R1 had suffered delusions and hallucinations. We had determined the bruising was not a result of abuse, bruising patterns were not consistent with somebody being rough. The DON stated during interview with NA-1, NA-1 had explained she had toileted R1, assisted with wiping her peri area, had stopped because she noticed redness, then adjusted how she cleansed R1. The DON stated NA-1 had reported that R1 was fine at the time, but had been sore when she had wiped her. DON stated overall the physical attributes did not present as being caused by rough care stating, Her (R1) continued confusion and delusion all pointed to abuse or rough treatment not having actually occurred. The DON also stated the police had come to the facility during their investigation and interviewed other staff members, and the officer had informed her they had finished their investigation. The DON stated she had been informed in person, from the police detective, the abuse allegation was not substantiated, and therefore there was no reason to continue their internal investigation or keep NA-1 off the schedule. The DON stated she had not been provided with a written police report and/or conclusion, but reiterated based on the interviews with hospital staff, the police investigator, and their own facility investigation, the determination was made abuse did not occur. The DON further verified she had no record and/or documentation of any conversations with hospital staff or the police detective. The DON said she personally watched a transfer prior to R1 going to the hospital and stated, The way (R1's) legs were hitting the FEZ Stand, it looked liked the the bruises were from being bumped from transfer or bumping into something. The location the shape of them, did not look like bruises from a hand mark. During an interview on [DATE], at 1:41 p.m. the emergency room RN, (ER)-B, stated she remembered R1 coming into the emergency room from [ENTITY]. ER-B stated she remembered R1 was brought in due to changes in mental status and not for further evaluations of assault however, stated the ER staff had been informed by the ambulance crew of allegations of rough treatment/abuse from the previous night. ER-B stated when the physician and nurses went to insert a catheter to collect a urine specimen, they discovered vaginal abrasions and organized bruise patterns on R1's perineum internally, and externally, which was not consistent with what would be expected from chaffing or other skin injury associated with moisture. ER-B stated R1 had reported to ER-A she had been abused. ER-B stated, Upon discovery of the injuries we had a sexual assault nurse examination (SANE) completed, they completed vaginal swabs for lab testing. During an interview on [DATE], at 3:07 p.m. the hospital's sexual assault nurse examiner (SANE)-A, stated she remembered R1, and had assisted with R1's examination. SANE-A stated during the exam R1 had been pretty alert and orientated however had some confusion. SANE-A stated R1 had been cooperative, agreeable, definitely consented to the exam and was quiet during the exam. SANE-A stated there was one vaginal internal injury and stated R1, Had extensive bruising in the genital area. SANE-A further stated regarding the abrasions in R1's vaginal area, We wouldn't see what we saw from scratching or from self-infliction. SANE-A stated R1 did not have any signs of yeast infection and/or other signs of skin breakdown. SANE-A stated R1 did not complain of vaginal itching and did not attempt to scratch herself. SANE-A also stated SANE nurses gather and record evidence but did not make conclusions. SANE-A stated she had not had any contact with the family and/or the facility. During an interview on [DATE], at 3:31 p.m. SANE-B stated she remembered R1, and had performed the examination with SANE-A. SANE-B stated R1 had been transferred from the nursing home because of altered mental status, and SANE nurses were called because of an allegation R1 had been assaulted. SANE-B stated R1 presented with some lower extremity bumps and bruises that could have been caused by regular activity that were not all that concerning. However, SANE-B stated R1 also had vaginal injuries. SANE-B stated, I don't know if the injuries had been caused by sexual abuse, but there was obviously trauma. SANE-B stated R1's peri-area skin had not appeared red and/or raw, and nothing that indicated that R1 had a yeast infection. SANE-B stated R1's vaginal injuries were well defined and were localized to the genital area. SANE-B stated, We asked (R1) if it hurt. (R1) could tell us she wanted help, she wanted the police, and she told us she had been hurt. SANE-B stated she had gotten the report that a traveling nursing assistant had caused the injuries and had been escorted out of the nursing home. SANE-B stated, (R1's) injuries were not consistent with itching, scratching, or self-infliction. However, SANE-B verified she could not confirm what caused R1's injuries adding, (R1) suffered some kind of trauma and had traumatic injuries. I can't imagine you would be able to traumatize that area without knowing it, that area is quite tender, and a very sensitive area of the body. We can't say it was sexual abuse, but the injuries were consistent with trauma, those were traumatic injuries. SANE-B stated in her professional judgement and experience R1's injuries were consistent with some type of abuse however, again stated, It is not our role to determine what or who caused the injuries. Instead, SANE-B stated the role of the SANE was to complete the physical assessment and provide police with evidence. SANE-B indicated after the exam, they made sure that a report had been made to the State Agency for suspicion of sexual and/or physical abuse. SANE-B indicated after a traumatic experience the first ,[DATE]'s the victim has a very difficult time recalling information, which could have been a contributor to R1's confusion however, acknowledged R1 had other clinical things going on that could have caused the sudden onset of confusion as well. SANE-B verified she had not had any contact with the facility and/or family. During an interview on [DATE], at 4:04 p.m. ER-A stated she remembered R1 coming into the emergency room for altered mental status, that R1 had normally been alert and orientated to person, place, and time, but was now only alert to person. ER-A stated the ambulance driver had mentioned that R1 had been physically assaulted by a staff member at St. Mark's, something had happened, and the staff member had been fired and walked off the property. ER-A stated the transfer form had not mentioned anything about allegations of abuse so she called the facility to get more information. ER-A said, The facility nurse (RN-A) told me (R1) had been physically assaulted the night before by a prior aide, the aide had been really rough with (R1) while getting her ready for bed. (RN-A) reported (R1) had bruising to her legs and one scratch around perineal area, and that the aide had long finger nails. ER-A added, The facility chose not to send (R1) into the hospital at the time of the incident for further examination of her injuries, but they should have, given the extent of her injuries. ER-A stated after she received the information from the nurse, she had to catheterize R1 to obtain a urine sample however, upon removal of R1's incontinent garment she immediately saw R1's injuries, which was more than what the facility nurse had mentioned. ER-A stated, I saw bruising on the outside of the vaginal opening, bruising in the thighs, there was ,[DATE] abrasions inside the labia. ER-A stated R1 had been crying, so ER-A could not recall if R1 had voiced pain while in the ER. ER-A stated she immediately informed the ER doctor who obtained consent from R1 and R1's family to perform a SANE. ER-A stated she then called RN-A back to inquire when R1 had last had a bath or shower. ER-A said RN-A informed her R1 had a shower that day, which ER-A said should not have been done. ER-A also said RN-A had stated the alleged abuser was a a traveling NA. ER-A stated she had informed RN-A that R1 was referred to the SANE nurses for further evaluation, th

Based on observation, interview and document review, the facility failed to comprehensively assess and provide treatment for 1 of 1 resident (R148) who exhibited acute symptoms of urinary tract infection, 1 of 3 residents (R32) who had non pressure related skin injuries, and 3 of 3 residents reviewed for [MEDICAL CONDITION] (R151, R40 and R22) who experienced weight increases. R148 experienced harm when treatment was delayed and he was diagnosed with [REDACTED]. R32 experienced harm when the resident developed redness, warmth and fever, care was delayed and the resident required hospitalization to treat [MEDICAL CONDITIONS]. Findings include Urosepsis During an interview on 9/30/19, at 6:26 p.m. family member (FM)-A stated R148 was hospitalized last Sunday (9/22/19), for treatment of [REDACTED]. FM-A stated R148 had experienced a high fever Friday night (9/20/19), the facility had tried to get a hold of the doctor however, was unable to reach him. FM-A stated R148 continued to run a fever on Saturday (9/21/19), but didn't think the physician had ever been reached. FM-A then stated R148 ended up being admitted to the hospital for a couple of days with an E.Coli (Escherichia coli, a type of bacterial) infection. R148's facility Admission Record dated 10/4/19, indicated R148 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Facility standing orders approved by the physician on 12/12/18, included Notify physician if fever (2.4 degrees over baseline/normal temperature) persists up to 24 hours, or if condition warrants. R148's baseline care plan dated 9/19/19, did not address R148's risk for infection and/or interventions for signs/symptoms of infection. R148's admission progress note 9/19/19, indicated R148 was alert and oriented to person, place and time; and indicated the resident required two person assist for activities of daily living. R148's record was reviewed from 9/19/19, through 9/22/19, the record indicated R148 developed an increase in body temperature without further assessment of signs/symptoms of infection, consistent implementation of interventions, evaluations of intervention effectiveness, or timely physician notification of R148's change in condition. -On 9/19/19, R148's temperature was recorded as 98.0 degrees F (Fahrenheit) -On 9/20/19, at 5:00 p.m. R148's temperature was recorded as 103.8 F -On 9/20/19, at 7:15 p.m. temperature recorded was 102.6 F -On 9/20/19, at 8:28 p.m. temperature recorded was 100.5 F Although R148 ran a high fever, the progress notes from 9/20/19, did not identify further assessment of R148's fever, other possible signs/symptoms of infection, and/or interventions that were put into place. In addition, R148's medication administration record (MAR) did not reflect administration of fever reducing medications ([MEDICATION NAME]) on 9/20/19. Although R148's family indicated they thought the facility had attempted to reach the physician without success, progress notes lacked evidence of any attempts to notify the physician. R148's medication administration note dated 9/21/19, at 2:41 a.m. indicated R148 was administered [MEDICATION NAME] for fever of 100.2. No reassessment of medication effectiveness was documented until a follow-up note at 5:33 a.m. indicated the medication was effective and the temperature had come down to 97.9 degrees F. R148's medication administration note dated 9/21/19, at 4:38 p.m. indicated R148 was administered [MEDICATION NAME] for a fever of 100.8 F. A follow-follow up note documented at 7:36 p.m. indicated the medication was effective with a pain score of zero, but did not identify the resident's temperature. R148's skilled nursing note dated 9/21/19, at 9:16 p.m. included, has been running a fever off and on; when temp (temperature) is elevated resident is confused. Summary/Additional Information section included, Resident has been running a fever last 24 hours, becomes afebrile with APAP ([MEDICATION NAME]) and cool wash clothes applied to forehead. Started 72 hr (hour) diary for suspected UTI (urinary tract infection). Resident complained of urgency and some burning sensation when voiding. R148's record continued to lack evidence of physician notification even though R148 continued to have increased temperature, change in cognition, and signs/symptoms of urinary tract infection. R148's medication administration progress note dated 9/22/19, at 5:42 a.m. indicated R148 was administered [MEDICATION NAME] for temperature of 102.0 F. R148's record indicated the effectiveness of the medication was not reassessed until 8:15 a.m., more than two hours later. The follow-up note at 8:15 a.m. included medication ineffective Resident's current temp is 102.0 F. R148's medication administration progress note dated 9/22/19, at 1:45 p.m. indicated R148 was administered [MEDICATION NAME] for temperature of 101.5 F. The record lacked any evidence of additional assessment of medication effectiveness until 4:20 p.m. that same day. The progress note at 4:20 p.m. included: Resident fever not breaking. Ice packs under arms. APAP administered, resident was confused and appeared to be weak. Discussed with wife the option of sending to ER (emergency room ) for evaluation. Wife agreed. A follow-up progress note at 4:45 p.m. indicated R45 was transferred to the hospital. A progress note dated 9/22/19, at 9:36 p.m., indicated the facility had been notified by the hospital R148 had been admitted to the hospital for treatment of [REDACTED]. R148's hospital Discharge Summary note dated 9/27/19, indicated R22 was admitted to the hospital on [DATE], with [DIAGNOSES REDACTED].Coli. The summary included: (R148) presented to the emergency room with a fever and cough that started two days prior (9/20/19). The highest the patient's temperature has reached was 105 degrees, Wife reports that nursing home staff did notice that he had foul-smelling urine, in the ER UA (urinalysis) was positive. Urinalysis came back with E. coli with multiple resistants. The note further indicated R148 required treatment with antibiotics, [MEDICATION NAME] (antibiotic), later switched over to Bactrim (antibiotic). During an interview on 10/3/19, at 12:02 p.m. registered nurse (RN)-B stated she had not worked the weekend R148 got sick. However, RN-B stated the physician should have been notified of R148's fever on 9/20/19. RN-B reviewed R148's record with the surveyor and verified nursing progress notes from 9/20/19, did not identify interventions and/or any further assessments when R148's fever was identified. RN-B stated she would have completed further assessments and tried to identify the cause and/or assess for other signs and symptoms of infection. During an interview on 10/3/19, at 12:23 p.m. registered nurse (RN)-C stated she was the nurse manager for the transitional care unit. RN-C stated she had not been notified of R148's change in condition on 9/20/19, when R148 developed fever, nor when it was ongoing and R148 had a change in cognition, and symptoms of urinary tract infection. RN-C stated there had been ongoing communication problems related to inconsistent staffing and the use of temporary agency nurses. RN-C reviewed R148's record with the surveyor and confirmed the physician was not notified but should have been. RN-C further confirmed the record lacked evidence of any further evaluation of R148's fever and/or other signs/symptoms of infection until late 9/21/19. RN-C stated she would have expected nurses to have looked at R148's new incision and assess for signs of urinary tract infection and complete documentation of all assessments and evaluations. In addition, RN-C verified R148's record lacked evidence of medication administration of [MEDICATION NAME] for fever control on 9/20/19, which should have been administered per physician order. During an interview on 10/4/19, at 2:52 p.m. the director of nursing (DON) stated the physician should have been notified of R148's elevated temperature on 9/20/19, and stated nursing should have assessed and evaluated the elevated temperatures further, and documented all assessments/evaluations and interventions. The facility's 6/2014 policy Urinary Tract Infections/Bacteriuria-Clinical Protocol, included: . 2) Staff and practitioner will identify individuals with signs and symptoms suggesting a possible urinary tract infection. a) Nurses should observe, document, and report signs and symptoms in detail and avoid premature diagnostic conclusions. Non pressure related skin issue During an observation and interview on 9/30/19, at 7:10 p.m. R32 sat in his wheelchair with family member (FM)-D at bedside. R32 was observed to have an [DEVICE] on his left leg. FM-D stated he had visited R32 almost daily since admission. R32 stated he had broken his leg and had surgery. R32 also stated after admission to the facility the left leg had become infected. FM-D stated before R32 was readmitted to the hospital, R32's leg had redness and warmth for a week prior to seeing a physician. FM-D stated he was seen by a facility physician first and then went to the orthopedic physician who put him on antibiotics. However, FM-D stated the leg continued to get worse. FM-D stated the day R32 was sent into the hospital he was despondent, lethargic, and had really low blood pressure. FM-D indicated R32 had been admitted to the hospital for [MEDICAL CONDITION], was septic, and also had a pneumonia component. FM-D then indicated he had concerns that R32's dressing changes were not being completed as prescribed by the orthopedic physician. FM-D stated when R32 had come back from the hospital, the dressing was only supposed to be changed once per day, however, they had that clarified at his next appointment, and an order was written for twice a day dressing changes. FM-D stated he has told nursing staff multiple times that the dressing changes were supposed to be done twice per day but they continued to only change them once a day. R32's facility Admission Record dated 10/4/19, indicated R32 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R32's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R32 did not have cognitive impairment, the primary [DIAGNOSES REDACTED]. The MDS indicated R32 had surgical wounds required surgical wound care, application of non-surgical dressings, and applications of ointments/medications to area(s) other than to his feet. R32's MDS dated [DATE], included the aforementioned information as well as a [DIAGNOSES REDACTED]. R32's pressure ulcer/injury Care Area Assessment (CAA) dated 9/12/19, included: Resident has 5 surgical pins on left lower extremity. Dressing changes to these areas are being done twice daily. Areas are healing well with no signs of infection noted at this time. Skin is otherwise intact. Staff will monitor skin and report changes for further evaluation/intervention/treatment as appropriate. R32's baseline care plan dated 8/30/19, indicated R32 had a potential for impaired skin integrity related to left leg [DEVICE], with the associated goal that R32 would be free of any skin-related infection by the end of the review date. The interventions included daily treatments to left leg fixator pins and observe for signs/symptoms of infection and report to the MD. R32's physician orders [REDACTED].>[MEDICATION NAME]-Pot (potassium) Clavulanate (an antibiotic) give one tablet two times a day for 5 doses for respiratory infection until 9/19/19 (start date 9/17/19, end date 9/19/19). Wound care: Pin site dressing change daily on the evening shift. Cleanse pin sites with [MEDICATION NAME] solution or peroxide daily. Apply Xeroform petroleum gauze to pin sites. Cover with 4 x 4 gauze and cling and ace wrap. (start date 8/30/19, end date 9/5/19) Wound care: Cleanse left lower leg pins with [MEDICATION NAME], apply Xeroform gauze to each pin cover with Kerlix change twice per day (start date 9/6/19, end date 9/17/19) Wound Care : Apply Xeroform gauze over the [DEVICE] holes once a day and cover with gauze pad one time a day (start date 9/18/19, end date 10/2/19) R32's Clinic Referral visit form dated 9/26/19, included an order to change the dressings on the left lower extremity twice per day. R32's record lacked evidence the order had been transcribed into the electronic medical record and implemented. Information regarding this was requested, but was not provided. R32's (MONTH) medication administration record (MAR), indicated only 4 of the 5 doses of the [MEDICATION NAME] were administered. R32's record did not address why the 5th dose was omitted, and lacked evidence of physician notification or change in order. R32's progress notes were reviewed; progress notes indicated R32 developed signs and symptoms of infection in the left lower extremity and the physician was not immediately notified. Progress note dated 9/5/19, indicated R32 was seen by the orthopedic surgeon who gave an order to change the dressings to pin sites twice daily. The note also indicated that R32 was not feeling well and the nurse was unable to obtain a blood oxygen saturation. Further the note indicated the nurse was unable to auscultate lung sounds in the lower lobes, and was only able to auscultate minimal air exchange in the upper lobes. A progress note dated 9/6/19, indicated the nurse was unable to obtain blood oxygen saturations. The progress note did not address lung sounds. A progress note dated 9/6/19, indicated R32's left lower extremity dressing was changed per physician order, and described as: Drainage noted from the pin site to the inside of the heel. The note indicated R32 tolerated well. Progress note dated 9/7/19, at 12:25 p.m. included Changed dressing to left leg. Five pin sites and scabbed area on top of foot, cleansed with [MEDICATION NAME]. Applied Xeroform to pin sites, covered with split dressing, wrapped with Kerlix and covered with Ace wrap. Pin sites had minimal drainage, some blooded (sic) noted on the drainage pad from the second pin site down from the knee and on the pin site to the inside of the left heel. Scabbed area on top of foot is a light red in color. Will monitor over the weekend. Progress note dated 9/7/19, at 9:31 p.m. included, left leg shin is very red and warm to touch. Request NP (nurse practitioner) look at leg on Monday. Pin sites look good, drainage from pin site to the inside of heel and also from the second pin site down from knee. Progress note dated 9/8/19, at 7:21 a.m. indicated Tylenol was administered for temperature of 101.4. A subsequent note at 9:51 a.m. included Effectiveness a little better, fever down to 100.4 Progress note dated 9/8/19, at 12:00 p.m. included, scabbed area on top of foot is red and left shin is reddish and warm to touch. No complaints of shortness of breath, respirations were after transferring to bed from wheelchair. Resident not feeling well this morning complained of body chills and aches. Temp was 101.4, Tylenol was given. Temp has steadily decreased since taking Tylenol. Progress note dated 9/8/19, at 9:56 p.m. included pin site directly below knee had small amount of drainage, pin site to inside left heel had small amount of drainage. Pin sites are pink. Wound on top of left foot is still red, marked boarder of red area to determine if irritation is getting bigger. The note also included, antibiotic ointment was applied to the area on top of the foot. Progress note dated 9/9/19, at 12:55 p.m. indicated R32 was seen by the nurse practitioner (NP) who had recommended R32 be seen by orthopedic surgeon. A subsequent progress note indicated R32 was seen by the orthopedic surgeon who prescribed another antibiotic, Keflex 500 milligrams every 6 hours. Progress notes dated 9/12/19, at 2:56 a.m. progress note indicated R32 was having significant pain in left foot and leg. A subsequent note at 7:12 a.m. indicated R32 had an appointment with orthopedic surgeon, experienced a near miss fall and R32 had to be lowered to the floor. A subsequent note at 12:07 p.m. indicated R32 would be admitted to the hospital. The hospital note dated 9/13/19, at 3:10 p.m. included: When (R32) was admitted on [DATE] he was very sick. (R32) was unresponsive and they had to put in an art (sic) line and a central line. (R32's) hemoglobin was 6.5 and he was given 1 unit of blood. (R32 is receiving IV (intravenous) antibiotics and fluids. They are not sure the source of the infection, possible [MEDICAL CONDITION]. R32's After Visit Summary dated 9/17/19, indicated R32 had been admitted to the hospital [MEDICAL CONDITION]. In addition, R32 was found to have concerns including: failed outpatient [MEDICAL CONDITION] treatment, acute [MEDICAL CONDITION], hypertension, [MEDICAL CONDITION] and was admitted to the intensive care unit. The note [MEDICAL CONDITION] was possibly from left leg [MEDICAL CONDITION] (caused by skin scratch over left shin) and unlikely from the hardware. The associated Discharge Summary physician note, identified the admission [DIAGNOSES REDACTED]. Orthopedics was consulted and did not feel that it was related to the hardware and that was not discontinued. R32's record was reviewed from 9/17/19 through 10/2/19, lacked skin evaluations, evaluation of antibiotic effectiveness, and evidence of monitoring for signs and symptoms of infection. During an interview on 10/2/19, at 2:38 p.m. registered nurse (RN)-B stated R32 received once a day dressing changes to the left leg. RN-B stated after R32 was readmitted from the hospital the orders were changed from twice a day to once a day per the hospital discharge summary. RN-B stated after admission to the facility, R32's pin sites were not draining very much, RN-B reviewed the progress notes and stated the physician should have been notified when R32 started to show signs/symptoms of infection and should not have waited until the NP would be in the facility. RN-B reviewed the physician visit form and confirmed the physician had written an order to clean R32's pin sites twice a day. During an interview on 10/2/19, at 2:40 p.m. RN-C reviewed R32's progress notes and stated, the physician should have been notified immediately when the nurse saw changes to the pin sites and for sure when his symptoms worsened with fever. A progress note dated 9/7/19, only indicated a request for R32 to be added to physician rounds. During a subsequent interview on 10/2/19, at 3:03 p.m. RN- C stated the physician should have been made aware on 9/7/19, when the resident's shin was noted to be red and warm to touch. RN-C stated a request was made for the NP to see R32 on Monday 9/9/19. RN-C stated she had not been aware of the scratch noted on the hospital discharge summary that was a potential cause of the [MEDICAL CONDITION]. Further, RN-C stated any resident skin impairments were to be assessed, monitored and documented. RN-C reviewed R32's MAR and confirmed there was an antibiotic dose omitted. RN-C also stated when a resident was receiving antibiotics for skin issues, nurses were supposed to evaluate for effectiveness of the antibiotic, and document details of the resident's skin integrity. RN-C reviewed the physician order [REDACTED]. RN-C stated she would would seek order clarification. R32's physician orders [REDACTED]. During an observation and interview 10/3/19, at 11:11 a.m. R32 was laying in bed and FM-D was sitting at the bedside. RN-B entered the room and explained to R32 she was going to complete his dressing change. RN-B informed R32 and FM-D the dressing change was changed to twice a day. FM-D stated he had been telling staff that since the order was written on 9/26/19, and stated those directions were on a piece of paper that came back from the doctor's office. During an interview on 10/4/19, at 3:55 p.m. the director of nursing (DON) stated she expected staff were expected to implement physician orders [REDACTED]. The DON stated she further expected staff to document evaluation of antibiotic effectiveness, and stated if there had been a scratch with signs/symptoms of infection, that should also have been documented. The facility's 10/2010 policy Wound Care, included: 1) Verify there is a physician's orders [REDACTED]. 