Every finding on record at Terra Bella Health and Wellness Suites

Based on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 resident (CR #1) reviewed for comprehensive care plans. The facility failed to develop a comprehensive care plan for CR #1's catheter. This failure could place residents at risk catheter related complications, infections, and a decline in health status.Findings included: Record review of CR #1's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and expired in the facility on [DATE]. His diagnoses included: Malignant neoplasm of prostate (prostate cancer), Urinary tract infection (a bacterial infection that affects any part of your urinary system, including the bladder, urethra, or kidney), Immunodeficiency due to conditions classified elsewhere (refers to a secondary immune system weakness caused by another primary disease or medical problem), Chronic kidney disease (a long-term condition where the kidneys are damaged and cannot filter blood well), Overactive bladder (a condition causing a sudden, hard-to-control urge to urinate, frequent urination), and anemia (common blood condition where your body lacks enough healthy red blood cells or hemoglobin to carry sufficient oxygen to your tissues). Record review of CR #1's admission MDS dated [DATE] revealed a BIMS score of 8 out of 15 indicating his cognition was moderately impaired. Further review of the MDS revealed he had an indwelling catheter. Record review of CR #1's comprehensive care plan started on [DATE] revealed no problem areas of indwelling catheter. Record review of CR #1's progress note dated [DATE] at 7:20pm revealed in part, .resident admitted from hospital at 7:15pm. Admitting diagnosis: Anemia. Foley catheter (a flexible plastic tube inserted through the urethra into the bladder to drain urine, held in place by a water-filled balloon )in place and patent (the tube is completely open, clear, and unobstructed.). Resident is incontinent of bowel. Record review of CR #1's progress note dated [DATE] at 3:23pm revealed in part, .Suprapubic catheter (a thin, flexible tube placed directly into your bladder through a small cut in your lower belly to drain urine when you cannot pee on your own) in place and draining clear, yellow urine. No redness or irritation to insertion site . Record review of CR #1's physician orders started [DATE] and ended [DATE] revealed orders for:Suprapubic catheter care every shift and PRNCatheter leg strap in place - to secure the catheter and facilitate flow of urine every shiftEmpty foley catheter bag every shift and document output Record review of CR #1's History and Physical progress note dated [DATE] by MD revealed in part under Diagnoses, Assessment, and Plan, .Suprapubic catheter. Patient has risk of recurrent urinary tract infections secondary to long term use of catheter. Phone interview on [DATE] at 5:58pm, CR #1's RP said CR #1 had recently passed away at the facility on [DATE]. The RP stated CR #1 had prostate cancer and was placed on hospice shortly before he passed away. She said CR #1 had two catheters, a foley catheter and a suprapubic catheter that both needed be emptied every 2 hours and she did not think they were doing so. RP said she had a care plan meeting with the facility on [DATE] where she expressed concerns with ADL care and the emptying of his catheter bags timely and she said they did implement some changes after the meeting, however, the resident passed away a few days after the care plan meeting. Interview on [DATE] at 2:07pm, LVN B denied there was ever an issue with CR #1's catheter bags not being emptied timely and said she rounded every 2 hours to check if they needed emptying. LVN B said the nurses or the CNA's could empty the catheter bags. LVN B added the nurses would document how much urine output the resident had and would also assess his catheter and urine output every shift. Phone interview on [DATE] at 3:30pm, LVN C said she never observed any blood in CR #1's urine and said his catheter bags were frequently emptied, and she had never observed an issue with them getting too full. LVN C said she did routinely provide catheter care for CR #1 and the CNA's did as well. LVN C said she would assess CR #1's catheter and urine every shift and document findings. Interview on [DATE] at 4:15pm, the DON said CR #1 had an extensive medical history which caused a lot of health complications for him including two catheters but stated staff were caring for the catheters appropriately. The DON said CR #1's baseline care plan included he had a suprapubic catheter but acknowledged the comprehensive care plan did not include mention of the catheter or interventions regarding the catheter. The DON said if a resident has a catheter it should be included in the residents care plan. Interview on [DATE] at 4:33pm, the ADON said that she rounded on CR #1 often and made sure staff were attentive to his needs after RP voiced concerns with care. The ADON said CR #1's catheter bags were emptied often and said they never got to the point where they were full. The ADON said she never observed CR #1's catheter bags more than half full and all staff including the nurses or CNA's could provide catheter during perineal care or as needed. The ADON said the MDS Coordinator completes the care plans for residents. Interview on [DATE] at 4:57pm, the MDS Coordinator said she completes the baseline care plan at admission and the comprehensive care plans after the comprehensive assessment was completed. The MDS Coordinator acknowledged that CR #1's catheter was mentioned in the baseline care plan but not the comprehensive care plan. The MDS Coordinator said if CR #1's catheter was marked in the comprehensive assessment then it should have been included in the care plan. The MDS Coordinator said around the time CR #1's comprehensive care plan was due she was just stepping into the role by herself and was not as familiar with the facility electronic records system at the time. She stated it could have been an oversite since she was in that time of transition. The MDS Coordinator stated care plan interventions were discussed amongst the team and in care plan meetings. The MDS Coordinator said some typical interventions for a catheter may include change per the doctors orders or as needed, monitor the catheter for complication, and follow facility protocols. The MDS Coordinator said the purpose of care plans was so nursing staff know how to take care of the resident. Record review of the facility Care Plan Process, Person-Centered Care policy (Revised [DATE]) revealed in part, .The facility will develop and implement a baseline care and comprehensive care plan for each resident that includes the instructions needed to provided effective and person-centered care of the resident that meet professional standards. Following RAI Guidelines develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a residents medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The Interdisciplinary Team will review for effectiveness and revise the person-centered care plan after each assessment. This includes both the comprehensive and quarterly assessments. For comprehensive assessment the review will be completed with seven (7) days of V0200B2 (Item V0200B2 in the Minimum Data Set represents the Care Area Assessment completion date) and no more than 21 days after admission. The person-centered care plan includes: A. Date; B. Problem; C. Resident goals for admission and desired outcomes; D. Time frames for achievement; E. Interventions, discipline specific services, and frequency.

Based on interview and record review that facility failed to timely provide or obtain laboratory services to meet the needs of its residents for 1 of 6 residents (CR #1) reviewed for laboratory services. The facility failed to timely collect a urine specimen to complete CR #1 order for urinalysis with culture ordered on [DATE] for blood in urine. The urine sample was not collected until [DATE] when resident presented with fever and decrease in energy and he was diagnosed with a urinary tract infection. This failure placed residents at risk for delayed identification and treatment of infections, worsening symptoms, and complications related to untreated infections. Findings included: Findings included: Record review of CR #1's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and expired in the facility on [DATE]. His diagnoses included: Malignant neoplasm of prostate (prostate cancer), Urinary tract infection (a bacterial infection that affects any part of your urinary system, including the bladder, urethra, or kidney), Immunodeficiency due to conditions classified elsewhere (refers to a secondary immune system weakness caused by another primary disease or medical problem), Chronic kidney disease (a long-term condition where the kidneys are damaged and cannot filter blood well), Overactive bladder (a condition causing a sudden, hard-to-control urge to urinate, frequent urination), and anemia (common blood condition where your body lacks enough healthy red blood cells or hemoglobin to carry sufficient oxygen to your tissues). Record review of CR #1's admission MDS dated [DATE] revealed a BIMS score of 8 out of 15 indicating his cognition was moderately impaired. Further review of the MDS revealed he had an indwelling catheter. Record review of CR #1's comprehensive care plan started on [DATE] revealed no problem areas of indwelling catheter or UTI. Record review of CR #1's progress note dated [DATE] at 7:20pm revealed in part, .resident admitted from hospital at 7:15pm. Admitting diagnosis: Anemia. Foley catheter (a flexible plastic tube inserted through the urethra into the bladder to drain urine, held in place by a water-filled balloon )in place and patent (the tube is completely open, clear, and unobstructed.). Resident is incontinent of bowel. Record review of CR #1's progress note dated [DATE] at 3:23pm revealed in part, .Suprapubic catheter (a thin, flexible tube placed directly into your bladder through a small cut in your lower belly to drain urine when you cannot pee on your own) in place and draining clear, yellow urine. No redness or irritation to insertion site . Record review of CR #1's progress note dated [DATE] at 4:14am revealed in part, .Suprapubic catheter in place and draining clear, yellow urine. No redness or irritation to insertion site. Record review of CR #1's progress note dated [DATE] at 4:13pm revealed in part, .Suprapubic catheter in place and draining clear, yellow urine with 2 leg bags on bilateral lower extremities. No redness or irritation to insertion site. Record review of CR #1's progress notes dated [DATE], [DATE], and [DATE] noted his suprapubic catheter was in place and draining clear yellow urine with no irritation or redness at insertion site. Record review of CR #1's History and Physical progress note dated [DATE] by MD revealed in part under Diagnoses, Assessment, and Plan, .Suprapubic catheter. Patient has risk of recurrent urinary tract infections secondary to long term use of catheter. Record review of CR #1's progress note dated [DATE] at 5:11am by LVN A revealed in part, . Suprapubic catheter in place and draining clear, yellow urine. No redness or irritation to insertion site. Record review of CR #1's progress note dated [DATE] at 6:04pm by LVN B revealed in part, .Resident noted during shift to have hematuria (blood in the urine) draining in both leg bags. No discomfort or pain reported at insertion sites; NP notified and made aware. New orders for CBC (blood test used to evaluate overall health, screen for medical conditions, and monitor treatments), BMP (blood test that measures eight specific substances in your blood), Urinalysis with culture (evaluates urine physically, chemically, and microscopically for signs of disease or infection, while the culture grows any present bacteria or yeast to identify the specific germ and test which antibiotics will cure it.) diagnosis: Hematuria; RP notified and left a voicemail to call back. Awaiting for response at this time. Patient care ongoing. Record review of CR #1's progress note dated [DATE] at 6:47pm by LVN B revealed in part, .Suprapubic catheter in place and draining clear, yellow urine. No redness or irritation to insertion site. Record review of CR #1's physician orders revealed an order started on [DATE] for Urinalysis Reflexed to Culture Sensitivity if indicated (The lab first analyzes your urine sample for signs of a urinary tract infection. If those initial results show specific markers of infection, the lab automatically performs a urine culture and sensitivity test). Record review of CR #1's progress notes dated [DATE] at 5:28am by LVN A revealed in part, .Resident noted to have hematuria in both leg bags. No discomfort or pain reported at insertion sites; NP notified and made aware. New orders for CBC, BMP, Urinalysis with culture diagnosis: Hematuria. Awaiting for response at this time. Record review of CR #1's laboratory results collected on [DATE] at 8:25am, received [DATE] at 4:01pm and resulted on [DATE] at 12:47am revealed BMP and CBC were resulted, however, Incomplete lab report was noted for Urinalysis. Further review of the lab report for Urinalysis revealed in part, .Disposition: specimen not collected; Test not performed: UA; Action: Please collect specimen and notify lab. Record review of CR #1's progress notes dated [DATE] at 5:40am by LVN A revealed no mention of specimen collection, catheter or assessment of urine but noted frequent rounding with no concerns. Record review of CR #1's progress notes dated [DATE] at 2:00pm by LVN C revealed no mention of specimen collection, catheter or assessment of urine but noted frequent rounding with no concerns. Record review of CR #1's progress notes dated [DATE] at 11:27am by LVN C revealed no mention of specimen, collection catheter or assessment of urine but noted frequent rounding with no concerns. Record review of CR #1's progress notes dated [DATE] at 6:50am by LVN A revealed no mention of specimen collection, catheter or assessment of urine but noted frequent rounding with no concerns. Record review of CR #1's progress note dated [DATE] at 2:34am by RN A revealed no mention of specimen collection, catheter or assessment of urine but noted frequent rounding with no concerns. Record review of CR #1's progress note dated [DATE] at 3:28pm by LVN B revealed in part, .Suprapubic catheter in place and draining clear, yellow urine. No redness or irritation to insertion site. Record review of CR #1's progress note dated [DATE] at 4:21pm by LVN B revealed, Urinalysis with culture collected and placed in specimen fridge. Lab contacted and made aware of collection. Patient care ongoing at this time. Record review of CR #1's progress notes dated [DATE] at 5:22pm by LVN B revealed, Resident presented to have decrease in energy. This nurse assessed and obtained vital signs. Vital signs resulted to blood pressure: 116/70, Pulse: 106, Temperature: 100.6F, Respiration: 18 bpm, O2: 97%; No Shortness of breath or respiratory distress noted. No discomfort/pain reported at this time. NP notified and made aware. New orders initiated for Ceftriaxone (antibiotic given via injection into a vein or muscle by a healthcare professional to treat severe bacterial infections) 1 gram via IM daily x 3 days; Notify MD/NP once UA results are completed. Will continue to check and monitor vital signs every shift. RP notified and sent a voicemail. Awaiting for a response at this time. Record review of CR #1's urinalysis results collected on [DATE] at 4:06pm, received on [DATE] at 2:44pm, and reported on [DATE] at 7:30pm revealed the urine was dark yellow and cloudy, negative for blood, but had many bacteria and WBC of 15-20 with a normal reference range being none seen (WBCs in your urine could indicate there is inflammation or an infection somewhere in your urinary tract). Record review of CR #1's physician orders and [DATE] MAR revealed an order started on [DATE] and ended on [DATE] for ceftriaxone reconstituted solution (antibiotic ceftriaxone that has been mixed with a sterile liquid to turn it into a liquid medicine ready for injection) 1 gram injected once a day for Fever was administered at 8:00am [DATE] - [DATE]. Record review of CR #1's progress note dated [DATE] at 5:57pm by LVN C revealed in part, .Resident continues on IM Rocephin 1GM QD 1 of 3 related to UTI. C&S pending at this time. No adverse effects noted; resident remains afebrile (without a fever). Suprapubic catheter in place and patent. Record review of CR #1's progress note dated [DATE] at 3:36am by LVN A revealed in part, .Resident continues on IM Rocephin 1GM QD day 1 of 3 related to UTI. C&S pending at this time. Record review of CR #1's progress note dated [DATE] at 8:38pm by RN B revealed in part, .Resident is on day 2 of 3 of Ceftriaxone 1g IM therapy administration once daily. Medication was administered as ordered and tolerated well with no adverse reactions noted. Ongoing care continues, including Suprapubic intact, dry with no infection noted. Record review of CR #1's progress note dated [DATE] at 5:00am by LVN A revealed in part, .Resident is on day 2 of 3 of Ceftriaxone 1g IM therapy administration once daily no adverse reactions noted. Resident is resting in bed without signs of distress. Record review of CR #1's progress note dated [DATE] at 4:45pm by LVN B revealed in part, .Resident is Status post Day 3/3- Ceftriaxone 1g IM therapy. Resident remains afebrile. No discomfort or pain reported. PO fluids encouraged and tolerated. Foley catheter care completed, observed clear and yellow urine; No clogging or obstruction noted. Record review of CR #1's progress notes dated [DATE] - [DATE] revealed residents status post administration of Rocephin IM for 3 days was monitored with no adverse findings. Record review of CR #1's Urine Culture results collected [DATE] at 4:06pm, received [DATE] at 12:10am, and reported on [DATE] at 8:20pm revealed there was a pathogen (a biological agent that causes disease) detected of Proteus mirabilis (a bacterium commonly found in the human gut, soil, and water that is a frequent cause of urinary tract infections, particularly in patients with catheters). Record review of CR #1's progress notes dated [DATE] at 4:38pm by LVN C revealed, UA C&S results received and reported to NP; received new order for Cipro 500mg every 12hrs x 5 days related to UTI. Orders endorsed accordingly. RP notified. Fluids encouraged and tolerated. Foley catheter care completed, observed clear and yellow urine; No clogging or obstruction noted. Record review of CR #1's physician orders and [DATE] MAR revealed an order started on [DATE] and discontinued on [DATE] for ciprofloxacin HCl tablet 500 mg, administer 1 tablet every 12 hours for urinary tract infection was administered on [DATE] at 8:00pm and [DATE] at 8:00am. Record review of CR #1's progress notes dated [DATE] at 4:41pm by LVN C revealed in part, .NP in facility at this time and changed order of Cipro 500mg BID from 5 days to 7 days. Record review of CR #1's physician orders and [DATE] MAR revealed an order started on [DATE] and discontinued on [DATE] for ciprofloxacin HCl tablet 500 mg, administer 1 tablet every 12 hours for urinary tract infection was administered on [DATE] - [DATE]. Phone interview on [DATE] at 5:58pm, CR #1's RP said CR #1 had recently passed away at the facility on [DATE]. The RP stated CR #1 had prostate cancer and was placed on hospice shortly before he passed away. The RP stated she had concerns about how the facility cared for CR #1 when he was admitted to the facility. She said CR #1 had two catheters, a foley catheter and a suprapubic catheter that both needed be emptied every 2 hours and she did not think they were doing so. The RP said there were visitors who would go see CR #1 and observe both catheter bags full and she felt this could have contributed to the UTI he developed. The RP said CR #1 was at risk of developing UTI's because of his catheters and around the first week in July CR #1 had blood in his catheter and was diagnosed with a UTI in which he received antibiotics to treat. RP said she had a care plan meeting with the facility on [DATE] where she expressed concerns with ADL care and the emptying of his catheter bags timely and she said they did implement some changes after the meeting, however, the resident passed away a few days after the care plan meeting. Interview on [DATE] at 2:07pm, LVN B said she did remember caring for CR #1 and does remember their being blood in his foley bag. LVN B could not recall the exact dates when things happened but after reviewing notes and her work schedule she said she worked day shift on [DATE] which was when the blood was noticed in catheter bags and she notified the NP who ordered labs which included the urinalysis with culture. LVN B remembered placing the order for the labs but could not recall if she collected urine sample for urinalysis or if she was not able to but stated if for whatever reason she was not able to collect the sample on her shift the next shift should collect it. LVN B said the next shift would know there was a urine sample pending collection by the shift report. LVN B said if she did not collect the sample and it was pending it would have been in the shift report which they write up and gave verbal report. LVN B said she was off the next couple of days according to her calendar and returned to work on [DATE]. LVN B said she recalled that on [DATE] CR #1 seemed to have less energy and had developed a fever. She said this prompted her to check on UA results and when she realized it was never completed. She said she immediately went and collected a urine sample which she said was a simple task since the resident had a catheter. LVN B said she notified the NP right away and she ordered the Rocephin IM for three days. LVN B said when she returned to work on [DATE] she did not see blood in the urine again and stated the urine sample she got on [DATE] looked better than the urine she saw in the bags on [DATE] but still did not look good and described it as dark, cloudy, and thick. LVN B denied there was ever an issue with the catheter bags not being emptied timely and she rounded every 2 hours to check if they needed emptying. LVN B said staff knew she had collected the pending UA sample on [DATE] from [DATE] order, however, she did not complain or question anyone about why it was not completed. LVN B said during the week the ADON would typically monitor if labs were being completed timely and will remind them to collect samples or complete labs but on the weekends it was the nurses responsibility to ensure ordered labs were being completed. LVN B said [DATE] was noted to be a Thursday and [DATE] was a Tuesday. LVN B added that typically the expectation was for them to collect the UA sample as soon as the order was made for a urinalysis. Record review of the facility's 24-hour report dated [DATE] revealed remarks/change of condition notes for CR #1 of, Nebulizer treatment: CBC, BMP, monitor for pain, appt today. Further review of 24-hour report revealed no mention of urinalysis. Record review of the facility 24-hour report dated [DATE] revealed remarks/change of condition notes for CR #1 of, Nebulizer treatment, monitor for pain / blood in urine. Further review of 24-hour report revealed no mention of urinalysis. Record review of the facility 24-hour report dated [DATE]-[DATE] revealed remarks/change of condition notes for CR #1 of, Nebulizer treatment, monitor for pain. Further review of 24-hour report revealed no mention of urinalysis. Record review of the facility 24-hour report dated [DATE]-[DATE] revealed remarks/change of condition notes for CR #1 of, Nebulizer treatment, monitor for pain, status post Norco 1/3. Nebulizer treatment, monitor for back pain. Further review of 24-hour report revealed no mention of urinalysis. Record review of the facility 24-hour report dated [DATE]-[DATE] revealed remarks/change of condition notes for CR #1 of, Change of condition - low grade fever. New order Ceftriaxone x 3 days via IM. Phone interview attempted with LVN A on [DATE] at 2:57pm however call was not answered, and voicemail was left. Phone interview on [DATE] at 3:30pm, LVN C said she did not recall there being a pending UA order for CR #1 on [DATE]. LVN C said she was typically informed of pending orders from previous shift by shift report. LVN C said if she was aware UA sample was needed, she could have easily collected it on her shift but she was not aware. LVN C said she never observed any blood in CR #1's urine and said his catheter bags were frequently emptied, and she had never observed an issue with them getting too full. LVN C said ADON would assist the nurses in keeping up with lab orders and ensuring they were completed by doing audits. LVN C said when they get orders for urinalysis the nurse who receives the order would usually try to immediately collect the sample. Interview on [DATE] at 3:36pm, the NP said she did recall ordering a Urinalysis with culture for CR #1 due to hematuria but cannot speak to the exact date. The NP said if she placed an order for a urinalysis, she expected the sample to be immediately collected so the test can be completed as soon as possible. The NP said after reviewing her notes she does remember there was a delay in the sample collection and she did not know why there was a delay, but it was not good. The NP said when the facility contacted her about the delay and the resident having fever this was why she immediately started him on the Rocephin IM. The NP said after she got culture results, she then started him on Cipro to make sure UTI was treated. The NP said not timely collecting lab specimens could delay them getting results and the infection could get worse. Interview on [DATE] at 4:15pm, the DON said CR #1 had an extensive medical history which caused a lot of health complications for him so there could have been many different reasons why blood was in his catheter. The DON said before CR #1 was admitted , he was in the hospital, and they recommended hospice, but the resident was not ready to be on hospice yet when he first admitted to facility. The DON said CR #1's condition continued to deteriorate despite them doing everything they could and after a final hospital visit from the resident hemoglobin becoming critical, the RP and resident agreed to hospice. CR #1 started hospice services around [DATE] and passed away approximately 2 weeks later. The DON said the ADON would typically run the facility activity report every weekday morning, which included lab orders, to ensure they were completed and results were followed up on. The DON said she expected nursing staff to obtain urine samples for urinalysis at the time they were ordered. The DON could not say why CR #1's UA sample was not collected until [DATE] when it was ordered on [DATE]. The DON said she did know that the CR #1 was not found to have blood in his catheter bag again after the one occurrence on [DATE] and stated he presented no other UTI symptoms until [DATE]. The DON said as soon as CR #1 presented symptoms the NP was immediately notified and he started a strong antibiotic to address the possible UTI while the culture was pending. The DON said not timely collecting the urine sample for CR #1 could cause a delay in receiving the results but denied it affected CR #1 receiving treatment for the UTI. Interview on [DATE] at 4:33pm, the ADON said she works Monday - Friday and every day she goes through the facility report and 24-hour report and in this process, she does check for outstanding labs and ensuring results were followed up on and documented. The ADON said she was out on vacation from the Friday - Monday ([DATE] - [DATE]) and the UA for CR #1 unfortunately was something that may have fallen through the cracks in her absence. The ADON said urinalysis sample collection should be completed when the order was placed and if it was not completed on the shift it was ordered on then it should be completed by the next shift and it should be in the shift report. After being informed the shift report did not mention the urinalysis test the ADON said she had completed lots of training with the staff about what to include in the shift report and said she would continue to try and train the nurses on completing lab orders and effectively communicating and documenting between shifts. The ADON said they would want to try and carry out lab orders as soon as possible to not have a delay in care. Record review of the facility Laboratory Testing policy (Revised [DATE]) revealed in part, .Policy: To provide laboratory services that are accurate and timely, ensuring the utility of laboratory testing for diagnosis, treatment, prevention, or assessment is maximized. Orders for diagnostic services will be promptly carried out as directed in the physician's or physician extender order. Should the attending physician order cultures, they shall be obtained and completed as soon as practical. Urine cultures may be obtained by the charge nurse if a resident develops cloudy urine or other signs of urinary tract infection. An order from the physician must be obtained before the specimen is sent to the laboratory.

Based on observation, record review and interviews, the facility failed to ensure the resident's environment remains as free of accident hazards as is possible and residents received adequate supervision to prevent accidents for 1 out of 5 residents (Resident # 1) reviewed for quality of care.The facility failed to ensure Resident # 1's head of bed was upright and elevated, and that Resident # 1 was closely supervised during and after administration of oral medications on 5/23/26.This failure places residents at risk of aspiration and choking when administering oral medications. Findings include: Record review of Resident # 1's Face Sheet revealed a [AGE] year-old female with an admission date of 3/29/2023. Diagnoses were hypertension (a chronic medical condition in which the force of blood against your artery walls is consistently too high), unspecified dementia (used when a patient exhibits a clear decline in cognitive abilities (such as memory loss or problem-solving), but the underlying cause or specific type of dementia (e.g., Alzheimer's, vascular) cannot be definitively determined), rheumatoid arthritis (systemic autoimmune disease in which the immune system mistakenly attacks the lining of the joints (synovium), causing painful inflammation, cartilage destruction, and bone erosion), dysphagia (difficulty or discomfort in swallowing), cognitive communication deficit (an impairment in the ability to communicate effectively that stems from underlying cognitive issues).Record review of Speech Language Discharge Summary for Resident # 1 dated 12/12/2025 reflected Interventions included instruction and training in safe swallow strategies to increase PO intake and decrease overall aspiration risk. Strategies indicated to facilitate safety and efficiency for oral intake were to alternate liquids or solids, rate modification (slow down/regulate), general swallow techniques, precautions upright during meals and upright for 30 minutes after meals with close supervision.Record review of Resident # 1's Care Plan goal dated 5/19/2026 indicated Resident # 1 will not choke or aspirate through next review date. Care Plan updated 6/1/2026 indicated Resident # 1 has nausea and vomiting and risk of aspiration related to diagnosis of difficulty swallowing (Dysphagia) with interventions of appropriate head of bed elevation during and after meals and medication administration. Approah did not include close supervision during PO intakeRecord review of MDS dated [DATE] for Resident # 1 revealed the ability to use utensils or to bring food or liquid to mouth and swallow required assistance to complete tasks.Record review of grievance dated 5/23/2026 for Resident # 1 read in part I seen on video a Medication Aide is giving medication while Resident # 1 is lying flat in the bed.Reported Resident # 1 began to vomit as seen on video cameraRecord review of progress note dated 5/23/2026 at 9:37 am for Resident # 1 read in part Resident was observed during morning rounds to have emesis (vomiting) on pillowcase on bed. Resident noted to have some residue around mouth area.Observation of recorded video dated 5/23/2026 at 7:43 am revealed Resident # 1 in bed. Bed observed to be in lowest position to the floor and head of bed was lower than 45 degrees, not upright. MA A walked into Resident # 1's room with two cups of pudding mixed with medication in left hand and a plastic cup of water in right hand. MA A walked to Resident # 1's nightstand on the left side of Resident # 1's bed. MA A placed plastic cup from right hand and one pudding cup from left hand onto nightstand. MA A did not raise Resident # 1's bed higher from floor or head of bed upright before administration of pudding cup and water to Resident # 1. MA A was seen bent over and leaned in closer to Resident # 1's upper body near head with one pudding cup in left hand to assist feed Resident #1. MA A was seen placing pudding cup from left hand on to nightstand and picking up second pudding cup from Resident # 1's nightstand using right hand to assist feed Resident # 1. MA A was seen bent over and leaning towards Resident # 1's upper body near head. MA A was then seen picking up plastic cup of water with right hand and leaning over to Resident # 1 before placing plastic cup back on nightstand and continued with second pudding cup. MA A then grabbed all three cups and exited Resident # 1's room. MA A returned to Resident # 1's room, grabbed a Kleenex near door of room, looked in the direction of Resident # 1 and exited room again and closed door. MA A was seen in Resident # 1's room for approximately 4 minutesIn an interview on 6/9/2026 at 12:15pm LVN stated Resident # 1 was to sit up at 90 degrees and medications were to be crushed when given with water. LVN stated Resident # 1 needed to sit up at 90 degrees due to aspiration precautions. LVN stated MAR or care plan would indicate whether the resident head of bed was to be at 90 degrees or 45 degrees during PO medications and meals.In an interview on 6/9/2026 at 12:37pm CNA B stated Residents were to sit at a 45-to-90-degree angle to be sure the resident does not choke when given food or medication by mouth. CNA B said she has seen Resident # 1 at a 45-degree angle when staff administered medication. CNA B explained a 90-degree angle would be straight up and 45 is in between 0 and 90 for the head of the bed. CNA B stated Resident # 1 should be straight up after meals, and after given medication. CNA B stated policy was to ask the nurse on the floor about any position questions for residents however CNA B was trained to have residents at least 45-degree angle.In an interview on 6/9/2026 at 1:17pm Family Member stated Resident # 1 was often given medication using pudding or liquid to help Resident # 1 swallow the medication. Family Member stated Resident # 1 was typically in a higher position and upright when given food or medication. Family Member stated ADON A was aware of the concern regarding video dated 5/23/2026 of Resident # 1 not upright when given food or medication.Interview on 6/9/2026 at 1:43pm MA A stated she was PRN with the facility and would come in once in a while. MA A was expected to find out resident needs from the nurse on duty since MA A did not work with the residents daily. MA A stated the process of medication administration was to look at the MAR of which medication to give and if the resident takes the medication crushed or not. Check blood pressure if need and other vitals. Go into the resident's room, introduce self, and inform resident of the process or medication given, also align the resident in the right position. MA A said the correct position was to be sitting upright and the head should not be laid flat. MA A stated hands should be sanitized before going into resident's room. MA A stated Resident # 1's bed was not raised from the floor, but the head was raised enough for Resident # 1 to swallow. MA stated if she could not bend down to administer, she would raise the bed. MA A stated she did not give medication with Resident # 1 lying flat because they might choke. MA A stated she was told by LPN to stop administering medications on the floor and someone else would administer because Resident # 1's head was not raised and Resident # 1 vomited. MA A stated she was informed there were cameras in Resident # 1's room that saw Resident # 1's bed in a low position to the floor and head was not raised. MA A did not see Resident # 1 vomit as she saw Resident # 1 swallow the medication before MA A left Resident # 1's room. MA A stated the only report was to crush Resident # 1's medication and there were no instructions on HOB level. MA A was given in-service after the incident, however, and has not been at the facility since 5/23/2026.In an attempted interview on 6/9/2026 at 2:00 pm left voicemail for LPN with call back information.In an interview on 6/9/2026 at 2:12 pm ADON B stated the process of medication administration was to follow the rights, verify orders, and prepare the medications. Knock on door and introduce self and medications, verify resident, then give medications and make sure medications are swallowed and do not leave any medications at the bedside and HOB was elevated between 30 and 45 degrees. ADON B stated remembered someone told her (unable to remember who) that Resident # 1's HOB was not completely elevated and Resident # 1 got choked up a little. ADON B stated said there is a risk of choking or aspiration and for digestion when HOB was not elevated to swallow medication correctly which was a nursing standard for at least 30 degrees.In an interview on 6/9/2026 at 2:38pm ADON A stated received a call from family member that MA A had the resident flat ADON A spoke to MA A and was told Resident # 1's bed was not completely flat, however was not as high as other MAs. ADON A asked MA A to go home for the day. ADON A stated Resident # 1's bed was at 30-degree angle but should have been 45 or higher. ADON stated order for HOB would not be needed but all residents are individualized with needs. ADON A stated Resident # 1 had a speech study in the past but would need to review when that was completed. ADON did not see vomit on Resident # 1's face however she did receive a report vomit was on Resident # 1's mouth. Resident # 1 would alternate with the use of pudding cups to help administer crushed medication and sips of water.Interview on 6/9/2026 at 3:18 pm with SLP said Resident # 1 was discontinued speech services as of 12/12/2025 as goals were met to the best of Resident #1's ability. SLP completed a swallow test on Resident # 1 on 5/29/2026 and recommended Resident # 1 to be upright 90 degrees during medication pass and meals and can lower head of bed to 45 degrees to be sure food digested. Resident # 1 has a narrow space to swallow and digest. Resident #1 was at risk of and higher chance of aspiration with the head of bed at a low angle. To maximize safety Resident # 1 head of bed was to be elevated during meals and PO for medication. SLP stated when Resident # 1 was discharged from speech services it was recommended to have Resident # 1 upright during oral intake including food however that would not exclude medication because Resident # 1 took medications orally by mouth. Resident # 1 took an extended time to swallow or eat and acknowledged it would take Resident # 1 the same rate with swallowing medications. SLP observed video dated 5/23/2026 and stated Resident # 1 was not flat however Resident # 1 was also not elevated.In an interview on 6/9/2026 at 3:35pm DON stated residents should be 30 to 45 degrees for any PO medications unless there are recommendations from physician or any other service. DON stated spoke to MA A and was told Resident #1 was not flat and HOB was elevated and MA A held the Resident #1's head up during PO for medication. DON stated there were orders or recommendations for Resident # 1's HOB to elevate higher than 30 degrees. DON stated PRN staff report to the nurse and complete morning huddle and review the resident file for any special recommendations. There was a swallow study requested for Resident #1 due to feeding assistance and takes time with meals to swallow. DON stated 30 degrees was not completely upright and there would be a risk for aspiration, choking or breathing difficulty.In an interview on 6/9/2026 at 3:55 pm Administrator said she was informed that MA A gave medications while Resident # 1 was laying down. Administrator stated that MA A was interviewed and stated Resident # 1 was not flat but was not elevated and elevated Resident # 1's head with MA's arm to administrator medication. Administrator stated Resident # 1 was not flat but was not at recommended HOB. Administrator stated there may be a risk of choking if HOB was not elevated during PO for medication.Record review of facility policy CMA Job Description dated 11/2016 read in part Intervene in any safety hazard or other potential hazard. Safety concerns are identified and appropriate actions are taken to assure patient safety. Observes patient/ resident needs while giving medications and notifies floor staff for assistance as appropriate.