5) Any change in the resident's condition 6) All assessment date (wound bed color size, drainage) obtained when inspecting the wound . Reporting: 1) Notify the supervisor if the resident refuses wound care. 2) Report other information in accordance with facility policy and professional standards of care. [MEDICAL CONDITION] During an observation and interview on 9/30/19, at 3:50 p.m. R151 sat in her wheelchair in her bed with her feet dependent (down). R151 had low stretch wraps on up to her knee; R151 legs were observed to be [MEDICAL CONDITION]. R151 stated when she was discharged from the hospital she had been wearing compression stockings that came up to her thigh, however her legs became more swollen, and the stockings become too tight and they hurt so bad. R151 stated they finally they got the wraps. R151's facility Admission Record dated 10/4/19, indicated R151 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R151's hospital discharge summary dated 9/13/19, indicated on 9/12/19, included No extremity [MEDICAL CONDITION] R151's admission Nursing assessment dated [DATE], included, has significant amount of [MEDICAL CONDITION] with noted pitting +1 on the top of her foot. In section 31. Venous, [MEDICAL CONDITION] was checked and where the assessment asked to Specify location/pitting ect: response was Bilateral legs from the knee down. Non-pitting. R151's admission Minimum Data Set ((MDS) dated [DATE], indicated R151 did not have cognitive impairment, required extensive assistance from one staff for dressing, and weighed 145 pounds. The MDS also indicated R151 did not use a diuretic medication. R151's dehydration and fluid maintenance Care Area Assessment (CAA) dated 9/26/19, included Resident also had redness and swelling noted to lower extremity so [MEDICAL CONDITION] could be a possibility. As well and indicated at the time of the assessment R151 did not display symptoms of dehydration. R151's care plan dated 9/30/19, included R151 had [MEDICAL CONDITION] with a goal of having no signs and symptoms of complications related to fluid overload. The care plan directed staff to monitor/document/report as need the following signs and symptoms: [MEDICAL CONDITION], weight gain of over 2 pounds. R151's cardiovascular care plan dated 9/20/19, included monitor/document/report as needed any changes in lung sounds on auscultation, [MEDICAL CONDITION], and changes in weight. R151's physician orders [REDACTED].>-Compression stockings on in the morning to help with swelling off at night (start date 9/20/19) -Bilateral lower extremity ace wraps to knees every morning and off at night every day to for [MEDICAL CONDITION] (start date 9/25/19.) R151's weight record was reviewed; the record indicated 8.9-pound weight gain. -9/13/19, weight was 244.7 lbs. (pounds) -9/23/19, weight was 253.6 lbs. R151's record lacked evidence of physician notification of the weight gain and consistent monitoring/evaluation of [MEDICAL CONDITION]. R151's progress note indicated the first time [MEDICAL CONDITION] was mentioned was on 9/18/19, note indicated R151 had 2+ [MEDICAL CONDITION] to both lower legs and feet. R151's progress note dated 9/20/19, indicated R151 was seen by orthopedic surgeon for follow up appointment; new orders included compression stockings daily to help with swelling. R151's progress note dated 9/21/19, indicated stockings were not applied because they needed to be ordered. R151's progress note dated 9/22/19, included non-[MEDICAL CONDITION] to bilateral lower extremities R151's progress note dated 9/23/19, included no signs of [MEDICAL CONDITION] R151's progress note dated 9/24/19, included no [MEDICAL CONDITION] a subsequent note indicated compression stocking were no applied, in Ace wraps until compression stockings come in, they have been ordered. R151's progress note dated 9/29/19, indicated compression stockings were not applied. R151 declined them because digs into her leg. R151's progress note dated 10/2/19, included [MEDICAL CONDITION] noted to bilateral lower extremities a subsequent progress note at 12:14 p.m. included, declined compression stockings stated they hurt my legs, the note also included, bilateral legs swollen, non-[MEDICAL CONDITION], therapy notified and will re measure and order bigger size, Ace wraps applied. R151's progress note dated 10/4/19, indicated skin assessment had been completed on 10/3/19. Note indicated, bilateral chronic [MEDICAL CONDITION] to right lower leg, firm, non-[MEDICAL CONDITION] to right lower leg up to knee/ankle, 2+ [MEDICAL CONDITION] to right lateral side of foot, no signs/symptoms of [MEDICAL CONDITION], no weeping noted. Left leg chronic [MEDICAL CONDITION] from just below knee to ankle 2+ [MEDICAL CONDITION], left lateral foot 2+ [MEDICAL CONDITION], no signs/symptoms of [MEDICAL CONDITION]. Per 151 she does have history of chronic [MEDICAL CONDITION] also noted history of [MEDICAL CONDITION]. Refuses compression stockings because they are too tight, therapy measuring for a new pair. Ace wraps are applied however, she takes them off, encouraged to lay with legs elevated daily. Placed on daily weight monitoring for three days, weight down today at 237.2 pounds. During an interview on 10/3/19, at 11:53 a.m. (RN)-B reviewed R151's record and verified R151 had an weight gain. RN stated the physician should have been notified with the weight increase, supposed to notify if over 3 pounds in one day, however would not know that because R151 was not on daily weights. RN-B stated R151 had a lot of [MEDICAL CONDITION] right now. RN-B indicated she just talked to therapy today because R151 had [MEDICAL CONDITION] on the side of [MEDICAL CONDITION] and the right one is more swollen. RN-B indicated she had not notified the physician with the increase. RN-B stated [MEDICAL CONDITION] was supposed to be assessed and documented daily; documentation needed to be thorough so there is something to compare to. During an interview on 10/3/19, at 12:57 p.m. (RN)-C stated nursing staff were supposed to notify her when there were changes in a resident's condition. RN-C indicated she was not aware of the weight increase and staff should have first reweighed the resident and if it was accurate the physician should have been notified with the change. RN-C stated [MEDICAL CONDITION] should be monitored and documentation should include location and extent of [MEDICAL CONDITION], and also evaluated for a change in the [MEDICAL CONDITION]. During an interview on 10/3/19, at 1:22 p.m. the NP indicated Senior Care encouraged short term residents to keep their own primary physician. NP indicated that Senior Care did not take call after hours or on weekends. NP indicated Senior Service physician's did not typically see short term residents on a routine basis but would if requested to do so. NP indicated she was not notified when R148 had an elevated temperature, and was not aware of R151's increase in weight or [MEDICAL CONDITION]. NP indicated she was made aware of R32's changes to pin sites however, was not aware of how long he had been displaying symptoms. NP indicated if residents are showing signs/symptoms of a change in condition, nursing staff should notify a physician whether it be on-call service, primary care physician, or a physician with Senior Care. During an interview on 10/4/19, at 3:54 p.m. the DON stated R151 saw the provider on 9/25/19. The DON stated it was expected the physician would be notified of weight gain related to [MEDICAL CONDITION], and that [MEDICAL CONDITION] be monitored and evaluated consistently. The DON stated when R151 had a significant weight increase, there should have been further evaluation. R40's Admission Record, indicated an admission date of [DATE] and [DIAGNOSES REDACTED]. R40's After Visit Summary, dated 6/8/19, indicated, R40 was hospitalized from [DATE], to 6/8/19, with acute on chronic diastolic [MEDICAL CONDITION], with new orders for daily weights, low sodium diet, 1500 ml fluid restriction, and to call provider for weight gain over 3 lbs. in one day, or more than 5 lbs. over baseline weight. R40's physician progress notes [REDACTED]. (R40) was [MEDICATION NAME] in the hospital with 8 kilogram (kg) weight loss. (17.6 lbs.) Impression: [MEDICAL CONDITION]-weight is stable, continue present regimen, (R40) was changed from [MEDICATION NAME] to [MEDICATION NAME] and [MEDICATION NAME] 1 week ago, weight has been stable since. [MEDICAL CONDITION] not prominent while lying in bed with recent weight loss. R40's annual, Minimum Data Set (MDS) assessment dated [DATE], indicated R40 to have intact cognition. R40 needed extensive assist with most activities of daily living (ADL'S), received diuretics and oxygen therapy. R40's current, Physician order [REDACTED]. -1500 milliliter (ml) fluid restriction daily -oxygen via nasal cannula at 4 liters (L) per minute to keep oxygen saturations level 90 - 92% every shift, for shortness of breath (SOB) related to [MEDICAL CONDITION] with [MEDICAL CONDITION], -[MEDICATION NAME] (used to treat fluid retention and high blood pressure) 1 mg two times a day (BID) for diuretic therapy -[MEDICATION NAME] (used to treat high blood pressure and heart failure) 2.5 mg daily -[MEDICATION NAME] (used to treat high blood pressure and fluid retention) 12.5 mg daily. R40's care plan, revised 8/19/19, indicated a focus: The resident has nutritional problem .related to [DIAGNOSES REDACTED].Goal: The resident will maintain adequate nutritional status as evidenced by maintaining weight within 227 - 237 pounds (lbs.), through review date. Interventions: no added sodium diet (NAS) with 1500 ml fluid restriction, weigh at the same time of day and record any weight over 3 lbs., in one day or 5 lbs. in 1 week, If weight increases or decreases by 5 lbs. call the provider. Review of R40's care plan lacked a focus, goals, and interventions for R40's [DIAGNOSES REDACTED]. R40's medication administration record (MAR) for 10/2019, indicated R40 received [MEDICATION NAME], and [MEDICATION NAME] per provider order. R40's treatment administration record (TAR) for 10/2019, indicated the following order was monitored for any weight over 3 lbs. in one day, 5 lbs. over baseline weight, or if weight increases or decreases by 5 lbs. to call the provider. Further indicated f

Based on observation, interview, and document review, the facility failed to assess, develop and implement interventions consistently to reduce the risk of pressure ulcer development or decline for 3 of 3 residents (R22, R5 and R21) reviewed with pressure ulcers. R22 and R5 experienced harm, deterioration or persistence of pressure ulcers related to the facility's failures. Findings include: According to the National Pressure Ulcer Advisory Panel (NPUAP): Stage II (2) Pressure Injury includes: Partial thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. Stage III (3) Pressure Injury includes: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage IV (4) Pressure Injury includes: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Unstageable Pressure Ulcer includes: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. R22 According to R22's electronic health record (EHR) Admission and [DIAGNOSES REDACTED]., type 2 diabetes mellitus (DM2), [MEDICAL CONDITION] stage 3 (reduced ability of kidneys to remove excess fluids and waste from the body), [MEDICAL CONDITION] (excess fats such as cholesterol in the bloodstream which can result in arterial plaques), pressure ulcer of sacrum and an unspecified disorder of the circulatory system, coagulation and also [MEDICAL CONDITION]. In addition, a hospital summary of care document dated 9/16/19, indicated R22 had additional [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE], indicated R22 was totally dependent on staff to transfer and required extensive assistance from staff for repositioning. The MDS also indicated R22 was unable to stand, and did not walk. During an observation and interview at 6:28 p.m. on 9/30/19, R22 was seated in her wheelchair with a cushion under her however, she was also observed to be seated on a lift sling for a mechanical lift. The sling was observed to be wadded and tucked up between the resident's legs. R22's bed was noted to have a standard pressure reducing mattress. R22 stated she had a sore on her bottom and said the nurses were watching it. She stated she thought they might put salve or medication on the sore and said she thought they did a dressing change every few days. R22 said the nurses would look at the wound, but stated she could not remember a physician looking at her wound recently. R22 was unable to say how often she was repositioned in her chair but stated she thought it was quite often. At that time, R22 confirmed she had not had any assistance with repositioning since sometime prior to supper which she had at 5 p.m. R22 was unable to provide any further information about the size or severity of her wound, and stated she thought she had another wound, on her right heel, but could not provide any information about it. She was unable to recall why her left leg had recently been amputated. A review of R22's current care plan updated 7/12/19, included: ADL (activities of daily living)/FUNCTIONAL STATUS: The resident has an ADL self-care performance deficit d/t (due to) impaired mobility r/t (related to) Dx (diagnosis) of [MEDICAL CONDITION], [MEDICAL CONDITION], chronic lower extremity [MEDICAL CONDITION], Hx (history) of falls with subdural hematoma (bleed around brain). Hx of Foley catheter placement (a tube into bladder to drain urine). Hx of refusal to work with therapy. S/P (status [REDACTED]. TRANSFER: The resident requires extensive assist by 2 staff with use of Hoyer lift to move between surfaces every 2 hours and as necessary. Monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. R22's care plan had focus updated 9/20/19: SKIN INTEGRITY: Impaired mobility r/t Dx [MEDICAL CONDITION],Dx [MEDICAL CONDITION], gout, DM2, chronic lower extremity [MEDICAL CONDITION], Hx [MEDICAL CONDITION] to lower extremities . tends to lean to the left. Hx and current MASD (moisture associated skin damage) . refused alternating air mattress, frequently refuses interventions. Pressure injury to heel, left buttocks . Associated interventions included: follow facility policies/protocols for the prevention/treatment of [REDACTED]. Recent surgical debridement of wound to left buttocks-follow orders and participate in follow up appointments. Requires frequent explaining and encouraging to follow through with skin interventions. Teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes. Staff assist with repositioning every 2 hours and PRN. The care plan did not include any interventions related to laying down between activities, or building trust by returning to get R22 up in time to attend activities of her choice. According to a document in the EHR titled Weekly Ulcer/Complex Wound Observation Tool (WU/CWO Tool) dated 6/12/19, R22 had a pressure wound on her left buttock measuring 1.5 centimeters (cm) in length and 2.5cm in width and depth was marked as not applicable. At that time, R22 had a documented unstageable pressure ulcer on her right heel. The buttock wound was described as having 100% slough tissue and some clear yellow drainage. Additional information noted R22's buttocks had black/purple on the right side with some peeling skin and some maceration (moisture associated damage) from urine dribbling. A note within the document indicated as of 5/29/19, R22 was refusing pressure relieving interventions and was refusing to lay down. However, it noted R22 was on a turning and repositioning routine. WU/CWO Tools dated 6/20 and 6/23/19, included the same description of the left buttock wounds as documentation 6/12/19. A WU/CWO Tool dated 6/27/19, also included identical measurements as previous WU/CWO documentation that month, but also included: left buttock/sacrum ulcer stage 2 with 50% slough, 2cm by 1.5 cm by 0.25 cm, no odor. In addition, an additional wound was mentioned right buttock/inner thigh stage 2. Measurements for that wound were identified as 4.75 cm by 3 cm by 0.25 cm. 75% slough. A WU/CWO Tool dated 7/3/19 included identical measurements to previous WU/CWO Tool with the depth of the wound identified as na (not applicable). An evaluation note indicated the following measurements; left buttock sacrum ulcer stage 2, 50% slough, 2 cm by 1.5 cm by 0.5 cm (increased depth) and right inner thigh stage 2, 5cm by 3 cm by 0.5 cm, 100% slough. (increased length, depth and slough.) According to a MDS discharge assessment, R22 was hosptalized on [DATE]. An MDS tracking record showed R22 was re-admitted to the facility on [DATE]. A Skin Assessment (SA) document dated 7/12/19, indicated R22 had a stage 4 sacral ulcer with tunneling present 1 cm deep. The SA did not indicate where the tunneling was located, and indicated the wound measured 1.25 cm wide and 1cm in length. In addition, the SA indicate an area of 5 cm by 6.5 cm of redness and irritation. A WU/CWO Tool dated 7/15/19, included: 7/12/19: Hospital return left above knee amputation. No changes in interventions were documented on any of the WU/CWO Tools. Measurements in the evaluation portion of the document included: left sacrum ulcer 1 cm by 1.25 cm by 1 cm with 5 cm by 6.5 cm red irritation surrounding tissue. 75% slough with tunneling. No further description of the tunneling was provided. A WU/CWO Tool dated 7/30/19 contained new measurements sacrum, pressure, 1.4cm length by 2.4cm width by 1.6cm depth, stage 3 (stage three is a full thickness with loss of tissue but bone, tendon or muscle are not visible.) The WU/CWO Tool stated the wound was unchanged and did not indicate any tunneling. No special equipment or preventative measures was listed, but read R22 was on a turning and repositioning program. Under current treatment plan indicated resident often refuses to be in bed more and to turn from side to side and under area to describe changes in the treatment plan indicated, encouraged by staff to lie down for a short period after lunch. No further evaluation present. Although the tool indicated it was effective 7/30/19 it included documentation stating MD was updated 8/1/19 during weekly rounds. WU/CWO Tool dated 8/6/19, included the same pressure ulcer wound measurements with no additional interventions listed. WU/CWO Tool dated 8/13/19, also included the same wound measurements of the sacral area pressure ulcer, and also included the following: left buttock, pressure, unstageable with no measurements. The note also indicated the resident's family member was informed of changes on the resident's wound status and noncompliance with treatment plan. WU/CWU tool also included documentation to indicate the MD was notified of her condition during weekly provider rounds 8/15/19. No update in treatment plan or interventions was documented except Resident refuses majority of time. The director of nursing (DON) was notified of the worsening of the wound on the date of documentation. WU/CWO Tool dated 8/23/19 indicated the sacral wound was the same size. No documentation was included regarding the left buttock pressure area as previously documented, but contained the following information about a wound, site-left gluteal fold, type-pressure. No other measurements were included. No update to the treatment plan or interventions was listed even though the wound was marked as worsening. The evaluation included: sacral wound has worsened with increased drainage and odor noted. The document indicated the medical provider had been updated and an order received for a snap-vac wound drainage system. A skin assessment dated [DATE], indicated R22 had a stage 2-3 pressure injury on her right buttock, a stage 3-4 pressure injury on her left buttock and a surgical incision on her left knee. Documentation included, did not measure areas. Stage 3-4 pressure area has gotten bigger in diameter since last time author observed it. Large amount of foul smelling exudate present on dressing. Stringy slough coming out of wound with cleaning. Overall impression: worsening. No documentation included related to reporting to supervisor, medical provider or family. No documentation related to treatment, interventions or resident response to cares. A physician's office visit note dated 9/4/19 stated R22's primary problem at the time was a sacral decubitus ulcer. The note indicated family member (FM)-C attended the visit and informed physician the wound vac was only placed over one wound, but R22 had two wounds. The note further indicated the physician was unable to look at the wound because R22 required a mechanical lift to lay her down, and no such lift was available at the clinic. The note indicated a referral had been made to Senior Services so R22 could be seen by the medical providers that make rounds at the facility. The following statement was included, advised patient and the nursing home staff on frequent repositioning. A skin assessment dated [DATE], indicated R22 had a slit in her abdominal fold, an excoriated area around her whole buttocks area left and right and a wound on her left buttock measuring 8 cm by 8.2 cm and 3 cm deep. Additionally, the left heel wound was identified as having a 32 (sic.) cm red area on the heel. This document stated her wound was unchanged but very tender to touch. There was no documentation related to treatment, interventions or resident response to cares. There was also no documentation related to reporting the condition of the wound to the medical provider or family identified. A skin assessment dated [DATE], indicated R22 had a stage 4 wound on left buttocks near coccyx with wound vac. No measurements or other description were included, but documentation indicated the wound was improving. There was no documentation related to treatment or interventions found. There was also no documentation related to reporting the condition of the wound to the medical provider or family was included. No additional WU/CWO Tool was found from 8/23/19 until one dated 10/2/19, which indicated R22 had a pressure wound on the coccyx measuring 9 cm in length, 5 cm wide and 6.4 cm deep, which was identified as a stage 4 pressure ulcer. The document indicated the physician had last been updated 9/23/19 during an appointment. During interview on 10/2/19, at 3:28 p.m., registered nurse (RN)-A stated she had already completed R22's wound care for the day. RN-A described the wound as really deep, you can see bone. RN-A stated she'd had to contact the equipment provider of the Snap-Vac wound vac system because the sponge was no longer filling the wound and the system wouldn't seal correctly. RN-A also said they needed to get larger vacuum canisters for the system because it was draining so much. RN-A stated she had just learned that week, that she was supposed to do wound assessments and measurements on a weekly basis. However, RN-A said she had not done measurements because R22 had recently been to an appointment and the wound had been measured at the appointment. RN-A was unable to provide a copy of that report stating I don't know where I put it. I left it here on the desk last night so I could get back to it when I came in today. During interview on 10/3/19, at 7:37 a.m., RN-A stated R22 had been in the hospital for about a week in (MONTH) because of her sacral ulcer, and had returned without any new recommendations. RN-A stated the hospital had recommended R22 be encouraged to lay down, but RN-A said R22 refuses to lay down because she doesn't want to miss any activities. RN-A said she had placed the new wound vac system yesterday, but had concerns because the suction tube came out very close to the wound. Finally, RN-A stated she had not checked R22's dressing yet that morning because R22 was already dressed and was not patient to wait. According to an interview 10/3/19 at 7:57 a.m., RN-E who was the nurse manager, stated it was expected the nurse would look at resident wounds every day. RN-E stated staff should educate residents about interventions that will help with healing, such as repositioning and laying down. RN-E also said they should refer patients to occupational therapy for further recommendations regarding use of cushions and special mattresses, and a nutritional consult should be conducted to see if any nutritional supplements should be added to promote improved healing. During an interview on 10/3/19, at 11:16 a.m., R22 stated she couldn't remember what things she could do to help her bottom heal. She stated she could not remember if anyone had talked to her about the importance of pressure relief for her wound to heal. She did not think anyone had told her that continued pressure to her wound might be dangerous to her health. She did not remember having ever refused a pressure relieving mattress, stating, I don't know why I wouldn't want that. R22 said she would probably be willing to lay down if they made sure to arrange it around the activities she wanted to attend. R22 was able to remember what activities were happening and the approximate time to attend. A continuous observation for repositioning was initiated 10/3/19 at 11:16 a.m. R22 was taken to the dining room in her wheelchair at 11:20. At that time, nursing assistant (NA)-F stated she was a float staff so she was not exactly sure how often R22 should lay down. NA-F added, they ask after lunch and breakfast, I'm pretty sure. However, NA-F said she had not asked R22 to lay down that day because she hardly ever worked with R22. NA-F stated she was on her way to take R22 to the dining room because R22 liked to go to lunch at that time. At 11:30 a.m. R22 was seated at the table waiting for her meal. At 11:45 a.m. she received her meal. R22 was noted to lean slightly to her left while sitting in the chair, sitting more heavily on her left buttock. At 12:00 p.m. R22 remained in the same position and had not made any attempts, or been reminded, to reposition herself or to shift her weight from her left side. At 12:14 p.m. R22 had finished drinking all of her fluids and had eaten about half of her meal. Her position remained unchanged. At 12:19 p.m. trained medication aid (TMA)-C approached R22 to see if she was done eating. TMA-C then took R22 to her room and parked her wheelchair in front of the television without repositioning or offering to assist R22 to lay down or off load. TMA-C left the room after telling R22 she would return in a little bit. At 12:30 p.m. R22 remained in her room and had not changed position or shifted her weight. At 12:40 p.m. there was no change. At 12:47 p.m. TMA-B entered the room with medications. TMA-B chatted with R22 about his (TMA-B's) schooling and when he would be working again and left the room. TMA-B had not offered any repositioning and R22 remained in the same position. At 12:48 a therapist entered the room and chatted with R22 about crafts, dogs, R22's past work history and about R22's leg. The therapist left the room at 1:03 p.m. after asking R22 if she needed anything. R22 was not repositioned or asked if she would like to lay down. At 1:13 p.m. TMA-C returned to the room and said, do you want to lay down? R22 talked about activities. TMA-C said it would be good for your bottom (to lay down). R22 mumbled and TMA-C left the room at 1:14 p.m. R22 remained in her wheelchair in the same position. At 1:19 p.m. TMA-A was in the area passing meds. At that time, when questioned, TMA-A stated staff were to offer the resident repositioning every two or four hours. TMA-A stated, If the doctor would tell her she needs to lay down, I think it would help. TMA-A said it was the responsibility of the nursing assistants to offer repositioning and confirmed that he had not asked R22 about laying down or repositioning either. R22 at that time remained in her room with no change in position. At 1:23 p.m. TMA-C was interviewed and said she had asked R22 twice to lay down. TMA-C stated R22 was supposed to be repositioned every two hours, but added, she refuses a lot. TMA-C stated at those times, she would normally return in five to ten minutes to lay her down. Then TMA-C added, I just asked her and she agreed to lay down, but everyone is busy and I'm going on break. TMA-C said she had reported this to the director of nursing (DON), and then TMA-C left for her break. R22 remained sitting in the same position in her room. According to an interview 10/3/19 at 1:32 p.m., the DON stated staff were expected to follow a resident's care plan for repositioning. In the case of R22 who may be resistant to repositioning, the DON stated, My expectation would be for staff to educate the resident on the importance of laying down or off-loading. The DON also stated she would expect staff to work with the resident to provide repositioning in a way that would best fit the resident needs and preferences. The DON said she was aware R22 was afraid she would miss activities if she laid down so she expected staff to make sure R22 would have a schedule allowing her to lay down, but be up for activities. The DON also stated nursing staff needed to continue to provide R22 and other residents like her with continuous education about risks/benefits. The DON said education and efforts should be documented, and if a resident continues to refuse, this should be adequately documented. The DON said the facility was revamping their pressure ulcer monitoring process, The plan going forward is for the nurse manager to do follow-up assessments weekly. The DON described they had two different documentation tools for nurses to choose from, and stated the Ulcer Observation Tool should be completed weekly if a resident had a pressure ulcer. The DON also they had received an order to do pressure mapping so a new cushion could be developed for R22 to reduce pressure. However, the DON stated this had not yet occurred, but she thought it would be occurring soon. According to a telephone interview on 10/4/19 at 10:54 a.m., the registered dietician (RD) stated she conducted remote nutritional assessments for the facility once a month. The RD said she had no way to run any reports from the EHRs and was therefore, reliant on the resident lists provided by the facility's certified dietary manager (CDM). The RD stated she'd get a list that generally included the names of persons with weight loss, or skin issues, and said when she was made aware of a problem, she would review the weekly skin assessments in the resident's chart. The RD said this was the only way she would know if a resident had any skin issues. The RD further stated, I wouldn't be looking for anyone else (other than those on the list), I have to trust what they give me. When asked, the RD did not recall R22. However, after reviewing her notes the RD stated, I did not assess her in August. In (MONTH) I don't see her name on the list. July? Let me pull that up, nope, she is not on the list. RD confirmed that she had not done any assessments and had not written any notes on R22 in the last year. She stated any nutrition notes in R22's chart would have been completed by the CDM. When informed of R22's pressure ulcers, the RD stated R22's situation definitely warrants a nutritional consult. The RD stated due to R22's stage 4 pressure ulcer, her case should have been reviewed. The RD stated she would look at R22's oral intake, use of vitamins, and evaluate calorie and protein needs in relation to her intake, and assess her blood sugars. RD stated healing would be poor if BS was high. She also felt it would be important to check to see if she had adequate micro-nutrients for healing, such as zinc and vitamin C. Additionally, she would want to make sure R22 wasn't suffering from [MEDICAL CONDITION]. During an interview 10/4/19 at 11:18 a.m., the CDM stated she used to get a list of facility residents with skin issues every Tuesday, a risk management sheet. The CDM stated her protocol at that time had been to send those to the RD. However, the CDM said she was no longer getting such a list and said, now we have a morning meeting and generally there is nothing mentioned about skin. The CDM said sometimes she would get an email from nurse managers about skin problems and she would let the RD know about those issues as they arose. The CDM confirmed she was aware of R22's skin issues and had known for a long time. She was unable to remember how long it had been since R22's status had been reviewed by a dietician. CDM then stated, (R22) is very non-complaint with diet and repositioning. During a telephone interview 10/4/19 at 11:35 a.m., FM-C stated she'd been unaware R22 had a bed sore on her bottom until after R22 had been hospitalized to have her left leg amputated in (MONTH) 2019. FM-C stated she believed the hospital had discovered the sore upon admission and had initiated treatment. FM-C stated she was told the wound was looking good at that time. Further, FM-C reported R22 continued to receive treatments to the wound on her bottom after she returned to the nursing home and stated, It didn't seem to be getting better. FM-C said she felt the facility was slow to respond to changes and said she was NOT kept up on R22's status through routine reporting. FM-C stated, The facility should have made me more aware of (R22's) condition without my having to question them as to her status. After some time, I noticed (R22) had developed an odor and when I asked the nurses about it, I was told the wound looked awful. FM-C said when she asked the facility what they were doing for R22 they reported they had started a treatment involving a [DEVICE], but had stated the vacuum wouldn't stay on the wound. FM-C said RN-A had reported the wound did not look good at all and had recommended R22 be seen by a provider. FM-C said this recommendation had not occurred until she had reported the odor. FM-C stated after R22 went to see the medical provider 9/11/19, it was determined R22 had an infection in the wound that had reached the bone. During the telephone interview, FM-C stated she was aware that R22 would at times, refuse preventative interventions, such as laying down. FM-C said, R22 wanted to attend activities and family was supportive of this as she used to be very isolative. FM-C said she felt there was a need for R22 to develop trust with the staff as there had been times R22 had agreed to lay down if they would get her up for the activity, only to be forgotten or left in bed. FM-C stated she had observed this to happen recently, and had to question the nursing staff on why R22 had not been gotten up as agreed. FM-C said she thought the director of nursing (DON) was aware of the plan to educate R22, lay her down and get her back up again in time for activities. FM-C said R22 would often be compliant for a few days, but then would start refusing again. FM-C stated she still expected staff to continue to attempt interventions and provide reminders and re-education as to the importance of laying down and repositioning. FM-C also stated she thought the plan to lay down between activities was supposed to be in R22's care plan, as well as instruction to turn and reposition every two hours, but was unsure whether this routinely occurred. The facility's nurse practitioner (NP) reported during interview 10/4/19 at 4:19 p.m., she had not been following R22's case because R22 was being seen by her primary doctor at the clinic, so had not previously been seen on routine rounds by Senior Services. The NP futher stated Senior Services had recently been notified R22 had agreed to be seen by their service, but she herself had not seen R22's wound. The NP stated she remembered seeing a picture of the wound previously and had attempted to see R22 after being asked by primary physician, but R22 was unable to reposition herself and due to no staff assistance that day, the NP had been unable to see the wound. The NP stated staff were expected to keep medical providers updated with changes in wounds, but stated she had not been contacted immediately about R22 having a foul odor in her wound. The NP stated, They told me the next time I got here, and (R22) had to be sent to the hospital shortly after that. Additional record review included: R22's behavior summary reports indicated the following rejection of care documentation: Week Ending 10/3/19- one episode of rejecting care during a night shift only. Week Ending 9/26/19-one episode of rejecting care during a night shift only. Week Ending 9/12/19- no episodes of rejecting care Week Ending 9/5/19- one episode of rejecting care during a night shift only. Week Ending 8/29/19- no episodes of rejecting care Week Ending 8/22/19- no episodes of rejecting care Week Ending 8/15/19- no episodes of rejecting care Week Ending 8/8/19- one episode of rejecting care during a night shift only. Week Ending 8/1/19- no episodes of rejecting care R22's (MONTH) and (MONTH) 2019 treatment administration records (TAR) R22 had an order to reposition frequently, at least every 2 hours for excoriation to coccyx. The order start date was 3/7/19 and the stop date was 8/11/19. According to TAR documentation, in (MONTH) 2019, R22 was in the hospital from 7/3-7/12/19. Of the remaining dates, 7 opportunities for repositioning were not documented, and the remaining opportunities had a check mark. There was no indication of refusal of care documented. In (MONTH) 2019, 3 opportunities for repositioning were not documented, and for the remainder of the month there were no documented refusals of care. The (MONTH) and (MONTH) 2019 TARs also included: Encourage to lay down after breakfast or in the afternoon, at least for a half an hour. The order start date was 4/8/19 and the stop date was 9/7/19. In (MONTH) 2019, there were no documented refusals of care noted. Each opportunity was marked as having been done. In (MONTH) 2019, there were 6 opportunities for laying down out of 62 documented as refused. R22's (MONTH) 2019 TAR showed the order to lay down after breakfast or in afternoon was restarted 9/7/19, but was on hold during a hospitalization [DATE] to 9/16/19. Out of the remaining 36 opportunities, 8 were marked as refused and 20 were marked as no. There was no indication as to whether no meant the opportunity was not offered, or whether it indicated R22 had refused. No additional documentation was included on the TAR to demonstrate if staff had provided education to R22 about the risks related to refusing repositioning or laying down, nor did the TAR documentation indicate whether staff had re-approached R22 when she refused care. Finally, it was unable to be determined whether the resident's refusals of care had been communicated with the physician, staff leadership or to R22's family. The (MONTH) 2019 TAR no longer included directions to reposition the resident every two hours. A hospital discharge summary dated 7/12/19 stated an appointment had been made for seat mapping and wheelchair fitting. R22's EHR progress note dated 9/9/19, indicated it was a late entry but reported NP had visited resident at facility. Note said, Resident was in her wheelchair during the visit so provider was unable to examine the sacral decubitus. A progress note dated 9/11/19 at 11:17 a.m., indicated staff had reported an increased odor, and continual discharge from the sore near R22's rectum. A call was placed to the physician to request evaluation at the emergency department. According to a CT report dated 9/11/19- FINDINGS: There is a sacral decubitus ulcer with gas within fistula (a tunnel between tissues) tracking to the S5 posterior elements. There is [MEDICAL CONDITIONS] from phlegmon (soft tissue swelling within the body) surrounding the posterior sacrum and coccyx. There is new [DIAGNOSES REDACTED] (pathological destruction of bone) of the coccyx, implying osteo[DIAGNOSES REDACTED] (infection of the bone). According to a progress note dated 9/12/19 at 10:50 a.m., R22 was admitted to the hospital, was diagnosed with [REDACTED]. R5 R5's undated Admission Record included Diagnoses: [REDACTED]. R5's quarterly MDS assessment dated [DATE], included a brief interview for mental status (BIMS) score of 14 indicating R5 was cognitively intact. The MDS further indicated R5 required extensive assist of two with bed mobility and t (TRUNCATED)

Based on observation, interview and record review, the facility failed to assess, develop and implement appropriate patient-centered interventions, to prevent and/or reduce the likelihood of future falls for 1of 3 residents (R23) reviewed for falls. This resulted in actual harm for R23 who experienced falls and sustained a right hip and sacrum fracture; In addition, the facility failed to develop and implement interventions to prevent accidents related to smoking for 1 of 1 resident (R152) reviewed for smoking. Findings include: R23's Admission Record identified an admitted [DATE], and included [DIAGNOSES REDACTED]. R23's care plan revised 2/5/19, included: Fall/Safety Risk-History of left pubic fracture secondary to a fall. Impaired cognition/dementia, known to self-transfer, [MEDICATION NAME] degeneration, and [MEDICAL CONDITION]. Does not remember to use the call light for assistance. History of using the over bed table as a walker. The goals for the resident included: will be free of falls through the review date. Interventions included: be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, every 2 hour assist to the bathroom and PRN (as needed), anticipate needs as able, follow facility fall protocol, lay down in bed in afternoon as resident requests, bed in lowest position, routine safety checks with increased restlessness, auto lock brakes to the wheelchair, no over the bed side table in room, gripper socks on while in bed, contoured mattress, assist to the bathroom at 4 am, do not leave resident alone in room when up in chair, encourage resident to be up in wheelchair in common area per therapy for safety. R23's Morse Fall Scale dated 5/20/19, identified a score of 80, indicating the resident was at high risk for falls. The following risk factors were identified: has fallen before, more than one diagnoses, ambulatory aide used walker, weak gait-stooped but able to lift head without losing balance and steps are short and resident may shuffle. Mental status-over estimates or forgets limits. This assessment identified risk factors, but failed to identify interventions to reduce fall risks. No further fall risk assessments were received when requested. R23's quarterly minimum data set (MDS) assessment dated [DATE], indicated R23 had severe cognitive impairment, was frequently incontinent of urine, required 2 person extensive assist with toileting, had experienced 2 or more falls with no injury, had experienced 1 fall with an injury, and had experienced no falls with major injury. R23's Incident Reports, Nursing progress notes, and Emergency Record from 7/20 to 8/4/19, included: On 7/20/19, at 7:00 a.m. R23 was found on the floor in the dining room. R23 stated a need to use the toilet. On 7/21/19, at 3:00 p.m. R23 was observed by a visitor to get up from bed and stand up next to the night stand by the bed. R23's left foot seemed to slide when she noticed the visitor, and R23 lowered herself down, sliding from the walker to the floor. When nurse entered the room, R23 was lying on her left side with a pillow under her head. R23 denied hitting her head, was continent of bowel and bladder, denied having to go to the bathroom, and had gripper socks on her feet. After the fall, staff documented R23 had a slightly reddened area noted on her spine that was blanchable, and documented the resident had sustained No injury noted, no pain noted. According to the incident report, immediate action taken included: examined head, arms, back, hips and legs. Vital signs completed and recorded. No new interventions were identified, and the care plan was not updated. On 7/22/19, at 4:22 a.m. R23 complained of right hip pain and was given Tylenol. On 7/23/19 at 8:13 a.m., R23 was seated on the toilet complaining of pain to right hip/posterior pelvic area. Two staff assisted R23 to stand with gait belt, R23 unable to bear weight to right leg without significant pain, so staff assisted R23 to bed. The notes indicated R23's right leg did not appear shortened or rotated, so Tylenol was administered and the MD was notified. On 7/23/19, at 8:19 a.m. the case manager from (name)Hospice was notified of the resident's fall and complaints of right hip/pelvic pain. The hospice case manager stated they only provide comfort care, so if the family wanted an X-ray it would be up to them. At 8:32 a.m., family member (FM)-C was called and notified of R23's pain, and inability to bear weight. FM-C requested R23 be sent in for an X-ray. At 8:41 a.m., an ambulance was called for transfer to the local hospital, due to no mobile x-ray available. R23's Emergency Department (ED) Provider Notes dated 7/23/19, at 9:23 a.m. included: Reason for visit: hip pain Patient presents to the ED via ambulance with complaints of inability to bear weight to ambulate after a fall 2 days ago. Patient is on hospice, but family is requesting an X-ray of right hip as patient has been unable to bear weight to ambulate. Assessment /Plan: X-ray reveals an inferior and superior rami (bottom most portion of the pelvis) fracture, with questionable right femoral neck (just below the ball of the ball-and-socket hip joint) fracture .will obtain a CT scan to further evaluate this. CT scan revealed no acute femoral neck fracture, but there is a superior inferior rami fracture and with this a non-displaced sacral (area above the tailbone) fracture. I have discussed this case with the orthopedic on-call and advised that the patient does not want surgery as she is on hospice. I did call them for recommendations on weight bearing and instructions at home. They recommend toe-touch weight bearing as tolerated, pain control, and stated they would like follow up in 2-3 weeks if the family desired .I advised the family and the nursing home to contact hospice services if she has breakthrough pain, at this time R23 is pain free. R23's CT Pelvis without IV Contrast results dated 7/23/19, included: Impression: 1. Acute, comminuted (producing multiple bone splinters) fractures of the right superior and inferior pubic rami extending into the pubic body and pubic symphysis. 2. No proximal femoral fracture. 3. Small non-displaced [MEDICAL CONDITION] sacral ala should be acute. On 7/23/19, at 10:22 p.m. the ED papers/instructions with follow up included: follow up with ortho in 2 weeks, continue to give extra strength Tylenol, if R23 requires something more please contact hospice services for recommendations. Pelvic fracture information attached. Hospice recommends Hoyer lift for transfers. On 7/24/19 at 1:14 a.m. new orders were identified by hospice: discontinue current scheduled and PRN Tylenol orders. Start the following: extra strength Tylenol 500 (milligrams) mg give 2 tabs twice a day for pain/fever. An additional 1000 mg daily prn for pain/fever. Fall intervention-wear gripper socks at all times to help in preventing falls. New hospice orders on 7/23/19: [MEDICATION NAME] concentrate 20mg/ml (milliliter), give 5 mg every 3 hours prn pain/shortness of breath. [MEDICATION NAME] 50 mg, give 1 tablet twice a day and every 4 hours for fracture pain. On 7/24/19, at 5:11 a.m. Tylenol 1000 mg given at 12:40 a.m., R23 did not want staff to leave the room. R23 was talking about wanting to die due to pain. [MEDICATION NAME] and [MEDICATION NAME] not here yet. R23 seemed to calm and go back to sleep. On 8/3/19, at 2:40 p.m. R23 was found by staff in bathroom on her knees with wheelchair behind her, was attempting to stand and get onto the commode. R23 had slid down to her knees and was facing the commode. She had some slight redness on her knees. According to the note, R23 stated she had wanted to go to the bathroom. No new intervention put in place at this time. On 8/4/19 at 4:10 p.m. R23 was seated in her wheelchair with the foot rests up next to the table in the dining area on Unit 4/5. R23 had previously been assisted with bowel care prior to going to the dining room. The notes indicate R23 was observed to constantly move in her wheelchair stating she wanted to go to the bathroom. Then R23 pushed herself from the table, and had a pillow under her legs on the leg rests. R23 pushed the pillow between the leg rests and attempted to scoot self onto the leg rests to try and stand. At that time, the wheelchair pedals tipped forward and R23 slid from the seat of the wheelchair to the foot rests, and slid onto her right arm. R23 sustained a 2 centimeter (cm) x 1 cm open area to the outside of her right elbow. Vital signs taken and R23 was assisted to the bathroom to have her brief changed. Following this fall, R23's wheelchair was taken away and a Broda-chair (tilt in space wheelchair) was initiated. According to document review, including nursing notes and incident reports, R23 sustained falls: 12/14/18, 1/3/19, 1/10/19, 2/5/19, 4/5/19, 6/10/19, 6/19/19, 7/10/19, 7/13/19, 7/20/19, 7/21/19, 8/3/19, 8/4/19, 8/24/19, and 9/28/19. Eight of the 15 falls were related to toileting, others were related to rolling out of bed or just being found on the floor. Many falls lacked interventions developed after the fall, and the care plan was not always updated or followed. During continuous observations on 10/3/19, it was identified the facility did not implement the care plan for R23 to include: every 2 hour toileting, and toileting after meals as fall prevention interventions. At 7:07 a.m. R23 was seated in a Broda chair in her room, nursing assistant (NA)-E was observed leaving R23's room carrying a clear garbage bag containing a disposable incontinence brief, and disposed of it in the soiled utility room. At 7:11 a.m. NA-E wheeled R23 from her room and pushed her up to the dining table on the 4/5 Unit, in the common area outside her room. At 7:28 a.m. R23 continued to be seated up to the table in her Broda chair with her eyes closed. At 7:38 a.m. R23 continued to be seated up to the table in her Broda chair with her eyes closed. At 7:43 a.m. R23 continued to be seated up to the table in the Broda chair. At 7:54 a.m. R23 continued to be seated up to the table in the Broda chair, with her eyes opened, and had a Kleenex in her right hand. At 7:56 a.m. NA-C walked by and stated to R23, Well you look wide awake today. R23 stated, Ya. At 8:06 a.m. R23 continued to be seated up to the table in her Broda chair. At 8:12 a.m. R23 was wheeled to the main dining room and brought to the table where 3 other residents were being assisted with eating. At 8:20 a.m. R23 remained seated at the dining room table. At 8:25 a.m. R23 remained seated in her Broda chair up to the table in the main dining room, looking around. At 8:36 a.m. R23 was served breakfast. R23 was independently eating her jellied toast. At 8:46 a.m. R23 ate all of her toast, took a drink of her thickened water, remaining beverages at the table remain untouched. At 8:56 a.m. NA-C walked up to R23 and asked, Are you working on your drinks? R23 stated, Ya. NA-C walked away and began removing the other residents from the table as they were done eating. R23 remained seated at the table with food to eat. At 9:04 a.m. NA-C wheeled R23 from the main dining room and back up to the table on the 4/5 Unit. NA-C brought R23 a glass of cranberry juice, set it in front of R23 at the table, and walked away. At 9:10 a.m. NA-C told NA-E she was going to take a break. NA-C then left the floor. NA-E was seated at the table where R23 was. At 9:18 a.m. R23 continued to be seated up to the table in her Broda chair, with her eyes closed. At 9:26 a.m. R23 remained in the same position. At 9:27 a.m. NA-C was back from her break, NA-E told NA-C she was going to take a break. At 9:32 a.m. when R23 was asked what she was going to do for fun today, R23 stated, Sleep and then started laughing. At 9:37 a.m. trained medication aide (TMA)-A brought R23 her morning medications and gave her a glass of water. At 9:46 a.m. NA-E was back on the floor from break, R23 continued to be seated in her Broda chair up to the table. During interview on 10/3/19, at 9:57 a.m. NA-C was asked the last time R23 had been offered help to the toilet. NA-C replied, I am not sure, I didn't get (R23) up today. During interview on 10/3/19, at 9:58 a.m. NA-E was asked the last time R23 was offered to be toileted and NA-E stated, I haven't had a chance to toilet (R23) yet, she is supposed to be offered every 2 hours. I last toileted her around 7 a.m. when I got her up this morning. During interview on 10/3/19, at 2:03 p.m. NA-C and NA-E stated, We usually have time to toilet (R23) when we first get her up before and after lunch. We don't have time to take her every 2 hours, we just don't have enough staff, and it has been this way since (MONTH) when they cut our staffing. During Interview on 10/3/19, at 2:53 p.m. family member (FM)-C stated, I think it was at the end of July, that (R23) fell and was unable to bear any weight on her right leg. A couple days later they called me and asked me what to do about it, so they sent her via ambulance, because they didn't have portable X-ray services. The X-ray wasn't clear, so they did a CT scan and found 2 fractures in the pelvis and a fractured sacrum. During interview on 10/3/19, at 2:54 p.m. FM-B stated, Why can't they just bring her to the bathroom when they are supposed to, then she won't keep falling. During interview on 10/4/19, at 12:05 p.m. the director of nursing (DON) stated, My expectation is residents should be truly evaluated for their toileting needs. (R23's) toileting plan was not personalized. The staff were not following the care plan. I am going to make a personalized care plan for her toileting. During interview on 10/4/19, at 12:42 p.m. with the administrator and director of nursing (DON), they verified R23's falls were not always evaluated for root cause, and verified new interventions were not always identified or put in place. On 10/4/19 at 1:20 p.m. the DON stated, I feel that staff members were attempting to provide the root cause analysis for most of the falls, and after doing the time line, there were quite a few interventions that were put into place. However, I feel like R23 has had a decline, and we have had to reassess the interventions as we go. A facility policy for Falls was requested but not received. Smoking During on interview on 10/2/19, at 11:29 a.m. R152 indicated she smoked cigarettes, and was aware the facility was a non-smoking facility. R152 stated she would sneak out and go smoke and would smoke 20 feet from the door and the nurses would come outside and get her. R152 stated facility nursing staff had not watched her smoke since admission. R152 stated she was capable of wheeling herself outside, opening the door, light and manage her own cigarette without burning herself, would flick her cigarettes into the parking lot, and while residing at the facility had not sustained any burns. R152 facility Admission Record indicated R152 was admitted to the facility on [DATE]. R152's adminision Minimum Data Set ((MDS) dated [DATE], indicated R152 did not have cognitive impairment. The MDS also indicated R152 required extensive assistance from one staff member for transfers and supervision for locomotion on and off the unit. R152's base line care plan dated 9/19/19, or partially completed comprehensive care plan dated 9/30/19, did not identify history of smoking or nicotine dependence. R152's record lacked evidence of a safe smoking assessment. R152's skilled nursing note dated 9/27/19, at 9:43 p.m. included resident, has been sneaking outside and asking residents family members to buy her cigarettes and asking them if she can smoke with them, did speak to her about this she did become angry and did say yes she has been doing that but will stop, explained that she is aware we are a non smoking facility and that she till chose to come here, did give this writer 4 cigarettes she had in possession from another resident. R152's skilled nursing note dated 9/28/19, at 1:08 p.m. included res (resident) went outside without supervision-found her on side door smoking. Res was cooperative and come in. reminded res of not able to be outside unattended and too close to facility. R152's communication nursing note dated 9/30/19, included This writer also reinforced the non-smoking policy to resident by explaining there is no smoking on the facility grounds with no exceptions. Nursing has reported that resident was seen smoking outside the front and side doors. Resident was notified of non-smoking policy by the SW (social worker) before admission at the acute care hospital and upon admission to the facility here. She verbally agreed to this however she has not been compliant with the non-smoking rules. Will continue to monitor. R152's behavior note dated 10/2/19, included resident has been offered nicotine patches and sum to help quit smoking but resident refuses. Resident has also been talked to by the unit manager who explained St. Mark Livings policy. The note indicated the interventions were not effective. During an interview on 10/1/19, at 9:32 a.m. registered nurse (RN)-B, indicated the facility was a non-smoking. RN-B stated R152 would sneak outside and smoke cigarettes, would not sign herself out or alert nursing staff, and has been provided education. During an interview on 10/4/19, at 3:14 p.m. director of nursing (DON) stated the facility was a non-smoking facility and R152 was aware of that prior to admission. DON confirmed a safe smoking assessment was not completed. DON confirmed R152's baseline care plan did not address smoking and should have. DON indicated R152 was capable of signing herself out of the facility and leave the property to smoke. Adminstrator indicated the admission paperwork included the rules of the facility which included that the facility was non-smoking. During a subsequent interview on 10/4/19, at 8:28 p.m. DON indicated currently the facility did not have a policy for non-smoking, the only policy Ecumen had was for smoking.