Based on observation, interview and record review the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 9 residents (Resident #1) reviewed for pain management. The facility failed to timely identify Resident #1's pain following a fall as a change in condition, failed to appropriately assess the pain, and failed to ensure ongoing monitoring and communication of the resident's pain status. Resident #1 was observed yelling in pain during care and received pain medication for more than 24 hours before the pain was fully assessed and later required hospital evaluation, a pain management regimen, and experienced a decline in functional abilities. An Immediate Jeopardy (IJ) was identified on 5/22/2026 at 2:10pm. While the IJ was removed on 5/23/2026, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not an Immediate Jeopardy and a scope of pattern as the facility continued to monitor the implementation and effectiveness of their plan of removal. This failure placed residents at risk for delayed assessment and treatment, unmanaged pain, functional decline, and hospitalization Findings included: Record review of Resident #1's facesheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Cerebral infarction (type of stroke that occurs when blood flow to a part of the brain is blocked or significantly reduced, depriving brain tissue of oxygen and vital nutrients), blindness in right eye, low vision in left eye, osteoarthritis (degenerative joint disease where the protective cartilage that cushions the ends of the bones wears away over time), Age-related osteoporosis (progressive condition where bones lose mass and structural strength as you age, becoming porous and highly fragile), Cognitive communication deficit, Fibromyalgia (chronic disorder characterized by widespread musculoskeletal pain, profound fatigue, sleep disturbances, and cognitive issues), and chronic pain. Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 6 indicating severe cognitive impairment. Further review of the MDS revealed she had no behavioral symptoms or rejection of care, no scheduled pain regimen, had not received PRN pain medications, had no reports of pain, and had no falls. Record review of Resident #1's care plan revealed a problem start date of 7/13/2024 and edited on 5/13/2026 for her having osteoarthritis, fibromyalgia, and neuropathy and was at risk for pain due to impaired mobility. Interventions included to administer pain medications as ordered by physician. Document effectiveness; Assess location, frequency, duration of pain and document. Report increased pain trend to MD; Monitor and record any non-verbal signs of pain (e.g., crying, guarding, moaning, restlessness, grimacing, diaphoresis, withdrawal, etc); Monitor for s/s of pain/discomfort; Nonpharmacological intervention Reposition for comfort per routine rounds and PRN; Notify MD if inadequate pain relief. Record review of Resident #1 March and April 2026 MAR revealed physician order started on 3/7/2023 to EVERY shift check resident for level of pain utilizing numeric rating scale had rating of 0 out of 10 from 3/1/2026 - 4/30/2026. Record review of Resident #1 May 2026 MAR revealed physician order started on 3/7/2023 to EVERY shift check resident for level of pain utilizing numeric rating scale had rating of 0 out of 10 from 5/1/2026 - 5/12/2026 (7:00am - 7:00pm, day shift). Further review revealed on:5/12/2026 (7:00pm -7:00am, night shift) pain rating was 8 out of 10 marked by LVN B.5/13/2026 (day shift) - 0 out of 10 pain marked by RN A5/13/2026 (night shift) - 6 out of 10 pain marked by LVN C5/14/2026 (day shift) - 2 out of 10 pain marked by RN A5/14/2026 (night shift) - 2 out of 10 pain marked by LVN C5/15/2026 - 5/21/2026 - pain rating was 0 out of 10. Record review of Resident #1's March and April 2026 MAR revealed physician order started on 1/28/2026 for acetaminophen tablet; 325mg; 2 tabs oral every 8 hours as needed for mild pain was not administered. Record review of Resident #1's May 2026 MAR revealed physician order started on 1/28/2026 for acetaminophen tablet; 325mg; 2 tabs oral every 8 hours as needed for mild pain was administered on:5/11/2026 at 5:16pm by LVN A for pain rate of 6 out of 10 and was marked effective.5/12/2026 at 11:46am by LVN A for pain rate of 4 using FACES scale (clinical self-assessment tool used to measure pain intensity) and was marked effective.5/12/2026 at 9:59pm by LVN B for pain rate of 8 out of 10 using FACES scale marked somewhat effective.5/13/2026 at 7:42am by LVN B for pain rate of 4 out of 10 using FACES scale marked somewhat effective.5/13/2026 at 6:35pm by RN A for pain rate of 6 out of 10 using FACES scale marked other - pain upon palpation Record review of Resident #1's progress note dated 5/11/2026 at 12:01pm by LVN A revealed, While assisting CNA to transfer resident from shower chair to bed, resident slowly started falling. We then assisted resident slowly to the floor. No verbal complaints of pain or discomfort noted. Upon assessment of resident no injuries nor bleeding present. Vital signs within normal reading. Neurochecks started per facility protocol. NP and RP notified. No new orders, Safety measurements in place. Record review of Resident #1's progress notes revealed no other entries on 5/11/2026 regarding 6 out of 10 pain noted on MAR for administration of PRN Acetaminophen at 5:16pm. Record review of Resident #1's progress note dated 5/12/2026 at 5:04am by LVN B revealed, Resident day 1/3 Post fall remain stable during this time. Denies pain or discomfort. Resident slept well throughout night with chest rise and fall and peri care provided with barrier cream applied q2h. Vital signs within normal limit. Neuros in place. Fall precautions in place. Call light and side table with belongings within reach. Record review of Resident #1's progress note dated 5/12/2026 at 2:34pm by LVN A revealed, Observation for day 2 post fall. Resident had minor pain and discomfort, PRN pain medication administered as ordered with noted relief. Neurochecks remain ongoing per protocol with no acute changes observed. Vital signs stable and within normal limits. Call light within reach. Safety measurements in place. Further review of the progress note revealed no assessment of how it was determined resident was in pain, the location of the pain, or physician notification regarding the development of pain after a fall. Record review of Resident #1's progress note dated 5/12/2026 at 9:56pm by LVN B revealed, Observation post fall. Resident had pain and discomfort right knee upon providing peri care at this time. PRN pain medication administered as ordered. Neurochecks remain ongoing per protocol. Vital signs stable and within normal limits. NP notified and informed, pending provider recommendations. Record review of Resident #1's progress note dated 5/12/2026 at 10:11pm by LVN B revealed, New order received for right knee Xray 2views. Order placed and called in. called POA. informed of new order/changes. Verbalized understanding. Record review of Resident #1's progress note dated 5/12/2026 at 11:34pm by LVN B revealed, New order received to change order to STAT right knee Xray 2views. order placed and called in. Record review of Resident #1's progress note dated 5/13/2026 at 4:40am by LVN B revealed, Upon return from lunch break, covering nurse reported that the X-ray technician arrived and obtained an X-ray of the patient's right knee as ordered. Record review of Resident #1's progress note dated 5/13/2026 at 6:10am by LVN B revealed, Upon rounding, nurse observed resident in pain. PRN pain medication was administered per physician order. Peri care was provided, and resident was repositioned for comfort with assistance of nursing staff using proper fracture precautions, including the log-roll technique and supportive positioning to avoid movement of the affected extremity. Record review of Resident #1's Right Knee x-ray results signed on 5/13/2026 at 6:22am revealed an impression of Acute non-displaced fracture of lateral femoral condyle (a crack in the outer, ball-shaped end of the thigh bone at the knee joint). Record review of Resident #1's progress note dated 5/13/2026 at 6:30am by LVN B revealed in part, .Received X-ray results. NP was informed immediately. New orders were received to send resident to the ER for fracture to lateral femoral of right knee via EMS transport. Nurse (writer) contacted EMS for transportation. Assigned CNA was informed not to move resident until EMS arrival. EMS provided an estimated time of arrival of 20 minutes for pickup. RP informed of the situation, and verbalized understanding. reported to oncoming nurse of resident changes and arrival of EMS transport. Record review of Resident #1's SBAR dated 5/12/2026 at 10:00pm completed by LVN B revealed a situation of swelling and pain to the right knee that started on 5/12/2026 and had gotten worse since it started. It was noted moving the right leg makes the symptoms worse and PRN acetaminophen makes the symptoms better. Further review of the SBAR functional status evaluation revealed decreased mobility to right leg and pain evaluation noted new pain to right knee with pain rating of 8 out of 10 with non-verbal signs of facial grimacing. Record review of Resident #1's progress note dated 5/13/2026 at 3:50pm by RN A revealed, Resident returned to the facility via stretcher accompanied by two EMS transporters following hospital evaluation related to suspected fracture to the lateral femoral area of the right knee. Per EMS transporter report, resident had no evidence of fracture noted during hospital evaluation. Upon return assessment, skin intact with no redness noted. Slight swelling observed to the right knee compared to the left knee. Resident unable to perform active ROM to lower extremities. During passive ROM attempt by writer, resident complained of pain to the right leg. PRN Tylenol administered as ordered for pain management. Incontinent care provided and resident tolerated care well. Resident in bed and made comfortable. NP notified of resident's return from the hospital and complaint of right leg pain. Awaiting new orders at this time. Resident continues to be monitored. Record review of Resident #1's progress note dated 5/13/2026 at 5:58pm by LVN D revealed in part, Resident seen by wound care nurse today for head to eval upon return from hospital. Skin remains intact. Edema noted to right knee. No treatment warranted at this time. Continue with weekly skin observation and notify wound care nurse for any changes or concerns in integrity. Record review of Resident #1's May 2026 MAR revealed physician order started on 5/13/2026 and discontinued 5/18/2026 for diclofenac sodium gel; 1 %; 5 cc; topical; twice a day for pain was administered 5/14/2026 - 5/18/2026. Record review of Resident #1's May 2026 MAR revealed physician order started on 5/13/2026 and discontinued on 5/19/2026 for acetaminophen tablet; 325mg; 2 tabs oral three times a day for pain was administered at 7AM, 2PM, and 7PM on 5/13/2026 - 5/19/2026. Record review of Resident #1's May 2026 MAR revealed physician order started on 5/13/2026 for lidocaine adhesive patch, medicated; 4 %; topical once a day to right knee for pain was administered on 5/14/2026 - 5/21/2026. Record review of Resident #1's physician order started on 5/13/2026 revealed to transfer x 2 assist utilizing a mechanical lift. Record review of Resident #1's progress note dated 5/14/2026 at 1:07am by LVN C revealed in part, .Resident continues to have moderate swelling to right knee, unable to perform ROM due to pain. Resident is on scheduled Tylenol which was given at time of assessment. Record review of Resident #1's progress note dated 5/14/2026 at 12:59pm by RN A revealed in part, .Resident remains stable and alert at this time, but continues to report mild pain with pressure applied. No redness noted. Moderate swelling observed to the right knee compared to the left knee. Diclofenac topical applied as ordered and tolerated well. Legs elevated with pillow for comfort and to reduce swelling. Resident made comfortable in bed. Vital signs obtained. Incontinent care provided and tolerated well. Resident resting comfortably in bed at this time. Record review of Resident #1's progress note dated 5/15/2026 at 6:34am by LVN C revealed in part, .Resident continues to have moderate swelling to right knee, unable to perform ROM due to pain. Resident is on scheduled Tylenol which was given at time of assessment. No inflammation observed. Record review of Resident #1's progress note dated 5/18/2026 at 6:10pm by RN B revealed in part, . Resident in no distress. Remain on scheduled Tylenol 650mg PO three times daily until 5/19/26 and Diclofenac sodium topical to right knee twice daily until 5/20/26 related to Right knee pain. Denies pain during the shift. New order received for cold compression therapy to right knee for 10 minutes each three times daily x 5 days. Cold compression initiated per order. Knee continued to be monitored. Resident tolerated treatment without difficulty. Record review of Resident #1's May 2026 MAR revealed physician order started on 5/18/2026 and discontinued 5/20/2026 for diclofenac sodium gel; 1 %; 5 cc; topical; twice a day for right knee pain was administered 5/18/2026 - 5/20/2026. Record review of Resident #1's May 2026 MAR revealed physician order started on 5/18/2026 and discontinued 5/22/2026 for Apply Cold compression to right Knee for 10 minutes three times a day was administered 5/18/2026 - 5/21/2026. Record Review of Resident #1's May 2026 MAR revealed physician order started on 5/18/2026 for meloxicam tablet (prescription nonsteroidal anti-inflammatory drug that can be used to relieve pain, swelling, stiffness, and inflammation); 7.5mg; 1 tab oral once a day was administered 5/19/2026 - 5/21/2026. Record Review of Resident #1's May 2026 MAR revealed physician order started on 5/18/2026 for Tizanidine tablet (a short-acting prescription muscle relaxer); 2mg; 1 tab oral at bedtime was administered 5/19/2026 - 5/20/2026. Record review of Resident #1's progress note dated 5/19/2026 at 1:40am by LVN E revealed, Writer verified new medication order from NP B as follows: Meloxicam 7.5mg PO daily and Tizanidine 2mg PO at bedtime for pain management, nerves and muscle spasticity. Spoke with RP regarding new medication orders, no voice concerned at this time. Plan of care ongoing. Record review of Resident #1's progress note dated 5/19/2026 at 12:13pm by social worker revealed RP was contacted to schedule a care plan meeting on 5/20/2026 to discuss residents fall. Record review of Resident #1's progress note dated 5/20/2026 at 2:41am by LVN C revealed, Resident continues to remain stable, no complaints of pain or discomfort during the night. Resident remains on Diclofenac to right knee BID until 5/20. Resident tolerates cold compress to right knee TID well, will end on 5/22. Resident is Day 2/3 of Meloxicam 7.5mg QD and Tizanidine 2mg QHS which she is tolerating well with no adverse reactions noted. Will continue to monitor. Record review of Resident #1's progress note dated 5/20/2026 at 11:48am by NP B revealed in part, .chief complaint: ADL and mobility dysfunction right knee pain and fall causing decline in function. long-term resident at current facility requires consult for right knee pain s/p fall. Patient was sent to ER for further imaging. STAT x-ray ordered in facility revealed fracture to lateral femoral of right knee. Imaging in ED negative for dislocation and fracture. Primary diagnosis right knee contusion. Patient now on therapy services for decline in ADLs, function, mobility s/p hospitalization. Rehab potential is fair to good. Physiatry/PM&R consult requested for management of decline in function with impaired mobility and self-care. Patient started on lidocaine patch to right knee. Pain is controlled at rest. However, with range of motion and movement patient shows signs of pain and cannot tolerate. right knee contusion status post fall, Risk of complication: HIGH. The patient's multiple medical issues necessitate frequent clinical evaluations, placing them at high risk for readmission without proper care. Neglecting regular monitoring and management may result in symptom exacerbation and complications, possibly requiring hospitalization. Continue joint mobilization and stretching as needed as well as modalities including hot and cold packs. Pain, stiffness, and reduced joint mobility may limit therapy participation and functional gains. Deconditioning and ADL dysfunction: Case discussed with therapy team regarding goals of rehab to return patient to prior level of functioning to increase independence with mobility and self-care. Phone interview on 5/21/2026 at 11:00am, RP stated she was called on 5/11/2026 and staff told her Resident #1 had to be lowered to the floor when she was being transferred to her bed. She was told there was no injuries and the incident was no big deal and she was being contacted as a formality. The RP stated she heard nothing until the following night on 5/12/2026 where a nurse (LVN B) contacted her saying Resident was complaining of knee pain and they contacted the NP who ordered an x-ray. The RP said the next morning on 5/13/2026 the nurse (LVN B) called her back and said the x - ray showed she had a fracture and they were sending her to the hospital. The RP said this prompted her to check the camera footage from 5/11/2026 when she had her fall because she was unsure how an injury could come from something she was told was nothing major. The RP said the camera footage showed the incident was not like how they described it and it showed two staff members attempting to lift her from her chair by her arms and the resident immediately going to the ground. She was also concerned because the resident was still visibly wet from her shower and naked which caused issues with the transfer because she stated you could see the staff hands slipping and them trying to grab towels to dry her after she slipped. The RP said there were multiple failed attempts of them trying to pull her from her arms once she was on the ground and it wasn't until the bed was lowered to the ground they were able to maneuver Resident #1 onto the bed. The RP stated she was told it was not until 5/12/2026 night that a CNA noticed Resident #1 was in pain but she questioned why it was the CNA who noticed she was in pain and not the nurse if the nurse was supposed to be monitoring after a fall and completing assessments. The RP said she did have a care plan meeting with the staff on 5/20/2026 where they spoke about the transfer being incorrect and the actions they took to retrain the staff. The RP said she asked about why the nurse did not identify the resident was in pain if she was supposed to be completing post fall assessments and she was told that the nurses monitor for 72 hours after a fall and the pain was identified within this time frame so that meant the post fall assessments were properly being done. The RP said she had concerns on how the nurses were supposedly completing assessments because if they were checking the resident's range of motion then they should have been the ones that identified Resident #1 was in pain. The RP provided a copy of the video footage from Resident #1's witnessed fall on 5/11/2026. Record review of Resident #1 room video footage from 5/11/2026 at 11:35am, showed CNA A bring Resident #1 into the room in shower chair and positioned next to her bed. CNA A used a towel to dry off parts of Resident #1 and then leaves the area for a few minutes and returns with LVN A. The two staff get on both sides of the resident, LVN A faces the resident and wraps her left arm around Resident #1's left arm and places her right hand on her back. CNA wrapped her right arm around Resident #1's right arm while also holding the residents right upper arm with her left hand. LVN A and CNA A both lift Resident #1 from her chair with no gate belt and Resident #1 immediately slips down in front of the shower chair. CNA A while still holding onto Resident #1's right arm reaches over to the bed to grab the towel and attempts to dry Resident #1 arms off some more and then passes the towel to LVN A for her to also dry the resident some more while they are both still holding onto her arms. The resident was then lowered down completely to the ground where she appears sitting in front the shower chair and to the right of her bed. LVN A then goes and lowers the bed down and returns back over to the resident and the two staff attempt to pull her up from the ground by hooking their arms under her armpits and holding her upper arm. They pulled the resident from both her arms and her bottom lifted from the ground but not high enough to reach the bed and she immediately slips back down ground. LVN A then goes back to the foot of bed and lowers the bed down some more, then returned back with CNA A to attempt to transfer the resident again. Both staff grab Resident #1's arms and pulled her up where her bottom touched the side of the bed but slips back down off the side of the bed and goes back down while the staff are holding her, they try again to pull her up and she slipped back down off the side of the bed again. The two staff pull her up again and was able to get the top of her body on the bed. LVN A then picks up Resident #1's legs from the floor and brings them around to the bed so that her full body is on the bed at this time. Interview on 5/21/2026 at 1:28pm, CNA A said she gave Resident #1 a shower on 5/11/2026 and she and LVN A went to transfer Resident #1 back to her bed from the shower chair and had to lower her to the ground because they were not balanced. CNA A said when they lowered the resident to the floor she was sitting with her legs bent and to the side. CNA A said Resident #1 did not voice any pain during the transfer attempts and the lowering to the ground. CNA A said later in the shift around 4:00pm - 5:00pm Resident #1 did have some discomfort during perineal care (gentle cleaning of the genital and anal areas). CNA A said Resident #1 said ouch when she went to turn her. CNA A said she asked Resident #1 what was wrong but she did not say anything. CNA A said MA A was in the room tending to Resident #1's roommate when this happened and she was also aware the resident had discomfort during care. CNA A could not recall if she told the nurse herself about Resident #1 having discomfort, but she believed MA A did let the nurse know. Interview on 5/21/2026 at 3:34pm, LVN A said she recalled CNA A coming to get her to assist with transferring Resident #1 to the bed on 5/11/2026 around 11:50am and they had to assist Resident #1 to the ground due to complications with the transfer. LVN A said when they initially lowered Resident #1 to the floor she did not hit anything hard on the floor and stated they were standing on a fall mat where she was lowered to. LVN A said once lowered to the ground Resident #1 had her legs folded under and laying off to the side. LVN A said she did do an assessment after the incident and noted no injuries to Resident #1 and she stated she did check her range of motion and the resident had no complaints at the time of the incident. LVN A said she notified the NP of the incident and the NP texted her to continue to monitor the resident. LVN A said she did check back in on Resident #1 the remainder of the day shift and there were no complaints voiced by the resident and denied anyone reporting any pain concerns to her on 5/11/2026. LVN A said the following day on 5/12/2026 she did administer PRN Tylenol to the resident at the beginning of the shift. LVN A could not recall for sure what prompted her to give the PRN pain medicine but stated she believed Resident #1's roommate (Resident #2) called and said Resident #1 had been grunting in pain. LVN A said it was her right knee that was giving her issues because she recalled seeing resident's knee elevated with a pillow which she thinks was done by the CNAs. She said she recalled shifting when she went to touch the knee so she did not perform range of motion check. LVN A said she checked back with Resident #1 after she gave the medicine and it was effective and stated when she went to touch Resident #1's knee she did not shift. LVN A denied any visible swelling, redness, or skin tear to the knee. When asked more about how Resident #2 was the one to report Resident #1 was in pain LVN A said that she also remembered that maybe it was MA A who told her Resident #1 was in pain and when she went into the room Resident #2 confirmed she had heard Resident #1 groaning in pain. LVN A believed this was all on 5/12/2026 around 11:00am. LVN A said she did not notify the NP about the pain and stated she just gave the medication. LVN A could not say why she did not notify the NP about the pain and stated PRN medication was effective for the pain. LVN A was then shown the MAR by the surveyor and asked why the PRN Tylenol was given on 5/11/2026 at 5:16pm and LVN A could not recall giving the medication but stated the MAR did reflect that she gave the medication for a pain rating of 6 out of 10. LVN A was informed by surveyor that CNA A recalled the resident having discomfort during care around that time and perhaps that was why the medication was given, LVN A said this could maybe be why but she did not recall for sure. LVN A added that after the complaint of pain on 5/12/2026 she did make a progress note about it but denied documenting a full assessment of the resident regarding the pain. LVN A could not say if an assessment was done on 5/11/2026 when the complaint of pain was made because she did not recall the situation. Phone interview on 5/21/2026 at 4:18pm, MA A said she recalled on 5/11/2026 hearing Resident #1 holler out while she was tending to her roommate Resident #2. MA A said CNA A was attempting perineal care at the time and Resident #1 was saying her right leg was hurting. MA A said she did go over and assist CNA A with finishing perineal care and Resident #1 was able to voice that it was her leg that was hurting and pointed at her right knee when asked. MA A said when they finished with the care she did place a pillow under the resident's knee to help with the pain. MA A said she reported Resident #1 was in pain to LVN A and LVN A told her she was already aware Resident #1 was having pain. MA A said she was not sure if and when LVN A went to check on Resident #1 because she continued to care for other residents. MA A said she did later check on Resident #1 because she would hear her randomly yelling out like she was having muscle spasms. MA A said this was all very unusual for Resident #1 and not something she typically did which made her concerned. Interview on 5/21/2026 at 4:46pm, Resident #2 said she recalled when Resident #1 had to be assisted to the ground and stated she was in a lot of pain afterwards. Resident #2 said the same day of the fall she heard Resident #1 yelling in pain when they were trying to change her which she had never heard her do before. Resident #2 said after that Resident #1 would just be laying in bed with no one touching her and would randomly yell out and was groaning. Resident #2 said she did tell staff several times about how much pain Resident #1 was in and stated it felt like it took a few days of her being in pain before she went to the hospital. Resident #2 said she felt really bad that it took so long for them to address Resident #1's pain. Observation on 5/21/2026 at 4:50pm, Resident #1 was sleeping in bed. Bed was at the lowest setting. Surveyor attempted to greet the resident, but she remained resting with eyes closed. Interview on 5/21/2026 at 6:17pm, the Administrator and DON stated through their investigation they found issues surrounding Resident #1's transfer and shower procedure which were addressed and staff were in-serviced about. The Administrator and the DON did not voice any identification of issues regarding timely identification of Resident #1 change in condition of being in pain, assessment and documentation of pain, or physician notification. Phone interview on 5/21/2026 at 6:45pm, NP said she recalled being notified on 5/11/2026 that Resident #1 had to be lowered to the ground and there were no injuries or concerns reported. She advised to continue to monitor the resident but stated to her knowledge the resident was fine and it was not even really a fall that happened. NP said the next time she was notified about Resident #1 was the night of 5/12/2026 and LVN B called her saying Resident #1 was having knee pain so she ordered the x-ray for the knee. The NP said initially the x-ray showed a fracture, so she ordered to have her sent to the hospital, but the hospital sent her back saying their scans showed no fracture. The NP was informed by surveyor that Resident #1 had complained of knee pain prior to the night of 5/12/2026, the NP stated she only recalled being told about Resident #1 being in pain once which was the night of 5/12/2026. The NP said if a resident complains of acute pain after a fall the staff should let her know because depending on the pain it could be a sign of an injury. Interview on 5/21/2026 at 7:15pm, LVN B said when she came in for her shift on 5/11/2026 for the night shift, LVN A did report that Resident #1 had a fall where she was lowered to the ground during a transfer. LVN B said LVN A reported there were no injuries and the resident was fine. LVN B said there were no reports that Resident #1 had experienced pain or that PRN pain medication had to be administered. LVN B said the night of 5/11/2026 Resident #1 was fine, she typically does rounds with CNAs and said she did not observe nor did anyone report Resident #1 having pain the night of 5/11/2026. LVN B said CNA B worked with her on the night of 5/11/2026 and CNA C worked the night of 5/12/2026. LVN B said she came in on 5/12/2026 to work the night shift and did not recall LVN A reporting any concerns of Resident #1 having pain from the day shift or her having to administer pain medication. LVN B said it was reported Resident #1 was fine during the day shift. LVN B said during their first set of rounds the night of 5/12/2026 she was tending to Resident #1's roommate (Resident #2) while CNA C was attempting perineal care with Resident #1. LVN B said she heard Resident #1 yelling and CNA C asked her to take a look because the resident typically did not yell during care. LVN B said at that time Resident #2 mentioned that Resident #1 had been in pain all day. LVN B said she asked CNA C how she moved her that caused her to yell, and CNA C barely went to move Resident #1 right leg and she yelled out in pain. LVN B said she assisted CNA C with situating Resident #1 in bed, medicated her with PRN Tylenol, notified the NP and RP, and got orders for an x-ray to the knee. LVN B said early the next morning on 5/13/2026 she got the x-ray results which showed a fracture, she called the NP with the results, and she ordered to send Resident #1 to ER for evaluation. LVN B said Resident #1 did complain of pain again before she was transferred to the ER on [DATE] and had to medicate her with PRN Tylenol again. LVN B added that since she discovered Resident #1 was in so much pain, she told the CNA to not change her or move her until they got orders from the NP. Interview on 5/22/2026 at 11:41am, the DON said she had not heard about Resident #1 being in pain on 5/11/2026 and stated she would have to check into it. The DON said if the resident has a change in condition after a fall or just in general the Resident should be assessed and the provider should be notified about the change. The DON said a new onset of acute pain could be considered a change in condition, but it would depend on the assessment of the resident. On 5/22/2026 at 12:17pm, the RP sent a text message to surveyor noting she had reviewed more of Resident #1's room camera footage and forwarded a copy of video recording from 5/11/2026 at 4:30pm which showed, she is screaming out in pain. The RP noted sh

Based on observation, interview, and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 9 residents (Resident #1) reviewed for notification of changes. The facility failed to timely consult Resident #1's physician after she reported right leg/knee pain following a fall. Resident #1 complained of pain the evening of the fall and again the following morning; however, the physician was not consulted until more than 24 hours after the initial complaint. Resident #1 later required hospital evaluation, changes to her pain management regimen, and experienced a decline in functional abilities. An Immediate Jeopardy (IJ) was identified on 5/22/2026 at 2:10pm. While the IJ was removed on 5/23/2026, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated as the facility continued to monitor the implementation and effectiveness of their plan of removal. This failure placed residents at risk for delayed assessment and treatment, unmanaged pain, functional decline, and hospitalization.Findings included: Record review of Resident #1's facesheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Cerebral infarction (type of stroke that occurs when blood flow to a part of the brain is blocked or significantly reduced, depriving brain tissue of oxygen and vital nutrients), blindness in right eye, low vision in left eye, osteoarthritis (degenerative joint disease where the protective cartilage that cushions the ends of the bones wears away over time), Age-related osteoporosis (progressive condition where bones lose mass and structural strength as you age, becoming porous and highly fragile), Cognitive communication deficit, Fibromyalgia (chronic disorder characterized by widespread musculoskeletal pain, profound fatigue, sleep disturbances, and cognitive issues), and chronic pain. Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 6 indicating severe cognitive impairment. Further review of the MDS revealed she had no behavioral symptoms or rejection of care, no scheduled pain regimen, had not received PRN pain medications, and had no reports of pain. Record review of Resident #1's care plan revealed a problem start date of 7/13/2024 and edited on 5/13/2026 for her having osteoarthritis, fibromyalgia, and neuropathy and was at risk for pain due to impaired mobility. Interventions included to administer pain medications as ordered by physician. Document effectiveness; Assess location, frequency, duration of pain and document. Report increased pain trend to MD; Monitor and record any non-verbal signs of pain (e.g., crying, guarding, moaning, restlessness, grimacing, diaphoresis, withdrawal, etc); Monitor for s/s of pain/discomfort; Nonpharmacological intervention reposition for comfort per routine rounds and PRN; Notify MD if inadequate pain relief. Record review of Resident #1's March and April 2026 MAR revealed physician order started on 3/7/2023 to EVERY shift check resident for level of pain utilizing numeric rating scale had rating of 0 out of 10 from 3/1/2026 - 4/30/2026. Record review of Resident #1 May 2026 MAR revealed physician order started on 3/7/2023 to EVERY shift check resident for level of pain utilizing numeric rating scale had rating of 0 out of 10 from 5/1/2026 - 5/12/2026 (7:00am - 7:00pm, day shift). Further review revealed on:5/12/2026 (7:00pm -7:00am, night shift) pain rating was 8 out of 10 marked by LVN B.5/13/2026 (day shift) - 0 out of 10 pain marked by RN A5/13/2026 (night shift) - 6 out of 10 pain marked by LVN C5/14/2026 (day shift) - 2 out of 10 pain marked by RN A5/14/2026 (night shift) - 2 out of 10 pain marked by LVN C5/15/2026 - 5/21/2026 - pain rating was 0 out of 10. Record review of Resident #1's March and April 2026 MAR revealed physician order started on 1/28/2026 for acetaminophen tablet; 325mg; 2 tabs oral every 8 hours as needed for mild pain was not administered. Record review of Resident #1's May 2026 MAR revealed physician order started on 1/28/2026 for acetaminophen tablet; 325mg; 2 tabs oral every 8 hours as needed for mild pain was administered on:5/11/2026 at 5:16pm by LVN A for pain rate of 6 out of 10 and was marked effective.5/12/2026 at 11:46am by LVN A for pain rate of 4 using FACES scale (clinical self-assessment tool used to measure pain intensity) and was marked effective.5/12/2026 at 9:59pm by LVN B for pain rate of 8 out of 10 using FACES scale marked somewhat effective.5/13/2026 at 7:42am by LVN B for pain rate of 4 out of 10 using FACES scale marked somewhat effective.5/13/2026 at 6:35pm by RN A for pain rate of 6 out of 10 using FACES scale marked other - pain upon palpation Record review of Resident #1's progress note dated 5/11/2026 at 12:01pm by LVN A revealed, While assisting CNA to transfer resident from shower chair to bed, resident slowly started falling. We then assisted resident slowly to the floor. No verbal complaints of pain or discomfort noted. Upon assessment of resident no injuries nor bleeding present. Vital signs within normal reading. Neurochecks started per facility protocol. NP and RP notified. No new orders, Safety measurements in place. Record review of Resident #1's progress notes revealed no other entries on 5/11/2026 regarding 6 out of 10 pain noted on MAR for administration of PRN Acetaminophen at 5:16pm. Record review of Resident #1's progress note dated 5/12/2026 at 5:04am by LVN B revealed, Resident day 1/3 Post fall remain stable during this time. Denies pain or discomfort. Resident slept well throughout night with chest rise and fall and peri care provided with barrier cream applied q2h. Vital signs within normal limit. Neuros in place. Fall precautions in place. Call light and side table with belongings within reach. Record review of Resident #1's progress note dated 5/12/2026 at 2:34pm by LVN A revealed, Observation for day 2 post fall. Resident had minor pain and discomfort, PRN pain medication administered as ordered with noted relief. Neurochecks remain ongoing per protocol with no acute changes observed. Vital signs stable and within normal limits. Call light within reach. Safety measurements in place. Further review of the progress note revealed no assessment of how it was determined resident was in pain, the location of the pain, or physician notification regarding the development of pain after a fall. Record review of Resident #1's progress note dated 5/12/2026 at 9:56pm by LVN B revealed, Observation post fall. Resident had pain and discomfort right knee upon providing peri care at this time. PRN pain medication administered as ordered. Neurochecks remain ongoing per protocol. Vital signs stable and within normal limits. NP notified and informed, pending provider recommendations. Record review of Resident #1's progress note dated 5/12/2026 at 10:11pm by LVN B revealed, New order received for right knee Xray 2views. Order placed and called in. called POA. informed of new order/changes. Verbalized understanding. Record review of Resident #1's progress note dated 5/12/2026 at 11:34pm by LVN B revealed, New order received to change order to STAT right knee Xray 2views. order placed and called in. Record review of Resident #1's progress note dated 5/13/2026 at 4:40am by LVN B revealed, Upon return from lunch break, covering nurse reported that the X-ray technician arrived and obtained an X-ray of the patient's right knee as ordered. Record review of Resident #1's progress note dated 5/13/2026 at 6:10am by LVN B revealed, Upon rounding, nurse observed resident in pain. PRN pain medication was administered per physician order. Peri care was provided, and resident was repositioned for comfort with assistance of nursing staff using proper fracture precautions, including the log-roll technique and supportive positioning to avoid movement of the affected extremity. Record review of Resident #1's Right Knee x-ray results signed on 5/13/2026 at 6:22am revealed an impression of Acute non-displaced fracture of lateral femoral condyle (a crack in the outer, ball-shaped end of the thigh bone at the knee joint). Record review of Resident #1's progress note dated 5/13/2026 at 6:30am by LVN B revealed in part, .Received X-ray results. NP was informed immediately. New orders were received to send resident to the ER for fracture to lateral femoral of right knee via EMS transport. Nurse (writer) contacted EMS for transportation. Assigned CNA was informed not to move resident until EMS arrival. EMS provided an estimated time of arrival of 20 minutes for pickup. RP informed of the situation, and verbalized understanding. reported to oncoming nurse of resident changes and arrival of EMS transport. Record review of Resident #1's SBAR dated 5/12/2026 at 10:00pm completed by LVN B revealed a situation of swelling and pain to the right knee that started on 5/12/2026 and had gotten worse since it started. It was noted moving the right leg makes the symptoms worse and PRN acetaminophen makes the symptoms better. Further review of the SBAR functional status evaluation revealed decreased mobility to right leg and pain evaluation noted new pain to right knee with pain rating of 8 out of 10 with non-verbal signs of facial grimacing. Record review of Resident #1's progress note dated 5/13/2026 at 3:50pm by RN A revealed, Resident returned to the facility via stretcher accompanied by two EMS transporters following hospital evaluation related to suspected fracture to the lateral femoral area of the right knee. Per EMS transporter report, resident had no evidence of fracture noted during hospital evaluation. Upon return assessment, skin intact with no redness noted. Slight swelling observed to the right knee compared to the left knee. Resident unable to perform active ROM to lower extremities. During passive ROM attempt by writer, resident complained of pain to the right leg. PRN Tylenol administered as ordered for pain management. Incontinent care provided and resident tolerated care well. Resident in bed and made comfortable. NP notified of resident's return from the hospital and complaint of right leg pain. Awaiting new orders at this time. Resident continues to be monitored. Record review of Resident #1's progress note dated 5/13/2026 at 5:58pm by LVN D revealed in part, Resident seen by wound care nurse today for head to eval upon return from hospital. Skin remains intact. Edema noted to right knee. No treatment warranted at this time. Continue with weekly skin observation and notify wound care nurse for any changes or concerns in integrity. Record review of Resident #1's May 2026 MAR revealed physician order started on 5/13/2026 and discontinued 5/18/2026 for diclofenac sodium gel; 1 %; 5 cc; topical; twice a day for pain was administered 5/14/2026 - 5/18/2026. Record review of Resident #1's May 2026 MAR revealed physician order started on 5/13/2026 and discontinued on 5/19/2026 for acetaminophen tablet; 325mg; 2 tabs oral three times a day for pain was administered at 7AM, 2PM, and 7PM on 5/13/2026 - 5/19/2026. Record review of Resident #1's May 2026 MAR revealed physician order started on 5/13/2026 for lidocaine adhesive patch, medicated; 4 %; topical once a day to right knee for pain was administered on 5/14/2026 - 5/21/2026. Record review of Resident #1's physician order started on 5/13/2026 revealed to transfer x 2 assist utilizing a mechanical lift. Record review of Resident #1's progress note dated 5/14/2026 at 1:07am by LVN C revealed in part, .Resident continues to have moderate swelling to right knee, unable to perform ROM due to pain. Resident is on scheduled Tylenol which was given at time of assessment. Record review of Resident #1's progress note dated 5/14/2026 at 12:59pm by RN A revealed in part, .Resident remains stable and alert at this time, but continues to report mild pain with pressure applied. No redness noted. Moderate swelling observed to the right knee compared to the left knee. Diclofenac topical applied as ordered and tolerated well. Legs elevated with pillow for comfort and to reduce swelling. Resident made comfortable in bed. Vital signs obtained. Incontinent care provided and tolerated well. Resident resting comfortably in bed at this time. Record review of Resident #1's progress note dated 5/15/2026 at 6:34am by LVN C revealed in part, .Resident continues to have moderate swelling to right knee, unable to perform ROM due to pain. Resident is on scheduled Tylenol which was given at time of assessment. No inflammation observed. Record review of Resident #1's progress note dated 5/18/2026 at 6:10pm by RN B revealed in part, . Resident in no distress. Remain on scheduled Tylenol 650mg PO three times daily until 5/19/26 and Diclofenac sodium topical to right knee twice daily until 5/20/26 related to Right knee pain. Denies pain during the shift. New order received for cold compression therapy to right knee for 10 minutes each three times daily x 5 days. Cold compression initiated per order. Knee continued to be monitored. Resident tolerated treatment without difficulty. Record review of Resident #1's May 2026 MAR revealed physician order started on 5/18/2026 and discontinued 5/20/2026 for diclofenac sodium gel; 1 %; 5 cc; topical; twice a day for right knee pain was administered 5/18/2026 - 5/20/2026. Record review of Resident #1's May 2026 MAR revealed physician order started on 5/18/2026 and discontinued 5/22/2026 for Apply Cold compression to right Knee for 10 minutes three times a day was administered 5/18/2026 - 5/21/2026. Record Review of Resident #1's May 2026 MAR revealed physician order started on 5/18/2026 for meloxicam tablet (prescription nonsteroidal anti-inflammatory drug that can be used to relieve pain, swelling, stiffness, and inflammation); 7.5mg; 1 tab oral once a day was administered 5/19/2026 - 5/21/2026. Record Review of Resident #1's May 2026 MAR revealed physician order started on 5/18/2026 for Tizanidine tablet (a short-acting prescription muscle relaxer); 2mg; 1 tab oral at bedtime was administered 5/19/2026 - 5/20/2026. Record review of Resident #1's progress note dated 5/19/2026 at 1:40am by LVN E revealed, Writer verified new medication order from NP B as follows: Meloxicam 7.5mg PO daily and Tizanidine 2mg PO at bedtime for pain management, nerves and muscle spasticity. Spoke with RP regarding new medication orders, no voice concerned at this time. Plan of care ongoing. Record review of Resident #1's progress note dated 5/19/2026 at 12:13pm by social worker revealed RP was contacted to schedule a care plan meeting on 5/20/2026 to discuss residents fall. Record review of Resident #1's progress note dated 5/20/2026 at 2:41am by LVN C revealed, Resident continues to remain stable, no complaints of pain or discomfort during the night. Resident remains on Diclofenac to right knee BID until 5/20. Resident tolerates cold compress to right knee TID well, will end on 5/22. Resident is Day 2/3 of Meloxicam 7.5mg QD and Tizanidine 2mg QHS which she is tolerating well with no adverse reactions noted. Will continue to monitor. Record review of Resident #1's progress note dated 5/20/2026 at 11:48am by NP B revealed in part, .chief complaint: ADL and mobility dysfunction right knee pain and fall causing decline in function. long-term resident at current facility requires consult for right knee pain s/p fall. Patient was sent to ER for further imaging. STAT x-ray ordered in facility revealed fracture to lateral femoral of right knee. Imaging in ED negative for dislocation and fracture. Primary diagnosis right knee contusion. Patient now on therapy services for decline in ADLs, function, mobility s/p hospitalization. Rehab potential is fair to good. Physiatry/PM&R consult requested for management of decline in function with impaired mobility and self-care. Patient started on lidocaine patch to right knee. Pain is controlled at rest. However, with range of motion and movement patient shows signs of pain and cannot tolerate. right knee contusion status post fall, Risk of complication: HIGH. The patient's multiple medical issues necessitate frequent clinical evaluations, placing them at high risk for readmission without proper care. Neglecting regular monitoring and management may result in symptom exacerbation and complications, possibly requiring hospitalization. Continue joint mobilization and stretching as needed as well as modalities including hot and cold packs. Pain, stiffness, and reduced joint mobility may limit therapy participation and functional gains. Deconditioning and ADL dysfunction: Case discussed with therapy team regarding goals of rehab to return patient to prior level of functioning to increase independence with mobility and self-care. Phone interview on 5/21/2026 at 11:00am, RP stated she was called on 5/11/2026 and staff told her Resident #1 had to be lowered to the floor when she was being transferred to her bed. She was told there was no injuries and the incident was no big deal and she was being contacted as a formality. The RP stated she heard nothing until the following night on 5/12/2026 where a nurse (LVN B) contacted her saying Resident was complaining of knee pain and they contacted the NP who ordered an x-ray. The RP said the next morning on 5/13/2026 the nurse (LVN B) called her back and said the x - ray showed she had a fracture and they were sending her to the hospital. The RP said this prompted her to check the camera footage from 5/11/2026 when she had her fall because she was unsure how an injury could come from something she was told was nothing major. The RP said the camera footage showed the incident was not like how they described it and it showed two staff members attempting to lift her from her chair by her arms and the resident immediately going to the ground. She was also concerned because the resident was still visibly wet from her shower and naked which caused issues with the transfer because she stated you could see the staff hands slipping and them trying to grab towels to dry her after she slipped. The RP said there were multiple failed attempts of them trying to pull her from her arms once she was on the ground and it wasn't until the bed was lowered to the ground they were able to maneuver Resident #1 onto the bed. The RP stated she was told it was not until 5/12/2026 night that a CNA noticed Resident #1 was in pain but she questioned why it was the CNA who noticed she was in pain and not the nurse if the nurse was supposed to be monitoring after a fall and completing assessments. The RP said she did have a care plan meeting with the staff on 5/20/2026 where they spoke about the transfer being incorrect and the actions they took to retrain the staff. The RP said she asked about why the nurse did not identify the resident was in pain if she was supposed to be completing post fall assessments and she was told that the nurses monitor for 72 hours after a fall and the pain was identified within this time frame so that meant the post fall assessments were properly being done. The RP said she had concerns on how the nurses were supposedly completing assessments because if they were checking the resident's range of motion then they should have been the ones that identified Resident #1 was in pain. The RP provided a copy of the video footage from Resident #1's witnessed fall on 5/11/2026. Record review of Resident #1 room video footage from 5/11/2026 at 11:35am, showed CNA A bring Resident #1 into the room in shower chair and positioned next to her bed. CNA A used a towel to dry off parts of Resident #1 and then leaves the area for a few minutes and returns with LVN A. The two staff get on both sides of the resident, LVN A faces the resident and wraps her left arm around Resident #1's left arm and places her right hand on her back. CNA wrapped her right arm around Resident #1's right arm while also holding the residents right upper arm with her left hand. LVN A and CNA A both lift Resident #1 from her chair with no gate belt and Resident #1 immediately slips down in front of the shower chair. CNA A while still holding onto Resident #1's right arm reaches over to the bed to grab the towel and attempts to dry Resident #1 arms off some more and then passes the towel to LVN A for her to also dry the resident some more while they are both still holding onto her arms. The resident was then lowered down completely to the ground where she appears sitting in front the shower chair and to the right of her bed. LVN A then goes and lowers the bed down and returns back over to the resident and the two staff attempt to pull her up from the ground by hooking their arms under her armpits and holding her upper arm. They pulled the resident from both her arms and her bottom lifted from the ground but not high enough to reach the bed and she immediately slips back down ground. LVN A then goes back to the foot of bed and lowers the bed down some more, then returned back with CNA A to attempt to transfer the resident again. Both staff grab Resident #1's arms and pulled her up where her bottom touched the side of the bed but slips back down off the side of the bed and goes back down while the staff are holding her, they try again to pull her up and she slipped back down off the side of the bed again. The two staff pull her up again and was able to get the top of her body on the bed. LVN A then picks up Resident #1's legs from the floor and brings them around to the bed so that her full body is on the bed at this time. Interview on 5/21/2026 at 1:28pm, CNA A said she gave Resident #1 a shower on 5/11/2026 and she and LVN A went to transfer Resident #1 back to her bed from the shower chair and had to lower her to the ground because they were not balanced. CNA A said when they lowered the resident to the floor she was sitting with her legs bent and to the side. CNA A said Resident #1 did not voice any pain during the transfer attempts and the lowering to the ground. CNA A said later in the shift around 4:00pm - 5:00pm Resident #1 did have some discomfort during perineal care (gentle cleaning of the genital and anal areas). CNA A said Resident #1 said ouch when she went to turn her. CNA A said she asked Resident #1 what was wrong but she did not say anything. CNA A said MA A was in the room tending to Resident #1's roommate when this happened and she was also aware the resident had discomfort during care. CNA A could not recall if she told the nurse herself about Resident #1 having discomfort, but she believed MA A did let the nurse know. Interview on 5/21/2026 at 3:34pm, LVN A said she recalled CNA A coming to get her to assist with transferring Resident #1 to the bed on 5/11/2026 around 11:50am and they had to assist Resident #1 to the ground due to complications with the transfer. LVN A said when they initially lowered Resident #1 to the floor she did not hit anything hard on the floor and stated they were standing on a fall mat where she was lowered to. LVN A said once lowered to the ground Resident #1 had her legs folded under and laying off to the side. LVN A said she did do an assessment after the incident and noted no injuries to Resident #1 and she stated she did check her range of motion and the resident had no complaints at the time of the incident. LVN A said she notified the NP of the incident and the NP texted her to continue to monitor the resident. LVN A said she did check back in on Resident #1 the remainder of the day shift and there were no complaints voiced by the resident and denied anyone reporting any pain concerns to her on 5/11/2026. LVN A said the following day on 5/12/2026 she did administer PRN Tylenol to the resident at the beginning of the shift. LVN A could not recall for sure what prompted her to give the PRN pain medicine but stated she believed Resident #1's roommate (Resident #2) called and said Resident #1 had been grunting in pain. LVN A said it was her right knee that was giving her issues because she recalled seeing resident's knee elevated with a pillow which she thinks was done by the CNAs. She said she recalled shifting when she went to touch the knee so she did not perform range of motion check. LVN A said she checked back with Resident #1 after she gave the medicine and it was effective and stated when she went to touch Resident #1's knee she did not shift. LVN A denied any visible swelling, redness, or skin tear to the knee. When asked more about how Resident #2 was the one to report Resident #1 was in pain LVN A said that she also remembered that maybe it was MA A who told her Resident #1 was in pain and when she went into the room Resident #2 confirmed she had heard Resident #1 groaning in pain. LVN A believed this was all on 5/12/2026 around 11:00am. LVN A said she did not notify the NP about the pain and stated she just gave the medication. LVN A could not say why she did not notify the NP about the pain and stated PRN medication was effective for the pain. LVN A was then shown the MAR by the surveyor and asked why the PRN Tylenol was given on 5/11/2026 at 5:16pm and LVN A could not recall giving the medication but stated the MAR did reflect that she gave the medication for a pain rating of 6 out of 10. LVN A was informed by surveyor that CNA A recalled the resident having discomfort during care around that time and perhaps that was why the medication was given, LVN A said this could maybe be why, but she did not recall for sure. Phone interview on 5/21/2026 at 4:18pm, MA A said she recalled on 5/11/2026 hearing Resident #1 holler out while she was tending to her roommate Resident #2. MA A said CNA A was attempting perineal care at the time and Resident #1 was saying her right leg was hurting. MA A said she did go over and assist CNA A with finishing perineal care and Resident #1 was able to voice that it was her leg that was hurting and pointed at her right knee when asked. MA A said when they finished with the care she did place a pillow under the resident's knee to help with the pain. MA A said she reported Resident #1 was in pain to LVN A and LVN A told her she was already aware Resident #1 was having pain. MA A said she was not sure if and when LVN A went to check on Resident #1 because she continued to care for other residents. MA A said she did later check on Resident #1 because she would hear her randomly yelling out like she was having muscle spasms. MA A said this was all very unusual for Resident #1 and not something she typically did which made her concerned. Interview on 5/21/2026 at 4:46pm, Resident #2 said she recalled when Resident #1 had to be assisted to the ground and stated she was in a lot of pain afterwards. Resident #2 said the same day of the fall she heard Resident #1 yelling in pain when they were trying to change her which she had never heard her do before. Resident #2 said after that Resident #1 would just be laying in bed with no one touching her and would randomly yell out and was groaning. Resident #2 said she did tell staff several times about how much pain Resident #1 was in and stated it felt like it took a few days of her being in pain before she went to the hospital. Resident #2 said she felt really bad that it took so long for them to address Resident #1's pain. Observation on 5/21/2026 at 4:50pm, Resident #1 was sleeping in bed. Bed was at the lowest setting. Surveyor attempted to greet the resident, but she remained resting with eyes closed. Interview on 5/21/2026 at 6:17pm, the Administrator and DON stated through their investigation they found issues surrounding Resident #1's transfer and shower procedure which were addressed and staff were in-serviced about. The Administrator and the DON did not voice any identification of issues regarding timely physician notification. Phone interview on 5/21/2026 at 6:45pm, NP said she recalled being notified on 5/11/2026 that Resident #1 had to be lowered to the ground and there were no injuries or concerns reported. She advised to continue to monitor the resident but stated to her knowledge the resident was fine and it was not even really a fall that happened. NP said the next time she was notified about Resident #1 was the night of 5/12/2026 and LVN B called her saying Resident #1 was having knee pain so she ordered the x-ray for the knee. The NP said initially the x-ray showed a fracture, so she ordered to have her sent to the hospital, but the hospital sent her back saying their scans showed no fracture. The NP was informed by surveyor that Resident #1 had complained of knee pain prior to the night of 5/12/2026, the NP stated she only recalled being told about Resident #1 being in pain once which was the night of 5/12/2026. The NP said if a resident complains of acute pain after a fall the staff should let her know because depending on the pain it could be a sign of an injury. Interview on 5/21/2026 at 7:15pm, LVN B said when she came in for her shift on 5/11/2026 for the night shift, LVN A did report that Resident #1 had a fall where she was lowered to the ground during a transfer. LVN B said LVN A reported there were no injuries and the resident was fine. LVN B said there were no reports that Resident #1 had experienced pain or that PRN pain medication had to be administered. LVN B said the night of 5/11/2026 Resident #1 was fine, she typically does rounds with CNAs and said she did not observe nor did anyone report Resident #1 having pain the night of 5/11/2026. LVN B said CNA B worked with her on the night of 5/11/2026 and CNA C worked the night of 5/12/2026. LVN B said she came in on 5/12/2026 to work the night shift and did not recall LVN A reporting any concerns of Resident #1 having pain from the day shift or her having to administer pain medication. LVN B said it was reported Resident #1 was fine during the day shift. LVN B said during their first set of rounds the night of 5/12/2026 she was tending to Resident #1's roommate (Resident #2) while CNA C was attempting perineal care with Resident #1. LVN B said she heard Resident #1 yelling and CNA C asked her to take a look because the resident typically did not yell during care. LVN B said at that time Resident #2 mentioned that Resident #1 had been in pain all day. LVN B said she asked CNA C how she moved her that caused her to yell, and CNA C barely went to move Resident #1 right leg and she yelled out in pain. LVN B said she assisted CNA C with situating Resident #1 in bed, medicated her with PRN Tylenol, notified the NP and RP, and got orders for an x-ray to the knee. LVN B said early the next morning on 5/13/2026 she got the x-ray results which showed a fracture, she called the NP with the results, and she ordered to send Resident #1 to ER for evaluation. LVN B said Resident #1 did complain of pain again before she was transferred to the ER on [DATE] and had to medicate her with PRN Tylenol again. LVN B added that since she discovered Resident #1 was in so much pain, she told the CNA to not change her or move her until they got orders from the NP. Interview on 5/22/2026 at 11:41am, the DON said she had not heard about Resident #1 being in pain on 5/11/2026 and stated she would have to check into it. The DON said if the resident has a change in condition after a fall or just in general the Resident should be assessed and the provider should be notified about the change. The DON said a new onset of acute pain could be considered a change in condition, but it would depend on the assessment of the resident. On 5/22/2026 at 12:17pm, the RP sent a text message to surveyor noting she had reviewed more of Resident #1's room camera footage and forwarded a copy of video recording from 5/11/2026 at 4:30pm which showed, she is screaming out in pain. The RP noted she had a second video recording from 5/12/2026 at 9:30pm that also showed the resident in pain, and she believed this was when the pain was reported to her and the NP. Copies of the video were provided to the surveyor. Record review of video recording from Resident #1's room camera dated 5/11/2026 at 4:30pm revealed Resident #1 lying in bed and CNA A standing on the right side of the bed. Resident #1 begins yelling owe, owe, owe while CNA is preparin

Based on observation, interview and record review, the facility failed to ensure that the resident environment remained free of accident hazards as was possible for 1 of 9 (Resident #1) reviewed for accidents, in that Resident #1 was lowered to the floor when staff attempted to transfer Resident #1 while she remained wet from her shower and utilized an inappropriate transfer technique. Following the incident, Resident #1 complained of knee pain, required hospital evaluation, was placed on a pain management regimen, and experienced a decline in functional abilities. This failure placed residents at risk for falls, injury, increased pain, hospitalization, and further decline in functional abilities.Findings included: Record review of Resident #1's facesheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Cerebral infarction (type of stroke that occurs when blood flow to a part of the brain is blocked or significantly reduced, depriving brain tissue of oxygen and vital nutrients), blindness in right eye, low vision in left eye, osteoarthritis (degenerative joint disease where the protective cartilage that cushions the ends of the bones wears away over time), Age-related osteoporosis (progressive condition where bones lose mass and structural strength as you age, becoming porous and highly fragile), Cognitive communication deficit, Fibromyalgia (chronic disorder characterized by widespread musculoskeletal pain, profound fatigue, sleep disturbances, and cognitive issues), and chronic pain. Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 6 indicating severe cognitive impairment. Further review of the MDS revealed she was dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.) on staff for chair/bed-to-chair transfer, had no behavioral symptoms or rejection of care, no scheduled pain regimen, had not received PRN pain medications, had no reports of pain, and had no falls. Record review of Resident #1's care plan revealed a problem start date of 7/13/2024 and edited on 5/13/2026 for her having osteoarthritis, fibromyalgia, and neuropathy and was at risk for pain due to impaired mobility. Interventions included to administer pain medications as ordered by physician. Document effectiveness; Assess location, frequency, duration of pain and document. Report increased pain trend to MD; Monitor and record any non-verbal signs of pain (e.g., crying, guarding, moaning, restlessness, grimacing, diaphoresis, withdrawal, etc); Monitor for s/s of pain/discomfort; Nonpharmacological intervention Reposition for comfort per routine rounds and PRN; Notify MD if inadequate pain relief. Further review of the care plan revealed a problem start date of 7/13/2024 and edited on 5/13/2026 for risk for falls due to impaired vision, impaired mobility, incontinence of bowel and bladder and use of psychotropic medications. 5/11/2026 - witnessed fall during transfer. No apparent injuries indicated. The interventions included: Transfers x 2 assist utilizing a Hoyer Lift; Anticipate needs; Assure lighting is adequate and areas are free of clutter; Encourage to ask for assistance from staff; Encourage socialization and activity attendance as tolerated; Ensure call light is in reach, answer promptly; Monitor for incontinence per routine rounds and PRN; Therapy to eval and treat per orders. Further review of the care plan revealed a problem start date of 7/13/2024 and edited on 5/13/2026 for require assistance with ADL's due to impaired mobility, impaired vision, and incontinence of bowel and bladder. The interventions included: TRANSFERS: Assist x 2 utilizing a Hoyer Lift; Wheelchair for mobility; BATHING: Assist of 2; BED MOBILITY: Assist of 2; EATING: Assist of 1; Encourage independence, praise when attempts are made; Transfer rails to both sides of bed for bed mobility and transfers. Record review of Resident #1 May 2026 MAR revealed physician order started on 3/7/2023 to EVERY shift check resident for level of pain utilizing numeric rating scale had rating of 0 out of 10 from 5/1/2026 - 5/12/2026 (7:00am - 7:00pm, day shift). Further review revealed on:5/12/2026 (7:00pm -7:00am, night shift) pain rating was 8 out of 10 marked by LVN B.5/13/2026 (day shift) - 0 out of 10 pain marked by RN A5/13/2026 (night shift) - 6 out of 10 pain marked by LVN C5/14/2026 (day shift) - 2 out of 10 pain marked by RN A5/14/2026 (night shift) - 2 out of 10 pain marked by LVN C5/15/2026 - 5/21/2026 - pain rating was 0 out of 10. Record review of Resident #1's May 2026 MAR revealed physician order started on 1/28/2026 for acetaminophen tablet; 325mg; 2 tabs oral every 8 hours as needed for mild pain was administered on:5/11/2026 at 5:16pm by LVN A for pain rate of 6 out of 10 and was marked effective.5/12/2026 at 11:46am by LVN A for pain rate of 4 using FACES scale (clinical self-assessment tool used to measure pain intensity) and was marked effective.5/12/2026 at 9:59pm by LVN B for pain rate of 8 out of 10 using FACES scale marked somewhat effective.5/13/2026 at 7:42am by LVN B for pain rate of 4 out of 10 using FACES scale marked somewhat effective.5/13/2026 at 6:35pm by RN A for pain rate of 6 out of 10 using FACES scale marked other - pain upon palpation Record review of Resident #1's progress note dated 5/11/2026 at 12:01pm by LVN A revealed, While assisting CNA to transfer resident from shower chair to bed, resident slowly started falling. We then assisted resident slowly to the floor. No verbal complaints of pain or discomfort noted. Upon assessment of resident no injuries nor bleeding present. Vital signs within normal reading. Neurochecks started per facility protocol. NP and RP notified. No new orders, Safety measurements in place. Record review of Resident #1's progress note dated 5/12/2026 at 5:04am by LVN B revealed, Resident day 1/3 Post fall remain stable during this time. Denies pain or discomfort. Resident slept well throughout night with chest rise and fall and peri care provided with barrier cream applied q2h. Vital signs within normal limit. Neuros in place. Fall precautions in place. Call light and side table with belongings within reach. Record review of Resident #1's progress note dated 5/12/2026 at 2:34pm by LVN A revealed, Observation for day 2 post fall. Resident had minor pain and discomfort, PRN pain medication administered as ordered with noted relief. Neurochecks remain ongoing per protocol with no acute changes observed. Vital signs stable and within normal limits. Call light within reach. Safety measurements in place. Record review of Resident #1's progress note dated 5/12/2026 at 9:56pm by LVN B revealed, Observation post fall. Resident had pain and discomfort right knee upon providing peri care at this time. PRN pain medication administered as ordered. Neurochecks remain ongoing per protocol. Vital signs stable and within normal limits. NP notified and informed, pending provider recommendations. Record review of Resident #1's progress note dated 5/12/2026 at 10:11pm by LVN B revealed, New order received for right knee Xray 2views. Order placed and called in. called POA. informed of new order/changes. Verbalized understanding. Record review of Resident #1's progress note dated 5/12/2026 at 11:34pm by LVN B revealed, New order received to change order to STAT right knee Xray 2views. order placed and called in. Record review of Resident #1's progress note dated 5/13/2026 at 4:40am by LVN B revealed, Upon return from lunch break, covering nurse reported that the X-ray technician arrived and obtained an X-ray of the patient's right knee as ordered. Record review of Resident #1's progress note dated 5/13/2026 at 6:10am by LVN B revealed, Upon rounding, nurse observed resident in pain. PRN pain medication was administered per physician order. Peri care was provided, and resident was repositioned for comfort with assistance of nursing staff using proper fracture precautions, including the log-roll technique and supportive positioning to avoid movement of the affected extremity. Record review of Resident #1's Right Knee x-ray results signed on 5/13/2026 at 6:22am revealed an impression of Acute non-displaced fracture of lateral femoral condyle (a crack in the outer, ball-shaped end of the thigh bone at the knee joint). Record review of Resident #1's progress note dated 5/13/2026 at 6:30am by LVN B revealed in part, .Received X-ray results. NP was informed immediately. New orders were received to send resident to the ER for fracture to lateral femoral of right knee via EMS transport. Nurse (writer) contacted EMS for transportation. Assigned CNA was informed not to move resident until EMS arrival. EMS provided an estimated time of arrival of 20 minutes for pickup. RP informed of the situation, and verbalized understanding. reported to oncoming nurse of resident changes and arrival of EMS transport. Record review of Resident #1's SBAR dated 5/12/2026 completed by LVN B revealed a situation of swelling and pain to the right knee that started on 5/12/2026 and had gotten worse since it started. It was noted moving the right leg makes the symptoms worse and PRN acetaminophen makes the symptoms better. Further review of the SBAR functional status evaluation revealed decreased mobility to right leg and pain evaluation noted new pain to right knee with pain rating of 8 out of 10 with non-verbal signs of facial grimacing. Record review of Resident #1's progress note dated 5/13/2026 at 3:50pm by RN A revealed, Resident returned to the facility via stretcher accompanied by two EMS transporters following hospital evaluation related to suspected fracture to the lateral femoral area of the right knee. Per EMS transporter report, resident had no evidence of fracture noted during hospital evaluation. Upon return assessment, skin intact with no redness noted. Slight swelling observed to the right knee compared to the left knee. Resident unable to perform active ROM to lower extremities. During passive ROM attempt by writer, resident complained of pain to the right leg. PRN Tylenol administered as ordered for pain management. Incontinent care provided and resident tolerated care well. Resident in bed and made comfortable. NP notified of resident's return from the hospital and complaint of right leg pain. Awaiting new orders at this time. Resident continues to be monitored. Record review of Resident #1's progress note dated 5/13/2026 at 5:58pm by LVN D revealed in part, Resident seen by wound care nurse today for head to eval upon return from hospital. Skin remains intact. Edema noted to right knee. No treatment warranted at this time. Continue with weekly skin observation and notify wound care nurse for any changes or concerns in integrity. Record review of Resident #1's May 2026 MAR revealed physician order started on 5/13/2026 and discontinued 5/18/2026 for diclofenac sodium gel; 1 %; 5 cc; topical; twice a day for pain was administered 5/14/2026 - 5/18/2026. Record review of Resident #1's May 2026 MAR revealed physician order started on 5/13/2026 and discontinued on 5/19/2026 for acetaminophen tablet; 325mg; 2 tabs oral three times a day for pain was administered at 7AM, 2PM, and 7PM on 5/13/2026 - 5/19/2026. Record review of Resident #1's May 2026 MAR revealed physician order started on 5/13/2026 for lidocaine adhesive patch, medicated; 4 %; topical once a day to right knee for pain was administered on 5/14/2026 - 5/21/2026. Record review of Resident #1's physician order started on 5/13/2026 revealed to transfer x 2 assist utilizing a mechanical Lift. Record review of Resident #1's progress note dated 5/14/2026 at 1:07am by LVN C revealed in part, .Resident continues to have moderate swelling to right knee, unable to perform ROM due to pain. Resident is on scheduled Tylenol which was given at time of assessment. Record review of Resident #1's progress note dated 5/14/2026 at 12:59pm by RN A revealed in part, .Resident remains stable and alert at this time, but continues to report mild pain with pressure applied. No redness noted. Moderate swelling observed to the right knee compared to the left knee. Diclofenac topical applied as ordered and tolerated well. Legs elevated with pillow for comfort and to reduce swelling. Resident made comfortable in bed. Vital signs obtained. Incontinent care provided and tolerated well. Resident resting comfortably in bed at this time. Record review of Resident #1's progress note dated 5/15/2026 at 6:34am by LVN C revealed in part, .Resident continues to have moderate swelling to right knee, unable to perform ROM due to pain. Resident is on scheduled Tylenol which was given at time of assessment. No inflammation observed. Record review of Resident #1's progress note dated 5/18/2026 at 6:10pm by RN B revealed in part, . Resident in no distress. Remain on scheduled Tylenol 650mg PO three times daily until 5/19/26 and Diclofenac sodium topical to right knee twice daily until 5/20/26 related to Right knee pain. Denies pain during the shift. New order received for cold compression therapy to right knee for 10 minutes each three times daily x 5 days. Cold compression initiated per order. Knee continued to be monitored. Resident tolerated treatment without difficulty. Record review of Resident #1's May 2026 MAR revealed physician order started on 5/18/2026 and discontinued 5/20/2026 for diclofenac sodium gel; 1 %; 5 cc; topical; twice a day for right knee pain was administered 5/18/2026 - 5/20/2026. Record review of Resident #1's May 2026 MAR revealed physician order started on 5/18/2026 and discontinued 5/22/2026 for Apply Cold compression to right Knee for 10 minutes three times a day was administered 5/18/2026 - 5/21/2026. Record Review of Resident #1's May 2026 MAR revealed physician order started on 5/18/2026 for meloxicam tablet (prescription nonsteroidal anti-inflammatory drug that can be used to relieve pain, swelling, stiffness, and inflammation); 7.5mg; 1 tab oral once a day was administered 5/19/2026 - 5/21/2026. Record Review of Resident #1's May 2026 MAR revealed physician order started on 5/18/2026 for Tizanidine tablet (a short-acting prescription muscle relaxer); 2mg; 1 tab oral at bedtime was administered 5/19/2026 - 5/20/2026. Record review of Resident #1's progress note dated 5/19/2026 at 1:40am by LVN E revealed, Writer verified new medication order from NP B as follows: Meloxicam 7.5mg PO daily and Tizanidine 2mg PO at bedtime for pain management, nerves and muscle spasticity. Spoke with RP regarding new medication orders, no voice concerned at this time. Plan of care ongoing. Record review of Resident #1's progress note dated 5/19/2026 at 12:13pm by social worker revealed RP was contacted to schedule a care plan meeting on 5/20/2026 to discuss residents fall. Record review of Resident #1's progress note dated 5/20/2026 at 2:41am by LVN C revealed, Resident continues to remain stable, no complaints of pain or discomfort during the night. Resident remains on Diclofenac to right knee BID until 5/20. Resident tolerates cold compress to right knee TID well, will end on 5/22. Resident is Day 2/3 of Meloxicam 7.5mg QD and Tizanidine 2mg QHS which she is tolerating well with no adverse reactions noted. Will continue to monitor. Record review of Resident #1's progress note dated 5/20/2026 at 11:48am by NP B revealed in part, .chief complaint: ADL and mobility dysfunction right knee pain and fall causing decline in function. long-term resident at current facility requires consult for right knee pain s/p fall. Patient was sent to ER for further imaging. STAT x-ray ordered in facility revealed fracture to lateral femoral of right knee. Imaging in ED negative for dislocation and fracture. Primary diagnosis right knee contusion. Patient now on therapy services for decline in ADLs, function, mobility s/p hospitalization. Rehab potential is fair to good. Physiatry/PM&R consult requested for management of decline in function with impaired mobility and self-care. Patient started on lidocaine patch to right knee. Pain is controlled at rest. However, with range of motion and movement patient shows signs of pain and cannot tolerate. right knee contusion status post fall, Risk of complication: HIGH. The patient's multiple medical issues necessitate frequent clinical evaluations, placing them at high risk for readmission without proper care. Neglecting regular monitoring and management may result in symptom exacerbation and complications, possibly requiring hospitalization. Continue joint mobilization and stretching as needed as well as modalities including hot and cold packs. Pain, stiffness, and reduced joint mobility may limit therapy participation and functional gains. Deconditioning and ADL dysfunction: Case discussed with therapy team regarding goals of rehab to return patient to prior level of functioning to increase independence with mobility and self-care. Phone interview on 5/21/2026 at 11:00am, RP stated she was called on 5/11/2026 and staff told her Resident #1 had to be lowered to the floor when she was being transferred to her bed. She was told there were no injuries and the incident was no big deal and she was being contacted as a formality. The RP stated she heard nothing until the following night on 5/12/2026 where a nurse (LVN B) contacted her saying Resident was complaining of knee pain and they contacted the NP who ordered an x-ray. The RP said the next morning on 5/13/2026 the nurse (LVN B) called her back and said the x - ray showed she had a fracture and they were sending her to the hospital. The RP said this prompted her to check the camera footage from 5/11/2026 when she had her fall because she was unsure how an injury could come from something she was told was nothing major. The RP said the camera footage showed the incident was not like how they described it and it showed two staff members attempting to lift her from her chair by her arms and the resident immediately going to the ground. She was also concerned because the resident was still visibly wet from her shower and naked which caused issues with the transfer because she stated you could see the staff hands slipping and them trying to grab towels to dry her after she slipped. The RP said there was multiple failed attempts of them trying to pull her from her arms once she was on the ground and it wasn't until the bed was lowered to the ground they were able to maneuver Resident #1 onto the bed. The RP said she did have a care plan meeting with the staff on 5/20/2026 where they spoke about the transfer being incorrect and the actions they took to retrain the staff. The RP provided a copy of the video footage from Resident #1's witnessed fall on 5/11/2026. Record review of Resident #1 room video footage from 5/11/2026 at 11:35am, showed CNA A bring Resident #1 into the room in shower chair and positioned next to her bed. CNA A used a towel to dry off parts of Resident #1 and then leaves the area for a few minutes and returns with LVN A. The two staff get on both sides of the resident, LVN A faces the resident and wraps her left arm around Resident #1's left arm and places her right hand on her back. CNA wrapped her right arm around Resident #1's right arm while also holding the residents right upper arm with her left hand. LVN A and CNA A both lift Resident #1 from her chair with no gate belt and Resident #1 immediately slips down in front the shower chair. CNA A while still holding onto Resident #1's right arm reaches over to the bed to grab the towel and attempts to dry Resident #1 arms off some more and then passes the towel to LVN A for her to also dry the resident some more while they are both still holding onto her arms. The resident was then lowered down completely to the ground where she appears sitting in front the shower chair and to the right of her bed. LVN A then goes and lowers the bed down and returns back over to the resident and the two staff attempt to pull her up from the ground by hooking their arms under her armpits and holding her upper arm. They pulled the resident from both her arms and her bottom lifted from the ground but not high enough to reach the bed and she immediately slips back down ground. LVN A then goes back to the foot of bed and lowers the bed down some more, then returned back with CNA A to attempt to transfer the resident again. Both staff grab Resident #1's arms and pulled her up where her bottom touched the side of the bed but slips back down off the side of the bed and goes back down while the staff are holding her, they try again to pull her up and she slipped back down off the side of the bed again. The two staff pull her up again and was able to get the top of her body on the bed. LVN A then picks up Resident #1's legs from the floor and brings them around to the bed so that her full body is on the bed at this time. Interview on 5/21/2026 at 1:28pm, CNA A said she gave Resident #1 a shower on 5/11/2026 and her and LVN A went to transfer Resident #1 back to her bed from the shower chair and had to lower her to the ground because they were not balanced. CNA A confirmed that Resident was still wet from her shower which added complications as well with gripping the resident. CNA A said when they lowered the resident to the floor she was sitting with her legs bent and to the side. CNA A said Resident #1 did not voice any pain during the transfer attempts and the lowering to the ground. CNA A said later in the shift around 4:00pm - 5:00pm Resident #1 did have some discomfort during perineal care (gentle cleaning of the genital and anal areas). CNA A said Resident #1 said ouch when she went to turn her. CNA A said she asked Resident #1 what was wrong but she did not say anything. CNA A said MA A was in the room tending to Resident #1's roommate when this happened and she was also aware the resident had discomfort during care. CNA A could not recall if she told the nurse herself about Resident #1 having discomfort, but she believed MA A did let the nurse know. Interview on 5/21/2026 at 3:34pm, LVN A said she recalled CNA A coming to get her to assist with transferring Resident #1 to the bed on 5/11/2026 around 11:50am. LVN A said when they went to transfer Resident #1 to the bed she was not dried off all the way from her shower which caused complications with transfer. LVN A said typically Resident #1 could assist a little with the transfer and stated she had bilateral foot drop so she could not use her legs but she would usually be able to use upper body strength to hold onto them when they transfer her. LVN A said this time the resident could not assist at all. LVN A said when they initially lowered Resident #1 to the floor she did not hit anything hard on the floor and stated they were standing on a fall mat where she was lowered to. LVN A said once lowered to the ground Resident #1 had her legs folded under and laying off to the side. LVN A said it took them a few tried to get Resident #1 from the floor to the bed but was able to get the top of her body on the bed and then picked her legs up. LVN A said she did do an assessment after the incident and noted no injuries to Resident #1initially. LVN A said she did check back in on Resident #1 the remainder of the day shift and there was no complaints voiced by the resident and denied anyone reporting any pain concerns to her on 5/11/2026. LVN A said the following day on 5/12/2026 she did administer PRN Tylenol to the resident at the beginning of the shift. LVN A could not recall for sure what prompted her to give the PRN pain medicine but stated she believed Resident #1's roommate (Resident #2) called and said Resident #1 had been grunting in pain. LVN A said it was her right knee that was giving her issues because she recalled seeing residents knee elevated with a pillow which she thinks was done by the CNA's. She said she recalled shifting when she went to touch the knee so she did not perform range of motion check. LVN A said she checked back with Resident #1 after she gave the medicine and it was effective and stated when she went to touch Resident #1's knee she did not shift. LVN A denied any visible swelling, redness, or skin tear to the knee. Phone interview on 5/21/2026 at 4:18pm, MA A said she recalled on 5/11/2026 hearing Resident #1 holler out while she was tending to her roommate Resident #2. MA A said CNA A was attempting perineal care at the time and Resident #1 was saying her right leg was hurting. MA A said she did go over and assist CNA A with finishing perineal care and Resident #1 was able to voice that it was her leg that was hurting and pointed at her right knee when asked. MA A said when they finished with the care she did place a pillow under the resident's knee to help with the pain. MA A said she reported Resident #1 was in pain to LVN A and LVN A told her she was already aware Resident #1 was having pain. MA A said she was not sure if and when LVN A went to check on Resident #1 because she continued to care for other residents. MA A said she did later check on Resident #1 because she would hear her randomly yelling out like she was having muscle spasms. MA A said this was all very unusual for Resident #1 and not something she typically did which made her concerned. Interview on 5/21/2026 at 4:46pm, Resident #2 said she recalled when Resident had to be assisted to the ground and stated she was in a lot of pain afterwards. Resident #2 said the same day of the fall she heard Resident #1 yelling in pain when they were trying to change her which she had never heard her do before. Resident #2 said after that Resident #1 would just be laying in bed with no one touching her and would randomly yell out and was groaning. Resident #2 said she did tell staff several times about how much pain Resident #1 was in and stated it felt like it took a few days of her being in pain before she went to the hospital. Resident #2 said she felt really bad that it took so long for them to address Resident #1's pain. Observation on 5/21/2026 at 4:50pm, Resident #1 was sleeping in bed. Bed was at the lowest setting. Surveyor attempted to greet the resident but she remained resting with eyes closed. Interview on 5/21/2026 at 6:17pm, the administrator and DON stated through their investigation they found issues surrounding Resident #1's transfer and shower procedure which were addressed and staff we in-serviced to correct the issue surrounding the fall. Phone interview on 5/21/2026 at 6:45pm, NP said she recalled being notified on 5/11/2026 that Resident #1 had to be lowered to the ground and there were no injuries or concerns reported. NP said the next time she was notified about Resident #1 was the night of 5/12/2026 and LVN B called her saying Resident #1 was having knee pain so she ordered the x-ray for the knee. The NP said initially the x-ray showed a fracture so she ordered to have her sent to the hospital but the hospital sent her back saying their scans showed no fracture. Interview on 5/21/2026 at 7:15pm, LVN B said when she came in for her shift on 5/11/2026 for the night shift, LVN A did report that Resident #1 had a fall where she was lowered to the ground during a transfer. LVN B said LVN A reported there were no injuries and the resident was fine. LVN B said during their first set of rounds the night of 5/12/2026 she was tending to Resident #1's roommate (Resident #2) while CNA C was attempting perineal care with Resident #1. LVN B said she heard Resident #1 yelling and CNA C asked her to take a look because the resident typically did not yell during care. LVN B said at that time Resident #2 mentioned that Resident #1 had been in pain all day. LVN B said she asked CNA C how she moved her that caused her to yell, and CNA C barely went to move Resident #1 right leg and she yelled out in pain. LVN B said she assisted CNA C with situating Resident #1 in bed, medicated her with PRN Tylenol, notified the NP and RP, and got orders for an x-ray to the knee. LVN B said early the next morning on 5/13/2026 she got the x-ray results which showed a fracture, she called the NP with the results, and she ordered to send Resident #1 to ER for evaluation. LVN B said Resident #1 did complain of pain again before she was transferred to the ER on [DATE] and had to medicate her with PRN Tylenol again. LVN B added that since she discovered Resident #1 was in so much pain, she told the CNA to not change her or move her until they got orders from the NP. On 5/22/2026 at 12:17pm, the RP sent a text message to surveyor noting she had reviewed more of Resident #1's room camera footage and forwarded a copy of video recording from 5/11/2026 at 4:30pm which showed, she is screaming out in pain. The RP noted she had a second video recording from 5/12/2026 at 9:30pm that also showed the resident in pain, and she believed this was when the pain was reported to her and the NP. Copies of the video were provided to the surveyor. Record review of video recording from Resident #1's room camera dated 5/11/2026 at 4:30pm revealed Resident #1 lying in bed and CNA A standing on the right side of the bed. Resident #1 begins yelling owe, owe, owe while CNA is preparing supplies and not yet turning resident. The video shows MA A immediately come from the other side of the curtain and ask Resident #1 what was wrong. MA A tells Resident #1 she has to help CNA A change her and she was sorry if it was going to hurt. CNA A then rolls Resident #1 onto her right side while MA A is holding her in place so CNA A can clean Resident #1 and change her brief. Resident #1 did yell out again when she was turned and she could be heard moaning as she was held in place to be cleaned. The staff went to roll Resident #1 back on to her back and she yelled out again several times and could be heard moaning again. CNA A gathers some supplies off of the bed and then they turned Resident #1 back on to her left side to remove remaining supplies off the bed. CNA A leaves the camera view and MA A was left holding Resident #1 in place and attempted to ask Resident #1 where the pain was coming from on her right leg. MA A was observed rubbing the resident right hip and asking if it was her hip that was hurting her. A response from Resident #1 could not be heard in the recording. CNA A returned to the camera view with more supplies and a brief was placed under Resident #1, MA A was heard telling Resident #1 we are about to turn you again, it's going to hurt. The staff turned Resident #1 onto her back where she continued to yell out several times and then rolled her onto her right side to open her brief up to close it, the resident was also heard whimpering while on her side. Resident #1 was finally rested on her back for them to close her brief in the front where she yelled out some more when she was turned to lay flat on her back. Record review of video recording from Resident #1's room camera dated 5/12/2026 at 9:30pm, CNA C is seen providing perineal care to Resident #1 and she nudged Resident #1's right leg and the resident said ouch. The CNA immediately stops and calls LVN B's name who appears in the recording from behind a curtain, CNA C asked LVN B if she knew why Resident #1 was screaming and ouching and stated she had never done that with her before. CNA C then stated that Resident #2 had also told her Resident #1 had been screaming a lot. LVN B was observed to come over and assess Resident #1 to determine where the pain was coming from, she touched different areas of Resident #1's lower extremities and she yelled out when she touched her right knee. LVN B could be heard telling CNA C that Resident #1 had a recent fall and CNA C confirmed Resident #1 had not yelled out or said ouch with her before. On 5/28/2026 at 1:09pm, RP reached out to surveyor via text message and noted that Resident #1 had previously had issues with not wanting to leave her room or attend activities but over the past few months she had gotten better and had been getting up and going to dining room and attending activities in the facility which she felt was helping with her depression. RP noted since the incident she has only gotten out of bed to go to appointments and when staff do move her for care she winces in pain and say ow all the time now. The RP added, She is sleeping a lot and not eating as much the last few days. She's a