Based on observation, interview and record review, the facility failed to assess for safe transfers with the use of an EZ stand (mechanical lift) resulting in a fall with a skin injury and the risk of continued falls with injury which could cause potential serious harm, injury, impairment, or death to 1 of 1 residents (R1). This failure resulted in and immediate jeopardy (IJ) for R1. The immediate jeopardy began on 6/9/19 when R1 informed staff she had a fall during a transfer with an EZ stand, and reported her left hand was numb and she was afraid to use the EZ stand. The administrator and interim director of nursing (IDON) were notified of the immediate jeopardy on 6/21/19, at 9:47 a.m. The immediate jeopardy was removed on 6/23/19, at 3:15 p.m., but noncompliance remained at the lower scope and severity level of G-isolated, actual harm that is not immediate jeopardy. Findings include: On 6/19/19, at 2:35 p.m., surveyor entered R1's room with nursing assistant (NA)-C to observe a transfer with the EZ stand. R1 stated, I don't want it. I fell off it and that is how I got this (showed bandage on left forearm). I'm afraid of it. NA-C did not transfer R1 at the time. There was a large bruise on the top of R1's left hand. R1 stated, Yeah, that's from the fall. They said I would be all right. I said I could not hold on. I had my hand on the handle and she (staff person) had hers over mine holding it down. Somebody said she had a call and as soon as she let go of my hand, down I went. My hand is numb. I cannot hang on with it. R1 stated she did not want staff to continue to use the EZ stand, because I'm scared of it. During a follow up observation and interview in R1's room at 4:19 p.m on 6/19/19., NA-B stated R1 had told NA-B that she did not want to use the EZ stand. NA-B was heard to tell R1, (NA-B} will be with you. NA-B proceeded to apply the EZ stand straps around R1's legs. R1 looked at surveyor and stated, I don't want to use it, I don't want them to use it, I'm afraid. This machine could probably be the same machine. NA-B asked R1 if she were to get two people would she use the EZ stand to transfer. R1 stated, I'm afraid. Surveyor asked NA-B if she was still going to transfer R1. NA-B stated she would go get help. R1 stated, the day she had fallen she was standing up in the machine and she did not feel the strap around her waist, otherwise how would I have fallen. R1 also stated, I don't know if they did not have the strap tight enough, but something did not keep me up. At that time, the surveyor intervened and informed the IDON R1 was afraid to use the EZ stand for her transfer. At 4:28 p.m. on 6/19/19, the IDON entered R1's room. The IDON stated to R1, I understand you do not want to use the machine anymore. R1 responded, That's how I fell , I am afraid. IDON then encouraged R1 to try the use of a Hoyer lift (a machine using a lift sling to transfer). R1 stated, I will try the Hoyer if you promise it will hang onto me. During an observation at 4:34 p.m. on 6/19/19, when re-entering R1's room after obtaining the appropriate size sling and hoyer lift, the IDON stated to R1, Can we try to stand you with two people and a gait belt? R1 stated if you hold onto me, R1 again stated, I am afraid. The IDON said, Ok, we will use the Hoyer. The IDON, NA-C and trained medication aide (TMA)-A placed a sling underneath R1 while R1 was seated in her wheelchair. When lifting R1 with the sling, which was attached to the Hoyer lift, R1 stated, It hurts my legs, I am afraid. TMA-A stated, The sling is not in the right position and lowered R1 back down into her wheelchair. TMA-A stated,We have to get the sling underneath (R1's) hips more. R1 stated she did not want to use the Hoyer. At 4:40 p.m., the IDON again asked R1 if she would stand with two people using a gait belt. R1 was taken into the bathroom, a gait belt was placed around R1's waist by the IDON, and R1's wheelchair breaks were locked. R1 stated to the IDON, Do not drop me. The IDON stated, I won't drop you. The IDON and TMA-A asked R1 to hang onto the handrail in the bathroom and R1 stated, I cannot hang on with my left hand, because my left hand is stiff. The IDON and TMA-A stood R1 using the gait belt. R1's feet were observed to be dragging, and R1 was unable to bear full weight. R1's face was grimacing, and R1 stated, Oh! The IDON and TMA-A turned R1 around while bearing the full weight of R1, and sat R1 on the toilet with her pants remaining up. R1's walker was obtained and the IDON asked R1, Can you stand using the walker? The IDON and TMA-A assisted R1 to stand with the walker, but R1 was not able to hold onto the walker with her left hand and was unable to bear weight on her legs. The IDON and TMA-A had to sit R1 back down on the toilet with her pants remaining up. R1 stated, What am I doing wrong? The IDON reassured her stating, You are not doing anything wrong. The IDON asked R1 if she would use the EZ stand with two people assisting, with one person always holding your left arm. R1 agreed to allow the transfer with an EZ stand. During the transfer with the EZ stand R1 was observed to be unable to hold onto the EZ stand handle with her left hand. R1's Admission Record included [DIAGNOSES REDACTED]. R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R1 was moderately cognitively impaired with no rejection of cares. The MDS also indicated R1 needed assistance of two persons for transfers and toilet use, and she could only stabilize balance with human assistance. A Common Entry Point (CEP) Intake Form dated 6/17/19, identified an alleged perpetrator (AP) was transferring R1 to the bathroom using an EZ stand (mechanical lift). The CEP also indicated R1 had trouble with her hands and sometimes using the EZ stand. R1 told AP one of her hands was slipping and she was not going to be able to hold onto the handle. AP put a hand on top of VA's hand so VA would not fall. One of the staff outside of the room told AP she had a phone call. When this happened, AP let go R1's hand to answer the phone and R1's hand slipped off the handle and R1 fell off the EZ stand. Due to the fall, R1 received a large bruise on her left arm with a cut. A male nurse notified reporter after the incident. R1's care plan revision date 6/19/19, included a problem area under activities of daily living (ADL's) including: R1 has an ADL self-care performance deficit related to right total hip arthroplasty secondary to fall . Chronic Pain in bilateral lower extremities and left hand numbness. Transfers: Extensive assist of two with transfers. Use EZ stand and assist of one to two when unable to follow direction to participate in assist of two transfers. The care plan included a Fall/Safety Risks: R1 is at moderate risk for falls related to history of fall with fracture, impaired cognition and lack of safety awareness, intermittent confusion, medications in use, impaired mobility requiring extensive assist with mobility and transfers. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Anticipate and meet the resident's needs. Follow facility fall protocol. Physical therapy (PT) evaluate and treat as ordered or as needed (PRN). R1's progress notes included: On 6/6/19, at 7:25 p.m., licensed practical nurse (LPN)-B, noted resident has an older 5 x 4 centimeter (cm) bruise on the left forearm. When being assisted by two with the EZ stand to the bathroom, after she was sat down on the commode resident brought arm up and around the EZ stand arm. Resident scraped area of the bruise on the side of the connection point. This action caused the bruised area to become a 0.5 cm x 4 cm long skin tear. On 6/9/19, at 2:03 p.m., LPN-A, noted resident this morning would not sit on the side of the bed. She laid on the bed and cried that she was afraid because she fell with the EZ stand the other night and that was how she got the skin tear on her arm. She said that her left hand was numb, but her grasp was stronger in her left hand then the right. Staff had her hands on the grips holding her hands on. When staff turned her into the bathroom she let go with both hands. During interview on 6/19/19, at 1:20 p.m., trained medication aide (TMA)-A stated a week or so ago R1's arm was feeling numb, so her left hand was not holding the handle on the EZ stand well. During interview on 6/19/19, at 1:21 p.m., nursing assistant (NA)-E stated R1 was transferred using the EZ stand with assist of one. At 1:33 p.m., NA-E stated some days R1 does not hang onto the handles of the EZ stand or R1 will hang on with her right hand, but not her left hand. During interview on 6/19/19, at 1:24 p.m., NA-A stated R1 was transferred with the EZ stand with assist of one. NA-A stated R1's left hand will slip every once in a while. During interview on 6/19/19, at 1:44 p.m., family member (FM)-A stated a male nurse had called him a little over a week ago (unable to recall the exact date) to inform him R1 had fallen in the EZ stand. The nurse told me R1's left hand had slipped off of the EZ stand and R1 had fallen. FM-A stated R1's left hand had slipped because the staff person who had their hand over R1's left hand and had let go to answer a phone call. FM-A stated R1 had told the staff person her hand was going to slip. FM-A stated when staff let go of R1's hand she fell over to the side, almost onto the floor and had received a gash on left arm and a bruise. FM-A stated the Ombudsman (O)-D had been at a meeting for R1 yesterday (6/18/19) and they had discussed the fall. During interview on 6/19/19, at 2:24 p.m., O-D stated he had attended a meeting for R1 on 6/18/19, and the administrator, IDON, dietary director, activities director, R1 and FM-A were in attendance. O-D stated the administrator and IDON had not heard about the fall until the meeting. O-D stated R1 kept repeating the same story (fell when using the EZ stand, not able to hold on with left hand), no matter how many times she told the story. O-D stated FM-A had called him by phone the day prior to the meeting to inform him of the fall concern. During interview on 6/19/19, at 2:45 p.m., NA-B stated R1 was able to use the EZ stand with one or two assist depending on R1's response. NA-B stated about a week ago R1's left hand was not responding and R1 could not hold onto the handle of the EZ stand tight with her left hand. During interview on 6/19/19, at 2:49 p.m., LPN-A stated R1 transferred with one to two assist using the EZ stand. LPN-A stated when R1 was afraid, R1 does not do well with transfers. LPN-A stated some days R1 hangs onto the handles of the EZ stand well, but I have been in there (R1's room) when R1 does not hang on. LPN-A stated R1 had been afraid of the EZ stand for about a week. LPN-A stated early in the week, last week R1 stated she fell in the EZ stand. LPN-A said she could not find any documentation about the incident in R1 record. LPN-A confirmed she had documented the resident progress note dated 6/9/19. LPN-A stated R1 refused to sit up, as she was afraid to use the EZ stand. LPN-A stated she had informed registered nurse (RN)-A. LPN-A stated we did a hand over hand (staff placing their hand over the top of R1's hand) and got R1 into the bathroom that day using the EZ stand. During interview on 6/19/19, at 3:09 p.m., LPN-B stated he had been the nurse on duty 6/6/19, when R1 had received the skin tear to her left forearm. LPN-B stated R1 had bumped her left arm on the hook of the EZ stand and had received the skin tear, when staff had unfastened R1 from the lift. LPN-B stated he had called and informed FM-A of the incident. During interview on 6/19/19, at 3:20 p.m., NA-C stated R1 transferred using the EZ stand with one assist. NA-C stated R1 started having a limp left arm around the time R1 received the skin tear to her left arm. R1 has stated a few times she was afraid to use the EZ stand. During interview on 6/19/19, at 3:40 p.m., the administrator stated she had heard about the fall yesterday (6/18/19) during R1's care conference. The administrator stated during the care conference R1 had reported she was up on the EZ stand, felt her hand slip, a staff person had put their hand on top her hand and the staff person let go and R1 fell to the ground. The administrator stated from interviews with staff, the staff said R1 did not fall to the ground, but had flung her arm and that was how she hit her arm causing the skin tear. Administrator stated she was not aware of the resident progress note dated 6/9/19. Administrator said the nurse manager should have been notified, and depending on what the resident had reported, they would fill out the incident report. During interview on 6/20/19, at 9:11 a.m., IDON stated if a resident was not able to maintain a good grip on the handles of the EZ stand, staff should notify nursing leadership so they could get therapy involved for assessment. The IDON stated she became aware of R1 stating she had a fall in the EZ stand and complaining of not being able to hold on with left hand on Tuesday (6/18/19), during R1's care conference. Further, the IDON stated when a resident complains of being afraid to use a lift, staff should let the nurse know and try another means of transfer. The IDON stated when a resident tells staff they've fallen, an incident report should be completed with follow up to determine proper intervention are put in place. IDON stated for R1, staff should have filled out an incident report and interviewed R1 more so we could have followed up from the note dated 6/9/19. IDON confirmed last evening when IDON was assisting to transfer R1 with the EZ stand R1 was not able to hold tight with left hand on the EZ stand lift. During interview on 6/20/19, at 1:40 p.m., NA-F stated R1's left hand slips sometimes. During interview on 6/20/19, at 1:52 p.m., NA-A confirmed she had helped R1 on 6/9/19, when R1 had stated she'd fallen. NA-A stated R1 had put on her call light and wanted to use the bathroom. NA-A stated when she was going to transfer R1 with the EZ stand, R1 started freaking out and stated she was scared she was going to fall. NA-A stated R1 had reported she'd fallen and that was how she received the mark (skin tear) on her arm. NA-A stated R1 had laid back from sitting on the edge of the bed, was crying and kept saying I am going to fall. NA-A stated R1 pushed back and did not want to use the EZ stand. NA-A stated she had informed LPN-A and they were able to talk R1 into using the EZ stand. R1's physician orders [REDACTED]. R1's OT Plan of Care dated 6/20/19, identified reason for referral: per R1 was being transferred with use of EZ stand and fell during EZ stand transfer. R1 stated, My hand is numb. Underlying impairments identified for activity tolerance and standing tolerance. R1 demonstrated signs of fatigue at less than one minute. Dynamometer test (instrument for measuring the maximum isometric strength of the hand and forearm muscles, used for testing handgrip strength) identified grip for left hand was seven pounds and grip for right hand was 25 pounds. Precautions were fall precautions, left hand numbness, report of pain in left hand with movement and impaired left grip strength. R1's PT/OT/ST (speech therapy) Caregiver Recommendations sheet dated 6/20/19, indicated after the OT evaluation it was recommend R1 be transferred with use of a Hoyer (full body mechanical lift) for all transfers, with assistance of two, due to R1's inability to maintain left handgrip strength on EZ stand. R1 reports left hand pain and numbness, impaired left grip strength. During interview on 6/20/19 at 1:53 p.m., occupational therapist (OT)-E stated she had assessed R1 for use of the EZ stand with transfers. OT-E stated when she assessed R1 she noticed R1's left hand would slip off and R1 could not maintain a grip on the handle. OT-E further stated when she assessed R1's grip strength with a Dynamometer test, it identified R1's grip for left hand as seven pounds, with the grip for the right hand at 25 pounds. OT-E stated she saw weakness in the left versus the right grip and stated that R1 had told her (OT-E) her left hand was numb in the fingers. OT-E stated she had conducted a light touch sensation assessment, where she had R1 close her eyes and lightly touch each finger and had her say when she felt the touch. OT-E said R1 did not miss any on the right hand, but missed some on the left hand. In Addition, OT-E stated she stood R1 at the parallel bars, which she could do but required maximum assist of two people and her left hand did come off of the bar two times. She would move her hand back onto the bar but she could not maintain her grip very well. OT-E stated she recommend the use of the Hoyer lift for R1 at this time for safety, because R1 can not maintain strength. During interview on 6/20/19 at 2:51 p.m., NA-D confirmed he had worked with R1 on 6/6/19, when R1 had received the skin tear and cut. NA-D stated R1 had called and had wanted to use the bathroom. NA-D stated R1 was transferred with the EZ stand and one assist and when R1 was transferred the sling around R1's waist was secure and buckled, and R1's legs were secured with the leg strap. NA-D stated when he transferred R1 onto the toilet, R1 had weakness in her legs. NA-D stated when he started pushing the button on the EZ stand for R1 to be lowered, her legs became weak and she started to go down. R1's left hand slipped off of the EZ stand handle, hit the sling strap causing the skin tear to R1's left arm. NA-D went on to state that if the strap had not been fastened around her legs, when R1's legs started going down, she would have fallen. NA-D further stated he supported R1 when lowering R1 onto the toilet and called the nurse for help. The facility's undated policy for incident reporting included: An incident report is completed whenever an incident occurs. An incident is defined as an actual or potential injury to a resident. Incidents include, but are not limited to, an observed or unobserved fall, etc . As soon as possible after an incident, a licensed employee with knowledge of the incident completes a Report of Incident. The facility's 12/2013 policy Lifting Machine, Using a Portable, included: Reporting 1. Notify the supervisor if the resident refuses the care. 2. Report other information in accordance with facility policy and professional standards of practice. The facility's 12/2015 policy Acute Condition Changes Clinical Protocol, included: Assessment and Recognition . Direct care staff, including Nursing assistants will be trained in recognizing subtle but significant changes in the resident and how to communicate these changes to the nurse . Before contacting a physician about someone with an acute change of condition, the nursing staff will make detailed observations and collect pertinent information to report to the physician. The immediate jeopardy that began on 6/21/19, was removed on 6/23/19, when it could be determined the facility had implemented an acceptable removal plan including: education for staff including review of facility policies: abuse, acute condition changes, incident reporting, falls, fall risk management and fall risk assessment, use of mechanical lift machine, resident assessment instrument and person centered care plans. All staff were informed of the policies and educated and a method for auditing was developed to ensure ongoing compliance.