Based on record review and interview, the facility failed to ensure residents had the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 1 of 9 residents (CR #3) reviewed for resident rights. The facility failed to provide CR #3 a hot meal upon admission to the facility. CR #3 requested to receive the hot dinner meal being served to other residents; however, the facility did not provide the requested meal and later offered a sandwich and snacks, which she declined. As a result, CR #3's family had to provide her with a hot meal. This failure placed the resident at risk for loss of dignity, unmet nutritional needs, emotional distress, and diminished quality of life.Findings included: Record review of CR #3's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and discharged on 5/8/2026 to the hospital. Her diagnoses included: Metabolic encephalopathy (brain dysfunction caused by chemical or metabolic imbalances in the body ), protein-calorie malnutrition (inadequate intake or malabsorption of calories and protein), Type 2 diabetes mellitus (chronic metabolic condition where the body either resists the effects of insulin or doesn't produce enough to maintain normal glucose levels), Chronic kidney disease, stage 3b (kidneys are moderately to severely damaged and functioning at about 30% to 44% of their normal capacity). Record review of CR #3's admission MDS dated [DATE] revealed a BIMS score of 15 out of 15 indicating her cognition was intact. MDS further revealed resident required a therapeutic diet. Record review of CR #3 progress note dated 4/29/2026 at 5:11pm by LVN F revealed in part, .Received resident from ambulance transport at 2:00pm via stretcher. Resident is alert and oriented x 4. Diet: Renal/ Diabetic/ ADA & Cardiac House Diet with thin liquids. Resident now seen laying in bed, with bed wheels locked. No concerns voiced at this time. Patient care ongoing at this time. Record review of CR #3's physician order dated 4/29/2026 revealed a dietary order for Liberalized Renal; Special instructions: Renal; Cardiac/Diabetic. Interview on 5/22/2026 at 4:40pm, CR #3's family member stated CR #3 was admitted to the facility on [DATE] around 2:00pm. The family member stated the facility started to serve dinner around 5:00pm and CR #3 asked the staff if she was going to get a tray. CR #3 was told she was going to get a dinner tray and someone would bring it shortly. After some time passed no one brought CR #3's tray and she asked another staff member about getting her tray and was told by this time it was now the night shift (after 7:00pm) and the kitchen staff had already left. They attempted to give CR #3 a sandwich and some crackers, but CR #1 was upset because she wanted the hot meal that was being served to other residents. The family member stated she did later address the situation with staff and remembered talking to the ADON who told her that the kitchen did not get the communication of the resident diet order in time the day she admitted to have her in the system which was why she did not get served a hot tray. The family member said this was unacceptable because the resident was in the facility for several hours before dinner was served and CR #3 had even asked someone about the tray when they were being served and still did not get one. The family member said the ADON ultimately apologized that CR #3 did not get a hot tray and blamed it on staffing issues at the time. Interview on 5/23/2026 at 3:06pm, the Dietary Manager said if a resident is a new admit and they have not been entered into the system yet to generate a meal ticket, nursing staff are expected to bring a diet communication slip with the physician diet order. The Dietary Manager said the kitchen staff will not prepare or provide the tray without having the order and this was upon her directive to avoid any errors in providing the wrong diet to a resident. The Dietary Manager said they typically serve dinner around 5:00pm - 5:30pm and they always make extra trays of all the different diet types in case additional trays are needed. The Dietary Manager stated by 7:00pm the Dietary Staff are already gone but there are cold foods and snacks always available for the nursing staff to come and get if needed. The Dietary Manger could not recall CR #3 or any situation that may have happened with her not getting a dinner tray. The Dietary Manager stated if the order was brought down to the kitchen for the tray, then a tray would have been provided. Interview on 5/23/2026 at 4:24pm, the ADON said she recalled looking into the situation with CR #3 not getting a tray and recalled the family being very upset. The ADON said as she investigated the matter she found that upon CR #3's admission around 2:00pm the resident said she was not hungry and had already ate. The ADON also said she found out CR #3 was offered a tuna sandwich, peaches with cottage cheese, and some soup during the second shift on 4/29/2026 but resident did not want that food. The ADON said she did look into why CR #3 did not get the regular dinner tray during dinner time and said the nurse said the diet order was brought to the kitchen by LVN F, so it was unclear why the kitchen did not provide a tray during dinner time. Interview on 5/23/2026 at 5:26pm, LVN F said she was the nurse who admitted CR #3 on 4/29/2026. LVN F recalled their being an issues with CR #3 getting her dinner tray and breakfast tray but she did not learn of the issue until the morning of 4/30/2026. LVN F said the morning of 4/30/2026 CR #3 did not get a breakfast tray and this was when she was informed that she also did not get a dinner tray the night before. LVN F said she immediately reprinted the order and brought it to the kitchen the morning of 4/30/2026 and CR #3 did get a breakfast tray. LVN F stated on 4/29/2026 she brought CR #3's diet order to the kitchen before dinner was served so she would be provided a tray. LVN F said she checked CR #3 during her final rounds for the shift and she did not mention that she did not get a tray that night before she left. LVN F said when she went to the kitchen on 4/30/2026 they stated they did not have the diet communication form from the day before she had brought down and stated it must have gotten misplaced. Interview on 5/23/2026 at 7:30pm, the Administrator did not know of an incident involving CR #3 not getting a dinner tray on 4/29/2026 but did recall there was a lot of issues with CR #3 refusing things and the facility attempting to meet her needs and preferences. The Administrator stated she attempted to speak with CR #3's family member regarding concerns but was cursed at by the family member. The Administrator stated the CNA who worked with CR #3 the day she was admitted no longer worked at the facility. Record review of the facility Resident Right's policy revised on 11/1/2017 revealed in part, .Facility staff: 3. Will support the patient/resident's right to have autonomy and choice about how he/she wishes to live his/her daily life, and receive care subject to the healthcare rules in accordance with state and federal rules and regulations and Facility Procedures.

Based on observation, interview, and record review, the facility failed to ensure its medication error rate was not five percent or greater for 2 residents (Resident #10 and Resident #3) of 6 residents observed for Medication Pass. -Resident #10 was administered 9 medications that were prescribed to Resident #107. -Surveyor intervention prevented Resident #3 from receiving one medication that was prescribed to Resident #103. -The medication pass observation yielded 10 errors of 27 opportunities and resulted in a 37% error rate. The failure placed residents at risk of having harmful effects from being administered the wrong medications. Findings included:Record review of the Face Sheet for Resident #10 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included cerebral infarction (stroke), left side hemiplegia (loss of use of the left side), diabetes type 2, hypertension (high blood pressure), and embolism and thrombosis (blood clot) of an unspecified artery.Record review of Resident #10's Care Plan dated 12/05/2024 revealed he had diagnoses of atherosclerosis (buildup of fats and cholesterol in arteries), hyperlipidemia (high cholesterol), and hypertension (high blood pressure). The Care Plan read, in part, .Administer meds as ordered.Record review of the Face Sheet for Resident #107 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included cerebral infarction (stroke), left side hemiplegia (loss of use of left side), hypertension (high blood pressure), heart disease, chronic kidney disease, and cognitive communication deficit (difficulty communicating).Record review of Resident #107's Care Plan dated 11/26/2024 revealed he had diagnoses of hypertension, hypercholesterolemia (high cholesterol), Deep Vein Thrombosis (blood clot), Atrial Fibrillation (heart arrythmias), and Congestive Heart Failure. The Care Plan read, in part, .Administer meds as ordered.Observation on 03/25/2026 at 08:09 a.m. revealed MA A in Hall 200, standing in front of Resident #10 and Resident #107's doorway. She had the Hall 200 Medication Aide Cart. MA A had a wrist style blood pressure (BP) cuff. She entered the room and obtained the blood pressure and pulse rate for Resident #107. Resident #107's BP was 192/108 mmHg and the pulse was 60 bpm. MA A had addressed Resident #107 and Resident #10 by their correct first names and the residents appeared to be familiar with MA A. Continued observation revealed MA A informed RN B and RN C, who were in the hallway, that Resident #107's BP was high. MA A returned to the room and obtained Resident #107's BP and pulse with a different BP cuff. The retake reflected BP 198/98 mmHg and pulse was 63 bpm. MA A informed the Surveyor that RN B and RN C would address Resident #107. Continued observation revealed MA A then obtained the BP and pulse of Resident #10, the roommate of Resident #107. The results were: BP 129/78 mmHg and pulse 65 bpm. Continued observation revealed MA A return to the Medication Cart in the hallway. MA A pulled up the orders for Resident #107. MA A showed the label for each medication as she dispensed them, and the Surveyor documented them. MA A dispensed the following medications:Aspirin 81 mg chewable 1 tabBumetanide (Diuretic) 1 mg (milligram) 1 tabCarvedilol (to treat high BP)12.5 mg 1 tabClonidine (to treat high BP) 0.1 mg 1 tabEliquis (blood thinner) 5 mg 1 tabHydralazine (to treat high BP) 50 mg 1 tabJardiance (to lower blood sugar) 10 mg 1 tabLexapro (antidepressant)5 mg 1 tabLosartan Potassium (to lower BP) 100 mg 1 tabAll of the medication 'bubble packs' shown to the Surveyor had Resident #107's name on them. MA A verbalized the number of tablets in the medication cup was 9. Continued observation revealed MA A re-enter the room and hand the medications to Resident #10. MA A said Here, _______ [Resident #107]. Resident #10 replied I'm _____ [Resident #10] and quickly placed all 9 medications in his mouth and swallowed them before the Surveyor could intervene. Resident #107, who was in the bed next to Resident #10, did not say anything. Observation and interview on 03/25/2026 at 8:23 a.m. revealed MA A returned to the medication cart. The Surveyor asked MA A whose medications were administered to Resident #10. MA A said they were Resident #10's medications. The Surveyor asked MA A to log on to the laptop and see whose medications were dispensed. When the computer screen appeared, the medication orders for Resident #107 were on the screen. MA A again said she had dispensed the medications for Resident #10.Observation and interview on 03/25/2026 at 08:26 a.m. revealed the Surveyor asked RN B to compare the list made by the Surveyor when MA A dispensed the medications she just administered to Resident #10. RN B compared the list with Resident #107's eMAR, which was still displayed on MA A's computer screen. RN B compared the list of medications written by the Surveyor with the Medication orders for Resident #107. She confirmed that Resident #10 had received Resident #107's medications. During the observation of MA A, Resident #107 did not receive any medications. Record review of the current physician orders for Resident #107 revealed the following (not comprehensive):ASA (aspirin) 81 mg (milligram), one by mouth dailyBumetanide 1 mg, one by mouth twice dailyCarvedilol 12.5 mg, one by mouth twice dailyClonidine Hydrochloride (HCl) 0.1 mg, one by mouth daily, with special instructions to administer if blood pressure is greater than 160/90 mmHgEliquis 5 mg, one tablet by mouth twice daily.Hydralazine 50 mg, one by mouth three times daily, hold if systolic blood pressure is less than 110 mmHg or diastolic blood pressure is less than 60 mmHg Jardiance 10 mg, one tablet by mouth daily.Lexapro 5 mg, one tablet by mouth dailyLosartan Potassium 100 mg, one by mouth daily, hold if systolic blood pressure is less than 110 mmHg or diastolic blood pressure is less than 60 mmHg The physician orders for Resident #107 were consistent with the nine medications administered to Resident #10.Record review of the current physician orders for Resident #10 revealed the following (not comprehensive):ASA 81 mg EC (enteric coated) one by mouth dailyClonidine HCl (to treat high blood pressure) 0.1 mg one tablet daily, hold if systolic blood pressure is less than 110 mmHg or diastolic blood pressure is less than 60 mmHgClopidogrel (to reduce chance of blood clots) 75 mg one tablet dailyDecubivite (vitamin) one tablet dailyHydrochlorothiazide (to treat high blood pressure) 50 mg one tablet daily, hold if systolic blood pressure is less than 110 mmHg or diastolic blood pressure is less than 60 mmHgToprol ER (to treat high blood pressure) 100, mg one tablet daily, hold if systolic blood pressure is less than 110 mmHg or diastolic blood pressure is less than 60 mmHg.Nifedipine ER (to treat high blood pressure) 90 mg one tablet daily.KCL (Potassium Chloride) 20 milliequivalents one tablet three times dailyTylenol 325 mg, two tablets by mouth twice daily.Verapamil (to treat high blood pressure) 120 mg one tablet daily, hold if systolic blood pressure is less than 110 mmHg or diastolic blood pressure is less than 60 mmHg.The physician orders for Resident #10 were not consistent with the nine medications administered to Resident #10.In an interview on 03/25/2026 at 08:31 a.m., RN B said she would call the doctor. In an interview on 03/25/2026 at 08:51 a.m. RN B said MA A had been relieved of the medication cart. She said the facility would initiate vital sign checks every 15 minutes. She said the facility called the doctor and the family. An in-service was provided to MA A.In an interview on 03/25/2026 at 12:05 p.m. Resident #10 said the staff have been checking on him frequently, obtaining his blood pressure. He said he was informed that he received the wrong medications. In an interview on 03/25/2026 at 12:08 p.m. the DON said she was aware Resident #10 received Resident #107's medications. She said the facility did a head-to toe assessment of Resident #10. The resident denied having nausea or emesis, and did not complain of pain or discomfort. She said the possible negative outcomes could have been a drop of blood pressure or blood sugar levels. There could possibly be gastrointestinal upset. In an interview on 03/25/2026 at 12:10 p.m. the Administrator said the resident's blood pressure could go up or down, and the resident could possibly die. In an interview on 03/25/2026 at 2:20 p.m., the DON said the proper steps for the medication administration would have been prior to the administration the MA should have checked the five rights: right resident, right medication, right dose, right route, and right time. If giving BP medications, vital signs should have been obtained. After the medications were dispensed from the cart and the MA was back in the room, the resident's identity should have been verified again. Then the MA should have told the resident what medications she had, and asked the resident if he wanted to take all or some of the medications. Attempts to contact the physician on 03/25/2026 at 5:12 p.m. and again on 03/26/2026 at 09:40 a.m. were unsuccessful. A message to contact the Surveyor was provided. In an interview on 03/26/2026 at 09:45 a.m., the DON said she and the night supervisor conducted observation rounds with the nurses and medication aides to monitor medication administration. She said that on 03/25/2026 she did walking rounds with one of the nurses on the same hall as MA A, but not with MA A.Review of the competency checklist for MA A dated 08/27/2025 revealed she was to compare the resident's name with the Medication Administration Record (MAR).Record review of the Face Sheet for Resident #3 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included cerebral infarction (stroke), hypertension (high blood pressure), bipolar disorder, and seizures.Observation and interview on 03/26/2026 at 12:50 p.m. revealed LVN D was with a medication cart in front of room [ROOM NUMBER]. She said she was going to administer medications to Resident #3. LVN D retrieved two medication bubble pack cards from the cart. LVN D dispensed one tablet of Gabapentin 300 mg from the first card into a 30 cc cup. She set the card on the right side of the medication cart, face down. LVN D then dispensed one tablet of Tizanidine 4 mg from the second card into the 30 cc cup. She placed the second card on top of the first card, also face down. LVN D picked up both cards and started to place them in the medication cart. The Surveyor stopped her and asked which resident she was dispensing medications for. She said Resident _____ [Resident #3]. The Surveyor asked to see the medication card with the Gabapentin 300 mg tablets. LVN D presented the card. The Resident name on the card was Resident #103. LVN D said she knew the tablet of Gabapentin 300 mg was from a different resident than Resident #3. She said I was just trying to cover it. She said she knew she was not supposed to dispense medications from a different resident. In an interview via telephone on 03/26/2026 at 5:01 p.m., MA A said she did not have the computer mouse that she usually used, and thought she had closed out Resident #107's eMAR and had pulled up Resident #10's eMAR. She said the risk for administering the wrong medications could cause great harm or even death. Record review of the facility policy Pharmacy Policies and Procedures (revised 04/17/2024) read, in part, .1. The staff and practitioners shall strive to minimize potential for medication error by: Following The 8 Rights for administering medication:The Right Patient/Resident .

Based on interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one resident (Resident #1) of four residents reviewed for infection control. -Staff providing incontinent care for Resident #1 threw wet and/or soiled incontinent pads onto the floor. The failure placed the resident, visitors and staff at risk for acquiring infection. Findings include:Record review of the Face Sheet (no date) for Resident #1 revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, dementia (decline in cognitive ability), muscle wasting, and dysphagia (difficulty swallowing). Record review of Resident #1's Quarterly MDS, dated [DATE] revealed the resident had severely impaired cognition. The resident had limited functional range of motion (inability to fully move) in both arms and both legs. Record review of the Care Plan for Resident #1 dated 02/06/2025 revealed the resident was incontinent of bowel and bladder. Review of a video clip dated 12/24/2025 at 10:46 p.m. revealed an unidentified CNA providing incontinent care for Resident #1. The staff member was standing at the left side of the resident's bed. At the 1 minute mark of the video, the staff threw the used disposable pad onto the floor. Review of a video clip dated 12/26/2025 at 06:46 a.m. revealed the same unidentified CNA providing incontinent care for Resident #1. The staff member was standing at the left side of the resident's bed. At the 1:35 minute mark of the video, the staff threw the used disposable pad onto the floor behind her. Review of a video clip dated 12/30/2025 at 07:12 a.m. revealed the same unidentified CNA providing incontinent care for Resident #1. The staff member was standing at the left side of the resident's bed. At the 1:52 minute mark of the video, the staff threw the used disposable pad onto the floor. In an interview on 01/13/2026 at 1:58 p.m. Infection Preventionist B said when a pad was soiled or wet, it should be placed in a clear plastic bag and sent to the laundry or utility closet. If placed on the floor, it would be an infection control issue. If there were feces or urine on the pad it would definitely be an infection control issue. Housekeeping would do a deep-cleaning. On 01/13/2026 at 2:10 p.m. Infection Preventionist B viewed the three videos. She said, It's definitely an infection control issue. She said she would find out who the CNA was and correct it. Review of the facility policy Infection Control Policies and Procedures Subject: Linen and Laundry Procedures (revised 05/15/2023) revealed Policy: Sanitary storage and processing of clean and soiled linen will be used to prevent the spread of infection. Universal/Standard Precautions will be utilized by all personnel who come into contact with soiled linen.

Based on observation, interview, and record review, the facility failed to ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for one resident (Resident #1) of four residents reviewed for dietary services. -CNA C was in her first day of orientation and was assigned to assist Resident #1 with eating with no supervision. -Resident #1 had a diagnosis of dysphagia (difficulty swallowing). The failure placed Resident #1 at risk for choking and/or aspiration.Findings Include:Record review of the Face Sheet (no date) for Resident #1 revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, dementia (decline in cognitive ability), muscle wasting, and dysphagia (difficulty swallowing).Record review of Resident #1's Quarterly MDS, dated [DATE] revealed the resident had severely impaired cognition. The resident had limited functional range of motion in both arms and both legs. She required substantial/maximal assistance for eating. Record review of the Care Plan for Resident #1 dated 02/06/2025 revealed the resident was at risk for choking and aspiration related to difficulty swallowing. The Care Plan read in part .Short Term Goal target date: 03/12/2026: _____ [Resident #1] will not choke or aspirate [draw something into the lungs] thru the next review date. Observation on 01/13/2026 at 09:06 a.m. revealed CNA A assisting Resident #1 with her breakfast. The head of the bed was at approximately 75 degrees elevated. The resident received a pureed diet. She was eating very slowly with the assistance of staff. Follow-up observation at 9:29 a.m. revealed the resident had consumed approximately 50% of her meal. In an interview on 01/13/2026 at 11:30 a.m. ADON D said the facility usually provided training for 2 to 3 days and then asked the new CNA if they were comfortable working independently. In an interview on 01/13/2026 at 11:35 a.m., ST E said Resident #1 required to have the head of the bed elevated more than 45 degrees, with 90 degrees optimal. In an interview on 01/13/2026 at 11:41 a.m. CNA F said she was assigned to provide orientation for CNA C. CNA F said on the first day of orientation, CNA C assisted Resident #1 with her meal. CNA F said the new CNA worked with Resident #1 for 15 minutes by herself. In an interview via telephone on 01/13/2026 at 1:32 p.m., a family member said she observed on video that on 01/08/2026 CNA C worked with Resident #1 for 45 minutes without supervision. Review of the personnel file for CNA C revealed her date of hire was 01/07/2026. An attempt to call CNA C on 01/13/2026 at 2:39 p.m. was unsuccessful. A message with contact information was provided. No return call was received.In an interview on 01/13/2026 at 3:45 p.m. ADON D said the first day of orientation should be with another CNA. Every resident has a profile that takes time to learn. The first day is usually not hands-on, just shadowing. At the end of the orientation they are asked if they're comfortable. She said a complication could be using the wrong technique, and lack of following the care plan if not properly trained. Review of the facility policy Certified Nursing Assistant Orientation (revised 01/12/2024) revealed Appropriate instruction on any skill areas identified as a weakness shall be provided prior to delivering or completing a task.

Based on observation, interview, and record review, the facility failed to ensure, based on the comprehensive assessment of the resident that one resident (Resident #1) of four residents reviewed for quality of care received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan.Resident #1 had a wound dressing that was wet during a shower procedure and was not changed prior to being sent to an appointment.The failure could place the resident at risk for not receiving necessary care and treatment.Findings included:Record review of the Face Sheet for Resident #1 revealed she was [AGE] years old and was admitted on [DATE]. Diagnoses included, but were not limited to, unspecified wound of her left foot, subsequent-encounter left heel infection, and cognitive communication deficit.In an interview via telephone on 10/14/2025 at 11:20 a.m., a family member said Resident #1 had a wound care doctor's appointment the previous day. She said when the resident arrived at the appointment, the resident's bandages were noted to be wet. She said both wounds on the left foot were wet.Three attempts to contact the wound care clinic were unsuccessful. The attempts were made via telephone: 10/14/2025 at 2:24 p.m., 10/15/2025 at 3:58 p.m., and 10/16/25 at 3:10 p.m.On 10/14/2025 at 3:06 p.m. wound care for Resident #1 was observed, provided by LVN A. The resident's left sock and kerlix gauze (wrap) was removed. The resident had two dry/intact dressings; one on top of the foot, and one on the heel. The resident exhibited an open area on the top of her foot, approximately 2 cm[JM1] diameter. It was superficial. The resident had an open area on her left heel. The resident complained of pain when her leg was lifted, and the Surveyor was not able to obtain a clear view. LVN A stopped the procedure and wrapped the resident's foot. She said she would return after the resident received pain medication. On 10/14/2025 at 3:52 p.m. LVN A provided wound care for Resident #1. There were no concerns with technique noted. The Physician's Orders dated 10/13/25 read, in part, .Avoid getting wound wet in showers/baths to prevent bacteria getting washed into wound. Cover with cast cover [available at most pharmacies] or take a sponge bath. Dressing was soaked on 10/13/2025, PLEASE DO NOT GET WOUND DRESSING WET IN SHOWER. PLEASE COVER WITH CAST COVER OR PLASTIC BAG ENSURING TAP WATER DOESN'T SOAK DRESSING.In an interview on 10/14/2025 at 4:12 p.m. CNA B said she assisted Resident #1 with a shower on 10/13/2025, prior to her wound care doctor's appointment. She said the resident's left leg/foot was wrapped in plastic during the shower. CNA B said the floor was wet in the resident's room when the resident was transferred to the wheelchair. In an interview on 10/15/2025 at 2:20 p.m., the DON said that if a wound dressing was left wet, the wound could become macerated (tissue breakdown). She said if the dressing was wet, the nurse should have changed it.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #2) of four residents reviewed received adequate supervision and assistance devices to prevent accidents, in that:Resident #2 was lifted in a mechanical lift by a single staff, although the lift requires two people.Resident #2 was suspended in the air in the and moved by a single staff. The resident was swinging, with her weight shifting side to side.The failure could place residents at increased risk for inadequate supervision.Findings include:Record review of the Face Sheet for Resident #2 revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, dementia, contractures of both shoulders, and muscle wasting and atrophy.Record review of Resident #2's Quarterly MDS, dated [DATE] revealed the resident had severely impaired cognition. The resident had limited functional range of motion in both arms and both legs. The resident required maximum assist to go from sitting to lying positions, as well as lying to sitting position. She was dependent on staff for transferring from the chair to the bed and for bed-to-chair transfers.Record review of the Care Plan for Resident #2 dated 03/29/2025 revealed the resident required the for transfers. Review of a video clip dated 09/16/2025 at 12:15 p.m. from an in-room camera revealed an unidentified staff in Resident #2's room. There was a mechanical lift in the room. Resident #2 was in a shower chair facing the lift. The sling was under her. The staff person connected the mechanical sling to the lift. Resident #2 was then raised out of the shower chair and the shower chair was moved. The staff person then moved the mechanical lift approximately 10 feet towards the resident's bed, completing a 180 degree turn in the process. The resident remained approximately three feet above the ground. The resident was visibly swinging while suspended in the air.In an interview on 10/15/2025 at 2:20 p.m., the DON said there should be two staff for mechanical lift transfers. She said that if one person was used, the resident could fall during the transfer.Review of the facility policy Mechanical Lifts revised May 5, 2023, did not address the number of staff required for a mechanical lift transfer.

Based on observation, interview and record reviews, the facility failed to provide pharmaceutical services, including procedures that assured the accurate administration of all drugs and biologicals to meet the needs of 1 of 1 (Resident # 1) reviewed for enteral medication administration.LVN A failed to administer Resident # 1's enteral medications according to physician's order. This failure could place residents at risk for a clogged peg tube, adverse reaction, metabolic abnormalities and a decline in health. Findings included: Record review of Resident # 1's face sheet retrieved on 11/18/2025 at 09:53 a.m., revealed, Resident # 1 was an [AGE] year-old female admitted to the facility on [DATE]. She was admitted with the following medical diagnoses: Unspecified dementia(loss of cognitive functioning), gastrostomy status, ( the condition or situation of a patient who has undergone a medical procedure that involves placing a tube directly into the stomach for feeding or medication administration) hypertension (high blood pressure) , anemia (when you do not have enough healthy red blood cells or red blood cells do not work as they should), hydronephrosis (swelling of one or both kidneys that makes it impossible for urine to drain properly). Record review of Resident # 1's MDS dated [DATE] revealed a BIMS score of 03 on the cognitive pattern section C0500, indicative of severe cognitive damage. Record review of Resident # 1's care plan that was last conferenced on 10/17/2025 stated: Administer medications as ordered per MD. Monitor and record effectiveness. Monitor and report any adverse side effects. Care Plan stated Resident #1 had a g-tube on the stomach. Record review of Resident # 1's MAR, retrieved on 11/20/2025 did not reveal the enteral medication should be administered together. The order read: Enteral Feeding: Flush tube with30cc's warm water before and after tube feeding administration. An observation on 11/18/2025 at 12:16 p.m., LVN A administered, the following medications to Resident #1 as a cocktail (combination of different medications in one cup) ; calcitriol 1 mcg/ml solution to treat hydronephrosis with renal and ureteral calculous obstruction ( kidney tube blockage by kidney stones), diltiazem HCL 60 mg tablet used to treat hypertension, donepezil 10 mg tablet used to treat dementia, ferrous sulfate 220 mg used to treat anemia and lokelma 10 gram powder used to treat hyperkalemia. LVN A did not use warm water to administer the g-tube medications as specified in the MD's general order tap on 07/18/2023 06:25 a.m. During an interview with LVN B on 11/19/2025 at 10:24 a.m., she said peg tube medications are administered as follows; each medication is crushed separately and put in a separate cup and administered separately by gravity with warm water. She stated the reason for administering one medication at a time is because there might be an adverse reaction. During an interview with LVN C on 11/19/2025 at 12:15 p.m., she said peg-tube (a tube that allows you to receive medication and food through your stomach) medications are not supposed to be mixed, except if there is an order that stated they could be mixed. She stated they are supposed to be administered individually. LVN C stated, it is the responsibility of the nurse who is administering the medications to check the orders prior to medication administration. LVN C stated that the consequences of not administering each medication separately could cause stomach upset to Resident # 1, it could affect how the medication works, and it could clog the tube. She stated the facility had a bootcamp on peg tube medication administration two months ago, where they had mannequins / dummy (to demonstrate) peg medication administration. LVN C said the facility trainers did verbal explanation which was followed by demonstration. She stated the nurses did a return demonstration and were all checked off. During an interview with RN A on 11/19/2025 at 2:08 p.m., she said, I put the medications in separate cups. I crush them separately. I mix them separately and administer them one at a time via gravity. She stated she would administer the medications separately because the chemical compositions are different. RN A stated, she does not want to create any chemical reaction before the medications get into a resident's system. She said, if there was a reaction, Resident # 1 might have anaphylactic reaction (a severe life-threatening allergic reaction that can occur within minutes of exposure to a trigger like medications, food or insect stings), and abdominal issues. During an interview with LVN D on 11/19/2025 at 2:23 p.m., he acknowledged the fact that he was trained to administer peg tube medications. He said the facility's corporate nurse retrained all the nurses on all nursing skills six weeks ago. LVN D said during peg tube medication administration, he checks to make sure it's the right resident, the right medication and the right route. He said he would wash his hands and assemble all the required medications. LVN D said he would crush every medication individually in separate cups. He said, if there are five pills, he would have five separate cups. LVN D said prior to administering the medications, the nurse should stop the tube feeding. He said the medications are administered separately because some medications can react with others and ensure the residents tolerate each medication. Also, the residents might have an adverse reaction. LVN D said if the medications are not administered separately, it means a medication error has occurred. He said he had never seen any facility Dr who wrote an order for peg tube medications to be administered as a cocktail (combination of multiple medications). During an interview with RN B on 11/20/2025 at 11:00 a.m., She said, if she had a resident with enteral medications (medications administered directly into the gastrointestinal tract), she will crush the medications separately and administer them separately. RN B said, that is what she was told in nursing school. She said enteral medications are not administered together because the medications can react with one another. She said if the medications are administered together, the nurse will not know how much water to use because you must flush after each medication administration. The nurse is expected to flush each medication because you do not want the medication to clog the peg tube. RN B said if you administer enteral medications together, it might cause medication reaction, and you might be pushing too much medication at once. During a telephone interview with the DON on 11/20/2025 at 1:04 p.m., she said, if a resident had more than one enteral medication, the nurse should separate the medications except there is a Dr's order to administer otherwise. The DON said, if a nurse administered enteral medications as a cocktail, it might clog the peg tube. She said it depends on where the peg tube is clogged, it could prevent the residents from getting prescribed medications and can cause unwanted hospitalization if the facility cannot unclog the peg tube. The DON said, if a nurse was seen administering enteral medications as a cock tail, that nurse would be reeducated, followed by a check -off. During a telephone interview with LVN A on 11/20/2025 at 1:48 p.m., she said she was taught to administer enteral medications separately. She said she was nervous when she was watched by a state Surveyor on 11/18/2025 when she administered enteral medications to Resident # 1. She said it was also because she was nervous that she did not use warm water as stated in the order. LVN A said, if enteral medications are not administered correctly, the medications would not have their desired effects and Resident # 1 could have reaction such as hives ( outbreak of red, itchy, raised, and swollen areas on the skin that can be caused by allergic reactions and other factors) and anaphylactic shock (a severe allergic reaction that affects the whole body and can be life-threatening if not treated immediately). During an interview with the Administrator on 11/20/2025 at 12:29 p.m., she said she was not a nurse, her understanding of enteral medication administration was, you crush the medication and put them in the peg tube, flush with water. She said she had never attended any of the nursing competencies when they demonstrated medication administration. During a telephone interview on 11/19/2025 at 11:45 a.m., with Pharmacist A, he said the pharmacy was only responsible for dispensing the medications. The facility and the Drs decide on how the medication should be administered. During a telephone interview on 11/19/2025 at 5:20 p.m., Dr A said she would call back. There was no return call. On 11/20/2025 at 09:41 a.m., there was an unsuccessful phone call to Dr. A. Record review of enteral feeding-administering medications dated 05/05/2023 revealed: The licensed nurse will administer medications prescribed by the physician to be given by enteral tube, using the appropriate method according to recognized standards of practice. The licensed nurse will verify correct tube placement on those devices that are not inserted directly into the gut, per current clinical standards of practice. Record review of facility's staff education/orientation policies and procedures revised on 07/01/2013, 09/10/2019 and 11/18/2012 revealed: After medications have been administered, deliver the 30 ml post medication or per physician order and warm water flush by gravity. In the event where flushing with 30 ml before and after each single medication may overload the patient/resident with fluid, flush before and after a group of multiple medications is acceptable, unless there are known compatibility problems between medications being mixed. Administer medications separately. Do not mix, as this may cause a drug reaction. Record review of Resident #'s general peg order retrieved on 11/20/2025 at 09:50 a.m., did not reveal that the medication could have been administered as a cocktail.