Based on observation, interview and document review, the facility failed to ensure appropriate supplemental oxygen was delivered according to physician orders, failed to complete comprehensive respiratory assessments after changes to respiratory status changes, and failed to notify the physician of respiratory status changes for 1 of 1 resident (R44) reviewed for respiratory treatments. These facility failures resulted in an immediate jeopardy (IJ) for R44. The IJ began on 11/26/18, at 4:50 p.m. when a nursing assistant (NA) applied oxygen for R44 at 5 L (liters), the tank ran out, and R44's oxygen saturation level dropped to 82% causing R44 to be short of breath. It was determined the facility failed to implement physician orders for oxygen, failed to complete a full respiratory assessment and failed to ensure staff were competent to provide respiratory management. The administrator, director of nursing (DON), and corporate quality improvement registered nurse (RN) were notified of the IJ on 11/28/18, at 4:13 p.m The IJ was removed on 11/29/18, but non-compliance remained at the lower scope and severity of D-isolated scope, with no actual harm but potential for more than minimal harm that is not immediate jeopardy. Findings include: R44's Admission Record dated 11/29/18, indicated R44 had [DIAGNOSES REDACTED]. During an initial interview with R44 on 11/26/18, at 3:59 p.m. R44 was observed to be in bed with oxygen being administered by nasal cannula from a large tank. The head of the bed was slightly elevated and R44 was not observed to have any symptoms of shortness of breath or signs and symptoms of respiratory distress. During an observation on 11/26/18, at 4:50 p.m. R44 was observed sitting in a wheelchair at the dining room table. The resident was observed to have oxygen being administered by nasal cannula. A portable oxygen tank hung on the back of R44's wheelchair and the dial was observed to be set to 5 liters (L). During the observation R44 was observed to have pursed lip breathing (breathing technique that consists of exhaling through tightly pressed lips and inhaling through the nose with the mouth closed). At 5:03 p.m. R44's respirations were observed to be shallow, and continued to have pursed lip breathing. At that time, R44 stated he felt he was breathing ok but sometimes felt short of breath. At 5:21 p.m., licensed practical nurse (LPN)-B stated nursing assistants (NAs) were allowed to transfer oxygen from a stationary oxygen delivery system, to a portable oxygen tank, and could turn the dial on a tank to the prescribed flow rates. At 5:28 p.m. R44 was observed to remain seated in the dining room area with no change in breathing, and R44's portable oxygen tank continued to be set at 5 [MI] From 5:28 p.m. to 6:25 p.m. R44 was observed to have pursed lip breathing and shallow respirations. The resident was leaning slightly to the left throughout the meal. During this time, R44 occasionally took bites of food. NA-F was observed assisting other residents to eat, and provided occasional verbal cues to R44 to take bites of food. At 6:25 p.m. R44 was observed to have increased respirations. At 6:27 p.m. LPN-B was asked how much oxygen R44 was supposed to have per physician order, LPN-B responded she had him on 3 L yesterday, but the amount varied based on R44's oxygen saturations. LPN-B then checked R44's respiratory status. LPN-B used a pulse oximeter to check R44's oxygen (O2) saturation level and pulse. At that time, LPN-B reported R44's O2 saturation measured 82% and that his pulse was 123. LPN-B then checked R44's portable oxygen tank and stated it was empty. LPN-B removed the portable tank to go fill it, leaving R44 without oxygen. At 6:30 p.m., NA-G stated she had been the person to get R44 up from his bed and had transferred R44's oxygen to the portable tank. NA-G verified she had turned R44's portable oxygen tank to 5 [MI] NA-G also stated the nurse had not provided direction for how much oxygen to administer to R44 that day. NA-G stated sometimes R44 was supposed to have 3 L of oxygen. At 6:33 p.m. LPN-B returned from filling R44's portable oxygen tank, connected R44's oxygen tubing to the portable tank, and turned the oxygen on at 3 [MI] LPN-B then walked back to the medication cart without rechecking R44's respiratory status however, asked R44 what his pain level was. R44 was observed to continue to have pursed lip breathing with shallow respirations. At 6:36 p.m. on 11/28/18, LPN-B stated R44's oxygen requirements varied. She said yesterday he required 5 L and was previously on 3 [MI] At 6:42 p.m. LPN-B was observed to administer R44's pain medication and to use a pulse oximeter to check R44's O2 saturations and heart rate. LPN-B stated R44's O2 saturation had gone up now to 97% and his heart rate was now only 104. LPN-B also stated R44 had been in the hospital three or four times during the last few months for [MEDICAL CONDITION] and respiratory issues and that R44 was on hospice. LPN-B then reviewed R44's physician orders and verified R44's physician order was actually for 2L of oxygen to keep R44's O2 saturation above 90%, and verified there were no parameters in place to increase the oxygen. LPN-B stated R44's oxygen could be increased without obtaining a physician's order, but verified for resident's on hospice, the nurse should call hospice to obtain an order to increase the oxygen. In addition, LPN-B was initially unclear about R44's respiratory [DIAGNOSES REDACTED]. Progress notes were reviewed for documentation related to the oxygen issues observed 11/26/18 in the dining room. The progress note indicated R44's SATS (oxygen saturation) were 81% on an empty O2 tank at the dining table. Tank filled and set at 3 [MI] HR (heart rate) was 123. There was no documented description of R44's other respiratory symptoms including the rapid, shallow respirations and pursed lip breathing. A subsequent progress note documented on 11/26/18, indicated after evening meal R44's oxygen saturations were 94% on 2L, blood pressure was 93/65, and heart rate was 71. During an observation on 11/27/18, at 8:33 a.m. R44 was observed seated in a wheelchair at the dining room table eating independently. R44's portable oxygen tank was noted to be set at 2L. R44 was observed to be breathing normally with no signs or symptoms of respiratory distress. At 2:07 p.m. on 11/27/18, R44 was observed to be laying on his bed with oxygen via nasal cannula set at 2L. R44 was observed to breath normally with no signs and symptoms of respiratory distress. During an interview with NA-A at 2:28 p.m. on 11/27/18, NA-A stated the NA's fill oxygen tanks and the tanks last approximately 4 hours if a resident is on 2L. NA-A also stated nurses communicate how much oxygen residents should get during report at the beginning of the shift. However, NA-A then stated NAs could turn up the oxygen if a resident seemed short of breath during cares without communicating to a nurse first, but would later need to communicate to the nurse the resident had a need for more oxygen. At 2:58 p.m. on 11/27/18, LPN-B stated R44 had orders for full code and was not on hospice care, although hospice had been encouraged. LPN-B was able to articulate signs and symptoms of respiratory distress and verified R44 had exhibited symptoms yesterday including increased tiredness and heart rate. LPN-B further verified she had not completed a respiratory assessment when R44 displayed symptoms the prior evening but should have. LPN-B stated when a resident's oxygen needed to be increased related to decreased O2 saturations, the physician should be contacted with the change and a new ordered obtained. During interview with NA-H on 11/27/18 at 3:05 p.m., NA-H stated she was a temporary employee at the facility employed through a staffing agency. NA-H verified NAs at the facility did switch residents from stationary oxygen to a portable tank, and could turn the oxygen on to whatever liter flow was in the care plan. NA-H stated if a resident demonstrated shortness of breath she would increase their oxygen flow and notify a nurse. However, NA-H also stated agency NAs were not trained on the facility's policy for oxygen delivery. On 11/27/18 at 3:28 p.m., NA-F stated he was a temporary employee through a staffing agency. NA-F stated the nurses communicate how much oxygen a resident should be receiving during report prior to the start of the shift. NA-F stated if a resident displayed signs of shortness of breath he would notify a nurse and not turn up the oxygen unless directed by the nurse. The director of nursing (DON) confirmed at 3:36 p.m. on 11/27/18, NA's do not have access to physician orders for oxygen. However, the DON stated NA's could fill oxygen tanks and could set the oxygen dose. The DON stated, we teach the staff to dose the oxygen, the mentor teaches them to go according to the care plan. If there is a range order for oxygen, NAs should not move the oxygen to a different liter until they check with a nurse. The DON stated the NA who turned up R44's oxygen to 5 L should not have done so without having been instructed by the nurse, and stated she expected staff to follow resident specific physician and/or standing orders. The DON reviewed R44's orders and verified the standing orders for oxygen were not included in R44's medication list. The DON said the only order for R44 was for 2L per minute to keep R44's oxygen saturations above 90%. The DON further stated if a change was needed to increase the oxygen, a respiratory assessment should be completed and the resident monitored closely. During interview with registered nurse (RN)-B at 3:53 p.m. on 11/27/18, she stated she was not aware of R44's need for increased oxygen needs. RN-B said she had just become aware that day (11/27/18), that R44 was routinely receiving 5 L of oxygen the majority of time. RN-B also stated she had updated the physician today when she became aware pertaining to the increased level of oxygen need, and had obtained a new order based on verbal reports about R44's oxygen needs. She stated the physician had not been previously notified of R44's increased oxygen needs. RN-B said the physician had now given the order to titrate oxygen, 2L-5 LPM (liters per minute) solely based on verbal reports from nurses. RN-B verified the lack of respiratory assessment in the record and stated R44 has had multiple hospitalization s which were not related to exacerbations of [MEDICAL CONDITION]. RN-B stated she was not surprised the NA's and nurses were turning up the oxygen without obtaining a physician's order, or the lack of communication. RN-B stated she had not yet educated staff on oxygen use, but would provide training pertaining to dosing of the oxygen. On 11/28/18, at 7:32 a.m. R44 was observed to be laying in bed on his back, with oxygen on at 2L via nasal cannula. R44's respirations were observed to be 18-19 a minute with no signs of respiratory distress. At 8:03 a.m., NA-B and NA-D were observed to transfer R44 out of bed with a full body mechanical lift into his wheelchair. NA-B then removed the oxygen tubing from the large oxygen tank, and connected it to a smaller portable tank attached to the back of R44's wheelchair. At 8:08 a.m. NA-D left R44's room. At 8:13 a.m. NA-B wheeled R44 to the dining room, parked his wheelchair at the table and left the resident there. At 8:14 a.m. R44 was observed to be breathing through his nose and his respirations were observed to be quicker (approximately 30 per minute) with shallow breaths. At 8:26 a.m., R44 remained seated at the table in the dining room, and continued to be breathing quickly with shallow breaths. NA-B who was assisting another resident sitting at the table, did not identify an concerns with R44's increased respirations. Also at that time, NA-E approached R44 and asked how he was doing, but left the table without addressing R44's breathing. At 8:29 a.m. registered nurse (RN)-D, the facility's education coordinator, came into the dining room and the surveyor brought R44's respiratory distress to her attention, and questioned whether the resident's oxygen was on. Without checking the oxygen machine, RN-D left the dining room returning at 8:32 a.m. with a pulse oximeter. At that time, NA-B checked the resident's oxygen tank and identified it was off. NA-B turned the oxygen tank on and set the flow rate at 3 L without any direction provided by RN-D. RN-D then checked R44's oxygen saturation level and stated it was 89%. RN-D stated this saturation was normal for R44. RN-D indicated R44's pulse was 97. Although RN-D listened to R44's lungs, she did not assess for respirations until questioned about them. RN-D proceeded to count R44's respirations and stated R44's respirations were at a rate of 28 per minute which she RN stated that was R44's baseline respiration rate. RN-D then walked out of the area and without rechecking R44's oxygen saturations to ensure saturations returned to above 90%. R44's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated the resident had no cognitive impairment, and did not reject care. The MDS also indicated R44 had no signs or symptoms of shortness of breath or trouble breathing, and did not receive oxygen or [MEDICAL CONDITION]/[MEDICAL CONDITION] therapy or treatments. R44's activities of daily living Care Area Assessment (CAA) dated 11/13/18, indicated R44 has had several hospitalization s since admission to the facility on [DATE], with the latest on 10/23/18 through 11/1/18 for [MEDICAL CONDITION], and end stage lung disease ([MEDICAL CONDITION]), OSA (?) with [MEDICAL CONDITION] non-compliance. The CAA further indicated R44 had been diagnosed with [REDACTED]. The CAA further indicated R44 easily became short of breath even on 5 liters (L) oxygen, hospice care repeatedly offered and declined. R44's behavior CAA indicated R44 refused to wear [MEDICAL CONDITION] which subsequently resulted in an emergency room visit on 11/5/18, and despite education of risks and benefits R44 continued to refuse to wear [MEDICAL CONDITION]. The behavior CAA indicated staff would continue to encourage to [MEDICAL CONDITION] use and document refusals when they occur. R44's respiratory care plan dated 9/24/18, included the following: resident has altered respiratory status/difficulty breathing related to chronic [MEDICAL CONDITION] with significant hemidiaphragm elevation, O2 in use, [DIAGNOSES REDACTED]. The care plan also included the following interventions: [MEDICAL CONDITION] settings per respiratory therapy, assist resident with placing [MEDICAL CONDITION] every night and encourage him to keep it on and provide ongoing educations regarding use and if he declined to use it, oxygen is placed (initiated 9/24/18). Monitor/document changes in orientation, increased restlessness, anxiety, and air hunger (initiated 4/18/18). Monitor for signs and symptoms of respiratory distress and report to physician as needed: increased respirations, decreased pulse oximetry, increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, hemoptysis, cough, pleuritic pain, accessory muscle usage, skin color changes to blue/grey (initiated 4/18/18). The care plan for [MEDICAL CONDITION] dated 5/22/18, included Oxygen Settings: oxygen via nasal cannula at 2 LPM continuous. On 11/26/18, R44's current electronic medical record (EMR) physician orders included: oxygen 2 LPM to keep oxygen saturations above 90% every shift related to disorders of diaphragm, hypoxemia, shortness of breath with a start date of 7/25/18. When asked to provide physician orders for the last 3 months, current printed physician orders included: [MEDICAL CONDITION] on at night .Ensure is in place properly .every evening and night if resident declines to wear [MEDICAL CONDITION], place oxygen on him and document. R9's After Visits Summary hospital notes from 11/1/18, indicated R9 was hospitalized from [DATE] through 11/1/18, for [DIAGNOSES REDACTED]. The physician's hospital discharge orders included: Respiratory or Nursing to manage per oxygen therapy pathway, oxygen 2 LPM via nasal cannula to keep oxygen saturations above 90% or greater. R9's physician visit note dated 11/20/18, indicated R9 thought his breathing was doing better and he was sleeping well. The physical exam notes indicated R44's recent blood pressure was 103/65, and pulse oximetry 92% with fluctuation in oxygen from 2-5 LPM pulse 71. The section for Assessment/Plan indicated nursing staff had reported R44's breathing was doing well since his recent hospitalization , but the plan did not reflect an order change for the oxygen. R9's oxygen saturation records with corresponding progress notes were reviewed from 11/13/18 through 11/24/18; Although the records indicated R44's O2 saturations were all above 90%, the record did not consistently include how much oxygen R9 was receiving when the O2 saturations were obtained, lacked respiratory assessment to increase oxygen above the prescribed dose of 2 LPM, and did not reflect R44 required oxygen as high as 5 LPM as indicated by the physician note dated 11/20/18. R44's Medicare/Skilled Nursing progress note dated 11/16/18, at 3:59 a.m. indicated R44's oxygen saturation was 99% on 3.5 L per nasal cannula at 11:30 p.m. with no shortness of breath noted. The note further indicated R44 received a nebulizer treatment every six hours, and was wearing his [MEDICAL CONDITION] during the night. However, the progress note from 5:05 a.m. the same day indicated R44's oxygen saturations were 93% on oxygen at 2 LPM. 11/16/18, at 10:52 a.m. 90% 11/16/18, at 3:03 p.m. 93% 11/16/18, at 3:04 p.m. 93% 11/17/18, at 5:34 a.m. 93% 11/17/18, at 7:31 a.m. 93% 11/17/18, at 4:17 p.m. 91% 11/18/18, at 4:49 a.m. 99% 11/18/18 at 12:52 p.m. 93% 11/18/18 at 3:39 p.m. 93% 11/18/18, at 11:31 p.m. 92% R44's Medicare/Skilled Nursing progress note dated 11/19/18, at 4:14 a.m. included 92% oxygen saturations on 3.5 L of oxygen. [MEDICAL CONDITION] on at 11:30 p.m. after neb treatment given. No shortness of breath noted. 11/19/18, at 1:49 p.m. 93% 11/19/18, at 9:02 p.m. 94% 11/19/18, at 11:36 p.m. 97% 11/20/18, at 10:39 a.m. 90% 11/20/18, at 10:41 a.m. 90% 11/20/18, at 11:13 p.m. 91% 11/20/18, at 11:14 p.m. 91% 11/21/18, at 5:15 a.m. 98% 11/21/18,at 1:54 p.m. 93% 11/21/18, at 10:57 p.m. 93% 11/21/18, at 11:44 p.m. 97% 11/22/18, at 12:14 a.m. 98% 11/22/18, at 11:37 p.m. 97% 11/23/18, at 12:02 a.m. 96% R44's Medicare/Skilled Nursing progress note dated 11/23/18, at 4:05 a.m. included neb treatments every six hours scheduled. [MEDICAL CONDITION] on after neb given. 97% at 3 L of oxygen. 11/23/18, at 4:46 a.m. 97% 11/23/18, at 1:46 p.m. 96% 11/23/18, at 4:19 p.m. 97% 11/23/18, at 11:14 p.m. 92% R44's Medicare/Skilled Nursing progress note dated 11/24/18, at 3:52 a.m. indicated R44 had his [MEDICAL CONDITION] on, O2 saturations were 92% on 3 L of oxygen via nasal cannula with no shortness of breath. 11/24/18, at 10:52 a.m. 97% 11/24/18, at 3:19 p.m. 93% 11/24/18, at 10:00 p.m. 91% R44's historical physician visits and hospitalization s reflected the following: R44's physician visit note dated 8/31/18, indicated the reason for hospitalization follow-up: R44 was hospitalized 3 times in the last month. He was hospitalized from (MONTH) 20th through (MONTH) 24th (2018) for [MEDICAL CONDITION]. He was again hospitalized from (MONTH) 2nd through (MONTH) 7th for [MEDICAL CONDITION]. His most recent hospitalization was from (MONTH) 15th through (MONTH) 21st. During the hospitalization he was treated with [MEDICAL CONDITION] therapy and treated for [REDACTED]. R44's physician visit dated 9/25/18, indicated at the time of the visit R44 was lying in bed with O2 on, with an O2 saturation of 95% while on the oxygen (liter flow dose not indicated), and the note indicated R44 was short of breath. The note also indicated R44 used a [MEDICAL CONDITION] and was not always compliant. The note further indicated a nebulizer treatment had been ordered with no good response, so R44 should be sent to the ER (emergency room ) for further evaluation. R44's hospital notes dated 9/26/18, indicated R44 was admitted to the hospital on [DATE] and discharged on [DATE]. The acute conditions treated included: Acute or chronic dyspnea, chronic hypoxic and hypercapnic [MEDICAL CONDITION] (supplemental oxygen and titrate to maintain oxygen saturation 90% or greater, avoid inadvertent hypercapnia), [MEDICAL CONDITION] and probable urinary tract infection. A hospital stay respiratory therapy note dated 9/28/18, indicated R44 had a [DIAGNOSES REDACTED]. The note also indicated R44's [MEDICAL CONDITION] use times were downloaded and results showed only 4 hours of use nightly and R44 was encouraged to use the [MEDICAL CONDITION] more. A Hospital After Visit Summary note dated 10/18/18, indicated R44 was admitted to the hospital on [DATE] and discharged on [DATE]. The visit note indicated on 10/10/18, R44 presented to the hospital with complaints of shortness of breath with oxygen saturations in the 80's and was hypotensive. The note indicated R44 was treated with [MEDICAL CONDITION] therapy, fluid resuscitation, neb treatment etc, and moved to the intensive care unit. The note indicated R44 transitioned from [MEDICAL CONDITION] therapy to [MEDICAL CONDITION] therapy and was tolerating at home settings. R44's record indicated on 11/5/18, R44 was seen in the emergency room for shortness of breath and was then discharged back to the facility. On 11/28/18 at 9:43 a.m. the nurse practitioner (NP)-A indicated there could be multiple reasons for R44's recurrent respiratory distress including administration of too much oxygen and/or oxygen mismanagement. NP-A stated R44 had a complicated respiratory history with multiple hospitalization s related to respiratory distress and could require more than 2L of oxygen to keep his O2 saturations above 90%. NP-A stated the nurses were expected to follow physician orders for oxygen administration and if a resident required more oxygen than the prescribed order, the physician needed to be contacted for a new orders. NP-A indicated if a nurse was going to increase oxygen, even with range parameters, it was a standard of practice and expectation the nurses would complete a full comprehensive respiratory assessment that included, respiration rate, oxygen saturation, lung sounds, blood pressure, and heart rate. NP-A further stated a reassessment of increased oxygen dosages needed to be completed in order to determine effectiveness of the oxygen, and should be communicated with the physician. NP-A stated assessments should be documented in the resident's record. During an interview on 11/28/18, at 2:35 p.m. registered nurse (RN)-D verified she was the education coordinator. RN-D stated during employee orientation for the nursing assistants, a mentor checks off the new employee when the training is completed. RN-D stated NA training for oxygen only included filling the portable oxygen tanks and recording the filling of the tanks for billing purposes. RN-D stated the aides were not trained to dose a resident's oxygen. RN-D stated upon orientation she completed a competency checklist for hired staff; which included nasal cannula care and oxygen tubing safety. RN-D further indicated only some agency staff go through the competency checklist because some agencies provide their own training. The facility's 10/2010 policy Oxygen Administration, included: Preparation: 1) Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.2) Review the resident's care plan to assess for any special needs of the resident. Assessment: Before administering oxygen, and while the resident is receiving oxygen therapy assess the following. 1) signs or symptoms of cyanosis 2) signs or symptoms of [MEDICAL CONDITION] 3) signs or symptoms of oxygen toxicity (tracheal irritation, difficulty breathing or slow shallow rate of breathing). 4) vital signs. 5) lung sounds The IJ that began on 11/26/18, was removed on 11/29/18, when it could be verified by observation, interview, and document review that assessment had been initiated, care plans reviewed, physician orders reviewed, and staff training was conducted on policies for respiratory care for oxygen dependent residents. However, noncompliance remained at the lower scope and severity level of D.

Based on observation, interview and document review, the facility failed to implement interventions to promote healing, prevent decline, and/or prevent new pressure ulcer development for 1 of 3 residents (R9) reviewed for pressure ulcers. R9 sustained harm when the resident developed a stage III pressure ulcer. Findings include Facility policy Pressure Ulcer Treatment dated 2/2014 defined a stage III pressure ulcer as: Stage 3 pressure ulcer: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. During an observation on 11/26/18, at 4:23 p.m. R9 was observed lying in bed on his back. R9 had pressure-relieving boots on both feet; however, the boot heels were observed resting directly on the bed. During an observation on 11/27/18, at 2:09 p.m. R9 was observed lying in bed on his back. R9 was observed to be wearing gripper socks on and heels directly on the mattress. R9's heels were not floated and R9 was not wearing the pressure-relieving boots. During an interview on 11/26/18 at 2:09 p.m., R9 stated he currently had a sore on his right heel that developed after his admission, and had then become infected. R9 further stated he was taking an antibiotic medication to get rid of the infection. During an interview on 11/27/18, at 2:22 p.m. nursing assistant (NA)-A stated R9 was supposed to have the blue boots (pressure relieving boots) on. NA-A was unsure when R9 was last repositioned or what time R9 had laid down in bed because that information had not been passed along during shift to shift report. NA-A confirmed R9's heels were resting directly on the mattress and that he was not wearing the pressure relieving boots. NA-A also stated R9 was supposed to have a foot tent on to keep the weight of the blankets off his toes. At that time, NA-A repositioned R9 to a side lying position and stated he was not going to use the foot tent right now because he was going to leave the feet uncovered. R9's record was reviewed. A face sheet document titled Admission Record, included historical and current [DIAGNOSES REDACTED]. R9's admission Minimum Data Set (MDS) 7/17/18, indicated R9 was at risk for pressure ulcers, but did not have pressure ulcers upon admission. The MDS indicated R9 required pressure-reducing devices for chair and bed. R9's Significant Change MDS dated [DATE], indicated R9 was not cognitively impaired and did not have rejection of care behaviors. The MDS indicated R9 required extensive assistance from 2 or more staff members for bed mobility, transfers, and toileting; in addition to extensive assistance from one person for dressing and personal hygiene. The MDS also indicated R9 was at risk for pressure ulcers, and had current stage II and stage III pressure ulcers as well as an infection of the foot. The MDS indicated the interventions for skin and ulcer treatments included, pressure ulcer care and application of dressings to the feet. R9's pressure ulcer Care Area Assessment (CAA) dated 9/27/18, indicated at the time of assessment R9 had pressure ulcers on both of his heels that were being treated. The CAA further indicated, R9 was on antibiotic for heel ulcer infection and with his [DIAGNOSES REDACTED]. The CAA also included R9 was able to shift weight independently when he chose to do so and had a history of [REDACTED]. The CAA further included, will proceed to care plan. Staff will monitor skin daily for any other suspicious areas requiring further evaluation/treatment as appropriate. R9's skin risks/pressure ulcer care plan dated 7/27/18, included: the resident has blisters on both heels, potential for pressure ulcer development related to history of ulcers, immobility, extreme dry skin to lower extremities, ulcer on left foot 2nd digit. Wound Vac therapy to right heel. The care plan interventions directed staff to: elevate heels off the bed using bilateral blue boots, reposition every two hours in a sitting and laying position and more often as needed or requested. R9's podiatry visit note dated 10/9/18, indicated ulcer measurements of 5.0 centimeters (cm) x 3.5 cm x 0.5 cm. Podiatry documentation described the ulcer further as, at the 3 o'clock and 8:00 position there are small granular buds, the superior ½ of the ulcer is black dry eschar the inferior aspect has damp necrotic tissue. The note also indicated the eschar was removed and directed, nursing staff to again make sure that pressure is kept off this heel as much as possible. R9's physician visit dated 10/16/18, indicated R9 had been experiencing pain in the right heel ulcer that was being followed by podiatry, had been followed by orthopedics related to pelvic fracture and was allowed to have some weight-bearing although was limited by the heel ulcer. R9's podiatry visit note dated 10/25/18, indicated the right heel ulcer measured 5.3 cm x 3.4 cm (no depth was included). The note indicated the wound was debrided, bleeding resulted, and an absorbent dressing was put on the wound. Instructions for care included for staff to leave the dressing on until morning and reinforce if needed. Wound orders directed to treat the wound with Iodosorb/hydrogel 50:50 daily and ace wrap from toes to knee. An After Visit Summary (AVS) from the hospital, dated 11/7/18, indicated R9 had been admitted to the hospital on [DATE] and discharged back to the facility on [DATE]. The AVS indicated R9's admission diagnosis (to the hospital) included a pressure injury (ulcer) right heel which was a stage III. However, in the [DIAGNOSES REDACTED]. The AVS also indicated R9 had a wound vac initiated to the right heel. The AVS further indicated R9 had an infection in the right heel wound, and that he had been discharged with orders for antibiotics including: Ertapenem which was initiated 10/30/18 to treat a lower urinary tract infection [MEDICAL CONDITION] and soft tissue infection, with an end date of 12/17/18; and [MEDICATION NAME] intravenous solution which was initiated 10/28/18, also identified as treatment for [REDACTED]. Further, records from R9's hospital stay indicated R9's culture and sensitivity results collected during the hospital stay included: Right foot bone culture collected on 10/31/18 with results identified 11/3/18: Staphylococcus Aureus, [MEDICATION NAME] Faecalis, and [DIAGNOSES REDACTED] Pneumoniae; Tissue from right ankle culture collected on 10/28/18 with results identified 11/2/18: Staphylococcus Aureus, Corynebacterium Striatum, Staphylococcus Epidermis, [MEDICATION NAME] Faecalis, [DIAGNOSES REDACTED] Pneumoniae; Urine culture collected 10/28/18 with results identified 10/30/18: >100,000 [DIAGNOSES REDACTED] Pneumoniae; Stool culture collected 10/19/18, with results identified 10/29/18: positive for [MEDICAL CONDITION] toxin. R9's (MONTH) Medication Administration Record [REDACTED] -Ertapenem Sodium Solution (antibiotic) use 10 milliliters (ml) intravenously (IV) one time a day related to pressure ulcer of right heel stage 3 until 12/16/18, daily at 1:00 p.m. Flush with 20 ml saline before and after (start date of 11/6/18) -[MEDICATION NAME] HCL in sodium chloride solution 600 milligrams (mg) IV daily at 7:00 a.m. for right heel pressure ulcer until 12/16/18 (this order had a start date of 11/26/18, however, R9 was receiving doses of [MEDICATION NAME] since 11/6/18) -Wound Vac: for two months, change dressing every 3 days, cover wound with [MEDICATION NAME] and hydrogel. Leave adaptive piece in place. Pressure 125 mmHg (millimeters mercury). Setting continuous, intensity low. Do not remove graft. Complete wound measurement with each dressing change (start date of 11/6/18) R9's Weekly Ulcer/Complex Wound Observation Tool dated 11/9/18, included the following: Right heel unstageable pressure ulcer 5.5 cm x 4.0 cm x 0.2 in depth. Treatment plan and interventions included heel protectors when in bed/foot cradle, reposition every two hours. Changes since previous assessment included: resident is a hospital return on 11/6/18 with wound vac to be changed Monday, Wednesday, Friday's. The assessment further indicated the wound was showing signs of progress toward healing. Historical information included: On 9/13/18, wound was foul smelling, increased in size, swelling, had increased drainage and an antibiotic was started on 9/14/18 with great improvement. On 10/3, 10/18, and 10/18/18 no signs and symptoms of infection, on 10/25 faint odor and inflammation noted in wound surrounding tissues. R9's Braden Scale for Predicting Pressure Score Risk dated 11/14/18, indicated R9 was at risk for pressure ulcers. The evaluation included pressure relief for heels as an intervention to prevent pressure ulcers. The record indicated R9 was evaluated by an infectious disease (ID) practitioner related to the right heel ulcer infection. The ID visit note dated 11/14/18, indicated R9 had been residing at home until a fall in (MONTH) which had caused multiple fractures including pelvic fractures, so had not been ambulatory, but had remained in bed. The ID visit note indicated R9 had subsequently developed pressure ulcers on both heels, the left one healed but the right progressed to the point of requiring hospitalization . The ID visit described the current ulcer as: 5.3 x 3.4 x 0.5 cm with foul odor. Results from an MRI (magnetic resonance imaging) dated 10/29/18, indicated R9 had osteo[DIAGNOSES REDACTED] and ulceration of the Achilles tendon. Further the notes indicated R9 was started on three different antibiotics and the wound cultured out various bacteria identified as: MSSA, Corneybacterium striatum, coagulase-negative staphylococci, [DIAGNOSES REDACTED] pneumoniae, and [MEDICATION NAME] faecalis. On 10/31/18, R9 went for irrigation and debridement including bony debridement. Cultures from the surgery had MSSA, [DIAGNOSES REDACTED] penumoniae, [MEDICATION NAME] faecalis, and Prevotella. The note further indicated it was not known whether R9's wound would heal especially while on antibiotics due to R9's comorbidities; alternatives to wound closure including amputation were discussed in the event the antibiotics and wound vac did not work to heal the wound. R9's podiatry visit note dated 11/15/18, indicated wound size was 5.0 x 3.5 x .2 cm and directed to continue wound vac settings. R9's Weekly Ulcer assessment dated [DATE], included: right heel unstageable pressure ulcer that measured 5.3 cm x 3.5 cm x 0.2 cm in depth. Assessment indicated no changes to treatment plan. R9's weekly Ulcer assessment dated [DATE], again reflected an increase in size of the right heel pressure ulcer. The measurements documented were 5.5 cm x 4.0 cm by 0.2 cm. R9's (MONTH) Treatment Administration Record (TAR) directed staff to document every shift on overall level of function and complaints of pain, infusion, and wound care (wound vac function) with a start date of 11/8/18. Staff documented using check marks in boxes and initials. There were 6 shifts from 11/14/18 through 11/28/18 that were blank. R9's record and progress notes were reviewed from 11/7/18 through 11/25/18; the record lacked consistent documentation of pain, wound care, per the TAR. In addition, the record lacked consistent monitoring for signs and symptoms of infection and/or the effectiveness of the antibiotic. During an interview on 11/28/18, at 11:41 a.m. registered nurse (RN)-A confirmed she was the acting infection preventionist. RN-A stated she was not aware of which bacteria caused the infection in R9's foot. RN-A indicated that when the hospital discharged R9 back to the facility on intravenous (IV) antibiotics, the culture results of the wound were not in the hospital discharge summary. RN-A then indicated the facility had access to EPIC (hospital's electronic health record system) and was able to print wound culture results. RN-A indicated EPIC was very cumbersome, time consuming, and facility staff did not have formal training on how to use the system. RN-A stated the facility had been struggling with obtaining pertinent medical information for hospital returns and admissions. RN-A reviewed R9's nursing progress notes and confirmed there was a lack of evaluation documentation for antibiotic effectiveness and/or ongoing signs and symptoms of infection in the wound. During an interview on 11/29/18, 11:29 a.m. licensed practical nurse (LPN)-A, indicated R9 had an infection in his right heel wound however, indicated an unawareness of bacterium that caused the infection. During an interview on 11/29/18, at 1:19 p.m. licensed practical nurse (LPN)-C verified she was the last person to change R9's right heel dressing. LPN-C indicated she was aware R9 had an infection in the wound however, was not aware of the bacterium that caused the infection. LPN-C indicated the only personal protective equipment utilized during the dressing change was gloves. During an interview on 11/29/18, at 1:58 p.m. with the nurse practitioner (NP)-B, indicated the facility staff should have been aware of the type of infections in the wound for treatment and appropriate precautions were implemented. NP-B also stated she would expect universal precautions to be used during care of R9's wound. During an interview on 11/29/18, at 4:42 p.m. RN-C indicated the results of the wound culture that were obtained during R9's hospitalization had not been communicated to the facility during the readmission report phone call from the hospital. RN-C indicated she had not become aware of the type of bacterium in the wound until the day after admission when going through the hospital records that were provided. RN-C further indicated the care planned interventions should be followed. During an interview at 5:16 p.m. director of nursing (DON) stated staff should follow R9's care plan for pressure ulcers. The DON further stated the facility was having difficulty with the local hospital's discharge summaries and obtaining pertinent medical information. The DON stated the facility had procured new physician services which would be implemented 12/5/18, to alleviate some of the gaps the facility was facing. The facility's Pressure Ulcer Risk Assessment policy dated 2/2014, included; General Guidelines- 1) pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease in circulation to that area which destroys the tissues. 2) The most common site of pressure ulcer is where the bone is near the surface of the body including the back of head around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles, and toes. 5) Pressure ulcers are usually made worse by continual pressure, heat, moisture, irritating substances on residents skin, and decline in resident's physical and/or mental condition. 10) Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or skin breakdown. Assessment- 3) monitoring- a. staff will staff will perform routine skin inspections (with daily cares) 4) because a resident is at risk can develop a pressure ulcer within 2 to 6 hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. Documentation- 8) if the resident refused the treatment, the reason for refusal and the resident's response to the explanation of risk of refusing the procedure, the benefits of accepting available alternatives. The facility's Prevention of Pressure Ulcers policy dated 2/2014, indicated Interventions and Preventative Measures including: .The care process should include efforts to stabilize, reduce or remove underlying risk factors, to monitor the impact of the interventions, and to modify the interventions as appropriate. Risk Factor: bed-fast: a) change position at least every two hours and more frequently as needed. Risk Factor -Immobility: c) when in bed every attempt should be made to float heels (keep heels off of the bed) by placing a pillow from knee to ankle or with other devices as recommended by clinical staff or by the physicians.