Based on observations, interviews, and record review the facility failed to ensure residents received proper treatment and care to maintain mobility and good foot health, and provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) and assist the resident in making appointments with a qualified person for 1 of 5 residents (CR #1) reviewed for foot care - The facility failed to provide foot care or attain podiatry services for CR #1, a diabetic patient with severe PAD (a form of PVD in which narrowing of the blood vessels limit blood flow to the limbs) and a history of AKA from admission on [DATE] till she discharged on 06/17/25 to the hospital where she was diagnosed with osteomyelitis (a bone infection) that needed antibiotics, an AKA was recommended resulting in the family placing the resident on end of life care. An Immediate Jeopardy (IJ) was identified on 07/09/2025. The IJ template was provided to the Administrator on 07/09/2025 at 04:57 PM. While the immediacy was removed on 07/14/2025 at 3:18 PM, the facility remained out of compliance at a scope of pattern and severity level of no actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for injuries, infections, unwanted hospitalization, an amputation leading to a decrease in quality of life and death. Findings Included: Record review of CR #1's Face Sheet dated 06/22/25 revealed, a 69-year-olf female who admitted to the facility on [DATE] at 12:45 PM with diagnoses which included: Alzheimer's Disease, unspecified dementia with anxiety, hypertension (high blood pressure), acquired absence of right leg above knee (right above the knee amputation) and type 2 diabetes with other circulatory complications. Diagnosis of open wound of left great toe without damage to nail was added on 06/15/25; and unspecified wound, left foot initial encounter was added on 06/16/25. There was no documented diagnosis of PVD. Record review of CR #1's Quarterly MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making, resident was unable to complete a brief interview of mental status, lower extremity functional limitation in range of motion. CR #1 needed substantial/maximal assistance to : roll left and right, move from sitting to lying and lying to sitting on side of bed, was totally depended on to transfer from chair to bed and vice versa, evaluation of her ability to walk 10 ft, toilet transfer, tub/shower transfer or go from sit to stand was not attempted due to her medical condition or safety concerns. Active diagnoses of anemia, hypertension, diabetes, hyperlipidemia(high cholesterol), Alzheimer's Disease, seizure disorder, depression; there were no diagnosis of PVD or any circulatory complications. Record review of CR #1's undated Care Plan revealed, Focus- risk of falls due to immobility, muscle weakness and diabetes; Problem- CR #1 will be free from injury; approach- encourage resident to use environmental devices such as hand grips, handrails etc. Problem start date of 06/13/25- CR #1 has a diabetic ulcer to the left great toe; Goal target date 09/13/25- resident's wound will decrease in size with no complications as evidenced by wound documentation; Approach start date 06/13/25- nurse to complete wound documentation daily, refer to wound care doctor as needed, wound team to evaluate wound(s), treatments and healing status weekly. Problem start date of 06/16/25- CR#1 has trauma to left great toe; Goal target date: 09/16/25- wound will decrease in size as evidenced by wound documentation with no complications and comfort will be maintained; Approach start date: 06/16/25- CNA to inspect skin, especially over bony prominences, during bathing and personal care. Nurse to complete wound observation weekly. There was no mention of podiatry care or services or her vascular disease.Record review of CR #1's Physician Orders revealed, Start Date 09/18/24; Description- Consult: Podiatry, Ophthalmology, dental as needed .Record review of CR #1's Progress Notes from admission on [DATE] to discharge on [DATE] revealed, There was no documentation that CR #1 received podiatry care while at the facility with the following relevant entries.-06/12/25 at 11:27 PM signed by LVN D: upon assessment, the resident's left great toes appears bruised. No signs or symptoms of pain noted. Foot pulses were felt, no sign of compromised circulation. Foot is warm and dry to touch.-06/13/25 at 02:06 PM signed by Wound Care Nurse A revealed, nurse informed writer that patients left great toe appears to have bruising, writer assessed and observed a diabetic ulcer to left, great toe 08X0.5cm, no exudate, no odor or s/sx of infection, no pain. cleansed with normal saline, patted dry with sterile gauze, applied skin prep and left open to air. Called and spoke with patient's family and discussed the assessment and plan of care.-06/15/25 at 07:05 AM signed by LVN D- during morning rounds, the aired reported that CR #1's big toe appeared to be bleeding and bruised. Upon assessment, observed active bleeding from the toe, with bruising extending up the foot and lower leg. Resident verbalized pain upon palpation of the affected area. NP notified for further evaluation and management.- 06/15/25 at 07:05 AM signed by LVN D- NP ordered STAT Xray to the affected toe and leg-06/16/25 at 05:34 PM signed by Wound Care Nurse B, nurse reported CR #1's left great toe has bruises and bleeding. Upon assessment, noted trauma to left toe measuring 1.2X2X0.1 cm with moderate bright red sanguineous exudate (bloody fluid), mild swelling noted, purple discoloration to left great toe extending to foot, no odor, no s/sx of infection. NP made aware, wound cleaned with normal saline, pat dry with sterile gauze, applied Bactroban (antibiotic ointment) and covered wound with gauze, procedure tolerated by patient. Requested for podiatry service to the Social Worker-06/16/25 at 05:46 PM signed by RN A- X-ray of the left foot was completed during this shift in response to an existing wound. Resident tolerated the procedure without any complications. Left foot wound remains covered with dressing intact; no signs of active bleeding, or foul odor noted. Awaiting radiology results at this time.-06/16/25 at 06:25 PM signed by RN A- C-ray results were received and reviewed by NP as negative for fracture. -06/17/25 at 04:31 PM signed by Wound Care Nurse A- CR #1 family stopped by the office to ask questions regarding resident wounds, family was informed that patient has a diabetic ulcer to the left great toe and its being treated with skin prep daily and left open to air, trauma to the left great toe and it's being treated with Bactroban and covered with gauze daily, patient has been added to the podiatry list by the Social Worker and the WCD will be rounding on Thursday and will further assess patient's wounds and family will receive a weekly call with an update. Family expressed concerns of patient getting gangrene due to past experience of getting the right leg amputated and wanted to send patient out to get antibiotics. Family educated on the use of Bactroban ointment and informed and no s/sx of infection observed at this time, but Wound Care Nurse A can only give information on the assessment of wounds and the treatments put into place by the WCD via telehealth.06/17/25 at 06:35 PM signed by RN A, CR #1 noted with a diabetic wound to the left foot. During a family visit today, the resident's family expressed concern that the foot might be infected and requested that the resident be transported to the emergency room for further evaluation. Upon assessment, no signs or symptoms of infection were noted. Contacted EMS for non-emergency transportation, resident transported to the hospital for further evaluation.Record review of CR #1's Point of Care History from 09/17/24 to 06/17/25 revealed, no documentation of toenail care to CR #1.Record review of CR #1's Shower Sheets from 09/17/24 to 06/17/25 revealed, the only documented nail care was on 05/29/25 and no clarification was made if it was finger or toenail care. Record review of CR #1's Wound Management Detail Report dated 06/22/25 revealed there were no previously documented wounds prior to 06/13/25:06/13/25 at 11:16 PM signed by Wound Care Nurse A: Wound Type: Diabetic Ulcer; Wound location left big toe; 0.8X0.5 cm, with no odor or drainage; depth of injury- through the dermis (skin) and down to the subcutaneous (under the skin) tissue, muscle.06/16/25 at 06:08 PM signed by Wound Care Nurse B: Wound Type: Trauma; Wound Location: Left big toe; to left great toe measuring 1.2x2x0.1cm with moderate bright red sanguineous exudate (bloody fluid), mild swelling noted, purple discoloration to left great toe extending to foot, no odor, no s/sx of infection.Record review of CR #1's Physician Order dated 06/16/25 revealed, PRN wound treatment. Trauma to the left great toe; cleanse with ns apply sterile gauze and Bactroban (topical antibiotic) and cover wound with gauze as needed.Record review of CR #1's NP Progress Note dated 06/16/25. During the weekend nursing report of bruising and pain left first toe unclear how this happened. STAT x-ray ordered, wound care team following applied Bactroban. Physical Exam-Skin: Extremities- right AKA, left first toe swelling and tenderness; Musculoskeletal: :left first toe tenderness swelling and bruising, right AKA. Left first toe open wound minimal drainage/no bleeding. Diagnosis/Assessment and Plan left first toe swelling and report of some bleeding during the weekend, wound care team following, trauma wound left great toe unclear how this happened. Discussed with the wound doctor. xray shows no fracture. Open wound- left great toe trauma wound nailbed, wound care team following continue care treatments monitored closely. Left great toe pain likely due to trauma wound, ordered Acetaminophen 650 mg twice daily for 7 days and monitor.Record review of CR #1's Final X-ray Report dated 06/16/25 at 03:13 PM revealed, negative for acute disease, mild bone weakening and degenerative changes present.Record review of an undated investigation summary signed by ADON A revealed, on 06/12/25 LVN A observed what appeared to be bruising to the left great toe of CR #1 and then on 06/15/25 she observed active bleeding to the left great toe, bruising extending from the upper foot to the left lower leg and pain when touched. LVN D notified the NP who gave a STAT order for c-rays of the left lower extremity. On 06/16/25, she interviewed CNA D, CNA K, CNA N, CNA AC, and none of them knew how the resident was injured or saw anything out of the ordinary with the resident's toes.Record review of CR #1 Hospital Records dated 06/17/25 revealed, CR #1 had a right foot diabetic foot ulcer in 07/2024 and then an above the knee amputation. She presented with left first toe ulceration and discharge and her final admitted diagnoses were toe infection and gangrene (death of body tissue due to lack of blood infection or a serious infection) of the toe. Record review of CR #1's Hospital Hospitalist Consult dated 06/18/25 revealed, CR #1 had a PMH of significant dementia, diabetes, hypertension, high cholesterol, severe PAD (vascular disease in which narrowing of the blood vessels result in the limbs not receiving oxygen), right heel wound with AKA who presents with left foot wound. Record review of CR #1 Hospital Podiatrist Consult dated 06/18/25 revealed, gangrene over 50% of the left foot, acute signs infection extending from the big toe to the middle of the top of his foot, with minimal pulses in the foot and pain when touching the big left toe. Record review of CR #1's Internal Medical Progress Note dated 06/18/25 revealed, left big toe with dry gangrene with variating tone skin changes extending to the ankle. Record review of CR #1's Hospital Vascular Surgery consult dated 06/19/25 revealed, left 1st toe with dry gangrene with no drainage, redness on the top of the foot and no withdrawing with pain when touched. Record review of CR #1's Hospital Vascular Ultrasound dated 06/20/25 revealed, significant blockage of blood flow to the lower leg and foot. Record review of CR #1's Hospital Podiatrist Consult dated 06/23/25 revealed, CR #1s left food infection had improved. Extensive conversation with multiple family members at bedside, although no urgent findings in the lower extremity, concerns for gas and osteomyelitis are stable within the digit and no systemic signs of infection. Given contralateral amputation, gangrene with vascular disease on clinical exam, patient in need of leg amputation. However, since family refuses amputation, conservative treatment options are unlikely to be successful without improved arterial flow to the foot. Record review of CR #1's Hospital Infectious Disease consult dated 06/24/25 revealed, without an amputation, conservative treatment options are unlikely to be successful especially in the setting of impaired arterial blood flow. Record review of CR #1's Hospital Palliative Care Consult dated 06/24/25 revealed, CR #1's family decided against leg amputation as was recommended as they do not believe that it would improve her quality of life and would likely cause her to suffer. The family discussed alternatives to pursuing leg amputation, and hospice was discussed as a way to provide CR #1 care to keep her comfortable. Record review of email communications between the Social Worker and Medical Records dated 07/09/25 revealed, CR #1 had no documented visits or services with podiatry.An observation of pictures of CR #1's left foot dated 06/13/25 at 03:14 PM revealed, resident's foot was dry and flaky. Toenails on her three lesser toes were long and curled around the tip of her toes; with an appearance that they had not been cut for months. Bruising was observed to the upper foot by the great toe and a thick deep callus with a dark/black hole in the center. Her great toenail was thickened and yellow but attached to the nail bed.An observation of texts and pictures of CR #1's foot dated 06/15/25 taken by LVN D sent to Wound Care Nurse A revealed, [CR #1's] toe kind of look worse and its bleeding. The picture revealed the CR #1's toenail bleeding in the right upper corner and under the nail, with her nail elevated off the nail bed.An observation of pictures of CR #1's left foot dated 06/16/25 at 06:33 PM revealed, the skin on the tip of her left toe to be open. The wound to the tip was shiny and red, with dry blood on the nail bed under the nail. He left great toenail appeared to be lifted off the nail bed with visible dry black blood under.An observation of pictures of CR #1's left foot dated 06/17/25 at 04:24 PM, CR #1's left great toenail was lifted from the nail bed.In an interview on 06/22/25 at 10:45 AM, Family Member #1 said on Friday 06/13/25 the facility notified CR #1's family that the resident had a diabetic foot ulcer but there were no issues. The facility staff said the facility would treat the ulcer and reassured the family that it was basic and normal and at 3 PM the following Friday the podiatrist would visit CR #1. Family Member #1 said on 06/16/25 the facility then notified them that the foot was bleeding so she came to the facility and saw the resident. Family Member #1 said on 06/17/25 when she went to see CR #1 facility staff could not tell them if and when the podiatrist was coming. She said Wound Care Nurse B said CR #1's wound was treated with Bactrim (topical antibiotic) and CR #1 now had a foot ulcer and an injury to the toenails. Family Member #1 said she suspected something happened over the weekend based on how the area deteriorated. They said CR #1's right foot was previously amputated after a similar situation so she was concerned the resident had gangrene and demanded CR #1 be sent to the hospital for treatment. Family Member #1 said CR #1's hospital physicians said the resident had osteomyelitis (bone infection) and must have had it for a while so she required an AKA. They said the family had asked for an oral antibiotic in the facility but their request was denied and the hospital physician said the topical antibiotic used by the facility would not have made CR #1's foot infection better. Family Member #1 said the hospital gave the family 2 options, hospice or an amputation, and since an AKA would worsen CR #1's quality of life so the family decided to place the resident on hospice care. An observation on 06/22/25 at 05:00 PM revealed, CR #1 lying in a hospital bed. The resident had no leg on the right side and her left foot was surrounded with a dressing, the tip of her great toe was exposed and red irritated skin with a circular callused area visible. CR#1 was confused and non-interviewable; she reference people and things that were not in the room. In an interview on 06/22/25 at 05:15 PM, the Hospital Nurse said CR #1 suffered from a diabetic ulcer and an injury at the toenail. She said the nail appeared to be partially detached from the nail bed from suspected trauma but there was no indication of pain.On 06/26/25 at 06:09 PM, Family Member #1 notified the surveyor via text message that CR #1 had been transferred to another facility from the hospital to receive hospice care. In an interview on 07/08/25 at 02:41 PM, the Hospital Podiatrist said CR #1 had significant history of PVD that resulted in her having an AKA on her right leg in 08/2024, and her vascular disease was so significant it caused her severe dementia. He said a resident with history of diabetes, PVD and a previous AKA should have had routine podiatrist visit. The Hospital Podiatrist said in the hospital CR#1 was diagnosed with osteomyelitis (bacterial bone infection) that needed to be treated with IV antibiotics in order to save the limb. He said routine podiatry would have prevented the acute traumatic event (toe infection) but due to her extensive PVD, CR#1 would have eventually needed an amputation in the future. The Hospital Podiatrist said from what he saw CR #1's left great toenail was lifted from the nail bed but there was no active or raging infection visible, the resident's WBCs were normal, and she did not have a fever during her entire stay. He said since an AKA would not better the CR#1's quality of life and the residents significant dementia, CR #1's family decided to place her on palliative (end of life) care. In an interview on 07/09/25 at 10:43 AM, Wound Care Nurse B said when she saw CR #1 on 06/16/25 she had a left great toe arterial ulcer and dried blood on her nailbed. She said Wound Care Nurse A had previously contacted the doctor, so she did the treatment for the day and CR #1's big toe had no active bleeding, but it was purple. Wound Care Nurse B said after treatment she requested a podiatry consult for the resident and CR #1 never had any podiatrist services prior to her request on 06/16/25 and the Social Worker was responsible for ensuring residents received podiatry services. She said she did not know how CR #1 suffered from the injury to her nailbed, but LVN D would be the best person to talk about the initial injury. In an interview on 07/09/25 at 11:04 AM, the Social Worker said she facilitated podiatry services for facility residents. She said anyone with feet could receive podiatry services but often not skilled because of funding, since the services will come from their pool of money, unless the resident had issues with their feet. The Social Worker said some issues that trigger podiatry services were ingrown or thick and long toenails, and if a resident had these issues she would ask their family/RP if they would like podiatry services and if they said yes she would send a referral to the podiatrist She said a resident with diagnoses of vascular disease, diabetes and a previous AKA should have been followed by Podiatry, she said she was notified by nursing staff on 06/16/25 and she put in a podiatrist referral but CR #1 went to the hospital the next day so she was never seen by a podiatrist. The Social Worker said only nurses were allowed to cut the nails of diabetics but after looking at the picture of CR #1's toenails she said facility nurses would not touch that, that would be podiatry and based on the picture CR#1 should have received podiatry care. She said after reviewing CR #1's chart there was no evidence to show the resident received podiatry care from admission till discharge and she had no records of placing a podiatry referral. The Social Worker said she did not remember being notified by a floor nurse or wound care nurse that CR #1 required podiatry services, and she does not know about referrals unless notified by the facility staff or family. In an interview on 07/09/25 at 11:39 AM, Wound Care Nurse A said CR #1 had a diabetic foot ulcer/callused area on her left great toe and she found out about in on the day she assessed it (06/13/25). She said the first day she saw it, the area was dry and callused, and it had been there for a while but there was nothing for her to follow at the time. Wound Care Nurse A said a resident that had a chronic area like what she observed on CR #1 should have been referred to podiatry and she did not recall the ulcer/callus being on CR #1's foot on admission so it was facility acquired. She said nurses do weekly skin assessments while the wound care nurse does the admission and readmission skin assessments, and they should always document what they saw. After reviewing the CR #1's chart Wound Care Nurse A said the first documentation of the left toe area of concern post admission was documented by 01/29/25 signed by LVN T and she should have notified the wound care team because diabetics wound injuries can be progress to a diabetic foot ulcer so they could watch it. She said diabetic foot management was important because diabetics can have prolonged wound healing, which could impact circulation, and a high-risk infection and podiatry should be involved because that was what they specialize in. Wound Care Nurse A said CR #1 should have been followed by podiatry based on her history and how her toes looked. She said based on the pictures of CR #1's toes between 06/13/25 and 06/16/25, the residents toenails appeared that she had not received nail care for a period she cannot say and based on the appearance of her toenails podiatry would have been responsible to cut CR #1's nails. Wound Care Nurse A said she did not know if CR #1 received podiatry services prior to her being alerted in June but she was placed on the list once she became aware. She said a podiatrist was required to cut resident's like CR #1's to prevent infections. Wound Care Nurse A said the facility podiatry protocol started when a floor nurse notified the wound care nurse of a foot concern, after the wound care nurse assess the resident, they notified the social worker who would then put in the referral and notified the physician who would then round on the resident. She said to her knowledge the facility protocol to request a podiatry referral was not followed because she was never notified of CR #1's foot concern. Wound Care Nurse A said podiatry care in residents like CR #1 was important to prevent the long nails that can become imbedded or snag leading to trauma. She said a resident with PVD who had unaddressed foot care could result in infection, gangrene and ultimately infection, Wound Care Nurse A said CR #1 had 2 issues with her big toe, when she first saw her it was suspected trauma to the big toe, there was discoloration to the top of the foot and blood on the edge of the nail but she had no idea how the trauma occurred. She said it looked like CR #1 snagged her left on something. Later on, CR #1 suffered from a diabetic foot ulcer on the tip of her great toe. In an interview on 07/09/25 at 12:20 PM, Wound Care Nurse B who was acting as the Interim DON at the time of the interview said the wound care team was never notified of any concerns to CR #1's feet prior to 06/13/25. She said when a resident had PVD and diabetes there was a concern that any wound could lead to a severe infection and with insufficient oxygen it can lead to necrosis (tissue death), so special focus should be placed on foot care. She said any toenail care provided to residents with extensive PVD, diabetes, or thick fungus nails should be provided by podiatry and CR #1's records showed had no documentation of any toenail care. Wound Care Nurse B said unkempt nails, can lead to scratches & wounds, and if the nail snagged on something it could result in trauma. Wound Care Nurse B said there were 2 different problems on CR #1's great toe, the 1st was a callus that had been there for a while that developed into an ulcer and then there was some kind of trauma but no one in the facility knows how it happened. She said the NP saw CR #1 and said the resident had suffered from trauma to her great toe. She said improper foot care in a resident with extensive PVD, diabetes and AKA could lead to worsening of a wound, improper circulation causing infection, necrosis, osteomyelitis and eventually amputation if not properly treated. In an interview on 07/09/25 at 12:35PM, the MD said CR #1 had extensive vascular disease and had an avulsed toenail (when toenail is partially or completely torn away from the nail bed). He said it looked like the toenail got hit on something and suffered some sort of trauma. The MD said the expectation for a resident like CR #1 who had vascular disease, diabetes and a previous AKA was for their foot or feet to get continuous evaluation by nursing to identify and issues. He said residents with vascular disease and diabetes should be followed by podiatry because they can trim resident nails without damage to reduce the risk of infection. The MD said infection was a concern in residents with PVD because they do not have adequate blood floor to the feet to take care of the infection and if not properly/timely treated could result in damage to the digit (toe), cellulitis (skin infection), sepsis (blood infection) and gangrene. He said his expectation was that nursing staff should have notified the primary doctor and wound care nurse of any foot concerns so that the appropriate treatment would be started. The MD said prior to mid-June he was not aware CR #1 had any chronic foot ulcers/calluses and he did not know she had long toenails or needed podiatry services because she was never on any list for any foot concerns. In an interview on 07/09/25 at 12:59 PM, ADON A said she was the ADON on CR #1's Hall. She said she was never aware of or notified of anything/concerns on CR #1's toes. She said in residents like CR #1 with diabetes, vascular disease, and a previous AKA nursing staff were concerned about feet especially any discoloration, openings or change in tissues because they can lead to ulcers and wounds which were made worse due to the resident having bad circulation. ADON A said infections in residents with PVD can lead to major wounds and ultimately amputation, so nail care was especially important to prevent scratches or other trauma. She said the Podiatrist was responsible for nail care in residents like CR #1 and their services were initiated when a CNA or family notify nursing administration of the residents need for podiatry services. ADON A said she was never notified that CR #1 needed podiatry services, and prior to June she was unaware CR #1 had a scabs, bruising, calluses, or areas of concerns on her toes. She said LVN T never alerted her of any concerns to her toes. ADON A said based on the record she reviewed and the presentation of CR #1 the area of concern documented for the 1st time on LVN T's documented skin assessment on 01/29/25 should have been a CIC and CNAs should have documented on the residents toes which included toenail length or the presence of any injuries/calluses etc. After looking at the pictures of CR #1's left great toe on 06/13/25 & 06/16/25, ADON A said she was never aware of anything like what the pictures showed until after CR #1 discharged from the facility. She said she investigated the trauma CR #1 suffered to her toenail between 06/13/25 and 06/16/25 and none of the nursing staff was aware of how the trauma occurred. ADON A said in the pictures presented it appeared CR #1 had not received nailcare for several months as the nails appeared to be double that of the nailbed with the 2-4th toenails curing around the tip of her toes. She said it was never on their radar that CR #1 had not received podiatry care while at the facility. In an interview on 07/09/25 at 01:22 PM, the NP said she was notified over the weekend (06/13 to 06/15/25) that CR #1 had bruising to her toe and foot, so she ordered and Xray of the foot which came back as negative for any acute findings. She said when she saw CR #1 on 06/16/25 the resident was experiencing pain and, there was an open area with a scab to her great toe. The NP said the wound care nurse already spoke to the wound care doctor and ordered a podiatry consult but no one knew what happened. She said there was bruising on the toes and foot, minor swelling, no drainage or other signs of infection and CR #1's left foot particularly the toe appeared to have suffered trauma. The NP said residents with diabetes, PVD and a previous AKA were expected to have their feet monitored for infection and receive podiatry follow up monthly to prevent infection that could lead to osteomyelitis. She said CR #1 was one of her residents and she did not have any wounds or areas of concern prior to mid-June. The NP said the first time she saw CR #1's feet she had concerns it was a fracture, the resident had a dry wound, but the resident's family was very concerned because this was how CR #1's right side AKA started and wanted her to go to the hospital for treatment. She said she did not think that CR #1 needed to go to the hospital at the time because it looked like bruising from trauma not cellulitis. The NP said she did not know that CR #1 had not received podiatry services from admission but after she saw her, she was referred to podiatry. In an interview on 07/09/25 at 03:33 PM, CNA K said she sometimes provided care to CR #1, and she was not aware of any wounds at the tip of her toes.In an interview on 07/09/25 at 04:23 PM, LVN D said during daily rounds on 06/12/25 it looked like CR In an interview on 07/09/25 at 04:23 PM, LVN D said during daily rounds on 06/12/25 it looked like CR #1 had stubbed her toe, it was light red, so she documented it and notified the wound care nurse. She said CR #1's toe appeared the same the next day but on the following day it looked like it was bleeding, so she texted the NP. LVN D said she worked with CR #1, and she thought the resident had a circular scab on the tip of her toe, but she cannot say if it was the chronic scab she documented on her weekly skin assessments, she said I always just saw it on her toe. LVN D said diabetics were expected to have weekly observations with emphasis on their feet, but she never notified anyone of the chronic scab on CR #1's foot because she thought the facility was already monitoring it, so it was not a change of condition and CR #1's nails were fine they were not long. LVN D said nurses performed toenail care and she could not think of the top of her head which residents required a podiatry referral but from what she could remember CR #1's toenails were normal and did not require a podiatrist. She said long toenails in a diabetic resident with vascular complications could lead to the nail splitting, getting snagged, damage, infection and if untreated it can quickly turn into a complicated situation leading to amputation.In an interview on 07/10/25 at 02:32 PM, Wound Care Nurse B who was the interim DON at the time said neglect was the failure to provide care for the resident. She said prior to admission the MDS Nurse and DON reviews the resident's chart looking at diagnosis, present history, medication list, plan and therapy needed to ensure the facility was able to meet the resident needs. Wound Care Nurse B said failure to provide services was neglect, which could result in deterioration/worsening of health conditions, untreated health conditions, infections, and other conditions. She said based on CR #1's diagnosis she should have had a podiatrist evaluation and been followed by the podiatrist based on her diagnosis of diabete

Based on observation, interviews and record reviews, the facility failed to protect the resident's right to be free from abuse, neglect, and exploitation for 1 of 5 residents (CR #1) reviewed for neglect.-The facility failed to have structures and processes in place to ensure CR #1's wound was identified, and interventions were implemented. CR #1, who had PAD (a specific form of PVD in which there is narrowing of blood vessels taking blood to the extremities, leading to low or no oxygen), diabetes and a previous right-side AKA, did not receive podiatry services and nail care from admission on [DATE] until she discharged to the hospital on [DATE] (9 months). CR #1's had a wound to her left big toe documented in weekly skin assessments from 01/29/25 until 06/17/25, and there were no interventions implemented prior to hospitalization. At the hospital, CR #1 was diagnosed with gangrene and osteomyelitis (bacterial bone infection), with a recommendation for a left side AKA and ultimately placed on hospice services. An Immediate Jeopardy (IJ) was identified on 07/10/2025. The IJ template was provided to the Administrator on 07/10/2025 at 12:44 PM. While the immediacy was removed on 07/14/2025 at 3:18 PM, the facility remained out of compliance at a scope of pattern and severity level of no actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of decline in health, infection, amputation, and death.Findings included:Record review of CR #1's Face Sheet dated 06/22/25 revealed, a 69-year-olf female who admitted to the facility on [DATE] at 12:45 PM with diagnoses which included: Alzheimer's Disease, unspecified dementia with anxiety, hypertension (high blood pressure), acquired absence of right leg above knee (right above the knee amputation) and type 2 diabetes with other circulatory complications. Diagnosis of open wound of left great toe without damage to nail was added on 06/15/25; and unspecified wound, left foot initial encounter was added on 06/16/25. There was no documented diagnosis of PVD.Record review of CR #1's Quarterly MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making, resident was unable to complete a brief interview of mental status, lower extremity functional limitation in range of motion. CR #1 needed substantial/maximal assistance to : roll left and right, move from sitting to lying and lying to sitting on side of bed, was totally depended on to transfer from chair to bed and vice versa, evaluation of her ability to walk 10 ft, toilet transfer, tub/shower transfer or go from sit to stand was not attempted due to her medical condition or safety concerns. Active diagnoses of anemia, hypertension, diabetes, hyperlipidemia(high cholesterol), Alzheimer's Disease, seizure disorder, depression; there were no diagnosis of PVD or any circulatory complications.Record review of CR #1's undated Care Plan revealed, Focus- risk of falls due to immobility, muscle weakness and diabetes; Problem- CR #1 will be free from injury; approach- encourage resident to use environmental devices such as hand grips, handrails etc. Problem start date of 06/13/25- CR #1 has a diabetic ulcer to the left great toe; Goal target date 09/13/25- resident's wound will decrease in size with no complications as evidenced by wound documentation; Approach start date 06/13/25- nurse to complete wound documentation daily, refer to wound care doctor as needed, wound team to evaluate wound(s), treatments and healing status weekly. Problem start date of 06/16/25- CR#1 has trauma to left great toe; Goal target date: 09/16/25- wound will decrease in size as evidenced by wound documentation with no complications and comfort will be maintained; Approach start date: 06/16/25- CNA to inspect skin, especially over bony prominences, during bathing and personal care. Nurse to complete wound observation weekly. There was no mention of podiatry care or services or her vascular disease.Record review of CR #1's Physician's Orders revealed, Start Date 09/18/24; Description- Consult: Podiatry, Ophthalmology, dental as needed .Record review of CR #1's Progress Notes from admission on [DATE] to discharge on [DATE] revealed, There was no documentation that CR #1 received podiatry care while at the facility with the following relevant entries included:-09/17/24 at 12:45 PM signed by LVN L- resident's skin is warm to touch, dry and no fresh injuries. The resident had an old scar from the above knew amputation. The resident requires assistance with feeding and is total care. -09/19/24 at 07:00 PM signed by Wound Nurse A- New admission skin assessment completed. Patient's skin intact and dry. Patient has a right knee amputation, old scar intact and dry, left lower leg has old scares, left great toe has old scab 0/8X0.5X0.1 cm, no exudate, no pain, no odor or s/sx of infection.-06/12/25 at 11:27 PM signed by LVN D: upon assessment, the resident's left great toes appears bruised. No signs or symptoms of pain noted. Foot pulses were felt, no sign of compromised circulation. Foot is warm and dry to touch.-06/13/25 at 02:06 PM signed by Wound Care Nurse A revealed, nurse informed writer that patients left great toe appears to have bruising, writer assessed and observed a diabetic ulcer to left, great toe 08X0.5cm, no exudate, no odor or s/sx of infection, no pain. cleansed with normal saline, patted dry with sterile gauze, applied skin prep and left open to air. Called and spoke with patient's family and discussed the assessment and plan of care.-06/15/25 at 07:05 AM signed by LVN D- during morning rounds, the aired reported that CR #1's big toe appeared to be bleeding and bruised. Upon assessment, observed active bleeding from the toe, with bruising extending up the foot and lower leg. Resident verbalized pain upon palpation of the affected area. NP notified for further evaluation and management.- 06/15/25 at 07:05 AM signed by LVN D- NP ordered STAT Xray to the affected toe and leg06/16/25 at 05:34 PM signed by Wound Care Nurse B, nurse reported CR #1's left great toe has bruises and bleeding. Upon assessment, noted trauma to left toe measuring 1.2X2X0.1 cm with moderate bright red sanguineous exudate (bloody fluid), mild swelling noted, purple discoloration to left great toe extending to foot, no odor, no s/sx of infection. NP made aware, wound cleaned with normal saline, pat dry with sterile gauze, applied Bactroban (antibiotic ointment) and covered wound with gauze, procedure tolerated by patient. Requested for podiatry service to the Social Worker-06/16/25 at 05:46 PM signed by RN A- X-ray of the left foot was completed during this shift in response to an existing wound. Resident tolerated the procedure without any complications. Left foot wound remains covered with dressing intact; no signs of active bleeding, or foul odor noted. Awaiting radiology results at this time.-06/16/25 at 06:25 PM signed by RN A- C-ray results were received and reviewed by NP as negative for fracture. -06/17/25 at 04:31 PM signed by Wound Care Nurse A- CR #1 family stopped by the office to ask questions regarding resident wounds, family was informed that patient has a diabetic ulcer to the left great toe and its being treated with skin prep daily and left open to air, trauma to the left great toe and it's being treated with Bactroban and covered with gauze daily, patient has been added to the podiatry list by the Social Worker and the WCD will be rounding on Thursday and will further assess patient's wounds and family will receive a weekly call with an update. Family expressed concerns of patient getting gangrene due to past experience of getting the right leg amputated and wanted to send patient out to get antibiotics. Family educated on the use of Bactroban ointment and informed and no s/sx of infection observed at this time, but Wound Care Nurse A can only give information on the assessment of wounds and the treatments put into place by the WCD via telehealth.06/17/25 at 06:35 PM signed by RN A, CR #1 noted with a diabetic wound to the left foot. During a family visit today[SP2] , the resident's family expressed concern that the foot might be infected and requested that the resident be transported to the emergency room for further evaluation. Upon assessment, no signs or symptoms of infection were noted. Contacted EMS for non-emergency transportation, resident transported to the hospital for further evaluation.Record review of CR #1's Point of Care History from 09/17/24 to 06/17/25 revealed, no documentation of toenail care to CR #1.Record review of CR #1's Shower Sheets from 09/17/24 to 06/17/25 revealed, the only documented nail care was on 05/29/25 and no clarification was made if it was finger or toenail care. Record review of CR #1's Weekly skin Assessments from admission on [DATE] to discharge on [DATE] revealed, the first documentation of any area of concern on CR #1's toe was made by LVN T on 01/29/25. Varied staff continued to document the area of concern as a scab or chronic scab. There was no notification or interventions noted.01/29/25 signed by LVN T- Skin warm dry and intact, scab to L great toe.02/02/25 signed by LVN T- Scab to left great toe. No new skin issues noted.02/11/25 signed by LVN T- Scab to left great toe. No new skin issues noted.02/18/25 signed by LVN S- no skin issues02/21/25 signed by Wound Care Nurse B- no new skin issue noted, right leg amputated, old scab to left great toe.02/25/25 signed by LVN T- old scab to left great toe. Right AKA with old scar. Skin warm, dry and intact.03/05/25 signed by Wound Care Nurse B- no new skin issue noted03/12/25 signed by LVN T- old scab/scar noted to left great toe.03/19/25 signed by LVN S- old scab to left great toe; skin intact.03/26/25 signed by LVN T- old scab to left great toe; skin warm, dry and intact.04/01/25 signed by LVN G- no new concerns.04/09/25 signed by LVN T- old scab to left great toe.04/15/25 signed by LVN D- no skin alterations.04/23/25 signed by LVN T- old scab L great toe.04/30/25 signed by LVN D- no skin alterations.05/06/25 signed by LVN T- chronic scab to left great toe.05/14/25 signed by LVN D- no skin alterations.05/20/25 signed by LVN T- chronic scab to left great toe.05/28/25 signed by LVN D- no skin alterations.06/01/25 signed by LVN B- no skin alterations.06/04/25 signed by LVN T- chronic scab/dry patch to left great toe.06/11/25 signed by LVN D- no new skin problems noted at this time, skin within limits.06/12/25 signed by LVN D- resident left big toe has bruising on the top of toe. Record review of CR #1's Assessments from 09/17/24 to 06/17/25 revealed, no documented CIC or SBAR regarding CR #1's left great toe.Record review of CR #1's Final X-ray Report dated 06/16/25 at 03:13 PM revealed, negative for acute disease, mild bone weakening and degenerative changes present.Record review of CR #1's Wound Management Detail Report revealed there were no previously documented wounds prior to 06/13/25:06/13/25 at 11:16 PM signed by Wound Care Nurse A: Wound Type: Diabetic Ulcer; Wound location left big toe; 0.8X0.5 cm, with no odor or drainage; depth of injury- through the dermis (skin) and down to the subcutaneous (under the skin) tissue, muscle.06/16/25 at 06:08 PM signed by Wound Care Nurse B: Wound Type: Trauma; Wound Location: Left big toe; to left great toe measuring 1.2x2x0.1cm with moderate bright red sanguineous exudate (bloody fluid), mild swelling noted, purple discoloration to left great toe extending to foot, no odor, no s/sx of infection. Record review of CR #1's NP Progress Note dated 06/16/25. During the weekend nursing report of bruising and pain left first toe unclear how this happened. STAT x-ray ordered, wound care team following applied Bactroban. Physical Exam-Skin: Extremities- right AKA, left first toe swelling and tenderness; Musculoskeletal: :left first toe tenderness swelling and bruising, right AKA. Left first toe open wound minimal drainage/no bleeding. Diagnosis/Assessment and Plan left first toe swelling and report of some bleeding during the weekend, wound care team following, trauma wound left great toe unclear how this happened. Discussed with the wound doctor. xray shows no fracture. Open wound- left great toe trauma wound nailbed, wound care team following continue care treatments monitored closely. Left great toe pain likely due to trauma wound, ordered Acetaminophen 650 mg twice daily for 7 days and monitor.Record review of CR #1's Physician Order dated 06/17/25 revealed, daily wound treatment: diabetic ulcer left big toe. Cleanse with ns, pat dry with sterile gauze apply skin prep and leave open to air daily.Record review of CR #1's Assessments from 09/17/24 to 06/17/25 revealed, no documented CIC or SBARs regarding the area of concern identified by LVN T on the weekly skin assessment dated [DATE].Record review of CR #1 Hospital Records dated 06/17/25 revealed, CR #1 had a right foot diabetic foot ulcer in 07/2024 and then an above the knee amputation. She presented with left first toe ulceration and discharge and her final admitted diagnoses were toe infection and gangrene (death of body tissue due to lack of blood infection or a serious infection) of the toe. Record review of CR #1's Hospital Hospitalist Consult dated 06/18/25 revealed, CR #1 had a PMH of significant dementia, diabetes, hypertension, high cholesterol, severe PAD (vascular disease in which narrowing of the blood vessels result in the limbs not receiving oxygen), right heel wound with AKA who presents with left foot wound.Record review of CR #1 Hospital Podiatrist Consult dated 06/18/25 revealed, gangrene over 50% of the left foot, acute signs infection extending from the big toe to the middle of the top of his foot, with minimal pulses in the foot and pain when touching the big left toe.Record review of CR #1's Internal Medical Progress Note dated 06/18/25 revealed, left big toe with dry gangrene with variating tone skin changes extending to the ankle. Record review of CR #1's Hospital Vascular Surgery consult dated 06/19/25 revealed, left 1st toe with dry gangrene with no drainage, redness on the top of the foot and no withdrawing with pain when touched.Record review of CR #1's Hospital Vascular Ultrasound dated 06/20/25 revealed, significant blockage of blood flow to the lower leg and foot.Record review of CR #1's Hospital Podiatrist Consult dated 06/23/25 revealed, CR #1s left food infection had improved. Extensive conversation with multiple family members at bedside, although no urgent findings in the lower extremity, concerns for gas and osteomyelitis are stable within the digit and no systemic signs of infection. Given contralateral amputation, gangrene with vascular disease on clinical exam, patient in need of leg amputation. However, since family refuses amputation, conservative treatment options are unlikely to be successful without improved arterial flow to the foot.Record review of CR #1's Hospital Infectious Disease consult dated 06/24/25 revealed, without an amputation, conservative treatment options are unlikely to be successful especially in the setting of impaired arterial blood flow.Record review of CR #1's Hospital Palliative Care Consult dated 06/24/25 revealed, CR #1's family decided against leg amputation as was recommended as they do not believe that it would improve her quality of life and would likely cause her to suffer. The family discussed alternatives to pursuing leg amputation, and hospice was discussed as a way to provide CR #1 care to keep her comfortable.Record review of email communications between the Social Worker and Medical Records dated 07/09/25 revealed, CR #1 had no documented visits or services with podiatry.An observation of pictures of CR #1's left foot dated 06/13/25 at 03:14 PM revealed, resident's foot was dry and flaky. Toenails on her three lesser toes were long and curled around the tip of her toes; with an appearance that they had not been cut for months. Bruising was observed to the upper foot by the great toe and a thick deep callus with a dark/black hole in the center. Her great toenail was thickened and yellow but attached to the nail bed.An observation of pictures of CR #1's left foot dated 06/16/25 at 06:33 PM revealed, the skin on the tip of her left toe to be open. The wound to the tip was shiny and red, with dry blood on the nail bed under the nail. Her left great toenail appeared to be lifted off the nail bed with visible dry black blood under.An observation on 06/22/25 at 05:00 PM revealed, CR #1 lying in a hospital bed. The resident had no leg on the right side and her left foot was surrounded with a dressing, the tip of her great toe was exposed and red irritated skin with a circular callused area visible. CR#1 was confused and non-interviewable; she reference people and things that were not in the room.In an interview on 07/08/25 at 02:41 PM, the Hospital Podiatrist said CR #1 had significant history of PVD that resulted in her having an AKA on her right leg in 08/2024, and her vascular disease was so significant it caused her severe dementia. He said a resident with history of diabetes, PVD and a previous AKA should have had routine podiatrist visit. The Hospital Podiatrist said in the hospital CR#1 was diagnosed with osteomyelitis (bacterial bone infection) that needed to be treated with IV antibiotics in order to save the limb. He said routine podiatry would have prevented the acute traumatic event (toe infection) but due to her extensive PVD, CR#1 would have eventually needed an amputation in the future. The Hospital Podiatrist said from what he saw CR #1's left great toenail was lifted from the nail bed but there was no active or raging infection visible, the resident's WBCs were normal, and she did not have a fever during her entire stay. He said since an AKA would not better the CR#1's quality of life and the residents significant dementia, CR #1's family decided to place her on palliative (end of life) care. In an interview on 07/09/25 at 10:43 AM, Wound Care Nurse B said when she saw CR #1 on 06/16/25 she had a left great toe arterial ulcer and dried blood on her nailbed. She said Wound Care Nurse A had previously contacted the doctor, so she did the treatment for the day and CR #1's big toe had no active bleeding, but it was purple. Wound Care Nurse B said after treatment she requested a podiatry consult for the resident and CR #1 never had any podiatrist services prior to her request on 06/16/25 and the Social Worker was responsible for ensuring residents received podiatry services. She said she did not know how CR #1 suffered from the injury to her nailbed, but LVN D would be the best person to talk about the initial injury. In an interview on 07/09/25 at 11:04 AM, the Social Worker said she facilitated podiatry services for facility residents. She said anyone with feet could receive podiatry services but often not skilled because of funding, since the services will come from their pool of money, unless the resident had issues with their feet. The Social Worker said some issues that trigger podiatry services were ingrown or thick and long toenails, and if a resident had these issues she would ask their family/RP if they would like podiatry services and if they said yes she would send a referral to the podiatrist. She said a resident with diagnoses of vascular disease, diabetes and a previous AKA should have been followed by Podiatry, she said she was notified by nursing staff on 06/16/25 and she put in a podiatrist referral but CR #1 went to the hospital the next day so she was never seen by a podiatrist. The Social Worker said only nurses were allowed to cut the nails of diabetics [SP5] but after looking at the picture of CR #1's toenails she said facility nurses would not touch that, that would be podiatry and based on the picture CR#1 should have received podiatry care. She said after reviewing CR #1's chart there was no evidence to show the resident received podiatry care from admission till discharge and she had no records of placing a podiatry referral. The Social Worker said she did not remember being notified by a floor nurse or wound care nurse that CR #1 required podiatry services, and she does not know about referrals unless notified by the facility staff or family. In an interview on 07/09/25 at 11:39 AM, Wound Care Nurse A said CR #1 had a diabetic foot ulcer/callused area on her left great toe and she found out about in on the day she assessed it (06/13/25). She said the first day she saw it, the area was dry and callused, and it had been there for a while but there was nothing for her to follow at the time. Wound Care Nurse A said a resident that had a chronic area like what she observed on CR #1 should have been referred to podiatry and she did not recall the ulcer/callus being on CR #1's foot on admission so it was facility acquired. She said nurses do weekly skin assessments while the wound care nurse does the admission and readmission skin assessments, and they should always document what they saw. After reviewing the CR #1's chart Wound Care Nurse A said the first documentation of the left toe area of concern post admission was documented by 01/29/25 signed by LVN T and she should have notified the wound care team because diabetics wound injuries can be progress to a diabetic foot ulcer so they could watch it. She said diabetic foot management was important because diabetics can have prolonged wound healing, which could impact circulation, and a high-risk infection and podiatry should be involved because that was what they specialize in. Wound Care Nurse A said CR #1 should have been followed by podiatry based on her history and how her toes looked. She said based on the pictures of CR #1's toes between 06/13/25 and 06/16/25, the residents toenails appeared that she had not received nail care for a period she cannot say and based on the appearance of her toenails podiatry would have been responsible to cut CR #1's nails. Wound Care Nurse A said she did not know if CR #1 received podiatry services prior to her being alerted in June but she was placed on the list once she became aware. She said a podiatrist was required to cut resident's like CR #1's to prevent infections. Wound Care Nurse A said the facility podiatry protocol started when a floor nurse notified the wound care nurse of a foot concern, after the wound care nurse assess the resident, they notified the social worker who would then put in the referral and notified the physician who would then round on the resident. She said to her knowledge the facility protocol to request a podiatry referral was not followed because she was never notified of CR #1's foot concern. Wound Care Nurse A said podiatry care in residents like CR #1 was important to prevent the long nails that can become imbedded or snag leading to trauma. She said a resident with PVD who had unaddressed foot care could result in infection, gangrene and ultimately infection, Wound Care Nurse A said CR #1 had 2 issues with her big toe, when she first saw her it was suspected trauma to the big toe, there was discoloration to the top of the foot and blood on the edge of the nail but she had no idea how the trauma occurred. She said it looked like CR #1 snagged her left on something. Later on, CR #1 suffered from a diabetic foot ulcer on the tip of her great toe.In an interview on 07/09/25 at 12:20 PM, Wound Care Nurse B who was acting as the Interim DON at the time of the interview said the wound care team was never notified of any concerns to CR #1's feet prior to 06/13/25. She said when a resident had PVD and diabetes there was a concern that any wound could lead to a severe infection and with insufficient oxygen it can lead to necrosis (tissue death), so special focus should be placed on foot care. She said any toenail care provided to residents with extensive PVD, diabetes, or thick fungus nails should be provided by podiatry and CR #1's records showed had no documentation of any toenail care. Wound Care Nurse B said unkempt nails, can lead to scratches & wounds, and if the nail snagged on something it could result in trauma. Wound Care Nurse B said there were 2 different problems on CR #1's great toe, the 1st was a callus that had been there for a while that developed into an ulcer and then there was some kind of trauma but no one in the facility knows how it happened. She said the NP saw CR #1 and said the resident had suffered from trauma to her great toe. She said improper foot care in a resident with extensive PVD, diabetes and AKA could lead to worsening of a wound, improper circulation causing infection, necrosis, osteomyelitis and eventually amputation if not properly treated.In an interview on 07/09/25 at 12:35PM, the MD said CR #1 had extensive vascular disease and had an avulsed toenail (when toenail is partially or completely torn away from the nail bed). He said it looked like the toenail got hit on something and suffered some sort of trauma. The MD said the expectation for a resident like CR #1 who had vascular disease, diabetes and a previous AKA was for their foot or feet to get continuous evaluation by nursing to identify any issues. He said residents with vascular disease and diabetes should be followed by podiatry because they can trim resident nails without damage to reduce the risk of infection. The MD said infection was a concern in residents with PVD because they do not have adequate blood floor to the feet to take care of the infection and if not properly/timely treated could result in damage to the digit (toe), cellulitis (skin infection), sepsis (blood infection) and gangrene. He said his expectation was that nursing staff should have notified the primary doctor and wound care nurse of any foot concerns so that the appropriate treatment would be started. The MD said prior to mid-June he was not aware CR #1 had any chronic foot ulcers/calluses and he did not know she had long toenails or needed podiatry services because she was never on any list for any foot concerns. In an interview on 07/10/25 at 02:32 PM, Wound Care Nurse B who was the interim DON at the time said neglect was the failure to provide care for the resident. She said prior to admission the MDS Nurse and DON reviews the resident's chart looking at diagnosis, present history, medication list, plan and therapy needed to ensure the facility was able to meet the resident needs. Wound Care Nurse B said failure to provide services was neglect, which could result in deterioration/worsening of health conditions, untreated health conditions, infections, and other conditions. She said based on CR #1's diagnosis of diabetes and previous AKA she should have had a podiatrist evaluation and been followed by the podiatrist. In an interview on 07/09/25 at 12:59 PM, ADON A said she was the ADON on CR #1's Hall. She said she was never aware of or notified of anything/concerns on CR #1's toes. She said in residents like CR #1 with diabetes, vascular disease, and a previous AKA nursing staff were concerned about feet especially any discoloration, openings or change in tissues because they can lead to ulcers and wounds which were made worse due to the resident having bad circulation. ADON A said infections in residents with PVD can lead to major wounds and ultimately amputation, so nail care was especially important to prevent scratches or other trauma. She said the Podiatrist was responsible for nail care in residents like CR #1 and their services were initiated when a CNA or family notify nursing administration of the residents need for podiatry services. ADON A said she was never notified that CR #1 needed podiatry services, and prior to June she was unaware CR #1 had a scabs, bruising, calluses, or areas of concerns on her toes. She said LVN T never alerted her of any concerns to her toes. ADON A said based on the record she reviewed and the presentation of CR #1 the area of concern documented for the 1st time on LVN T's documented skin assessment on 01/29/25 should have been a CIC and CNAs should have documented on the residents toes which included toenail length or the presence of any injuries/calluses etc. After looking at the pictures of CR #1's left great toe on 06/13/25 & 06/16/25, ADON A said she was never aware of anything like what the pictures showed until after CR #1 discharged from the facility. She said she investigated the trauma CR #1 suffered to her toenail between 06/13/25 and 06/16/25 and none of the nursing staff was aware of how the trauma occurred. ADON A said in the pictures presented it appeared CR #1 had not received nailcare for several months as the nails appeared to be double that of the nailbed with the 2-4th toenails curing around the tip of her toes. She said it was never on their radar that CR #1 had not received podiatry care while at the facility. In an interview on 07/09/25 at 01:22 PM, the NP said she was notified over the weekend (06/13 to 06/15/25) that CR #1 had bruising to her toe and foot, so she ordered and Xray of the foot which came back as negative for any acute findings. She said when she saw CR #1 on 06/16/25 the resident was experiencing pain and, there was an open area with a scab to her great toe. The NP said the wound care nurse already spoke to the wound care doctor and ordered a podiatry consult but no one knew what happened. She said there was bruising on the toes and foot, minor swelling, no drainage or other signs of infection and CR #1's left foot particularly the toe appeared to have suffered trauma. The NP said residents with diabetes, PVD and a previous AKA were expected to have their feet monitored for infection and receive podiatry follow up monthly to prevent infection that could lead to osteomyelitis. She said CR #1 was one of her residents and she did not have any wounds or areas of concern prior to mid-June. The NP said the first time she saw CR #1's feet she had concerns it was a fracture, the resident had a dry wound, but the resident's family was very concerned because this was how CR #1's right side AKA started and wanted her to go to the hospital for treatment. She said she did not think that CR #1 needed to go to the hospital at the time because it looked like bruising from trauma not cellulitis. The NP said she did not know that CR #1 had not received podiatry services from admission but after she saw her, she was referred to podiatry. In an interview on 07/09/25 at 03:33 PM, CNA K said she sometimes provided care to CR #1, and she was not aware of any wounds at the tip of her toes. She said she never assisted with showers because the resident was on afternoon showers but when showering residents staff were expected to look for anything new from head to toe. CNA K said staff may not specifically look at the tip of the toe. In an interview on 07/09/25 at 04:23 PM, LVN D said during daily rounds on 06/12/25 it looked like CR #1 had stubbed her toe, it was light red, so she documented it and notified the wound care nurse. She said CR #1's toe appeared the same the next day but on the following day it looked like it was bleeding, so she texted the NP. LVN D said she worked with CR #1, and she thought the resident had a circular scab on the tip of her toe, but she cannot say if it was the chronic scab she documented on her weekly skin assessments, she said I always just saw it on her toe. LVN D said diabetics were expected to have weekly observations with emphasis on their feet, but she never notified anyone of the chronic scab on CR #1's foot because she thought the facility was already monitoring it, so it was not a change of condition and CR #1's nails were fine they were not long. LVN D said nurses performed toenail care and she could not think of the top of her head which residents required a podiatry referral but from what she could remember CR #1's toenails were normal and did not require a podiatrist. She said long toenails in a diabetic resident with vascular complications could lead to the nail splitting, getting snagged, damage, infection and if untreated it can quickly turn into a complicated situation leading to amputation.In an interview on 07/11/25 at 09:19 AM, the Former DON, said she served as the [NAME] from 04/07/25 to 06/27/25 so she was not the DON when CR #1 admitted to the facility. She said she only has general knowledge about CR #1 because as the DON she

Based on observation, interview, and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a residents' mental, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 Residents (CR #1 ) reviewed for care plans. - The facility failed to develop and implement a plan of care for CR #1's PAD ( a specific form of PVD in which there is narrowing of blood vessels taking blood to the extremities, leading to low or no oxygen), which resulted in CR #1 not receiving podiatry care from admission on [DATE] till she discharged to the hospital on [DATE] (9 months) where she was diagnosed with a osteomyelitis (bacterial bone infection), with a recommendation for a left side AKA and ultimately placed on hospice services. An Immediate Jeopardy (IJ) was identified on 07/09/2025. The IJ template was provided to the Administrator on 07/09/2025 at 04:57 PM. While the immediacy was removed on 07/14/2025 at 3:18 PM, the facility remained out of compliance at a scope of pattern and severity level of no actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not having their needs met, injuries, infections, unwanted hospitalization, amputation leading to a decrease in quality of life and death. Findings include: Record review of CR #1's Face Sheet dated 06/22/25 revealed, a 69-year-olf female who admitted to the facility on [DATE] at 12:45 PM with diagnosis which included: Alzheimer's Disease, unspecified dementia with anxiety, hypertension (high blood pressure), acquired absence of right leg above knee (right above the knee amputation) and type 2 diabetes with other circulatory complications. Diagnosis of open wood of left great toe without damage to nail was added on 06/15/25; and unspecified wound, left foot initial encounter was added on 06/16/25. There was no documented diagnosis of PVD. Record review of CR #1's Quarterly MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making, resident was unable to complete a brief interview of mental status, lower extremity functional limitation in range of motion. CR #1 needed substantial/maximal assistance to : roll left and right, move from sitting to lying and lying to sitting on side of bed, was totally depended on to transfer from chair to bed and vice versa, evaluation of her ability to walk 10 ft, toilet transfer, tub/shower transfer or go from sit to stand was not attempted due to her medical condition or safety concerns. Active diagnoses of anemia, hypertension, diabetes, hyperlipidemia(high cholesterol), Alzheimer's Disease, seizure disorder, depression; there were no diagnosis of PVD or any circulatory complications. Record review of CR #1's undated Care Plan revealed, Focus- risk of falls due to immobility, muscle weakness and diabetes; Problem- CR #1 will be free from injury; approach- encourage resident to use environmental devices such as hand grips, handrails etc. Problem start date of 06/13/25- CR #1 has a diabetic ulcer to the left great toe; Goal target date 09/13/25- resident's wound will decrease in size with no complications as evidenced by wound documentation; Approach start date 06/13/25- nurse to complete wound documentation daily, refer to wound care doctor as needed, wound team to evaluate wound(s), treatments and healing status weekly. Problem start date of 06/16/25- CR#1 has trauma to left great toe; Goal target date: 09/16/25- wound will decrease in size as evidenced by wound documentation with no complications and comfort will be maintained; Approach start date: 06/16/25- CNA to inspect skin, especially over bony prominences, during bathing and personal care. Nurse to complete wound observation weekly. There was no mention of podiatry care or services, her circulatory complications or vascular disease.Record review of CR #1's Progress Notes from admission on [DATE] to discharge on [DATE] revealed, There was no documentation that CR #1 received podiatry care while at the facility with the following relevant entries.Record review of CR #1's Point of Care History from 09/17/24 to 06/17/25 revealed, no documentation of toenail care to CR #1.Record review of CR #1's Wound Management Detail Report dated 06/22/25 revealed there were no previously documented wounds prior to 06/13/25:06/13/25 at 11:16 PM signed by Wound Care Nurse A: Wound Type: Diabetic Ulcer; Wound location left big toe; 0.8X0.5 cm, with no odor or drainage; depth of injury- through the dermis (skin) and down to the subcutaneous (under the skin) tissue, muscle.06/16/25 at 06:08 PM signed by Wound Care Nurse B: Wound Type: Trauma; Wound Location: Left big toe; to left great toe measuring 1.2x2x0.1cm with moderate bright red sanguineous exudate (bloody fluid), mild swelling noted, purple discoloration to left great toe extending to foot, no odor, no s/sx of infection. Record review of CR #1 Hospital Records dated 06/17/25 revealed, CR #1 had a right foot diabetic foot ulcer in 07/2024 and then an above the knee amputation. She presented with left first toe ulceration and discharge and her final admitted diagnoses were toe infection and gangrene (death of body tissue due to lack of blood infection or a serious infection) of the toe. Record review of CR #1's Hospital Hospitalist Consult dated 06/18/25 revealed, CR #1 had a PMH of significant dementia, diabetes, hypertension, high cholesterol, severe PAD (vascular disease in which narrowing of the blood vessels result in the limbs not receiving oxygen), right heel wound with AKA who presents with left foot wound.Record review of CR #1 Hospital Podiatrist Consult dated 06/18/25 revealed, gangrene over 50% of the left foot, acute signs infection extending from the big toe to the middle of the top of his foot, with minimal pulses in the foot and pain when touching the big left toe.Record review of CR #1's Internal Medical Progress Note dated 06/18/25 revealed, left big toe with dry gangrene with variating tone skin changes extending to the ankle. Record review of CR #1's Hospital Vascular Surgery consult dated 06/19/25 revealed, left 1st toe with dry gangrene with no drainage, redness on the top of the foot and no withdrawing with pain when touched.Record review of CR #1's Hospital Vascular Ultrasound dated 06/20/25 revealed, significant blockage of blood flow to the lower leg and foot.Record review of CR #1's Hospital Podiatrist Consult dated 06/23/25 revealed, CR #1s left food infection had improved. Extensive conversation with multiple family members at bedside, although no urgent findings in the lower extremity, concerns for gas and osteomyelitis are stable within the digit and no systemic signs of infection. Given contralateral amputation, gangrene with vascular disease on clinical exam, patient in need of leg amputation. However, since family refuses amputation, conservative treatment options are unlikely to be successful without improved arterial flow to the foot.Record review of CR #1's Hospital Infectious Disease consult dated 06/24/25 revealed, without an amputation, conservative treatment options are unlikely to be successful especially in the setting of impaired arterial blood flow.Record review of CR #1's Hospital Palliative Care Consult dated 06/24/25 revealed, CR #1's family decided against leg amputation as was recommended as they do not believe that it would improve her quality of life and would likely cause her to suffer. The family discussed alternatives to pursuing leg amputation, and hospice was discussed as a way to provide CR #1 care to keep her comfortable.Record review of email communications between the Social Worker and Medical Records dated 07/09/25 revealed, CR #1 had no documented visits or services with podiatry.An observation of pictures of CR #1's left foot dated 06/13/25 at 03:14 PM revealed, resident's foot was dry and flaky. Toenails on her three lesser toes where long and curled around the tip of her toes; with an appearance that they had not been cut for months. Bruising was observed to the upper foot by the great toe and a thick deep callus with a dark/black hole in the center. Her great toenail was thickened and yellow but attached to the nail bed.An observation of pictures of CR #1's left foot dated 06/16/25 at 06:33 PM revealed, the skin on the tip of her left toe to be open. The wound to the tip was shiny and red, with dry blood on the nail bed under the nail. He left great toenail appeared to be lifted off the nail bed with visible dry black blood under.An observation on 06/22/25 at 05:00 PM revealed, CR #1 lying in a hospital bed. The resident had no leg on the right side and her left foot was surrounded with a dressing, the tip of her great toe was exposed and red irritated skin with a circular callused area visible. CR#1 was confused and non-interviewable; she reference people and things that were not in the room.In an interview on 07/08/24 at 02:41 PM, the Hospital Podiatrist said CR #1 had significant history of PVD that resulted in her having an AKA on her right leg in 08/2024, and her vascular disease was so significant it caused her severe dementia. He said a resident with history of diabetes, PVD and a previous AKA should have had routine podiatrist visit. The Hospital Podiatrist said in the hospital CR#1 was diagnosed with osteomyelitis (bacterial bone infection) that needed to be treated with IV antibiotics in order to save the limb. He said routine podiatry would have prevented the acute traumatic event (toe infection) but due to her extensive PVD, CR#1 would have eventually needed an amputation in the future. The Hospital Podiatrist said from what he saw CR #1's left great toenail was lifted from the nail bed but there was no active or raging infection visible, the resident's WBCs were normal, and she did not have a fever during her entire stay. He said since an AKA would not better the CR#1's quality of life and the residents significant dementia, CR #1's family decided to place her on palliative (end of life) care.In an interview on 07/09/25 at 11:04 AM, the Social Worker said a resident with diagnoses of vascular disease, diabetes and a previous AKA should have been followed by Podiatry, The Social Worker said only nurses were allowed to cut the nails of diabetes but after looking at the picture of CR #1's toenails she said facility nurses would not touch that, that would be podiatry and based on the picture CR#1 should have received podiatry care. She said after reviewing CR #1's chart there was no evidence to show the resident received podiatry care from admission till discharge and she had no records of placing a podiatry referral. The Social Worker said she did not remember being notified by a floor nurse or wound care nurse that CR #1 required podiatry services, and she does not know about referrals unless notified by the facility staff or family.In an interview on 07/09/25 at 12:35PM, the MD said prior to mid-June he was not aware CR #1 had any chronic foot ulcers/calluses and he did not know she long toenails or needed podiatry services because she was never on any list of any foot concerns.In an interview on 07/14/25 at 01:36 PM, the MDS coordinator said she was responsible for completing MDS assessments and care plans for long term care residents including CR #1, She said the MDS paints the entire picture of the resident including the level of care needed, level of ADLs, everything the facility is doing for the resident and it is a 7-day look back. The MDS nurse said the MDS functions to make sure appropriate level of care is given to a resident and it triggers CAAS which are care areas that are used to develop the residents plan of care. She said when a resident admits the MDS nurse enters the residents admitting diagnosis which can be retrieved from the hospital documents or provided by the facility doctor. The MDS Nurse said if there was an MDS discrepancy it would not trigger a care area that the resident might need services for, and the area may not make it to the resident's plan of care. She said the care plan painted a picture of the resident and functioned as their plan of care and addressed their diagnosis, medications, diet, wounds, etc. She said failure to not having a plan of care for a resident's diagnosis could place them at risk of not getting appropriate care, resulting in an untreated disease, or worsening health condition. After reviewing CR #1's records, the facility's diagnosis of diabetes with vascular complications should have been documented as PVD in the resident's MDS. She said PVD is when a resident did not get sufficient blood flow which brings oxygen to their peripheral (limbs) which leads to loss of feeling, loss of blood and ultimately a loss of a limb. The MDS nurse said when the resident admitted to the facility, nursing staff should have gotten clarification for what CR #1's circulatory complication was in order for her to receive adequate care she needed. She said after reviewing CR #1's chart, the resident did not have a plan of care for her circulatory condition, and the typical plan of care for PVD included podiatry services. The MDS nurse said the resident's circulatory complications did not make it into the residents plan of care because the CAAs were not triggered by the MDS.In an interview on 07/21/25 at 01:45 PM, Wound Care Nurse B said the facility failed to get clarification on what the diagnosis of the resident's circulatory complication was which then impacted her MDS, the plan of Care and ultimately resulted in the failure to provide podiatrist services.In an interview on 07/21/25 at 03:05 PM, the MDS Nurse said the facility's failure to provide CR #1' podiatry services started from the failure to get the correct diagnosis of PVD from the doctor and that trickled down.Record review of the facility policy Person-Centered Care Plan revised 10/1/2020 revealed, 3. The person-centered care plan is interdisciplinary and created to guide facility staff in providing the treatment, care, and services necessary for the patient/resident to obtain and maintain the highest physical, mental, and psychosocial well-being possible. The plan is also used to promote patient/resident and family involvement in planning care.Record review of the facility policy Care Plan Process, Person-Centered Care revised 05/05/25 revealed, The facility will develop and implement a baseline and comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. PROCEDURES: 1. Following RAI Guidelines develop and implement a comprehensive person- centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.Record review of the facility policy Foot Care revised 05/05/23 revealed, Policy: the facility ensures foot care is provided in a manner that is consistent with professional standards of practice. Foot care includes treatment to prevent complications form conditions such as diabetes, peripheral vascular disease, or immobility. Procedures: 1- Upon admission a resident will be assessed for any diagnosis or condition that poses a risk to foot health (diabetes, peripheral vascular disease, ingrown toenails, hammer toes, etc.). 2- Residents with a diagnosis or condition that places them at risk will be scheduled for routine foot care by the podiatrist. 3- Social services will validate the residents payer source coverage for podiatric visits and will discuss any payment issues with resident/legal representative prior to podiatric visit. 4- Social services will assist the resident in transportation to the podiatrist's office if the podiatrist does not see residents within the facility. 5- Nail trimming will be completed by the nursing assistant as necessary unless the following conditions are present; which require the skill of a licensed staff member. A- a resident has an at-risk diagnosis and has refused podiatric care. 6- The resident's care plan will reflect the need for podiatric services and any services that are provided by licensed nursing staff. An IJ was Identified on 07/09/2025. The Administrator was notified of the IJ, and the template was provided to the facility on [DATE] at 04:57 PM. The following Plan of Removal submitted by the facility was accepted on 07/11/2025 at 12:10 PM.PORThe facility failed to provide diabetic foot care which included podiatry services to CR#1. The facility failed to take action when an area of concern was first documented on 1/29/25 and 6/13/25 when it was the area became red, swollen with drainage.Resident #1 was discharged to the hospital on 6/17/25Residents in house will be assessed for any diagnosis or condition that poses a risk to foot health by the Director of Nursing/Designee by 7/10/25. 60 residents were identified with diagnosis or conditions that pose a threat to foot health. Eleven Residents not currently followed by podiatry were referred to podiatry services on 7/10/25Skin assessments will be conducted on residents inhouse on 7/10/25 by Nursing Leadership to identify skin integrity concerns on the feet. Findings will be communicated to the Director of Nursing/Designee. The Director of Nursing/designee will validate change of condition completed, provider and responsible party notified and interventions implemented on 7/10/25.Residents identified will be referred to podiatry by 7/10/25 by the Social Services Director.Podiatry services plan to visit facility to begin visits 7/14/25. Eleven residents were identified as needing a podiatry visit, a virtual visit was conducted on 7/10/25 with the medical director. No urgent needs were identified by the medical director during the visit and no new orders were given.Director of Nursing/designee will review by skin assessments from the last 7 days on 7/10/25 to validate provider notified, responsible party notified and interventions implemented. No new issues were identified.Residents identified will have provider notified for further direction and responsible party notified by 7/10/25 by the Director of Nursing/DesigneeResidents identified will have care plan's updated to validate appropriate interventions by the Director of Nursing/Designee by 7/10/25.Director of Nursing, Assistant Director of Nursing, and Social Services Director were reeducated by the Clinical Consultant by 7/10/25 on admission skin assessment including: identifying any diagnosis or condition that poses a risk to foot health (e.g., peripheral vascular disease, ingrown toenails, diabetes, hammer toes, etc.) when diagnosis or conditions posing a risk to foot health are identified, physician will be notified for treatment orders and social services will be notified for podiatry referral updating the care plan to reflect the current/new approaches during clinical morning meeting, concerns identified on a stop and watch form will be validating that concerns were addressed with physician and orders obtained and implemented.Licensed nurses will be re-educated by the Director of Nursing/Designee by 7/10/25 on the admission skin assessment including: identifying any diagnosis or condition that poses a risk to foot health (e.g., peripheral vascular disease, ingrown toenails, diabetes, hammer toes, etc.) when diagnosis or conditions posing a risk to foot health are identified, physician will be notified for treatment orders and social services will be notified for podiatry referral updating the care plan to reflect the current/new approaches Certified Nursing Assistants will complete skin checks during care to identify any skin integrity concerns. Any skin integrity concern is reported to the charge nurse upon discovery through use of stop and watch form. The licensed nurse will act upon the information communicated by evaluating the area of concern and notifying the physician for a treatmentLicensed Nurses will be re-educated by the Director of Nursing/Designee by 7/10/25 on change of condition including: Identifying, assessing and reporting acute change in condition, including abnormal vital signs, pain, changes in skin integrity and notifying the provider for further directionCertified Nursing Assistants will be reeducated by the Director of Nursing/Designee by 7/10/25 on: identifying and reporting changes in residents skin integrity to the licensed nurse upon discovery, skin integrity concerns identified will documented on a stop and watch form by the certified nursing assistant are given to the licensed nurse. The carbon copy will be placed in the Director of Nursing/Designee's box for reviewThis reeducation will be completed by 7/10/25. Target staff who have not received the re-education by this date will receive prior to their next scheduled shift and will be presented in New Hire and Agency Orientation.The Director of Nursing /Designee will review admission and weekly skin assessments Monday - Friday in clinical morning meeting beginning 7/11/25 to validate at risk residents with a diagnosis or condition that poses a risk to foot health (e.g., peripheral vascular disease, ingrown toenails, diabetes, hammer toes, etc.) have been identified with notifications to physician for treatment orders and social services for podiatry referral.The Director of Nursing/Designee will review residents identified at risk or with diagnosis or conditions that pose a risk to foot health in clinical morning meeting Monday - Friday to validate appropriate assessments are completed, care plans are updated with appropriate interventions, provider notified for treatment orders and responsible party notificationsDirector of Nursing or Designee will review the Facility Activity report and 24-hour report to identify any documentation regarding a change of condition and validate that the resident hasbeen assessed appropriately and provider notified. This will be completed Monday through Friday in the Clinical Morning meeting and by the weekend supervisor on the weekendsThe Director of Nursing/Designee will validate in clinical morning meeting any skin integrity concerns identified on a stop and watch form are addressed with physician and orders obtained and implemented.The Director of Nursing/Designee will validate following a podiatrist visit to the facility that residents with a podiatry referral were assessed by the podiatrist during their visit.Ad Hoc QAPI will be held on 7/9/25.The Medical Director was notified of the Immediate Jeopardy on 7/9/25 and updated of contents of this plan. Monitoring of the POR In an interview on 07/13/25 at 10:05 AM, day shift staff MA J said the facility abuse coordinator was the Administrator and she received an inservice on ANE, change of conditions, skin assessments, and care plans in the last 2 days. She said neglect was failure to provide services and she had not observed any in the building. MA J said when a CNA is providing showers, they were expected to observe the resident from head to tip of their toes and notify the nurse if there was anything out of the norm, document it on the shower sheet, the POC and complete a stop and watch form located at the nursing station. In an interview on 07/13/25 at 10:09 AM, day shift staff RN I said the facility administrator was the abuse coordinator, and she received training on ANE, change in condition, foot care, and care plans within the last week. She said neglect was failure to provide services and she had not observed any in the building. She said residents were to receive weekly skin assessments that assess the resident from head to toe for anything outside of normal limits. She said if something was identified the nurse must document it as a CIC, SBAR notify the MD and wound care team. She said diagnosis of diabetes, neuropathy and vascular disease placed residents at risk of foot issues, so residents with qualifying diagnosis should receive podiatry care and if they did not have an order staff should call the doctor to receive one. She said when a resident has a CIC nursing staff should make sure to update the residents care plan ensuring there were appropriate interventions in place. RN I said if a resident had a missing diagnosis nursing staff can add it to the residents chart after verification from the resident's MD. In an interview on 07/13/25 at 10:23 AM, day shift staff LVN E said the facility administrator was the abuse coordinator, and she received an in-service on ANE, CIC, foot care and care plans yesterday. She said neglect was failure to provide care and she had not observed any in the facility. LVN E said when performing a resident weekly skin assessments nursing staff must inspect the resident from head to toe, documenting everything they see on the chart, complete a CIC/SBAR for anything outside of the normal, and notify the MD and wound care team. She said residents with diabetes, PVD and neuropathy have increased risk for foot problems so they must observe them closely and ensure they have podiatry services in place. LVN E said nursing staff must notify the RN of any missing diagnosis or issues that need to get updated in the care plan. In an interview on 07/13/25 at 10:29 AM, day shift staff LVN O said the facility administrator was the abuse coordinator, and she received an in-service on ANE, CIC, foot care and care plans this morning. She said neglect was failure to provide care and she had not observed any in the facility. LVN O said when performing weekly skin assessments staff must document all changes in the residents chart, complete a CIC/SBAR and notify the care team. She said any changes in a resident should then be updated in their care plan and any missed diagnosis or care areas should be brought to the attention of the ADON and DON. In an interview on 07/13/25 at 10:35 AM, day shift staff RN C said the facility administrator was the abuse coordinator, and he received training on ANE, change in condition, foot care, and care plans earlier this week. He said neglect was failure to provide services and he had not observed any in the building. RN C said when a resident experienced a new skin condition, they must document it in the residents chart as a CIC/SBAR and notify the wound care team who then notifies podiatry. He said diabetics and those with PVD and neuropathy were at an increased risk of complications with their feet, so podiatry was important . RN C said if a resident was missing a diagnosis or focus area on their care plan, the must notify the care coordinator to make updates. In an interview on 07/13/25 at 10:48 AM, day shift staff CNA AD said the facility administrator was the abuse coordinator, and she received training on ANE, change in condition, foot care, and care plans in the last 3 days. She said neglect was not meeting the residents' need and she had not observed any in the building. CNA AD said when staff observe changes in skin during showers, they must document it in the residents chart and notify nursing administration. In an interview on 07/13/25 at 10:55 AM, day shift staff RN J said the facility administrator was the abuse coordinator, and she received training on ANE, change in condition, foot care, and care plans this morning. She said neglect was failure to provide services and she had not observed any in the building. She said new admits with diabetes should have orders for podiatry evaluation and any changes in a residents skin seen during skin assessments must be documented as a CIC/SBAR and notifications sent to the MD, and nursing administration. RN J said if a resident had a change of condition or if staff notice a missing diagnosis or care area, they must notify MD for clarification. In an interview on 07/14/25 at 06:56 AM, night shift staff CNA D said she last received an in-service on ANE, change in condition, foot care, and care plans within the last 3 days and the facility abuse coordinator was the administrator. She said abuse was the failure to provide care and she had not observed any in the building. CNA D said when providing showers staff must observe the resident from head to toe, and any abnormalities should be documented in the shower sheet, POC, reported to the nurse and a stop and watch completed. In an interview on 07/14/25 at 06:56 AM, night shift staff LVN X said she last received an in-service on ANE, change in condition, foot care, and care plans yesterday and the facility abuse coordinator was the administrator. She said the facility had insufficient staff and she had witnessed a delay in care and medication but had no safety concerns about the staffing level. LVN X said when performing skin assessments, residents must be observed from head to toe and for diabetics there should be extra focus on pressure ulcers and foot care. She said if staff observed any variations from the norm, they must complete a CIC/SBAR, notify the MD, ask for necessary consultations and notify the PCP. LVN X said residents with vascular disease, diabetes and neuropathy were at risk of issues with foot health and they can lose their foot due to the lack of blood supply to the area. She said if a resident was missing a diagnosis or care area staff must contact the physician for clarification to ensure the diagnosis and care plan is updated. In an interview on 07/14/25 at 06:56 AM, night shift staff CNA M said she last received an in-service on ANE, change in condition, foot care, and care plans within the last 2 days and the facility abuse coordinator was the administrator. She said she had not observed any neglect in the building and staff must observe residents from head to toe during showers. Any changes observed in skin must be documented in the POC, shower sheet and in a stop and watch. CNA M said if a resident had long, and thick nails CNAs must notify nurse and request podiatry services. In an interview on 07/14/25 at 07:14 PM, night shift staff RN J said the facility administrator was the abuse coordinator, and she received training on ANE, change in condition, foot care, and care plans in the last 1-2 days. She said neglect was failure to provide care and she had not observed any in the building. RN J said foot care was important in diabetes because it was important to catch things early to prevent infection. She said any changes in a residents skin seen during skin assessments must be documented as a CIC/SBAR and notifications sent to the MD, and nursing administration to get podiatry services for the resident. RN J said if a resident had a change of condition or if staff notice a missing diagnosis or care area, they must notify MDS nurse to ensure the resident record is updated. In an interview on 07/14/25 at 07:22 AM, night shift staff CNA S said she last received an in-service on ANE, change in condition, foot care, and care plans was yesterday and the facility abuse coordinator was the administrator. She said she had not observed any neglect in the building and staff must observe residents from head to toe during showers. Any changes observed in skin must be documented in the POC, shower sheet and in a stop and watch. She said failure to identify and notify skin changes could place the resident at risk of worsening and escalation of the condition. In an interview on 07/14/25 at 07:22 AM, night shift staff CNA I said she last received an in-service on ANE, change in condition, foot care, and care plans 2 days ago and the facility abuse coordinator was the administrator. She said she had not observed any neglect in the building and staff must observe residents from head to toe during showers. Any changes observed in skin must be documented in the POC, shower sheet and in a stop and watch. She said failure to identify and notify skin changes would leave the issue untreated which could lead to infection. In an interview on 07/14/25 at 07:32 AM, night shift staff LVN Y said he last received an in-service on ANE, change in condition, foot care, and care plans yesterday and the facility abuse coordinator was the administrator. He said venous disorder, diabetes, and hammer toes placed residents at an increased risk for foot problems. LVN Y said when performing skin assessments, residents must be observed from head to toe and for diabetics there should be extra focus on pressure ulcers and foot car