Based on observation, interview and record review, the facility failed to assess and provide effective pain management for 2 of 2 residents (R49 and R41) reviewed for pain. The facility further failed to ensure narcotic pain medication to control moderate to severe pain was available timely for R49. This deficient practice resulted in actual harm for R49, who experienced verbal and non-verbal indicators of unmanaged pain and disturbed sleep patterns. Findings include: R49's After Visit Summary dated 10/24/18, to 10/29/18, indicated R49's admitting [DIAGNOSES REDACTED]. During brief hospital course, R49 presented to the emergency room (ER) with progressive bilateral lower extremity (BLE) weakness and pain, ongoing since (MONTH) of this year (2018). The note further indicated R49's pain had been consistent, with onset of weakness that worse than prior, associated pain. Upon admission, R49 was started on [MEDICATION NAME] and [MEDICATION NAME] for symptom management with significant improvement in both pain and weakness. R49's Admission Record indicated an admitted [DATE], a primary [DIAGNOSES REDACTED]. On 10/29/18, R49 was prescribed [MEDICATION NAME] (a narcotic medication used to treat moderate to severe pain) 5 milligram (mg) immediate release tablet, 1 tablet by mouth every 4 hours as needed for severe pain (score of 7-10) with the most severe pain being a 10; and 2.5 mg by mouth every 4 hours as needed (PRN) for moderate pain (score of 4-6) of 10. R49's 14 day minimum data set (MDS) assessment dated [DATE], indicated R49 had intact cognition and frequent pain at a level of 7. R49's Pain Interview documented as conducted 11/5/18, indicated [REDACTED]. The nurse's comments indicated R49 continued to report left lower extremity pain radiating to the back, but reported relief of pain symptoms with (PRN) as needed [MEDICATION NAME]. The non-medication intervention for pain indicated repositioning was not effective. A follow up pain interview documented as conducted 11/8/18, also indicated [REDACTED]. Nurse comments indicated R49 continues to report left lower extremity pain radiating to the back and primary medical doctor (MD) will be contacted to obtain scheduled [MEDICATION NAME] for better pain management. Non-medication intervention for pain indicated repositioning was not effective. A pain interview documented as conducted 11/23/18, indicated frequent (daily) pain at a level 7. Nurse comments indicated R49 continued to report left lower extremity pain radiating to the back, and included, no [MEDICATION NAME] use in the last 5 days. Non-medication intervention for pain indicated repositioning does not indicate effectiveness. R49's Baseline care plan dated 11/29/18, indicated a focus of risk for alteration in comfort/pain related to left leg pain and debility with a goal of comfort alteration/pain resident will alert staff to pain/discomfort and resident will report satisfactory comfort level score of 4/10 throughout review period. Interventions are observe for non-verbal indicators of pain, adjust position pillows for comfort as needed, ice or heat for comfort as needed. Ice on for 20 minutes at a time. Offer prior to the administration of narcotic pain medication, and evaluate the effectiveness of pain interventions; review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition, and notify MD if pain relief interventions ineffective or adverse reactions to [MEDICATION NAME] noted. R49's Medication Administration Record [REDACTED] 10/29/18, for level 8 pain, received 5 mg [MEDICATION NAME] at 7:46 p.m. 10/30/18, for level 8 pain, received 5 mg [MEDICATION NAME] at 6:30 p.m. 10/31/18, for level 7 pain received 5 mg [MEDICATION NAME] at 9:31 a.m. and 9:54 p.m. R49's Medication Administration Record [REDACTED] 11/2/18, for level 8 pain, received 5 mg [MEDICATION NAME] at 6:50 p.m. 11/3/18, for level 7 pain, received 5 mg [MEDICATION NAME] at 8:02 a.m., 4:08 p.m., and level 8 pain 11:30 p.m. 11/4/18, for level 8 pain, received 5 mg [MEDICATION NAME] at 12:31 p.m., and level 7 pain at 4:32 p.m. 11/6/18, for level 7 pain, received 2.5 mg [MEDICATION NAME] at 3:27 p.m. 11/7/18, for level 4 pain, received 2.5 mg [MEDICATION NAME] at 11:48 a.m., and received 5mg for level 7 pain at 11:12 p.m. 11/8/18, for level 8 pain, received 5 mg [MEDICATION NAME] at 11:31 a.m. and level 5 pain at 4:34 p.m. 11/9/18, for level 7 pain, received 5 mg [MEDICATION NAME] at 8:05 p.m. 11/10/18, for level 7 pain, received [MEDICATION NAME] 5 mg at 1:01 p.m. and 7:14 p.m. 11/11/18, for level 8 pain, received 5 mg [MEDICATION NAME] at 4:21 p.m. 11/12/18, for level 8 pain, received [MEDICATION NAME] 5 mg at 9:25 p.m. 11/13/18, for level 8 pain, received [MEDICATION NAME] 5 mg at 8:13 p.m. 11/14/18, for level 7 pain, received [MEDICATION NAME] 2.5 mg at 8:09 p.m. Upon review of R49's medical record, pain monitoring completed daily with pain levels ranging from 0 to 8, without evidence of non-pharmacological interventions being implemented or effectiveness of pain management strategies identified. During interview on 11/26/18, at 3:19 p.m. R49 stated, My left leg hurts on and off all day, I only get Tylenol for it, I have asked for something stronger, but I guess that is up to the doctor. Right now my left knee pain is at a level 7 and travels to my back. I do not feel they (the facility) are controlling my pain very well, at least not with the stupid Tylenol. They want me to see a neurologist, until I see him, I don't suppose they will give me anything stronger than Tylenol. I used to take [MEDICATION NAME] and that helped more, I only took it twice a day, the doctor never renewed my prescription. I used to use ice on my knee at home all the time that did help. I also used balm on my knees, that was temporary, but it helped. When I asked about it here they said they could not recommend it. It (the leg) hurts me more when I stop using it. When I am exercising it I think it helps. I have a hard time sleeping at night because of the pain. During observation and interview on 11/27/18, at 2:52 p.m. R49 was observed to be sitting in her wheelchair in her room visiting with her husband. When asked how her pain was R49 replied, Right now I have a level 6.5 pain in my left knee, I can only have my Tylenol every 6 hours, and so I am waiting. I wish they would give me something stronger to help with this pain. During the conversation, R49 was observed to rub her left knee and stated, My pain is not under control. During observation and interview on 11/29/18, at 5:07 p.m., R49 was sitting at a table in the dining room waiting for supper. R49 stated, I still have pain in my left leg, that's why I am here, it never gets any better, the Tylenol does not help, the [MEDICATION NAME] was the only thing that helped and they won't give me that any more. During interview on 11/29/18, at 1:28 p.m. licensed practical nurse (LPN-D) verified R49 was at the facility for a short term stay due to her left leg pain. LPN-D stated, they will not refill her (R49's) [MEDICATION NAME], she hasn't had any since 11/14/18. They'll only give these people a 30 day dose then they are done, it's because of the big opioid crisis. During interview on 11/29/18, at 5:09 p.m. LPN-C stated R49 is here for left leg pain, and has not had her [MEDICATION NAME] available to her since 11/14/18. LPN-C verified R49 had a current doctor's order to receive [MEDICATION NAME] 2.5 mg for level 4-6 pain, and 5 mg for level 7-10 pain every four hours as needed. LPN-C further stated R49 also had an order for [REDACTED]. Under physician's comments, this was not addressed. LPN-C stated, we have had a problem getting controlled scripts for our residents because the providers are citing the opioid crisis. LPN-C expressed being unsure of any non-pharm interventions currently being used to help R49 with her pain. During interview on 11/29/18, at 5:23 p.m. registered nurse (RN-C) verified R49's [MEDICATION NAME] had not been available to her since 11/14/18. RN-C stated, I was aware R49 was having pain, but I did not know it was affecting her sleep. RN-C also stated, Non-pharmacologic measures to help with her pain include repositioning, and she (R49) can reposition herself. We could start offering heat or ice, we've had a hard time getting our controlled medication prescriptions filled during the last 6 months. RN-C stated, all residents should have their pain addressed and (R49) should be able to have her pain medication available to her, and should be able to take it as prescribed by the doctor. During interview on 11/29/18, at 5:38 p.m. the director of nursing (DON) verified R49 was there to recieve short term management of her pain, but verified R49's pain was not currently well managed. The DON stated, we need to be putting in non-pharm interventions for pain and keep trying to contact the doctor for that prescription, it should not take this long. We will have a new medical provider starting Wednesday and that will help some of the concerns with this. During an interview 11/26/18, 1:49 p.m. R7 said she had chronic pain due to having injured her right shoulder and elbow many years ago and it still hurts. When asked what was being done for her pain, R7 said she had been provided Tylenol. R7 also said she was unsure if the medication was helping anymore. A review of R7's medical record revealed she had a [DIAGNOSES REDACTED]. --[MEDICAL CONDITION]'s disease (a progressive neurological disorder that impacts movement) --[MEDICAL CONDITION] of right shoulder (degeneration of the shoulder joint) --History of traumatic [MEDICAL CONDITION] arm and right hip --History of falling --Age-related [MEDICAL CONDITION] (a thinning of the bone) R7's care plan included a focus problem area: pain, dated as initiated 6/15/18. The goal--verbalize adequate relief of pain or ability to cope and the target date for completion was identified as 12/24/18. Interventions listed included, but were not limited to the following: evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Monitor/document for side effects of pain medication. Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decreased ROM (range of motion), withdrawal or resistance to care. However, the care plan lacked evidence of non-pharmacological methods of reducing pain or enhancing comfort. R7's MEDICATION ORDERS FOR [REDACTED] --Tylenol extended release 650mg twice daily and 500mg every 6 hours as needed, order initiated 5/31/2017 --Aspercream/[MEDICATION NAME] 4% (a lotion with minor numbing properties) apply as needed for hip pain, order initiated 5/31/2017 On 11/29/18, 8:58 a.m. R7 was asked again about her pain. She stated that she often has pain, but if she is careful, her Tylenol will take care of it. When asked to explain what it meant to be careful she indicated that she had to reduce her movement, spend less time in activities or doing things in her room. When asked if she would like something else done to provide comfort, she said that she had asked for a change in pain medication a long time ago, but nothing came of it. According to an interview with licensed practical nurse (LPN)-A on 11/29/18 at 10:14 a.m., LPN-A said she hadn't heard of R7 having pain concerns and added, we usually don't talk about pain with her. LPN-A stated there was no prompt in the Medication Administration Record [REDACTED] During an interview on 11/29/18 at 11:59 a.m., registered nurse (RN)-C stated, Her pain is chronic and she went to therapy because of that. I'm surprised she is bringing it up again. When asked about how often a person with a [DIAGNOSES REDACTED]. According to RN-C, a pain assessment could include a numeric pain level and where the pain is located or intensity; however, RN-C added, we usually don't ask about a pain level unless they are recieving a PRN (as needed) pain medication. RN-C further stated, Nonverbal evidence of pain would be monitored during interactions. When asked about where the nurse should document these findings, RN-C said the nurses document by exception and if nothing was charted, it meant there was no pain. When asked how the effectiveness of pain interventions could be evaluated without documentation RN-C stated, I guess I could add a question about pain level to her scheduled Tylenol order. The director of nursing (DON) stated during interview at 2:57 p.m. on 11/29/18, that the nurses were supposed to follow the facility'spain policy. The DON stated nurses should be asking residents about their pain level daily and if they were following a doctor's order they should be checking to see if the pain medications were effective and should offer non-pharmacological comfort measures. When asked how often a person with a chronic pain [DIAGNOSES REDACTED]. When asked about documentation of pain assessments, the DON stated the nurses should chart their findings. When asked if the assessment found the resident did NOT have pain, what should be documented? The DON said it was expected that a finding of no pain should also be documented. The facility's 2/2014 Pain Management policy included: Asessment and recognition: 1. the physician and staff will identify individuals who have pain or who are at risk for having pain. This includes a review of each person's known [DIAGNOSES REDACTED]. It also includes a review for any treatments that the resident currently is receiving for pain, including complimentary (non-pharmacologic) treatments. 2. The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is new onset of new pain or worsening of existing pain. 3. The staff and physician will identify the nature (characteristics such as location, intensity, frequency, pattern, etc.) and severity of pain. 5. The staff and physician will also evaluate how pain is affecting mood, activities of daily living, sleep, and the resident's quality of life, including complications such as gait disturbances, social isolation, and falls . Cause Identification: 1. the physician will help identify causes of pain; for example, by examining the resident directly, reviewing the resident's history, and via discussion with the resident and staff .Treatment and Management: 1. with input from the resident, the physician and staff will establish goals of pain treatment; for example, freedom form pain with minimal medication side effects, less frequent headaches, or improved functioning, mood and sleep. 2. The physician will order appropriate non-pharmacologic and medication interventions to address the individuals pain. 3. The staff will evaluate and report how much and how often the individual asks for pain medication. 4. The staff will provide the elements of a comforting environment and appropriate physical and complementary interventions; for example, local heat or ice, repositioning, massage, and the opportunity to talk about chronic pain. Monitoring: 1. the staff will reassess the individuals pain and related consequences at regular intervals; at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in in stable chronic pain. 2. Periodically the physician will evaluate and summarize the status of an individual with chronic or fluctuating pain including the status of any active conditions that exacerbate pain, and effectiveness of current interventions for pain. 5. If the resident's pain is complex or not responding to standard interventions, the attending physician may consider a psychiatric evaluation or referral to a pain clinic or specialist. The facility's 10/2010 Administering Pain Medications policy, included: 1. the pain management program is based on a facility wide commitment to resident comfort. 2. Pain management is defined as the process of alleviating the resident pain to a level that is acceptable to the resident and is based on his or her clinical condition and establishment of treatment goals. 3. Residents are not at risk for addiction for narcotic [MEDICATION NAME] if used as prescribed for moderate to severe pain. 4. be familiar with physiologic and behavioral (non-verbal) signs of pain. For example: verbal expressions such as crying or moaning, facial expressions such as grimacing, frowning, clenching of the jaw, etc., changes in gait, skin color vital sign, or increased perspiration, behavior such as resisting care, irritability, depression, decreased participation in activities, limitations in his or her activity due to the presence of pain, guarding, rubbing or favoring a particular part of the body, difficulty eating or loss of appetite, and [MEDICAL CONDITION]. 6. Acute pain should be assessed every 30 to 60 minutes after the onset and reassessed as indicated after [MEDICATION NAME] relief is obtained.

Based on record review and interviews, the facility failed to immediately notify a resident's physician when a significant change occurred for one of five residents, R1, for change in condition. R1 was harm when he reported breathing difficulty, had significantly increased blood pressure and heart rate, and requested to be sent to the emergency department, but facility's nurse did not notify his physician in a timely manner and R1 died at the facility. The findings include: R1's medical record was reviewed. R1 was admitted to the facility for long term care with [DIAGNOSES REDACTED]. R1 had [DEVICE] ([DEVICE]) (tube placed in the stomach for feeding and medication) due to high risk of aspiration. R1 required close monitoring for signs of aspirations and assistance of two persons for all transfers. R1's care plan dated (MONTH) 18, (YEAR) required staff to monitor R1's vital signs and notify physician of significant abnormality. The care plan indicated staff should monitor and report R1's lung sounds, increased pulse and fever as appropriate to the resident's physician. R1's nutritional assessment note dated (MONTH) 25, (YEAR) indicated R1 was receiving feeding via [DEVICE] because of aspiration pneumonia risk and staff needed to monitor R1 for any complications (diarrhea, reflux, productive cough, shortness of breath) due to the tube feeding. Nursing progress note dated (MONTH) 28, (YEAR) indicated R1's [DEVICE] site had a small amount of yellowish drainage and frequent, productive cough with fever (having temperature of 100.2 degrees). The note had no indication of R1's physician notification regarding the fever, frequent, productive cough, and yellowish drainage. Nursing progress note dated (MONTH) 29, (YEAR) indicated R1's [DEVICE] site drainage was purulent and R1's cough had copious thick, greenish sputum. R1 had nebulizer treatment with no outcome documented. R1's progress note a day later indicated R1 had fever again with temperature of 100.1 degrees, Tylenol 650 milligrams (mg) administered, and was coughing up yellowish phlegm with head of bed greater than 30 degrees. About five hours later, R1's progress note indicated R1 had fever with temperature at 100.5 degrees. Staff gave another dose of Tylenol 650 mg which was said to be effective. Few hours later, R1's progress note indicated R1 had cough up moderate amount of thick, yellow sputum. The note had no indication of R1's physician notification for the persistent fever, coughing with increased production. Nursing progress note dated (MONTH) 30, (YEAR) indicated R1's oxygen saturation was 85 percent on room air with respiratory rate of 24 breaths per minutes. The note indicated R1 reported difficulty in breathing and lungs assessment indicated R1 had rhonchi (rattling or snoring-like lung sounds caused by obstruction or secretions in larger airways usually due to pneumonia) throughout. The note indicated R1 had copious, greenish sputum. Staff administered oxygen and R1's oxygen level and breathing improved. The note indicated the nurse did not notify R1's physician of the copious, greenish sputum, decreased oxygen, and difficulty in breathing. Nursing progress note dated (MONTH) 31, (YEAR) indicated R1 had abnormal vital signs of blood pressure ,[DATE], pulse 120 beats per minutes, and temperature of 99.7 degrees. The note indicated R1 was struggling to regurgitate a light brown substance, which a staff thought was his tube feeding. R1 was unable to catch his breath and requested for ambulance to go to the hospital. The note indicated staff administered nebulizer, but it was ineffective. The note indicated R1 was putting up so much phlegm and staff unable to understand R1's speech. The staff indicated this was a change as she was able to understand R1 verbally before this change. The staff indicated she called the physician office, but was unable to speak with a physician. The note indicated the staff was awaiting for call back and did not call the emergency medical services (EMS). The note indicated by the time staff was able to get order from the physician after hours of waiting. The note indicated when the EMS arrived, R1 had passed away in the facility. R1's death certificate indicated R1's death was due [MEDICAL CONDITION] (body's overwhelming and life-threatening response to infection), aspiration pneumonia, and [MEDICATION NAME] toxicity. During an interview on (MONTH) 6, (YEAR) at 5:03 a.m., Licensed Practical Nurse (LPN)-B stated she was notified of R1's change in condition while she was on break. LPN-B stated she was told R1 was spitting up his feeding. LPN-B stated R1's regurgitating his feeding was not new, but she had not notified R1's physician about it. LPN-B stated she obtained R1's vital signs, which was abnormal, and called the physician office. The nurse stated she was unable to reach a physician or obtain an order to send R1 to the hospital. LPN-B stated she continued to await a physician call back for over two hours. LPN-B stated, after obtaining call back, she called the EMS. The nurse stated, after the EMS arrived, staff found R1 has expired in his room. LPN-B stated she was not aware of alternative actions, like calling the director of nursing, medical director, or emergency medical services without a physician's orders [REDACTED]. LPN-B stated R1 requested to be sent to the hospital, but she was focused on getting a physician's orders [REDACTED]. During an interview on (MONTH) 6, (YEAR) at 6:40 a.m., nursing assistant (NA)-C stated she reported to R1's nurse that R1 was having difficulty in breathing and sounded like he was full of phlegm when she answered R1's call light. NA-C stated she was working on another unit and was not assigned to R1. During an interview on (MONTH) 6, (YEAR) at 9:11 a.m., the director of nursing stated staff were trained to notify family, physician, and nurse manager about changes in resident's condition, but there was no policy in place to address what nurses should do if they were not able to get hold of a physician and a resident requested to go to the hospital. The director of nursing stated, after R1's death, the facility re-educated nurses to sent a resident to the emergency if the condition dictates or the resident request to do so. During an interview on (MONTH) 5, (YEAR) at 12:35 p.m., Licensed Practical Nurse (LPN)-H stated he answered R1's call light and R1 requested to go to the hospital. LPN-H stated he notified R1's nurse, who was on break at the time. LPN-H stated he did not ask R1 why he wanted to go the hospital. LPN-H stated he did notify R1's physician due to his request to go to hospital. During an interview on (MONTH) 16, (YEAR) at 11:00 a.m., the Registered Nurse (RN)-J stated she noted R1 had fever of 100.2 degrees and productive cough on (MONTH) 28, (YEAR), but she did not notify R1's physician. RN-J stated she worked with R1 the next day and R1's [DEVICE] site had purulent drainage and R1 had copious amount of thick, greenish sputum with low oxygen, but she did not notify R1's physician. RN-J stated she worked with R1 the following day ([DATE], (YEAR)) and R1 had fever, greenish sputum, and difficulty breathing, but she did not notify R1's physician. RN-J stated she should have called R1's physician, but she did not. During an interview on (MONTH) 16, (YEAR) at 11:35 a.m., the facility's medical director stated she would expect the facility nurses to notify a physician for persistent fever [MEDICATION NAME] more than two days. The medical director stated the facility staff should notify a physician when staff suspected a resident with history of aspiration pneumonia may be experiencing regurgitation of tube feeding (feeding via [DEVICE] coming up through the mouth). The medical director stated she was not notified when staff was unable to reach a physician in a timely manner during the resident's change in condition. The facility's policy and procedure, Change in a Resident's Condition or Status, dated (MONTH) (YEAR), the facility indicated staff shall promptly notify the resident's physician of changes in the resident's medical/mental condition and/or status. The policy has no guidance for staff if unable to reach a physician or physician representative. The facility's Standing Orders revised (MONTH) 23, 2014 indicated staff may give Tylenol 650 mg for three to four hours as needed for elevated temperature of 2.4 degrees Fahrenheit or higher over resident's baseline/normal temperature and to notify a physician if fever persists for up to 24 hours or conditions warrants. The Standing Orders has no guidance for staff in case a resident had a change of condition and staff was unable to reach a physician.

Based on record review and interviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of five residents, R1, reviewed for a change in condition, physician notification and/or intervention. R1 was harm when he reported breathing difficulty, had significantly increased blood pressure and heart rate, and requested to be sent to the emergency room , but facility's did not assess, evaluate, intervene in a timely and appropriate manner. R1 was not sent to the hospital as he has requested earlier and died in the facility. The findings include: R1's medical record was reviewed. R1 was admitted to the facility for long term care with [DIAGNOSES REDACTED]. R1 had [DEVICE] ([DEVICE]) (tube placed in the stomach) for feeding and medication due to high risk of aspiration. R1 required assistance with assistance of two persons for transfers. R1's care plan dated (MONTH) 18, (YEAR) required staff to monitor R1's vital signs and notify physician of significant abnormality. The care plan indicated staff should monitor and report R1's lung sounds, increased pulse and fever as appropriate to the resident's physician. R1's nutritional assessment note dated (MONTH) 25, (YEAR) indicated R1 was receiving feeding via [DEVICE] because of aspiration pneumonia risk and staff needed to monitor R1 for any complications (diarrhea, reflux, productive cough, shortness of breath) due to the tube feeding. Nursing progress note dated (MONTH) 28, (YEAR) indicated R1's [DEVICE] site had a small amount of yellowish drainage and frequent, productive cough with fever (having temperature of 100.2 degrees). The note has no indication of R1's physician notification regarding the fever, frequent, productive cough, and yellowish drainage. Nursing progress note dated (MONTH) 29, (YEAR) indicated R1's [DEVICE] site drainage was purulent and R1's cough had copious thick, greenish sputum. R1 had nebulizer treatment with no outcome documented. R1's progress note a day later indicated R1 had fever again with temperature of 100.1 degrees, Tylenol 650 milligrams (mg) administered, and was coughing up yellowish phlegm with head of bed greater than 30 degrees. About five hours later, R1's progress note indicated R1 had fever with temperature at 100.5 degrees. Staff gave another dose of Tylenol 650 mg which was said to be effective. Few hours later, R1's progress note indicated R1 had cough up moderate amount of thick, yellow sputum. The note has no indication of R1's physician notification for the persistent fever, coughing with increased production. Nursing progress note dated (MONTH) 30, (YEAR) indicated R1's oxygen saturation was 85 percent on room air with respiratory rate of 24 breaths per minutes. The note indicated R1 reported difficulty in breathing and lungs assessment indicated R1 had rhonchi (rattling or snoring-like lung sounds caused by obstruction or secretions in larger airways usually due to pneumonia) throughout. The note indicated R1 had copious, greenish sputum. Staff administered oxygen and R1's oxygen level and breathing improved. The note indicated the nurse did not notify R1's physician of the copious, greenish sputum, decreased oxygen, and difficulty in breathing. Nursing progress note dated (MONTH) 31, (YEAR) indicated R1 had abnormal vital signs of blood pressure ,[DATE], pulse 120 beats per minutes, and temperature of 99.7 degrees. The note indicated R1 was struggling to regurgitate a light brown substance, which a staff thought was his tube feeding. R1 was unable to catch his breath and requested for ambulance to go to the hospital. The note indicated staff administered nebulizer, but it was ineffective. The note indicated R1 was putting up so much phlegm and staff unable to understand R1's speech. The staff indicated this was a change as she was able to understand R1 verbally before this change. The staff indicated she called the physician office, but was unable to speak with a physician. The note indicated the staff was awaiting for call back and did not call the emergency medical services (EMS). The note indicated by the time staff was able to get order from the physician after hours of waiting. The note indicated when the EMS arrived, R1 had passed away in the facility. R1's death certificate indicated R1's death was due [MEDICAL CONDITION] (body's overwhelming and life-threatening response to infection), aspiration pneumonia and [MEDICATION NAME] toxicity. During an interview on (MONTH) 6, (YEAR) at 5:03 a.m., Licensed Practical Nurse (LPN)-B stated she was notified of R1's change in condition while she was on break. LPN-B stated she was told R1 was spitting up his feeding. LPN-B stated R1's regurgitating his feeding was not new, but she had not notified R1's physician about it. LPN-B stated she obtained R1's vital signs, which was abnormal, and called the physician office. The nurse stated she was unable to reach a physician or obtain an order to send R1 to the hospital. LPN-B stated she continued to await a physician call back for over two hours. LPN-B stated, after obtaining call back, she called the EMS. The nurse stated, after the EMS arrived, staff found R1 has expired in his room. LPN-B stated she was not aware of alternative actions, like calling the director of nursing, medical director, or emergency medical services without a physician's orders [REDACTED]. LPN-B stated R1 requested to be sent to the hospital, but she was focused on getting a physician's orders [REDACTED]. During an interview on (MONTH) 6, (YEAR) at 6:40 a.m., nursing assistant (NA)-C stated she reported to R1's nurse that R1 was having difficulty in breathing and sounded like he was full of phlegm when she answered R1's call light. NA-C stated she was working on another unit and was not assigned to R1. During an interview on (MONTH) 6, (YEAR) at 9:11 a.m., the director of nursing stated staff were trained to notify family, physician, and nurse manager about changes in resident's condition, but there was no policy in place to address what nurses should do if they were not able to get hold of a physician and a resident requested to go to the hospital. The director of nursing stated, after R1's death, the facility re-educated nurses to sent a resident to the emergency if the condition dictates or the resident request to do so. During an interview on (MONTH) 5, (YEAR) at 12:35 p.m., Licensed Practical Nurse (LPN)-H stated he answered R1's call light and R1 requested to go to the hospital. LPN-H stated he notified R1's nurse, who was on break at the time. LPN-H stated he did not ask R1 why he wanted to go the hospital. LPN-H stated he did notify R1's physician due to his request to go to hospital. During an interview on (MONTH) 16, (YEAR) at 11:00 a.m., the Registered Nurse (RN)-J stated she noted R1 had fever of 100.2 degrees and productive cough on (MONTH) 28, (YEAR), but she did not notify R1's physician. RN-J stated she worked with R1 the next day and R1's [DEVICE] site had purulent drainage and R1 had copious amount of thick, greenish sputum with low oxygen, but she did not notify R1's physician. RN-J stated she worked with R1 the following day ([DATE], (YEAR)) and R1 had fever, greenish sputum, and difficulty breathing, but she did not notify R1's physician. RN-J stated she should have called R1's physician, but she did not. During an interview on (MONTH) 16, (YEAR) at 3:05 p.m., the facility's medical director stated she would expect facility's staff to report R1's persistent fever (ranging from 100.1 to 100.5 degrees) and increased cough production over days to R1's physician for timely interventions. During an interview on (MONTH) 16, (YEAR) at 11:35 a.m., the facility's medical director stated she would expect the facility nurses to notify a physician for persistent fever [MEDICATION NAME] more than two days. The medical director stated the facility staff should notify a physician when staff suspected a resident with history of aspiration pneumonia may be experiencing regurgitation of tube feeding (feeding via [DEVICE] coming up through the mouth). The medical director stated s/he was not notified when staff was unable to reach a physician in a timely manner during the resident's change in condition. The facility's Standing Orders revised (MONTH) 23, 2014 indicated staff may give Tylenol 650 mg for three to four hours as needed for elevated temperature of 2.4 degrees Fahrenheit or higher over resident's baseline/normal temperature and to notify a physician if fever persists for up to 24 hours or conditions warrants. The Standing Orders has no guidance for staff in case a resident had a change of condition and staff was unable to reach a physician. The facility's policy and procedure, Abuse Prevention Plan, dated (MONTH) 28, (YEAR) indicated that all residents residing at the facility will be protected from maltreatment/mistreatment with a goal to maintain an environment free from maltreatment/mistreatment.

Based on interview and document review, the facility failed to adequately assess and implement interventions to treat fluid retention for 1 of 1 resident (R99) whose death record was reviewed. The facility's failure to provide adequate assessment and intervention resulted in harm for R99 who suffered anxiety and difficulty breathing requiring subsequent hospitalization . Findings include: R99 was admitted to the nursing facility on [DATE], from a local hospital with [DIAGNOSES REDACTED]. R99's admission Minimum Data Set ((MDS) dated [DATE], identified R99 had intact cognition and was able to verbalize her needs. R99's care plan dated [DATE], indicated problem areas related to altered cardiovascular status due to [MEDICAL CONDITIONS] and oxygen dependence. Interventions included: Daily weights, monitor pedal [MEDICAL CONDITION], vital signs weekly, notify medical doctor of significant abnormalities, monitor and document as needed changes in lung sounds on auscultation, [MEDICAL CONDITION], changes in weight, monitor and document for signs and symptoms of [MEDICAL CONDITION] including- chest pain, pressure, nausea, dependent [MEDICAL CONDITION], changes in capillary refill, and change in color/warmth of extremities. R99's admission orders [REDACTED]. The physician had also ordered continuous oxygen via nasal cannula 1 liter, to keep oxygen (O2) saturations greater than 90 percent (%). Although R99 had been admitted to the facility on [DATE], the first weight completed was on [DATE] (eight days after admission), and was documented as 95.9 lbs found in the weight section of the electronic medical records (EMR). While the admission orders [REDACTED] [DATE]: 108 lbs. [DATE]: 105 lbs. [DATE] 105.8 lbs A nursing progress note documented on [DATE] at 12:54 p.m., identified R99 had been admitted for rehabilitation, and continued to receive therapy services. The note identified limitation with activities of daily living, ambulation and deconditioning which required rest periods for therapy. The progress noted did not include any documented concerns related to the resident's breathing, [MEDICAL CONDITION] status, weight gain or [MEDICAL CONDITION]. A nurse's note documented in the EMR dated [DATE], indicated a message had been sent to the nurse practitioner (NP)-A at the local clinic, regarding R99's having inspiratory wheezes, lower lobe diminished breath sounds, and three plus [MEDICAL CONDITION]. The note did not indicate the NP-A had been informed of R99's weight gain of 12 pounds from [DATE] weight 95.9 lb and on [DATE] was 108 lb. A faxed response from the NP-A had been received by the facility on [DATE], indicating she appreciated the update and wanted staff to continue to keep her updated on R99's condition. On [DATE], an interdisciplinary team (IDT) meeting note identified R99 had been noted to have 3+ [MEDICAL CONDITION] in her lower extremities over the weekend, had a 10 lb weight gain, and had utilized the [MEDICATION NAME] (diuretic). The IDT note also indicated the occupational therapist was going to hold the [MEDICAL CONDITION] treatment until her fluid overload was back in line. The electronic Medication Administration Record [REDACTED]. However, there was no indication the facility had fully assessed R99's [MEDICAL CONDITION] status (breathing) as part of the overall health assessment especially with the over 10 pound weight gain in one day, nor had they updated the physician/NP-A about R99's 10 pound weight gain and subsequent use of [MEDICATION NAME]. Further record review indicated R99 had experienced an increase in anxiety behaviors. Nursing notes documented [DATE] at 1:05 p.m. indicated R99 was yelling out, attempting to strike out at staff, and was very demanding. The note indicated as long as staff remained in R99's room, she was calm but when staff started to leave her room she would yell out for help. The note indicated the resident stated she was coughing up phlegm and indicated this was the first time staff had seen an increase in anxiety and behaviors. An entry in the EMR dated [DATE] at 1:57 p.m., indicated R99 had been speaking to the chaplain and was upset. The note indicated during the visit the resident had stated she could not breathe and they don't believe me. According to the EMR note, an aide, the Chaplain, and the facility social worker talked with the resident and tried to comfort her. The note indicated: Resident was asking for her doctor and stated that he was going to come again today and indicated the resident's oxygen levels had been checked and the nursing assistant had increased the oxygen level at the nurse's request. Another EMR entry dated [DATE] at 2:02 p.m. indicated: (family member (FM)-A) gave a verbal ok over the phone to transfer resident to ER (emergency room ) for eval and treatment. On [DATE] at 7:03 p.m. there was an entry in the EMR that indicated R99 had been transferred from the local hospital to St. Mary's Hospital in Rochester due to requiring a higher level of care due to [MEDICAL CONDITIONS]. The resident's record was reviewed further, and there was no documentation found to indicate the facility had contacted the physician regarding R99's weight gain, increased anxiety, breathing difficulty and decline in [MEDICAL CONDITION] status. Even though there was an admission order to do so. Instead, the facility staff had contacted the family to obtain permission to send R99 to the emergency room . An entry in the EMR dated [DATE], indicated FM-A had notified the nursing home that R99 died on [DATE]. During an interview with the registered nurse (RN)-M a manager on [DATE] at 2:43 p.m., RN-M stated she had been aware R99 was having trouble breathing, had anxiety and had lower extremity [MEDICAL CONDITION]. RN-M stated she had assessed R99 and had subsequently provided direction to the licensed practical nurse (LPN) to call the family for permission to transfer R99 to the emergency room . When asked whether she had notified the physician prior to transfer, RN-M said she had not contacted the resident's physician because it could have taken a day and a half for them to call back. Review of the EMR failed to include any documented assessment of R99's condition prior to her being sent to the hospital. During the interview with RN-M at 2:43 p.m. on [DATE], RN-M confirmed R99's admitted , and verified a weight had not been documented until the 8th day after admission even though R99 was supposed to have been weighed daily. RN-M said when she had realized R99 had not been weighed per protocol, she said she immediately educated all day shift nursing staff because the weights are done on the day shift. RN-M stated she was monitoring this process. The education was documented with staff signatures to confirm the nurses had received training per the RNM. On [DATE] at 3:30 p.m. a phone message was left for the LPN to return a call for an interview with no return call. On [DATE] at 2:31 p.m., the licensed social worker (LSW) was interviewed. The LSW recalled having been in R99's room with an unknown nursing assistant (NA) and the chaplain. The LSW stated R99 had been hallucinating the weekend before however, there was no documentation of any hallucinations in the EMR. The LSW stated R99 had been very scared and agitated which she thought had caused R99 to become short of breath. When interviewed on [DATE] at 3:32 p.m., the director of nursing (DON) stated R99 should have been weighed daily and the expectation for an admission weight was that it would be obtained within the first 24 hours from admission. The DON confirmed the lack of weights had been identified by RN-M and as a result staff education had been provided and monitoring of weights had been implemented. A request was made for a policy related to status change and was not provided. An undated policy, for weights was reviewed. The policy did not address the nursing facility's process for obtaining weights.