Based on observation, interview, and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 1 medication carts (100 Hall Nurse Cart) reviewed for medication storage . - LVN D failed to ensure the 100-200 Hall Nursing cart was locked when not under direct supervision of authorized staff. This failure could place residents at risk of adverse reactions to medications and misappropriation of medications.Findings included: An observation on 07/10/25 starting at 08:55 AM revealed, an unlocked and unattended nursing cart in front of room [ROOM NUMBER] and #115. The back of the cart was pushed against, and the drawers were exposed to the hallway. At 09:00 AM LVN D walked from behind the double doors that led to the hall with the dining area and kitchen and walked up to the unattended cart.In an observation and interview on 07/10/25 at 09:01 AM, inventory of the 100 Hall Nurse Cart with LVN D revealed,Drawer 1- OTC medications, syringes, prescription medication, > 30 lancets (a device with a small needle used to prick fingers to collect blood for blood sugar monitoring.), >100 pen needles (needles attached to insulin pens).Drawer 2- liquid OTC and RX Only medications, solid form Resident prescription medications.Drawer 3- inhalation solutions, inhalers, and topical creamsLVN D said nursing carts should be locked when unsupervised to prevent unauthorized access to the carts contents. She said unlocked carts could place residents at risk of injury and adverse drug reactions if they consumed medications from the cart. LVN D said she left her cart unattended because she was interrupted by a resident request during medication pass.In an interview on 07/11/25 at 09:29 AM, Wound Care Nurse B who was acting as the Interim DON at the time said nursing carts were to be locked when unsupervised to prevent unauthorized access by residents especially the cognitively impaired. She said unlocked nursing carts could place residents at risk for adverse drug reactions and overdose.Record review of the facility policy Medication Management revised 07/01/16 revealed, Security and Safety Guidelines: 1. Staff who are not authorized or permitted into the Medication Room or having access to a medication cart, are supervised by authorized personnel when accessing for non-clinical reasons. 2. The Medication room is always locked when not in use and in direct line of sight. 3. The medication cart is locked when not in use and in direct line in sight. 4. Keys to the medication room and cart are kept with the authorized staff and are the responsibility of the person assigned those keys.

Based on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 5 residents (CR #1) reviewed for accuracy of assessments. - The facility failed to identify CR # 1's diagnosis of vascular diseases (narrowing of the blood vessels that result in oxygen not getting sent to the limbs also called PVD) and document it in her MDS(s) which resulted in CR #1 not having a plan of care for her diagnosis. These failures could place residents at risk of a compromised plan of care, worsening of health conditions, infection, injury, and amputation. Findings include: Record review of CR #1's Face Sheet dated 06/22/25 revealed, a 69-year-olf female who admitted to the facility on [DATE] at 12:45 PM with diagnosis which included: Alzheimer's Disease, unspecified dementia with anxiety, hypertension (high blood pressure), acquired absence of right leg above knee (right above the knee amputation) and type 2 diabetes with other circulatory complications. Diagnosis of open wound of left great toe without damage to nail was added on 06/15/25; and unspecified wound, left foot initial encounter was added on 06/16/25. There was no documented diagnosis of PVD. Record review of CR #1's Quarterly MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making, resident was unable to complete a brief interview of mental status, lower extremity functional limitation in range of motion. Active diagnoses of anemia, hypertension, diabetes, hyperlipidemia(high cholesterol), Alzheimer's Disease, seizure disorder, depression; there were no diagnosis of PVD or any circulatory complications. Record review of CR #1's undated Care Plan revealed , Focus- risk of falls due to immobility, muscle weakness and diabetes; Problem- CR #1 will be free from injury; approach- encourage resident to use environmental devices such as hand grips, handrails etc. Problem start date of 06/13/25- CR #1 has a diabetic ulcer to the left great toe; Goal target date 09/13/25- resident's wound will decrease in size with no complications as evidenced by wound documentation; Approach start date 06/13/25- nurse to complete wound documentation daily, refer to wound care doctor as needed, wound team to evaluate wound(s), treatments and healing status weekly. Problem start date of 06/16/25- CR#1 has trauma to left great toe; Goal target date: 09/16/25- wound will decrease in size as evidenced by wound documentation with no complications and comfort will be maintained; Approach start date: 06/16/25- CNA to inspect skin, especially over bony prominences, during bathing and personal care. Nurse to complete wound observation weekly. there was no mention of podiatry care or services or her vascular disease. Record review of email communications between the Social Worker and Medical Records dated 07/09/25 revealed, CR #1 had no documented visits or services with podiatry. An observation of pictures of CR #1's left foot dated 06/13/25 at 03:14 PM revealed, resident's foot was dry and flaky. Toenails on her three lesser toes where long and curled around the tip of her toes; with an appearance that they had not been cut for months. Bruising was observed to the upper foot by the great toe and a thick deep callus with a dark/black hole in the center. Her great toenail was thickened and yellow but attached to the nail bed.An observation of pictures of CR #1's left foot dated 06/16/25 at 06:33 PM revealed, the skin on the tip of her left toe to be open. The wound to the tip was shiny and red, with dry blood on the nail bed under the nail. He left great toenail appeared to be lifted off the nail bed with visible dry black blood under.An observation on 06/22/25 at 05:00 PM revealed, CR #1 lying in a hospital bed. The resident had no leg on the right side and her left foot was surrounded with a dressing, the tip of her great toe was exposed and red irritated skin with a circular callused area visible. CR#1 was confused and non-interviewable; she reference people and things that were not in the room.In an interview on 07/08/24 at 02:41 PM, the Hospital Podiatrist said CR #1 had significant history of PVD that resulted in her having an AKA on her right leg in 08/2024, and her vascular disease was so significant it caused her severe dementia. He said a resident with history of diabetes, PVD and a previous AKA should have had routine podiatrist visit. The Hospital Podiatrist said in the hospital CR#1 was diagnosed with osteomyelitis (bacterial bone infection) that needed to be treated with IV antibiotics in order to save the limb. He said routine podiatry would have prevented the acute traumatic event (toe infection) but due to her extensive PVD, CR#1 would have eventually needed an amputation in the future. The Hospital Podiatrist said from what he saw CR #1's left great toenail was lifted from the nail bed but there was no active or raging infection visible, the resident's WBCs were normal, and she did not have a fever during her entire stay. He said since an AKA would not better the CR#1's quality of life and the residents significant dementia, CR #1's family decided to place her on palliative (end of life) care.In an interview on 07/14/25 at 01:36 PM, the MDS coordinator said she was responsible for completing MDS assessments for long term care residents including CR #1. She said the MDS paints the entire picture of the resident including the level of care needed, level of ADLs, everything the facility was doing for the resident and it was a 7-day look back. The MDS nurse said the MDS functions to make sure appropriate level of care was given to a resident and it triggers CAAS which were care areas that were used to develop the residents plan of care. She said when a resident admits, the MDS nurse enters the residents admitting diagnosis which can be retrieved from the hospital documents or provided by the facility doctor. The MDS Nurse said if there was an MDS discrepancy it would not trigger a care area that the resident might need services for, and the area may not make it to the resident's plan of care. She said failure to not having a plan of care for a resident's diagnosis could place them at risk of not getting appropriate care, resulting in an untreated disease, or worsening health condition. After reviewing CR #1's records, the facility's diagnosis of diabetes with vascular complications should have been documented as PVD in the resident's MDS. She said PVD was when a resident did not get sufficient blood flow which brings oxygen to their peripheral (limbs) which leads to loss of feeling, loss of blood and ultimately a loss of a limb. The MDS nurse said when the resident admitted to the facility, nursing staff should have gotten clarification for what CR #1's circulatory complication was in order for her to receive adequate care she needed. She said after reviewing CR #1's chart, the resident did not have a plan of care for her circulatory condition, and the typical plan of care for PVD included podiatry services. The MDS nurse said the resident's circulatory complications did not make it into the residents plan of care because the CAAs were not triggered by the MDS.In an interview on 07/21/25 at 01:45 PM, Wound Care Nurse B said the facility failed to get clarification on what the diagnosis of the resident's circulatory complication was which then impacted her MDS, the plan of Care and ultimately resulted in the failure to provide podiatrist services.In an interview on 07/21/25 at 03:05 PM, the MDS Nurse said the facility's failure to provide CR #1' podiatry services started from the failure to get the correct diagnosis of PVD from the doctor and that trickled down.Record review of the facility policy Minimum Data Set (MDS) revised 05/05/23 revealed, POLICY: A licensed nurse will conduct or coordinate each assessment with the interdisciplinary team. An MDS, which is a comprehensive, accurate, standardized reproducible assessment will be completed for each resident, using the RAI process. Facility staff complete a comprehensive assessment of each resident's needs, strengths, goals, life history, and preferences, and offer guidance for further assessment once problems have been identified. The comprehensive assessment is completed initially and periodically. Quarterly and Significant Change assessments are completed as required, following the RAI specific guidelines. State-specific versions of such assessments are completed within the required timeframes according to applicable law and regulations. The Facility uses the RAI specified by CMS (which includes the MDS, utilization guidelines and the CAAs) to assess each resident and develop a comprehensive care plan. The facility is responsible for addressing all the needs and strengths of each resident. Each staff member will note their liability for the accuracy of the data recorded by signing (electronically) their name and identifying the MDS sections and questions to which they provided responses. A registered nurse (RN) must sign and certify that the assessment is completed. PROCEDURES: 1. Review the resident's medical record. This review may include pre-admission activities. Identify resident's status, care and services rendered during the Observation Period for the current assessment. Review is to include, but not be limited to pre-admission, admission, and transfer notes; current plan of care, physicians' orders, progress notes, history and physical; nursing, dietary, activity, social service, and therapy notes and assessments; monthly summaries, lab and x- ray reports, consultations, medication administration records, treatment administration records, and resident, staff and family interviews. 2. If a Care Area Assessment (CAA) is triggered, the facility will further assess the resident to determine whether the resident is at risk of developing, or currently has a weakness or need associated with that CAA, and how the risk, weakness or need affects the resident. Supplemental information must be gathered and analyzed by the facility based on the triggered CAAs prior to developing the comprehensive care plan. Documentation of the facility's rationale for deciding whether or not to proceed with care planning for each area triggered is recorded in the medical record. The Facility addresses all risks identified within the context of the MDS assessment, even if they do not cause a CAA to trigger. 9. Each assessment must represent an accurate picture of the resident's status during the observation period of the MDS.

Based on interview and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 (Resident #1) of 17 residents reviewed for food form. The facility failed to ensure Resident #1 was served a pureed (blended or mashed to a smooth pudding like consistency) lunch tray on 03/28/2025 as ordered by her physician. Resident #1 was served a mechanical soft (soft chopped, ground foods) lunch tray. This failure could place residents at risk of consuming foods that could cause aspiration (food or liquids enter the airway) or choking. Findings included: Record review of Resident #1's face sheet (undated) revealed a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included dysphagia (difficulty swallowing foods or liquids). Record review of Resident #1's annual MDS assessment (a standardized assessment to collect data on residents' health, functional status and care needs) dated 02/05/2025 revealed Resident #1 rarely or never made herself understood. Resident #1 rarely or never had the ability to understand others. Resident #1's BIMS (test used to evaluated cognitive function) was unable to be scored. The resident's Cognitive Skills for Daily Decision Making was scored at three which indicated her cognition was severely impaired. The resident rarely or never made decisions. The MDS revealed Resident #1 required substantial to maximum assistance to eat. Resident #1's active diagnoses included dysphagia. The MDS read Resident #1's Nutritional Approaches were mechanically altered diet included pureed. Record review of Resident #1's care plan problem 'start' dated 02/06/2025 and edited 03/14/2025 revealed the following: Problem: Resident #1 was at risk of choking and aspiration related to difficulty swallowing. Goal: Resident #1 would not choke or aspirate. Approach: Monitor Resident #1's diet consistency. Speech Therapy to evaluate as needed. Record review of Resident #1's care plan problem 'start' dated 02/06/2025 and edited 04/15/2025 revealed the following: Problem: Resident #1 received regular pureed diet. Goal: Resident #1 would have adequate nutrition and fluid intake. Approach: Serve diet as ordered Record review of Resident #1's nurses progress notes by RN A dated 03/28/2025 read in part .Entered Resident #1's room. Observed the resident was delivered the wrong consistency tray. The tray was removed. The tray was taken to the kitchen. The dietary manager was notified. The CNA told the ADON she may have had four bites. The food was removed from Resident #1's mouth. had no signs or symptoms of coughing, choking, gagging, wheezing, difficulty breathing, vomiting or drooling. The resident's physicians' team was notified. Record review of Resident #1's physician order report dated 04/01/2025- 04/30/2025 revealed pureed diet with diagnosis of dysphagia. The Order was dated 02/27/2024. In a phone interview on 04/23/2025 at 11:09 AM, the RD stated he was notified Resident #1 was delivered a diet that was not pureed. The RD stated Resident #1 had not swallowed the food. The RD stated the tray was removed, and the issue was corrected. The risk to the resident was aspiration. During a phone interview on 04/23/20255 at 12:01 PM, Resident #1's family member stated one day Resident #1 received a mechanical soft tray in place of a pureed diet. Resident #1's family member stated her mouth was cleaned with a towel. In a phone interview on 04/25/2025 at 8:15 AM, the Dietary Aide stated the cook put the food on the plates. The Dietary Aide stated she was rushed, she read the ticket wrong and picked up a mechanical soft plate not the pureed plate for Resident #1. The Dietary Aide stated she was the one responsible for putting the incorrect plate on the tray. The Dietary Aide stated this occurred during lunch when fixing the hall trays. She continued the interview and stated the risk to the resident was choking, she would slow down and fix Resident #1's tray first. During an interview on 04/25/2025 at 11:08 AM, CNA C stated the lunch trays were delivered. CNA C stated she believed the trays were already checked by RN A because she did not see the nurse in the hall when she took the tray off the cart. Most the time they communicated orally. CNA C stated she removed the tray for Resident #1 and went to her room. CNA C stated Resident #1 was sitting up in her chair and she gave her one bite. CNA C continued she attempted to give the resident a second bite, but she squeezed her lips together. CNA C stated RN A came in the room and stated the resident had the wrong tray. The CNA stated RN A checked the resident. The resident was alert, breathing good and not coughing. CNA C stated RN A removed the tray from the room and the ADON came into the room. CNA C stated she thought the RN did check the trays. CNA C stated she did not see the ticket on the tray. CNA C stated the nurses review the resident's care with the CNA's in the morning. The CNA continued and stated she the risk to the resident was aspiration . During an interview on 04/25/2025 at 11:17 AM, RN A stated she was in a resident's room when the lunch trays arrived. RN A stated she left the resident's room and saw the lunch cart on the 400 hall. RN A stated she went in to Resident #1's room, she saw CNA C was feeding the resident the wrong diet with the correct meal ticket. RN A stated she removed the tray and assessed the resident. RN A stated Resident #1 was not having any changes in her level of alertness or breathing. RN A stated she reported to the ADON and took the tray to the kitchen and reported to the dietary manager. RN A stated she returned to the room the ADON was with the resident. RN A reported they cleaned the resident's mouth to remove any food. RN A stated she did not swallow anything. RN A stated the pureed diet arrived and the resident ate her lunch. RN A stated the nurse was responsible for making sure the correct diet was provided to the resident. RN A stated the kitchen provided the meals to the units, the nurse was to check the tray with the meal ticket before the CNA passed the tray to the resident. Risk to the resident was aspiration, choking and death. During an interview on 04/25/2025 at 11:54 PM, the Dietary Manager stated when the kitchen staff prepared the tray for Resident #1 our staff put the wrong plate on the tray. The Dietary Manager stated the nurses on the floor were to make sure the trays and the tickets were correct before it was served. The Dietary Manager stated the dietary aide was responsible for making sure the correct plate was with the correct meal ticket. The Dietary Manager stated the Dietary aide was rushed. The Dietary aide was in-serviced and disciplined. The Dietary Manager stated the risk was choking and stated she takes pictures of the trays before leaving her kitchen. During an interview on 04/25/2025 at 12:01 PM, the ADON stated RN A was in a room with another resident when the lunch trays arrived on the unit. The ADON stated the RN saw the trays were being passed. The ADON stated RN A notified her of the incident and she went into the room Resident #1 was sitting up in the chair we cleaned her mouth. The ADON stated the resident was assessed, she was at her normal alertness, she had no tearing, shortness of breath, facial redness, drooling, or breathing changes. She ate her normal tray when it arrived. The ADON stated responsibility for making sure the correct tray and meal ticket matched started in the kitchen, then the nurses on the units and the CNA before feeding the resident. The ADON stated the physician was notified, they got a stat (immediate) chest x-ray, respiratory assessment, swallowing assessment, speech assessment and MBSS (modified barium swallowing study) (A special x-ray to evaluate swallowing function and if food is getting into the lungs). In an interview on 04/25/2025 at 12:16 PM, speech therapist stated she was called in to evaluate Resident #1 because the resident received the wrong food. The speech therapist stated the ticket was correct but the plated food was not. The speech therapist stated she had been assessing the resident since this occurred. The risk to the resident could have been aspiration. During a phone interview on 04/25/2025 at 12:36 PM, Resident #1's physician stated the physicians were notified of the incident on 03/28/2025. The physician stated a chest x-ray was ordered, speech therapy and swallowing studies were ordered. The physician stated the risk to the resident could have been an aspiration event. In an interview on 04/25/25 at 1:44 PM, the DON stated she was told that this occurred prior to her employment. The DON stated the plan was to double check the meal before serving to prevent this again. The DON stated the risk could have been aspiration or choking. In an interview on 04/25/2025 at 2:02 PM, the Administrator she stated the dietary aide did not put the plate on the tray that matched the ticket. The Administrator stated the tray was not checked prior to the CNA starting to feed the resident. The Administrator stated it was caught and handled immediately. The Administrator stated responsibility for the correct diet was with dietary services, the nurses, and the CNA. The Administrator stated the risk was choking.