Based on observation, interview and document review, the facility failed to implement interventions, including repositioning and toileting, based on the comprehensive assessment for 1 of 1 resident (R68) in the sample reviewed who had a current pressure ulcer. This resulted in harm for R68 who had a current stage III (Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure ulcer. Findings Include: During observation on 10/2/15 at 8:04 a.m., R68 was assisted by nursing assistants (NA)-A and NA-E to transfer from her bed to the wheelchair. At 8:16 a.m. NA-A wheeled R68 to the dining room. At 9:27 a.m. R68 was observed sitting in her wheelchair next to the doorway of her room. At 10:45 a.m. R68 was observed sitting in her wheelchair at the balloon-volleyball activity. At 12:41 p.m. (four hours and thirty seven minutes after transfer to wheelchair), R68 was observed sitting in her wheelchair next to the doorway of her room. At 12:58 p.m. R68 was lying in her bed with her eyes closed. On 10/2/15 at 1:26 p.m. registered nurse (RN)-E removed an old duoderm dressing (an opaque dressing for wounds) which covered the stage II pressure ulcer located on the coccyx and it was reddened around edges, open ulcer and approximately 3.5 x 2 centimeters (cm) in size. RN-E treated wound with topical medication and a duoderm dressing to R68's coccyx. R68's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R68 had severe cognitive impairment, required an extensive two person physical assist with bed mobility and transfer, and had a stage III pressure ulcer. In addition, the quarterly MDS indicated R68 was not able to fully reposition self when in bed or in wheelchair. Documentation on the facility's Weekly Ulcer/Complex Wound Observation Tool included the following measurements for R68's wound: 9/30/15 Coccyx Pressure 1 x 0.3 cm Stage III 9/23/15 Coccyx Pressure 1 x 0.3 cm Stage III 9/16/15 Coccyx Pressure 2 x 0.5 cm Stage III 9/9/15 Coccyx Pressure 3 x 0.7 cm Stage III 9/2/15 Coccyx Pressure 2 x 1 cm Stage III 8/26/15 Coccyx Pressure 1 x 0.5 cm Stage III 8/20/15 Coccyx Pressure 2 x 1 cm Stage III 8/15/15 Coccyx 0.5 cm x 0.5 cm blanchable with no pain noted on the Skin Assessment form. Care Plan dated 9/9/15 identified skin care/pressure ulcer risk and included intervention of pressure reducing mattress and wheel chair cushion, gentle perineal cares and Strict every two hour repositioning sitting and laying. On 10/2/15 at 1:32 p.m. NA-A who was assigned cares for R68 for the shift was interviewed and asked if R68 had been repositioned which included offloading (removing pressure to the buttocks area for at least two minutes), since her transfer to the wheelchair at 8:04 a.m. and prior to her transfer back to bed just before 1 p.m NA-A said, No, she hasn't. Sometimes we just put her in her recliner and sometimes we just leave her in her wheelchair all morning to watch TV (television). Today was a typical day. On 10/2/15 at 1:45 p.m. NA-E who helped with cares for R68 during day shift stated, Normally you work on your own group (each NA has an assigned group of residents to provide care and services for during their shift), and after lunch we lay (sic) everyone down. No, I did not reposition her (R68) since we got her into her wheelchair this morning. NA-A and NA-E were then asked about R68's care plan for repositioning. NA-E stated, I think she is every two hours. I don't know with her wound if she is currently one or two. On our point click care tab (computer program) it is every two hours to reposition. NA-A added, Sometimes it just gets crazy and we don't get to it. On 10/2/15 at 2:41 p.m. the director of nursing (DON) stated, The expectation is that the care plan is followed. If staff are unsure of what is in it they need to ask the charge nurse, nurse manager, or myself. The DON added that if a resident it to be repositioned every two hours they should be repositioned within that time frame. The facility's policy Pressure Ulcer Treatment revised September 2013, defines a stage II pressure ulcer Partial thickness loss of dermis presenting as a shallow open ulcer with a pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Stage III pressure ulcer is defined, Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

Based on observation, interview and document review, the facility failed to comprehensively investigate causative factors following falls to determine resident centered interventions to minimize the risk of further falls for 1 of 3 residents (R50) with history of frequent falls and who had sustained an injury from a fall. This caused harm to R50. Findings include: R50 was observed on 9/30/15 at 1:14 p.m. in bed lying on side, room darkened, and pressure reducing pad in wheelchair. At 3:22 p.m. R50 was in the wheelchair and located in doorway to room. R50 had no shoe or sock on the left foot but did on the right foot. R50's [DIAGNOSES REDACTED]. Also was admitted to the facility on [DATE] and currently lives in the facility. R50's care plan identified R50 was risk for falling related to dementia with behavioral disturbances, and schizoaffective disorder. The care plan identified R50's history included: balance issues with transfers, self-transfers, hip fracture after fall prior to admission, resistance to cares/abusive behaviors toward staff. The Care Plan included; Aggressive behavior increases falls risk and risk of injury. The goal was that he would not be injured due to a fall. Fall interventions directed staff to: monitor increased confusion and signs/symptoms acute illness, encourage resident to sit in common area as allows to monitor closely when increased restless/agitation and during the day, remind resident to sit down, provide walker/wheel chair for use, have walker within easy reach, use green gripper pad in wheelchair to reduce sliding, encourage use of call light, instruct resident on safety measures, anticipate needs, monitor in bed, frequent checks as needed if restless, attempt to lay down in bed as he allows when viewed sleeping in wheelchair and monitor closely when increased restlessness. The care plan also indicated the resident had a history of [REDACTED]. Pain interventions included: monitor pain, establish causative factors and ways to alleviate them. The goal was for R50 to be as comfortable as possible. The care plan further indicated R50 had bowel and bladder incontinence and directed staff to check for incontinence and change pad every two hours and as needed. R50's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R50 had severe cognitive impairment, and required extensive staff assistance with bed mobility, transferring, locomotion on and off unit and activities of daily living. In addition, the MDS indicated R50 had sustained one fall with injury within the MDS reference period. A Morse Scale Fall Assessment (tool used to determine falls risk) dated 5/1/15, identified R50 was at high risk for falls. Documentation indicated R50 had experienced 11 falls since 3/7/15 as follows: -4/23/15, at 9:00 a.m. R50 found on the floor in his room. Description of incident indicated, rolled out of bed. No injuries noted. No interventions implemented. 24 hour follow up dated 4/24/15, indicated interventions had been found to be working. Registered nurse (RN) Root Cause Analysis identified risk factors/potential causes for fall as behavior/immobility. Patterns were identified as history of falls. Specific areas identified had been impaired mobility, balance and impaired cognition. RN-E documented an assessment and plan of action which directed staff to continue to monitor resident when restless, and which indicated R50 had history of falls, no injury, and for staff to monitor signs and symptoms of acute illness. The Root Cause Analysis completed following the fall indicated R50's behavior and immobility had been risk factors and were potential causes of the fall. The report indicated interventions had been found to be working however, there were no specific interventions noted. In addition, no actual causal factors were identified. -4/23/15, at 9:00 a.m. R50 found on the floor in his room. Description of incident indicated, rolled out of bed. No injuries noted. No interventions implemented. 24 hour follow up dated 4/24/15, indicated interventions had been found to be working. RN Root Cause Analysis identified risk factors/potential causes for fall as behavior/immobility. Patterns were identified as history of falls. Specific areas identified had been impaired mobility, balance and impaired cognition. RN-E had documented an assessment and plan of action which directed staff to continue to monitor resident when restless, has history of falls, no injury, monitor signs and symptoms of acute illness. Root Cause Analysis indicated behaviors and immobility were risk factors and potential causative factors for the fall. The report indicated interventions had been found to be working however, there had been no specific interventions noted. Even though the nurse completed the Root Cause Analysis and had circled Yes or No for areas of Medication, Environment, Functional Status, Psychological, and Underlying illness/condition, there was no resident specific cause of fall from the bed identified, and no interventions identified based on the assessed cause of fall developed. -5/01/15, at 8:00 a.m. R50 was found sitting on the floor in his room next to his wheelchair. No injuries noted. R50 reported to staff that he had been trying to get to the bathroom and slid from his wheelchair. No interventions implemented. RN Root Cause Analysis identified risk factors/potential causes for fall as immobility. Specific areas identified had been impaired mobility and behavioral. No patterns had been identified. RN assessment and plan of action directed staff to continue to monitor resident when increased restless, encourage to sit in common area as he allows to monitor closely when increased restless and agitation and during the day. The form was signed as completed by RN-E Root cause analysis had indicated immobility had been a risk factor and potential cause for the fall. No documentation found that indicated R50's attempt to get to the bathroom had been identified. No actual causal factors were identified even though R50 was attempting to toilet self independently. Report did not identify interventions nor if interventions had been found to be working. -6/08/15, at 7:00 a.m. R50 was found sitting on the floor in the doorway of his room next to his wheelchair. No injuries noted. No interventions implemented. RN Root Cause Analysis identified risk factors/potential causes for fall as behavior & mobility. Patterns were identified as history of falls. Specific areas identified had been impaired mobility, change in mood, and behavioral. RN assessment and plan of action indicated R50 had history of increased agitation at times with falls, staff directed to continue to monitor closely when increased agitation, monitor for self-transfers and monitor signs and symptoms of acute illness. The form was signed as completed by RN-E. Root cause analysis had indicated behavior and immobility had been risk factor and potential cause for the fall. No actual causal factors were identified that may have caused the fall. Report did not identify an new interventions nor if interventions had been found to be working. -6/18/15, at 1:25 p.m. R50 was found sitting on the floor in his bathroom with pants pulled down. A red mark was noted in the center of R50's forehead. Note on bottom of form directed staff to continue to monitor for increased behaviors, self-transfers and acute signs and symptoms of infection. RN Root Cause Analysis identified risk factors/potential causes for fall as mobility. No patterns noted. Specific areas identified had been impaired mobility, and impaired cognition. RN assessment and plan of action directed staff to continue to monitor increased behaviors, self-transfers and acute signs and symptoms of infection. The form was signed as completed by RN-E. Root cause analysis had indicated mobility had been risk factor and potential cause for the fall. No actual causal factors were identified. Report did not identify new interventions nor if care planned interventions had been found to be working. -6/24/15, at 7:15 a.m. R50 was found sitting on the floor in his room next to his bed. No injuries noted. RN Root Cause Analysis identified no risk factors/potential causes for fall. No patterns had been identified. Specific areas identified had been impaired mobility and behavioral. RN assessment and plan of action read gripper pad in wheelchair to prevent sliding. The form was signed as completed by RN-E. Again no actual causal factors were identified to develop specific interventions to prevent another fall. -7/17/15, at 1:15 p.m. R50 was found on the floor in his room lying on his right side after staff heard a loud crash and R50 yelling for help. R50 stated he had fallen on his head. One centimeter (cm) x one cm abrasion noted on top of his head, right side. Ice was placed as treatment. Hand written note on bottom of form directed staff to attempt/offer to lay resident down in bed as he allows when viewed sleeping in wheelchair. Continue use of green gripper in wheelchair. RN Root Cause Analysis identified risk factors/potential causes for fall as mobility. No patterns noted. Specific areas identified had been acute illness, impaired mobility, and behavioral. RN assessment and plan of action directed staff to attempt/offer to lay resident down in bed as he allows when viewed sleeping in chair. Green gripper replaced to wheelchair. Note dated 7/20/15 indicated R50 had been sent to the emergency room for signs and symptoms of respiratory infection and hospitalized . Note indicated acute illness may have contributed to fall. The form was signed as completed by RN-E Root cause analysis had indicated mobility had been risk factor and potential cause for the fall. No actual causal factors were identified to possible cause of fall. Report did not identify if interventions had been found to be working. -7/26/15, at 11:10 a.m. R50 was found lying on the floor on his right side with a large puddle of blood under his head. He was located by the bathroom with his wheelchair next to him. A large laceration was noted on top of right side of head, staff held pressure on the area and called ambulance. Report indicated R50 appeared to have had a seizure. Interventions implemented included to request doctor to restart medication for seizures. RN Root Cause Analysis identified risk factors/potential causes for fall as immobility. No patterns noted. Specific areas identified had been recent medication change, impaired mobility, and impaired cognition. RN assessment and plan of action indicated R50 had seizure activity during fall. MD updated to restart seizure meds, fall mattress removed due to increased tripping hazard. The form was signed as completed by RN-E The Root Cause Analysis for this fall indicated mobility had been a risk factor and potential cause for the fall however, the report indicated he had a medication change, potential seizure and included the removal of fall mattress. There were no new interventions put in place following the return of R50 to the facility even though seizures may have been the cause of fall. -9/06/15, at 4:30 a.m. R50 was found sitting on the floor in his room. R50 reported to staff that he had been trying to get into his wheelchair when the fall occurred. No injuries noted. Intervention implemented was for resident to call for assistance with transfers however, R50 is assessed to be severely cognitively impaired. Hand written note on bottom of form directed staff to monitor closely when increased restlessness noted. RN Root Cause Analysis identified immobility as risk factors/potential causes for fall. History of falls identified as a pattern with no specific fall history information. Specific areas identified had been impaired mobility and behavioral. RN assessment and plan of action read to continue to monitor closely when increased restlessness noted. Root cause analysis had indicated immobility had been risk factor and potential cause for the fall. No actual causal factors were identified. Report did not identify new interventions based on possible cause of fall nor if care planned interventions had been found to be working. -9/06/15, at 11:15 p.m. R50 was heard yelling out by staff and found lying on the floor in his room on his right side in front of his closet. Juice was noted to be spilled on the floor, and R50 had removed gripper socks from feet. No injuries noted. Hand written note directed staff to monitor for placement of shoes or gripper socks, continue green gripper pad in chair and monitor when increased restlessness. RN Root Cause Analysis identified immobility and mood as risk factors/potential causes for fall. History of falls identified as a pattern with no specific fall history information. Specific areas identified had been impaired mobility and behavioral. RN assessment and plan of action read monitor for placement of shoes or gripper socks, continue gripper pad in chair and monitor when increased restless. The form was signed as completed by RN-E. Root cause analysis had indicated immobility and mood had been risk factor and potential cause for the fall. No actual causal factors were identified and no new interventions or if care planned interventions were affective. -9/16/15, at 9:30 a.m. R50 was found in his room sitting on the floor in front of his wheelchair by the bathroom door. No injuries noted. The facility replaced the green gripper pad in R50's wheelchair as intervention to prevent further falls. 24 hour follow up dated 9/17/15 indicated interventions had been found to be working. RN Root Cause Analysis identified immobility as risk factors/potential causes for fall. History of falls identified as a pattern with no specific fall history information. Specific areas identified had been impaired mobility and behavioral. RN assessment and plan of action read green gripper replaced in wheelchair to prevent sliding. Resident has history of self-transfers with falls. The form was signed as completed by RN-E. Root cause analysis had indicated immobility had been risk factor and potential cause for the fall. The facility replaced the green gripper pad as intervention, however, indicated interventions had been found to be working. No actual causal factors were identified. There was no system in place to monitor the placement of the gripper pad. During review of falls, and interview on 10/1/15, at 2:12 p.m. RN-E verified the above findings and further verified tracking and trending had not been completed after each fall. RN-E stated there are no patterns to his falls, he just self-transfers and doesn't call. RN-E verified R50 had severe cognitive impairment and indicated the interdisciplinary team reviews falls daily however was unable to provide documentation the above falls had been reviewed. During review of falls, and interview on 10/2/15, at 2:27 p.m. the director of nursing (DON) verified above falls had not been comprehensively assessed for causative factors and appropriate interventions. The facility's policies including fall investigation procedure, were requested but were not provided.

Based on observation, interview and document review, the facility failed to provide care and services to prevent and promote healing of pressure ulcers for 2 of 3 residents (R62, R31) in the sample reviewed for pressure ulcers. R62 had not been repositioned or offered to be repositioned for four hours and twenty one minutes and currently had a stage III gluteal fold ulcer and a stage II scrotum ulcer. Also the ROHO cushion had not been inflated for optimal pressure reduction according to the manufactures instructions. This resulted in harm for R62. Findings include: R62 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) (a comprehensive assessment and screening tool) was done on 8/4/2011. The MDS also indicated risk for developing pressure ulcers and there were two stage II pressure ulcers present at the time of the annual assessment. Both the scrotum ulcer and the gluteal ulcer were currently present during the survey. The scrotum ulcer remained a stage II ulcer and the gluteal ulcer increased from a stage II to a stage III ulcer on 9/11/11. The brief interview for mental status (BIMS) done with the annual MDS assessment indicated that R62 had intact cognition and no memory deficit. During observations on 11/3/2011, at 9:09 a.m. R62 was out of bed and in the wheelchair at 10:09 a.m. R62 was in the main hallway playing cards with spouse. At 11:09 a.m. R62 remained in the hallway visiting with spouse and other residents. When asked if he had been repositioned or offered to be repositioned, R62 stated that no one had offered yet. At 1:00 p.m. R62 was in room and again stated when asked if staff had assisted him to reposition he stated, "No one offered to reposition me since I got up this morning." R62's spouse was present with the resident most of the day and confirmed that staff had not repositioned him or offered to reposition him. At 1:30 p.m. on 11/3/2011, nursing assistant (NA)-G came into the room with a Hoyer lift to transfer R62 into bed for his wheelchair. At this time NA-G was asked by this surveyor how often R62 should have been repositioned and if he had been repositioned during the a.m. NA-G said that he is to be repositioned every 2 hours but that doesn't always happen because of limited staffing and staff breaks. R62 had been observed from 9:09 a.m. until 1:30 p.m. on 11/3/2011 by this surveyor without repositioning. R62 went from 9:09 a.m. to 1:30 p.m. a total of 4 hours and 21 minutes without being repositioned. This time interval was confirmed by R62 and his spouse at 1:25 p.m. on 11/3/2011. On 11/3/2011, at 2:30 p.m. this surveyor observed nursing assistant (NA)-G positioned R62 so the scrotal and gluteal wounds could be observed. Clinical Coordinator (CM)-A or staff nurse on the unit were not available to measure the wound at this time. The full thickness scrotal ulcer was observed to be open and approximately 5-6 cm long. The left gluteal fold ulcer was also observed to be open and was approximately 6 cm in length. The Skin ulcer data collection and assessment forms were reviewed and the gluteal fold ulcer was first noted to develop on 7/6/11 and was a stage II ulcer measuring 1 cm by 2 cm, depth of wound not documented. On 9/21/11, the ulcer increased form a stage II ulcer to a stage III and measured 6 cm x 6 cm. On 11/1/2011, the ulcer was identified as a stage III and measured 6 cm x 4 cm. The stage II ulcer located on the scrotum was assessed by the wound care nurse consultant (WCNC) from American Medical Technologies. The WCNC's documentation on a Patient Wound Care Sheet dated 6/8/2011, (no time of visit) indicated R62 had a full thickness posterior scrotum pressure ulcer that was unstageable which was a full thickness tissue loss in which the base of the ulcer is covered by slough-yellow, tan, gray, green or brown colored and/or eschar a tan, brown or black color in the wound bed. The scrotal ulcer measured 3.5 centimeters (cm) by 2 cm. The wound bed had 40% yellow slough, 30% eschar and 30% clean viable tissue. The WCNC ' s visited the resident and documented on 7/6/2011, (no time of visit) she indicated that R62 had a posterior scrotum ulcer that was " A healing stage III (full thickness tissue loss, subcutaneous fat may be visible) pressure ulcer that measured 2 cm. by 2 cm. At that time the wound bed had 100% clean viable tissue. The WCNC ' s visited the resident and documented on 8/3/2011, (no time of visit) she indicated that R62 had a full thickness posterior scrotum pressure ulcer and was a "pressure-healing stage III" with measurements of 7.0 cm. by 4 cm. which had become larger in size since the last measurement. The wound bed had 80% slough and 20 % viable tissue. This surveyor asked for WCNC visits on 9/21/11 and 10/19/11 notes however, they were not provided by the facility. A Braden Scale (used for predicting pressure ulcer risk) was done on 8/1/2011, and on 11/1/2011. R62 had a score of 15 each time. A score of 15 indicated that resident is at risk of developing pressure ulcers. The plan of care, dated 8/7/2008, indicated R62 was dependent and required assistance for cares and repositioning as well as the assistance of 2 staff for all transfers with the use of a mechanical lift. The plan of care, with an original date of 6/17/2008, identified pressure ulcers. The interventions listed included a ROHO cushion (air flotation cushion to reduce pressure to the buttocks) to chair; pressure reduction mattress on bed; reposition resident 1 hour after getting out of bed in a.m. and eve (evening). Then every 2 hours. The charge nurse was to complete a skin assessment to scrotum and buttocks prior to resident leaving and another skin assessment on returning to the facility. On 11/17/2011, the interdisciplinary progress notes were reviewed. Documentation indicated that R62 left the faciity on the following days, to include but not limited to 5/8/2011, 5/13/2011, 5/17/2011, 5/20/2011, 8/26/2011, and 8/28/2011. According to the comprehensive care plan, a skin assessment was to be done prior to R62 leaving the facility and upon return to the facility. This information had not been completed. At 9:45 a.m. on 11/3/2011, CM-A was interviewed regarding the low-profile ROHO cushion that was used in R62 ' s wheelchair. CM-A was asked if the ROHO cushion was checked routinely to ensure proper inflation. CM-A stated that it was not checked. The ROHO manufacturer ' s recommendations were reviewed with CM-A; they indicated that the resident should have been seated on the ROHO cushion to ensure proper inflation. It also indicated the cushion should have been checked daily to ensure that the resident didn ' t "bottom out." CM-A indicated unawareness of the manufacturer's recommendations and stated there was not a policy for the use of the ROHO cushion, and that the NA's were responsible for the monitoring of the ROHO cushion. At 1:30 p.m. on 11/3/2011, the maintenance director (MD) was observed returning R62's wheelchair to his room. The MD stated that the ROHO cushion was inflated in the maintenance area per request of CM-A. The MD stated he added air to the cushion until it was "more firmly inflated but I know the resident should be in the chair when this is done." At 11:52 a.m. on 11/4/2011, the director of nursing (DON) was interviewed and stated she was trying to locate the policy regarding the ROHO cushion. None had been provided. The DON was also informed of the lack of repositioning and lack of skin assessments when leaving and returning to the facility. At 2:00 p.m. on 11/4/2011, a phone interview was done with the Occupational Therapist (OT) that serves the nursing facility. When asked about the proper inflation of the ROHO cushion, the OT indicated the ROHO cushion is checked and maintained according to the manufacturers recommendation by them if they are seeing the resident however, R62 was not being seen by them at this time. R31 was not repositioned for two hours and forty minutes and during second observation for three hours and twenty minutes. Although the care plan instructed the resident was to be repositioned every two hours. R31 was admitted to the facility in 2006 and had [DIAGNOSES REDACTED]. The care area assessment (CAA) dated 3/5/11 indicated [REDACTED]. In addition the CAA indicated R31 was incontinent of bowel and bladder, was at nutritional risk, and was at risk for skin breakdown. The care plan dated October 2011 directed staff to turn and reposition the resident every 2 hours and as needed. At 12:40 p.m. on 11/2/11, R31 was observed during a Hoyer transfer into bed. Incontinence care was provided at this time for the resident. When R31 was rolled to the side it was noted the resident's coccyx and right buttock were red. Nursing assistant (NA)-A stated that R31 had not been up long enough to be red because he had been assisted to the chair at 10:00 a.m. (a period of 2 hours 40 minutes sitting in the chair.) On 11/4/11, R31 was observed from 8:40 a.m. to 10:20 a.m. lying on his back in bed. The nursing assistant documentation indicated R31 had been assisted to the reposition at 7:00 a.m. (a period from 7:00 a.m. to 10:20 a.m. or 3 hours 20 minutes in the bed). At 10:20 a.m. the resident was rolled to the right and the buttock and coccyx area was noted to be bright red. The buttock had indentations from incontinence brief folds. A large white raised area approximately 3 inches in length was observed to the right of the coccyx and a second raised white area approximately 1 inch in diameter was noted by the anus. On asking how often the resident was to be repositioned at this time NA-A stated the resident was to be repositioned every 2 hours. The Pressure Ulcer CAA dated 3/5/11 indicated R31 was at risk for skin breakdown related to decreased mobility, bowel and bladder incontinence, [MEDICAL CONDITION], diabetes. The CAA indicated R31 required staff physical assistance with mobility, including bed mobility, transfers and ambulation. The CAA noted R31 had a Braden score of 14 indicating moderate risk for skin breakdown. Skin ulcer data collection & assessment documentation dated 4/30/11 indicated R31 had two (2) stage II open areas, that increased in size on 5/7/11 and resolved on 6/6/11. Skin ulcer data collection and assessment documentation dated 7/1/11 indicated R31 had a coccyx open area stage II pressure area and on 7/6/11 it was resolved Skin assessment documentation dated 8/31/11 indicated no open areas, but that the resident remained at high risk for skin breakdown. The nursing assistant documentation Toileting and Turning Schedule for 10/23/11 to 10/31/11 was reviewed. The documentation for each 24 hour period indicated R31 had two or more 3 to 5 hour blocks of time in which he was not repositioned, even though the care plan stated the resident was to be repositioned every two hours. At 3:30 p.m. on 11/3/11, the clinical nurse manager (CNM)-A indicated she was unaware of the resident's reddened buttock and coccyx area and verified R31 had a recent history of pressure areas. At 4:00 p.m. on 11/3/11 CNM-A verified the resident continued to have a reddened buttock and coccyx area and R31 would be reassessed for pressure tolerance. At 11:53 a.m. on 11/4/11, CNM-A stated that R31 had been reassessed and that it showed that every 2 hour repositioning was adequate. She added that when lying for 2 hours, R31 did show indentations from the sheets. She stated that the resident needed to be repositioned every 2 hours not every 3 hours.

Based on medical record review and interviews, the facility failed to provide supervision to prevent a fall for one of four residents (Resident #1) reviewed. Resident #1 continued to be left unattended on the toilet after a determination was made to not leave her unattended on the toilet. The care plan and care guide were not updated. As a result, the resident fell sustaining a head injury and hip fracture. Findings include: Resident #1's medical record was reviewed. The comprehensive annual assessment note of 2/4/2011 indicated Resident #1 was alert and oriented. She had [DIAGNOSES REDACTED]. She ambulated with staff assistance. She was at risk for falls due to a history of falls and her diagnoses. She was incontinent of urine. She required assistance of one staff with transferring, including to the toilet. Nursing progress notes dated 12/22/2010 indicated Resident #1 was found unresponsive while sitting on the toilet. The physician was called and Resident #1 was transferred to the emergency department for an evaluation. The emergency department notation of 12/22/2010 indicated that Resident #1 was seen at the emergency department for conditions of vasovagal syncope and urinary tract infection. Orders sent from the hospital noted to take Resident #1's blood pressure daily and report it to her physician and to make an appointment for her physician to see her in two weeks to recheck her blood pressure and urine. A nursing progress note dated 2/5/2011 indicated Resident #1 was placed on the toilet for a bowel movement per her request. When staff went back to the room to check on her, they found her unresponsive while sitting on the toilet. Facility morning report notes dated 2/7/2011 indicate staff need to stay with Resident #1 while she is on the toilet. A nursing progress note dated 2/25/2011 indicated Resident #1 fell off of the toilet onto the floor after receiving assistance to the toilet for a bowel movement. She was found lying on the floor with the toilet seat broken. She had an emesis, had blood coming from the back of her head, and complained of hip pain. She was sent to the hospital to be evaluated. Resident #1 was admitted to the hospital with [REDACTED]. Hospital medical records dated 3/2/2011 indicated Resident #1 returned to the facility after surgery for [REDACTED]. Her care plan updated March, 2011, after returning from the hospital, noted Resident #1 required staff assistance of two and a mechanical lift to transfer. Employee (E)/nurse was interviewed on 4/5/2011 at 1:50 p.m. and stated Resident #1 could be left alone on the toilet before her fall on 2/25/2011. Employee (B)/nursing administration was interviewed on 4/5/2011 at 2:27 p.m. she stated that at the interdisciplinary team meeting on 2/7/2011 it was determined that Resident #1 required direct supervision while on the toilet. Her care plan was not updated after this meeting. Staff told her they continued to leave Resident #1 unsupervised on the toilet. As a result, the resident fell and fractured her hip. Employee (B) stated the care plan and care guide were not updated to reflect the change until after Resident #1 returned from the hospital after the fall on 2/25/2011 when she sustained a hip fracture. Employee (F)/Nursing Assistant (NA) was interviewed on 4/25/2011 at 11:12 a.m. and stated she transferred Resident #1 onto the toilet the day she fell . There was no notation on the care guide nor was Employee (F) informed that Resident #1 was not to be left unattended on the toilet. She stated that on 2/ 25/2011, she assisted Resident #1 to the toilet when she requested to use the toilet to have a bowel movement. Employee (F) stated she assisted Resident #1 according to the care guide with one assist and used a gait belt. Resident #1 denied any dizziness when questioned her. She gave Resident #1 the call light and left the room. Employee (F) left Resident #1 sitting alone on the toilet. She did not know Resident #1 could not be left unattended on the toilet. Another staff member found Resident #1 lying on the floor in the bathroom. Employee (F) stated the care plan did not reflect the need for staff to stay with Resident #1 while she was on the toilet until after she sustained the hip fracture.