Based on observations, interviews, and record review, the facility failed to ensure a resident received care, consistent with professional standards of practice, to prevent ulcers and not develop pressure ulcers for 1 of 8 residents, CR #1, reviewed for pressure ulcers. 1. LVN A failed to follow the facility's protocol and initiate adequate wound interventions when CNA B noted CR #1 had redness to her buttocks area on 01/04/2025 until 01/20/2025 when CR #1 was noted to have a stage 3 (a full-thickness tissue loss where the subcutaneous fat layer is visible within the wound, but the bone, tendon, or muscle is not exposed) sacral pressure ulcer, and an unstageable pressure injury (a type of pressure ulcer where the depth of the wound cannot be determined due to the presence of slough or eschar) (the wound was initially staged as a 3, but was changed to unstageable on 02/06/2025) to her right buttock. 2. The facility failed to ensure nurses completed comprehensive weekly skin assessments for CR #1 and resulted in a delay in initiating wound care. An IJ was identified on 02/20/2025 at 12:48 p.m. The IJ template was provided to the facility on [DATE] at 12:48 p.m. While the IJ was removed on 02/21/2025 at 1:49 p.m., the facility remained out of compliance at a scope of pattern with severity level at a potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on 02/21/2025. These failures placed bedbound residents and those susceptible to skin injury at risk of experiencing pain and possible infection from developing avoidable pressure wounds. Findings included: Record review of CR #1's face sheet dated 02/19/2025 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with dementia (the loss of cognitive functioning), hemiplegia (paralysis that affects only one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebrovascular disease (a medical emergency that encompasses a range of conditions affecting the brain's blood vessels and circulation) affecting the left non-dominant side, functional quadriplegia (a condition in which a person is unable to move all four limbs due to factors other than a spinal cord injury), muscle wasting and atrophy (loss of muscle mass and strength), mild protein-calorie malnutrition (a condition where someone is not getting enough protein and calories in their diet), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), chronic kidney disease (longstanding disease of the kidney leading to renal failure), diabetes mellitus (too much sugar in the blood), blindness in one eye, and hypertension (a condition in which the force of the blood against the artery walls is too high). CR #1 was discharged to an acute care hospital on 02/18/2025 (unrelated to the pressure ulcers). Record review of CR #1's quarterly MDS dated [DATE] revealed her vision was severely impaired; she had a BIMS score of 12 (moderate cognitive impairment); she did not exhibit behaviors related to rejection of care; her upper and lower extremities had limited range of motion; she used a wheelchair for mobility; she required supervision or touching assistance from staff for eating and oral hygiene; she was dependent on staff for toileting, showering/bathing, lower body dressing, sitting to lying/lying to sitting, and transferring; she required substantial/maximal assistance from staff for rolling to the left/right while lying on her back; she required moderate assistance from staff for personal hygiene; she was always incontinent of bowel and blader; and she was at risk for developing pressure ulcers. Record review of CR #1's care plan, revised on 02/14/2025 revealed the following care areas: * Pressure Ulcer/Injury: The resident has xerosis (rough, dry skin) with hardened dry skin [and] scaly plaques to bilateral lower legs. Goal included: The resident's wound will decrease in size as evidenced by wound documentation with no complications and comfort will be maintained. Approach included: CNA to inspect skin, especially over bony prominences, during bathing and personal care. Licensed Nurse to complete wound observation weekly. Wound care as ordered. Wound team to determine etiology (the cause of a disease), evaluate wound(s), treatment(s), and healing weekly. * Pressure Ulcer/Injury: CR #1 has a current wound/disruption of skin surface: Stage 3 to the right buttocks. Goal included: The resident's wound will decrease in size as evidenced by wound documentation with no complications and comfort will be maintained. Approach included: Wound care as ordered. * Pressure Ulcer/Injury: CR #1 has a current wound/disruption of skin surface: stage 4 (the most severe of a pressure sore, where the wound extends deep into the tissue, exposing muscle, tendon, or bone, often with significant damage to surrounding tissue and a high risk of infection) to the sacral. Goal included: CR #1's wound will decrease in size as evidenced by wound documentation with no complications and comfort will be maintained. Approach included: Wound care as ordered. * Pressure Ulcer/Injury: CR #1 is at risk for skin breakdown due to impaired mobility and incontinence of bowel and bladder. Goal included: Skin will remain clean, dry, and intact without evidence of breakdown. Approach included: Assist with repositioning as needed. Monitor for incontinence per routine rounds and PRN, change promptly. Monitor for skin break down, report to M.D. and RP. Provide pressure relieving and positioning devices as needed. * Behavioral Symptoms: CR #1 has mood, and behavior needs related to her diagnosis of: Dementia, blindness, osteoarthritis (type of arthritis that occurs when flexible tissue at the end of bones wears down), reduced mobility as evidenced by agitation, short temper, refusing to get out of the bed, refusing care, medications, lab draws, and showers. Goal included: CR #1 will have a reduction in identified behaviors, will allow needed care for health and safety as evidenced by documentation in the medical record. Approach included: Encourage CR #1 to become involved with activities that she enjoys, even in room or one on one as needed. Will respect choice to refuse participation. Ensure all physical needs are met such as pain, hunger, thirst, toileting needs, labs, adequate sleep. Give medications as ordered, monitor for side effects and effectiveness, notify physician of changes, attempt GDR as able. Refer to psych as needed. Resident may refuse to take her medications. Medication Techs must notify Nurse in charge, ADON or DON for refusals. Documentation must be noted at that time. * ADLs Functional Status/Rehabilitation Potential: CR #1 is limited in mobility related to BLE impairments and requires the use of a wheelchair. Goal included: will safely help propel self with the use of wheelchair. Approach included: Allow sufficient time to complete activity. Instruct in proper technique. * ADLs Functional Status/Rehabilitation Potential: [CR #1] will maintain a sense of dignity by being clean, dry, odor free, and well groomed. Approach included: Bathing: Assist of 1 (prefers Bed Bath). Bed Mobility: Assist of 1-2. Eating: Assist of 1 (Blind). Toileting: Assist of 1. Transfer: Assist of 1-2 utilizing Hoyer Lift * Continence Status (Bowel/Bladder): CR #1 has Functional Incontinence of Bowel and Bladder and is at risk for skin breakdown. Goal included: CR #1 will remain clean, dry, and odor free and no occurrence of skin break down will occur thru the next review date. Approach included: Assess for causes of incontinence. Encourage fluid intake within dietary limits. Monitor for incontinence per routine rounds and PRN, change promptly and apply a protective skin barrier to skin. Monitor for s/s of skin break down - report to physician and responsible party. Record review of CR #1's Observations (the observation tab of the facility's computer system) in the electronic record revealed the following observations: * 01/03/2025, 2:53 p.m. - Form: Focused Observation. Short Description: --Invalid--Skin; Skin. Reason for invalidation: Incorrect Data. Schedule Details: Unscheduled. Created By: LVN A. * 01/04/2025, 12:41 p.m. - Form: Focused Observation. Short Description: Skin; Skin. Schedule Details: Unscheduled. Created By: LVN A. * 01/10/2025, 5:02 p.m. - Form: Focused Observation. Short Description: skin assessment; Skin. Schedule Details: Weekly Skin - 7:00 a.m. - 7:00 p.m. Scheduled: 01/10/2025. Due 01/11/2025. * 01/13/2025, 1:54 p.m. - Form: Braden Scale for Predicting Pressure Sore Risk. Short Description: Braden. Schedule Details: Unscheduled. Created By: Treatment LVN C. * 01/13/2025, 1:55 p.m. - Form: Skin Risk Analysis and Interventions. Short Description: Skin Risk Analysis. Schedule Details: Unscheduled. Created By: Treatment LVN C. * 01/20/2025, 4:37 p.m. - Form: Focused Observation. Short Description: Skin; Skin. Schedule Details: Unscheduled. Created By: Treatment LVN C. Further review of CR #1's Observations revealed no weekly skin assessments/observations were completed for the week of January 12-18, 2025. Record review of CR #1's Focused Observation dated 01/03/2025 at 2:53 p.m. (created by LVN A) revealed . Observation Type: Weekly. Short Description: Skin . Alteration in skin? No. Comments: no new areas. Record review of CR #1's Focused Observation dated 01/04/2025 at 12:41 p.m. (created by LVN A) revealed . Observation Type: Weekly. Short Description: Skin . Alteration in skin? Yes. Comments: Patient has reddish area to left buttock, wound care nurse notified. Record review of CR #1's Focused Observation dated 01/10/2025 at 5:02 p.m. (created by LVN D) revealed . Observation Type: Weekly. Short Description: skin assessment . Alteration in skin? No. Comments: no new skin issues. Record review of CR #1's Focused Observation dated 01/20/2025 at 4:37 p.m. (created by Treatment LVN C) revealed . Observation Type: Daily. Short Description: Skin. Reason for Skilled Service: Observation and assessment . Alteration in skin? Yes. Comments: Right buttock and sacrum. Record review of the facility's Activity Report (24-hour Report) dated 01/04/2025 revealed no entries related to CR #1. Record review of CR #1's Progress Notes for December 2024 - January 2025 revealed no documentation/entries from 12/24/2024 - 01/20/2025. Record review of CR #1's Progress Note dated 01/20/2025 revealed Treatment LVN C wrote, CNA reported patient had a wound on her buttock. I went and assessed, and patient has a stage 3 pressure injury to the right buttock, full thickness, light serous exudate (a clear, watery fluid produced in response to inflammation or injury), 2.5x1.5x0.1 cm, no odor or s/s of infection, no pain, granulation (new, pink or red, fleshy tissue that forms in the healing process of wounds) noted, peri wound (the area of skin around the wound) intact and dry. I cleansed with normal saline, patted dry with sterile gauze, applied alginate, and covered with a bordered foam. Patient has a stage 3 pressure injury to the sacrum, full thickness, light serous exudate, 2.5x1.5x0.1 cm, no odor or s/s if infection, no pain, granulation noted, peri wound intact and dry. I cleansed with normal saline, patted dry with sterile gauze, applied alginate, and covered with a bordered foam. Wound Care Doctor notified, new order. I called and spoke with the patient's RP and notified her of the new skin integrity issues and the plan of care. RP informed that the Wound Care Doctor will further assess patient on Thursday, and she will receive a weekly call with an update on the wounds. RP voiced no concerns. Record review of CR #1's Progress Note dated 01/23/2025 revealed RN E wrote, Patient was seen by Wound Care Doctor during wound rounds. Patient was evaluated and plan of care in place. Patient has stage 3 Pressure injury to sacral measuring 1.5x0.8x0.2 cm with moderate sero-sanguineous exudate (a combination of blood and serum that drains from a wound), red in color, no pain, no odor noted, bright red firm granulation present . Patient has trauma wound to left gluteal fold measuring 2.5x0.9x0.1 cm full thickness with moderate serous exudate . Patient has xerosis to lower extremities . Record review of CR #1's wound care notes for January 2025 and February 2025 revealed the following: . 01/23/2025 (CR #1 was assessed by the facility's regular wound care doctor) . Wound #1: Wound Location: Sacral. Wound Type: Pressure Ulcer. Acquired at Facility: Yes . Wound Measurements: 1.5x0.8x0.2 cm . Stage: Stage 3 Pressure Injury. Moderate serosanguinous exudate. Color: Bright Red . Wound #2: Wound Location: Left Gluteal fold. Wound Type: Trauma Wound. Acquired at Facility: Yes . Wound Measurements: 2.5x0.9x0.1 cm . Full Thickness, moderate serous exudate . . 02/06/2025 (CR #1 was assessed by a wound care doctor filling-in for the regular wound care doctor) . Wound #1. Wound Location: Sacral. Wound Type: Pressure Ulcer. Acquired at Facility: Yes . Wound Measurements: 3x1x0.2 cm . Stage: Stage 3 Pressure Injury. Wound Progress: Improving. Moderate serous exudate. Color: Clear . Wound #3 (unknown why the wound care doctor labeled it #3) Wound Location: Right Buttock. Wound Type: Pressure Ulcer. Acquired at Facility: Yes . Wound Measurements: 1x3x0 cm . Stage: Unstageable Pressure Injury Obscured full-thickness skin and tissue loss. Moderate serous exudate . Record review of CR #1's Shower Sheets for January 2025 revealed the following: * 01/04/2025 (day shift staff 0 7:00 a.m. - 7:00 p.m.): New Skin Issues? No . Comments: None . Signed by CNA G. * 01/04/2025 (night shift staff - 7:00 p.m. - 7:00 a.m.): New Skin Issues? No . Comments: Bed bath . Signed by CNA F. * 01/14/2025 (night shift staff): New Skin Issues? No . Comments: Shower . Signed by CNA F. * 01/18/2025 (night shift staff): New Skin Issues? No . Comments: Shower. Signed by CNA F. Observation and interview with CR #1 on 02/19/2025 at 3:11 p.m. revealed she was in bed at an acute care hospital. CR #1's eyes were closed, and she did not respond verbally or non-verbally to questions. CR #1's hospital nurse touched her head and eyes, and CR #1 began to wave her hand to remove the nurse's hand from her head. CR #1 never made any sound or gestures to indicate she understood or heard interview questions. The hospital nurses stated CR #1 had been nonresponsive since she was admitted to the hospital. In an interview with Treatment LVN C on 02/19/2025 at 11:30 a.m., she stated she was responsible for doing wound care treatments Monday - Friday and another treatment nurse, Treatment LVN H, did wound care on weekends (Saturday and Sunday). She stated floor nurses were responsible for completing each residents' weekly skin assessments. She stated CR #1's wounds (right buttock and sacral) were facility acquired. She said on 01/20/2025, a CNA (CNA B) told her CR #1 had a wound on her buttocks. She said she and CNA B went to assess CR #1 and there were two wounds, a stage 3 on her right buttocks and a stage 3 on her sacrum. She said when the wound care doctor assessed CR #1 on 01/23/2025, he changed the right buttocks wound to an unstageable. She said when she found the wounds on 01/20/2025, she asked the floor nurses and CNA's (she did not specify who she asked) why nobody saw the wounds and reported them to her when they saw redness or excoriation (a wound or abrasion caused by scratching), because the wounds did not just appear overnight. Treatment LVN C said no redness was reported to her regarding CR #1. She said she reviewed CR #1's electronic record and saw that nobody charted/documented about CR #1's skin issue since LVN A wrote she had redness on 01/04/2025. She said Treatment LVN H was the wound nurse on duty on 01/04/2025, she was usually very thorough. She said LVN A probably did not report the redness to Treatment LVN H because she (Treatment LVN H) would have reported it to her, and she would have started a treatment plan. Treatment LVN C said she almost lost her mind (she was very upset) when CNA B reported the wounds on 01/20/2025. She said if the floor nurses and CNAs were doing their jobs, the wounds would not have gotten that bad. She said if the staff saw something, they should have reported it to her or the weekend wound care nurse. She said even though LVN A's note said he reported the redness, she knew he did not. She said he failed to describe the redness he saw. She said something as minor or small as redness could have been eliminated with treatment. She said the CNAs told her either they had not cared for CR #1, or they just did not see it. She stated if the floor nurses were doing their skin assessments, they would have found the wounds. She said CR #1 never said anything about the wounds. She said CR #1 was the type of person who would only speak when you asked her questions. She said if you did not ask, CR #1 would not say anything. She said CR #1 never complained of pain or discomfort once they started treatment. She said once she found the wounds, she contacted the wound care doctor and CR #1's RP. She said after she found the wounds on 01/20/2025, she got CR #1 on an air mattress and wedge. She said she also made sure the CNAs repositioned CR #1 regularly to offload the wounds. She stated she had never seen CR #1 before 01/20/2025 because she only assessed and treated residents with wounds. She said LVN A was a full-time nurse at that time (01/04/2025), but as of 02/14/2025, he was PRN. An attempt was made to contact LVN A by phone on 02/19/2025 at 12:16 p.m. A voicemail message was left. He returned the call on 02/19/2025 at 2:58 p.m. and left a message. More attempts to contact LVN A by phone were made on 02/19/2025 at 3:54 p.m., and 02/21/2025 at 10:45 a.m. A text message was left for him on 02/19/2025 at 6:23 p.m. The calls and text were never returned. In an interview with RN E on 02/19/2025 at 12:10 p.m., she stated she sometimes filled-in for Treatment LVN C when she was off. She stated she treated CR #1's wounds on 02/10/2025 and 02/14/2025. She said CR #1 did not complain of pain or discomfort. She said if a resident was found to have redness, the floor nurse would notify the wound care nurse after doing an assessment. She said the nurse would also contact the wound doctor and get orders to start treating the redness, which would likely be barrier cream. She said if they catch the redness, it does not always turn into a wound. She said the redness would turn into a wound if the skin experiences friction and pressure. In a telephone interview with Treatment LVN H on 02/19/2025 at 3:56 p.m. she stated she only worked at the facility on Saturdays and Sundays. She said LVN A never told her CR #1 had any redness. She stated she only found out about CR #1's wounds after she showed up on the wound list the weekend after 01/20/2025. She said she never would not have assessed CR #1 otherwise because she only did wound care on weekends and the floor nurses did skin assessments. She said redness did not usually turn into a stage 3 wound overnight. She said some wounds developed quickly, but usually there was a progression from redness to stage 3. She said if the nurses were doing what they were supposed to do, such as doing skin assessments when they pop up on the electronic MAR, they would have caught the issue before it turned into a wound. She said LVN A should have written a progress note describing the redness and noting who it was reported to. She said LVN A should have reported the redness to CR #1's doctor as well. She said if the redness was reported to her, she would have written another progress note and said what treatment she did and who she reported it to. In a telephone interview with LVN I on 02/19/2025 at 10:33 p.m., she stated she worked the night shift and often cared for CR #1. She stated staff repositioned CR #1 regularly prior to finding the wounds and after they found the wounds. She stated CR #1's skin assessments were scheduled for every Friday on the day shift, so she never did one for her. She stated she never observed CR #1 with redness and only found out about the wounds after they were noted on 01/20/2025. In a telephone interview with CNA F on 02/19/2025 at 10:50 p.m., she stated she often cared for CR #1 on the night shift. She stated she did not recall when she observed CR #1's wounds, but approximately 2.5 - 3 weeks ago, she reported the wound to LVN I. She said she thought she observed the wound as soon as it popped up. She said she saw one little spot on CR #1's back sometime in the beginning of January 2025. She said the spot was very small between CR #1's buttocks (cheeks) and it was a little red with a small opening. She said they started doing wound treatments on the wound pretty much immediately after that because she saw the dressings on it. She said she saw one spot and it did not get bigger, but a second spot formed maybe a couple of days after the first spot. She said she did not care for CR #1 that many days in a row. She said LVN I treated the wound right after she reported it. She stated she reported the wound many days before the holiday in January (01/20/2025 was a holiday), but she could not recall what day it was. In an interview with the ADON on 02/20/2025 at 9:20 a.m., she stated the facility did not currently have a DON to oversee the wound care program, so they had a consultant or corporate DON (Clinical Services Director) who came in, and the wound care nurse worked with the wound care doctor. She stated the facility's staff worked as a team to oversee the wound care program. She said if redness was observed on a resident, the nurse should alert the wound care nurse, the RP, and the resident's NP so they can all monitor it and get interventions in place. She said if a nurse observed redness, they should complete a skin observation, progress note, and they should document whatever orders came from that. She stated LVN A did not follow normal procedure because he should have made a skin assessment/observation and completed a progress note, which would have alerted the other nurses. She said LVN A should have notified the wound care nurse and then followed up. She said the CNAs should have been looking for skin issues during showers/bed baths too. She said if redness was not reported, assessed, and treated, it could progress into a wound. She said she could not say a stage 3 wound would have progressed overnight. She said a wound could progress rapidly, but she did not have the expertise to say it could happen that fast. She said she never saw CR #1's wounds. She said every resident should have a weekly skin assessment. She said the ADONs (the facility had two ADONs, but this one was responsible for CR #1's care) were responsible for making sure weekly skin assessments were done. She said CR #1's skin assessments were done weekly to her knowledge. She said she ran a report on Mondays (for Monday - Sunday each week), and she checked off the list as the skin assessments were completed and documented for the week. She reviewed CR #1's electronic record and said CR #1 did miss a skin assessment and she could have missed it by mistaking the focused skin observation for a skin assessment (there was no focused skin observation January 12 - 18, 2025). She said she would normally make sure they all got done. In an interview with CNA B on 02/20/2025 at 10:15 a.m., she stated she often cared for CR #1 on the day shift. She said during care, she looked at CR #1's, entire back side. She said before CR #1 had a wound, she noticed redness the second week of January 2025. She said she observed that CR #1 had a bed sore (the redness) on the right-side buttocks and she let LVN A know. She said LVN A told her to use skin protector (barrier cream) on CR #1's sore but it was not working, and it got worse. She said she cared for CR #1 other times, and she saw the sore get worse, so she let Treatment LVN C know. She said when she initially saw the sore, it was like a red baby rash. She said when she told LVN A about it, he went and looked at it, but she was not sure he alerted the wound care nurse. She said she did not think LVN A alerted the wound care nurse because she notified Treatment LVN C in mid-January 2025 because the wound had progressed. She said the redness never went away, it progressed into the wound. She said CNA F also noted the redness because when she switched off with her during shift change, they talked about it and CNA F also used barrier cream on CR #1. She said she and CNA F both repositioned CR #1 every two hours. She said after she notified Treatment LVN C, they started doing wound care on CR #1's wounds. She said prior to seeing CR #1 with redness on 01/04/2025, she never had any skin issues. She said she did not know if LVN A notified CR #1's doctor about the redness. She said after Treatment LVN C started treating CR #1's wounds, they started clearing up. She said CR #1 was scheduled to have showers/bed baths on Tuesdays, Thursdays, and Saturdays during the night shift. In an interview with LVN D on 02/20/2025 at 10:30 a.m., she stated she was familiar with CR #1, and she worked with her a lot in the past. She said she was responsible for doing weekly skin assessments. She said the floor nurses had a set schedule for skin assessments. She said the skin assessment schedule was posted and they were also set on each resident's electronic MAR. She said if the skin assessment popped up on the computer, then they have to do it. She said she had not done many skin assessments on CR #1 because she was not on her regular hall. She said she did not recall the last time she did one for CR #1, but if she wrote no new skin issues, it could have been that she did not see anything. She said CR #1 could have developed something over a couple of days. She said she did not recall seeing any redness or wounds at that time (01/10/2025). She said the nurses had to look between the residents' buttocks during a skin assessment. She said if she saw any redness, she would have documented it. She said if the nurses saw redness, they had to let the wound nurse know, call the doctor, and call the wound doctor. She said if she saw redness, she would have called the doctor then. She said the doctor may have said to add barrier cream and regular repositioning, but they still had to let the wound care nurse know. She said not reporting redness could lead to it getting overlooked and it could turn into a wound or something worse. She stated 01/10/2025 was on a Friday and if that was CR #1's regular day for a skin assessment, it would have popped up on her computer to do it. In an interview with the wound care doctor on 02/20/2025 at 11:15 a.m., he stated he was filling-in for the regular wound care doctor while he was on vacation. He said he recalled CR #1 a little. He said CR #1 had two wounds and both were pressure wounds. He stated he could not say how quickly a stage 3 wound developed because it depended on the patient. He said if someone reported that a patient had redness, he would recommend repositioning regularly and barrier cream. He said relieving the pressure would cause the redness to go away in one day. In a telephone interview with CR #1's RP on 02/20/2025 at 12:10 p.m., she stated nobody ever notified her CR #1 had any redness. She said she was only notified when CR #1 developed wounds two weeks ago (she could not recall the date). In a follow-up interview with Treatment LVN C on 02/20/2025 at 12:31 p.m., she stated after she found CR #1's wounds on 01/20/2025, she spoke to LVN A and asked him how CR #1 got the wounds, and nobody saw them or reported them. She said LVN A said it was just red, the day he saw it. She said she asked LVN A what they were doing about the redness, and he said he told the CNA to do barrier cream. She said she told him CR #1's wounds were more than just red at that time, and he said he had been off a few days and the wounds looked different than when he saw it. Treatment LVN C said for redness, she would have instructed the nurses to do barrier cream with zinc with each incontinence episode. She said the CNAs could only administer regular barrier cream without zinc, but the nurses could administer the cream with zinc. She stated failing to follow-up and monitor CR #1's redness could have resulted in progression into a wound and possible infection if it was not caught in time. In a telephone interview with CR #1's physician on 02/21/2025 at 10:09 a.m., she stated she had been responsible for CR #1's care for several years. She said to her knowledge, this was the first time CR #1 ever had any skin issues. She said she did not recall anybody notifying her about any skin issue or redness in early January 2025. She said she did not recall anybody telling her about a stage 3 wound, but she worked with eight nurse practitioners, and they may have received notification. She said one NP usually visited CR #1. She said if the facility called her about CR #1's redness, she would have instructed them to use barrier cream, offload the wounds, avoid access moisture with frequent brief changes, and notify the wound care doctor for treatment. She stated failing to monitor CR #1's redness closely for changes could have contributed it to developing into a stage 3 wound. In an interview with the Clinical Services Director on 02/21/2025 at 11:19 a.m., she stated she was a consultant and was not employed through the facility. She stated she helped the facility with systems and made suggestions and recommendations for improvements. She stated she previously looked at the facility's wound care program and put an action plan in place. She said when a CNA observed redness, they should notify the nurse immediately. She said the nurse should assess the resident and notify the doctor, family, and the treatment nurse. She said the nurse should also communicate with the rest of the team, including the oncoming nurses and CNAs. She said the nurse should get orders from the doctor and implement the orders. She said if the redness was noted in the middle of the night, the nurse should leave a note for the treatment nurse notifying they found something on the resident. She said the nurse should also leave a note in the facility's 24-hour communication book. In a telephone interview with CR #1's NP on 02/21/2025 at 12:04 p.m., she stated she rounded at the facility every Monday and Thursday and she visited CR #1 weekly. She stated nobody ever told her CR #1 had any wounds until now (02/21/2025). She stated she laid eyes on CR #1 weekly and checked in with the nurses, but she never did a head-to-toe assessment. She said had the staff told her CR #1 had redness or any skin changes, she would have instructed them to add barrier cream, reposition often, and have the treatment nurse assess and watch to make sure it did not progress. In an interview with the Administrator on 02/24/2025 at 2:15 p.m., she stated she attempted to contact LVN A to speak with him about CR #1, but he had not returned her phone calls. She stated LVN A was a PRN nurse, but she did not plan to call him for work again. Record review of the facility's policy titled, Wound Care Policies and Procedures 03/23/2017 revealed, Policy: Pressure ulcers will be evaluated and treated in accordance with professional standards of practice to heal and prevent pressure ulcers unless clinically unavoidable . Record review of the facility's policy titled, Physician and Other Communication/Change In Condition revised 07/0 [TRUNCATED]

Based on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming for 1 of 8 residents (CR #1) reviewed for ADL's. 1. The facility failed to ensure CR #1's hair was adequately washed and combed for an unknown period and resulted in a thick accumulation of a brown, flakey substance on her entire scalp, and a large amount of matted hair in the back of her head which had to be cut off. 2. The facility failed to ensure CR #1's nails were cut and appropriately groomed which resulted in an accumulation of a dark brown/black substance underneath the nails. 3. The facility failed to notify CR #1's RP and physician that she had matted hair and an accumulation of a brown, flakey substance on her scalp which resulted in a delay in treatment/care. These failures placed dependent residents at risk of experiencing scalp itch, odors, infection, skin tears, and undesirable haircuts. Findings included: Record review of CR #1's face sheet dated 02/19/2025 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with dementia (the loss of cognitive functioning), hemiplegia (paralysis that affects only one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebrovascular disease (a medical emergency that encompasses a range of conditions affecting the brain's blood vessels and circulation) affecting the left non-dominant side, functional quadriplegia (a condition in which a person is unable to move all four limbs due to factors other than a spinal cord injury), muscle wasting and atrophy (loss of muscle mass and strength), mild protein-calorie malnutrition (a condition where someone is not getting enough protein and calories in their diet), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), chronic kidney disease (longstanding disease of the kidney leading to renal failure), diabetes mellitus (too much sugar in the blood), blindness in one eye, and hypertension (a condition in which the force of the blood against the artery walls is too high). CR #1 was discharged to an acute care hospital on 02/18/2025 (unrelated to the pressure ulcers). Record review of CR #1's quarterly MDS dated [DATE] revealed her vision was severely impaired; she had a BIMS score of 12 (moderate cognitive impairment); she did not exhibit behaviors related to rejection of care; her upper and lower extremities had limited range of motion; she used a wheelchair for mobility; she required supervision or touching assistance from staff for eating and oral hygiene; she was dependent on staff for toileting, showering/bathing, lower body dressing, sitting to lying/lying to sitting, and transferring; she required substantial/maximal assistance from staff for rolling to the left/right while lying on her back; she required moderate assistance from staff for personal hygiene; she was always incontinent of bowel and blader; and she was at risk for developing pressure ulcers. Record review of CR #1's care plan, revised on 02/14/2025 revealed the following care areas: * Behavioral Symptoms: CR #1 has mood, and behavior needs related to her diagnosis of: Dementia, Blindness, Osteoarthritis (type of arthritis that occurs when flexible tissue at the end of bones wears down), Reduced Mobility as evidenced by agitation, short temper, refusing to get out of the bed, refusing care, medications, lab draws and showers. Goal included: CR #1 will have a reduction in identified behaviors, will allow needed care for health and safety as evidenced by documentation in the medical record. Approach included: Encourage CR #1 to become involved with activities that she enjoys, even in room or one on one as needed. Will respect choice to refuse participation. Ensure all physical needs are met such as pain, hunger, thirst, toileting needs, labs, adequate sleep. Give medications as ordered, monitor for side effects and effectiveness, notify physician of changes, attempt GDR as able. Refer to psych as needed. Resident may refuse to take her medications. Medication Techs must notify Nurse in charge, ADON or DON for refusals. Documentation must be noted at that time. * ADLs Functional Status/Rehabilitation Potential: CR #1 is limited in mobility related to BLE impairments and requires the use of a wheelchair. Goal included: will safely help propel self with the use of wheelchair. Approach included: Allow sufficient time to complete activity. Instruct in proper technique. * ADLs Functional Status/Rehabilitation Potential: [CR #1] will maintain a sense of dignity by being clean, dry, odor free, and well groomed. Approach included: Bathing: Assist of 1 (prefers Bed Bath). Bed Mobility: Assist of 1-2. Eating: Assist of 1 (Blind). Toileting: Assist of 1. Transfer: Assist of 1-2 utilizing Hoyer Lift. Record review of CR #1's Progress Notes for December 2024 - January 2025 revealed no documentation/entries from 12/24/2024 - 01/20/2025. Further review of the progress notes revealed no documentation to indicate CR #1 refused any showers/bed baths, hair washes, hair combing, or nail care. There was no documentation regarding CR #1's thick brown scalp accumulation and none regarding the matted hair on the back of her head. Record review of CR #1's Shower Sheets for January 2025 and February 2025 revealed the following: * 01/01/2025: New Skin Issues? No . Nail Care Complete? No. Comments: Bed bath. Signed by CNA F. * 01/04/2025: New Skin Issues? No . Nail Care Complete? Yes. Comments: None . Signed by CNA G. * 01/04/2025: New Skin Issues? No . Nail Care Complete? No. Comments: Bed bath . Signed by CNA F. * 01/14/2025: New Skin Issues? No . Nail Care Complete? No. Comments: Shower . Signed by CNA F. * 01/18/2025: New Skin Issues? No . Nail Care Complete? Yes. Comments: Shower. Signed by CNA F. * 01/25/2025: New Skin Issues? No . Nail Care Complete? No. Comments: bed bath. Signed by an unknown staff member. * 01/28/2025: New Skin Issues? No . Nail Care Complete? Yes. Comments: Blank. Signed by CNA F. * 01/30/2025: New Skin Issues? No . Nail Care Complete? Yes. Comments: Blank. Signed by CNA S. * 02/01/2025: New Skin Issues? No . Nail Care Complete? Yes. Comments: Blank. Signed by CNA F. * 02/04/2025: New Skin Issues? No . Nail Care Complete? Yes. Comments: Blank. Signed by CNA S. * 02/06/2025: New Skin Issues? No . Nail Care Complete? Yes. Comments: Blank. Signed by CNA F. * 02/11/2025: New Skin Issues? No . Nail Care Complete? Yes. Comments: Blank. Signed by CNA F. * 02/15/2025: New Skin Issues? No . Nail Care Complete? Yes. Comments: Blank. Signed by CNA F. Observation and interview with CR #1 on 02/19/2025 at 3:11 p.m. revealed she was in bed at an acute care hospital. CR #1's eyes were closed, and she did not respond verbally or non-verbally to questions. CR #1's hospital nurse touched her head and eyes, and CR #1 began to wave her hand to remove the nurse's hand from her head. CR #1's entire scalp was covered with a thick brown, flakey substance. The hospital nurse said CR #1 may have seborrheic dermatitis on her scalp or she may just have an accumulation of natural oil and hair products. The hospital nurse said it appeared as though nobody had agitated or scratched CR #1's scalp (while washing it) for some time. She said CR #1 may need a special shampoo if she had dermatitis. CR #1 also had a large amount of matted hair in the back of her head. On one side, the matted hair resembled the shape of the palm of a hand and measured approximately 4x3 inches. There was a smaller piece on the other side of CR #1's head that was connected to the larger piece. The smaller piece was shaped like a small, flat light bulb. Observation of CR #1's nails revealed they were all yellowish in color and most of the nails were long and had a dark brown/black substance underneath them. CR #1 never made any sound or gestures to indicate she understood or heard interview questions. The hospital nurse stated CR #1 had been nonresponsive since she was admitted to the hospital. In a telephone interview with LVN I on 02/19/2025 at 10:33 p.m., she stated she worked the night shift and often cared for CR #1. She stated CR #1 required total care and was confused, so staff had to anticipate her needs. She said she witnessed CNAs give CR #1 bed baths and she observed them wash her hair. She stated she observed staff wet CR #1's hair, then scrub her scalp and rinse it by pouring water over it from a basin. She said CR #1's hair had been matted for a while (she could not recall how long). She said they (she did not specify who they was) tried to brush CR #1's hair out. She said she was not sure if anybody ever notified CR #1's RP about the matted hair, but she did not. She said she never observed any accumulation on CR #1's scalp. She said the facility had a beauty shop and the beautician came once per week, but she did not think CR #1 ever went to the beauty shop. She said when a resident's hair was matted, they usually tried to resolve it by cutting it off. She said she was not sure why they never cut CR #1's matted hair off. In a telephone interview with CNA F on 02/19/2025 at 10:50 p.m., she stated she had worked at the facility for about four months, and she often cared for CR #1 on the night shift. She stated CR #1's hair was matted in the back for as long as she had been caring for her. She said the first time she bathed CR #1, she attempted to wash her hair with warm water and soap. She said she tried to massage CR #1's scalp and used a basin to rinse the soap out. She said she never noticed any accumulation on CR #1's scalp, but her hair could not be combed. She said she never attempted or inquired about cutting CR #1's hair because the matting was there when she started working there. In an interview with CNA B on 02/20/2025 at 10:15 a.m., she stated she had worked at the facility for a year-and-a-half, and she often cared for CR #1 on the day shift. She said CR #1's showers were scheduled for Tuesdays, Thursdays, and Saturdays on the night shift. She said the night shift CNA tried to wash CR #1's hair, but it was already matted. She said CR #1 was the type of resident who really did not want anybody to touch her. She stated CR #1 always had the brown, flakey accumulation on her scalp for as long as she had been working there. She said she did not know if CR #1's RP knew about the matting and brown accumulation, but the RP did know CR #1 refused to get out of bed. She said the facility had a beauty shop, but she was not sure if CR #1 ever went. She said she tried to comb CR #1's hair, but she was tender headed (her scalp was sensitive to pulling) and she did not let her. She said she was responsible for showering CR #1's roommate and she also cleaned CR #1's nails at that time, so the night shift CNA would only have to shower CR #1. In a telephone interview with CR #1's RP on 02/20/2025 at 12:10 p.m., she stated nobody ever called her to let her know CR #1's hair was matted or that she had the thick accumulation on her scalp. She stated CR #1 was always laying down when she visited her, so she never thought to look at the back of her head. She said the front of CR #1's hair always looked combed. She said the facility had a beautician and the staff could have sent CR #1 to the beauty shop any time. She said she had to cut off all CR #1's hair from the back on 02/19/2025. She said she also tried to scratch CR #1's scalp to remove the flakey, brown material, but all of it did not come off. She said she cut and cleaned CR #1's nails at the hospital as well. She said when she saw CR #1 at the hospital on 02/18/2025, she called the facility to ask them about her hair. She said the facility staff (she did not know who she spoke with) told her they bathed and washed CR #1's hair on Tuesdays, Thursdays, and Saturdays. She said the accumulation on CR #1's scalp looked like cradle cap (crusting and white or yellow scales on a baby's scalp which occurs because of excessive oil production by skin glands surrounding hair follicles) that a baby would have. In a telephone interview with CR #1's physician on 02/21/2025 at 10:09 a.m., she stated she had been responsible for CR #1's care for several years. She stated some residents got seborrheic dermatitis on their scalps, but nobody ever notified her that CR #1 had any issues because she would have ordered a special shampoo. She said CR #1 was always in bed, so she never saw the back of her head. In an interview with the ADON on 02/24/2025 at 11:35 a.m., she stated she was not aware CR #1 had matted hair or an accumulation on her scalp. She said she previously told the staff that even when CR #1 refused care, they should keep asking and encourage her. She said she previously called CR #1's RP to ask her about encouraging CR #1 to accept assistance with ADLs and taking medication. She said if she knew about CR #1's scalp and hair, she would have notified her RP. She said the nurses and CNAs were responsible for letting her (the ADON) know about these issues (the matted hair and scalp accumulation) so she could speak with CR #1's RP. She said the brown accumulation was probably caused by not washing CR #1's hair or putting oil on her hair, letting it build-up, and not washing it. She said the build-up could have caused CR #1 to have skin irritation and itch. Record review of the facility's policy titled, Activities of Daily Living, Optimal Function revised 05/05/2023 revealed, Definition: Activities of daily living (ADLs) refer to tasks related to personal care including, grooming, dressing, oral hygiene, transfer, bed mobility, eating, bathing, and communication system. Policy: The facility provides care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. The facility provides necessary care to all residents that are unable to carry out activities of daily living on their own to ensure they maintain proper nutrition, grooming, and hygiene . 3. Facility staff develop and implement interventions in accordance with the resident's assessed needs, goals for care, preferences, and recognized standards of practice that address the identified limitations in ability to perform ADLs .

47215 Based on observation, interview and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 14 residents (Resident#3 and #4) reviewed for pressure ulcers. -The facility failed to provide adequate treatment services to heal pressure ulcers for Resident #3's wound infection on the right buttock, stage 4 pressure ulcer injury that was noted on doctor's order for 12/29/2023. -The facility failed to ensure supplies were available for the ADON to provide adequate wound care treatment to Residents #3 and #4 on 1/14/2024. The ADON made her own dry dressing while providing treatment to Residents #3's and Resident #4's pressure ulcer by using gauze and tape. There were no sacral dressings or border gauze available for use. -The facility failed to follow the physician's orders while providing wound care treatment to Resident #3. The ADON did not give Bactroban which was an order given by the doctor to treat Resident #3's pressure ulcer. -The facility failed to ensure ADON A performed hand hygiene when moving from a dirty to clean site, while performing Resident #3's wound care on 01/14/2023. These failures could place residents with pressure ulcers at risk for developing new pressure ulcers or a decline in existing pressure ulcers. An Immediate Jeopardy (IJ) was identified on 01/15/2024 at 3:11 PM. While the IJ was removed on 01/18/2024 at 3:30 PM, the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that was not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. These findings included: Resident#3 Resident #3's face sheet revealed he was a [AGE] year-old man, admitted to the facility on [DATE] and readmitted on [DATE]. His diagnosis included, quadriplegia, abnormal blood-gas level (may be due to lung, kidney, metabolic diseases, or medicines), urinary tract infection (an infection in any part of the urine system, the kidneys, bladder, or urethra), need assistance for personal care, pain in unspecified joint, type 2 diabetes (a chronic condition that affects the way the body processes blood sugar), and neurogenic bowel (loss of normal bowel function, caused by a nerve problem). Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed BIMS score of 13, indicating cognition is intact. Further review of Resident 3's MDS revealed he needed total dependence for bed mobility and transfer and needed two persons physical assistance. He was total dependence for eating and toilet use and needed one-person physical assistance. Record review of Resident #3's care plan dated 11/30/2023 revealed Resident #3's problem is pressure ulcer injury. It revealed, Resident #3 has a stage 4 pressure injury to his sacrum. The goal: wound to heal without complications. Approach: follow MD orders as provided by MD, provide low air loss mattress, report any abnormal conditions to MD immediately, medicate for pain as needed. It also revealed stage III pressure injury to Rt elbow, pressure ulcer will heal without complications. Goal: keep clean and dry as possible, minimize skin exposure to moisture, lab work as ordered by physician. Record Review of Resident #3's physician orders dated 1/11/2024 revealed, wound number: 7, wound location: right buttock, wound type: stage 4 pressure ulcer, acquired wound condition: chronic, wound status: not healed. Cleanse wound with normal saline, apply Santyl, apply Bactroban, apply alginate, cover wound with dry absorptive dressing, and change dressing daily. The benefits of risk debridement with alternatives were discussed with Resident #3 who agreed with procedure on 1/11/2024. Record Review of Resident #3's physician orders dated 12/28/2023 revealed Resident 3's wound is infected and was acquired on 6/23/2021. Wound #7 S/S (signs and symptoms) infection confirmation description and treatment plan. Signs and symptoms present, systemic antibiotics prescribed, topical antibiotics prescribed. Observation and interview on 1/13/2024 beginning at 4:16p.m. with Resident #3, revealed him lying in bed with a bed table over him and he was watching television. He had an air mattress and boots on both feet. He also had a catheter. The resident is lying on a draw sheet. The wound Care Nurse and CNA A revealed that Resident #3 had an ABD pad and tape covering his wound in place of the dry dressing that was documented in the physician orders. The ABD pad was covering a sacral wound on the left and right buttocks. Resident #3 said the facility ran out of supplies. He said they ran out of bandages and the strap to hold his catheter cord in place. He said staff comes and change his wounds, but they do not use the correct supplies to cover his wounds. Nurse Surveyor Observation on 1/14/24 at 12:50p.m. revealed the ADON provided wound care for Resident #3. The ADON was assisted by CNA A. The ADON gathered the supplies at the treatment cart in the hallway before bringing them into Resident #3's room. Prior to initiation of the treatment, Resident #3 was assisted onto his right side. The ADON unhooked the foley catheter from the right side of the bedframe and placed the catheter on the bed next to Resident 3's legs. The ADON removed the Resident #3's soiled, left buttock, wound dressing, and placed it in the trash can, sitting by the foot of his bed. The dressing contained a moderate amount of serosanguinous drainage. No foul odor was noted. There was no date visible on the dressing. Continued observation revealed an open area of approximately 3 centimeters in diameter. The ADON then cleansed the pressure wound with the normal saline solution x2. The ADON, with soiled gloves, applied Santyl and Silver Alginate to the wound bed, covered with Kerlix super sponges measured 6x6-3/4 and hypafix adhesive non-woven fabric band. The ADON said, I am making dry dressing. The ADON removed her gloves, washed her hands, donned clean gloves, and removed sacral area dressing. Continued observation revealed an open area of approximately 3 centimeters in diameter. The ADON then cleansed the pressure wound with the Normal saline solution x2. Continued observation revealed an open area of approximately 3 centimeters in diameter. The ADON then cleansed the pressure wound with the normal saline solution x2. With the soiled gloves grabbed scissor and cut a small piece of Silver Alginate and placed it onto the wound bed. Covered with Kerlix super sponges measured 6x6-3/4 and hypafix adhesive non-woven fabric band. ADON removed soiled gloves and washed her hands. Resident #3 was assisted onto his left side by CNA A while the ADON donned clean gloves. The ADON removed the Resident #3's soiled Right buttock wound dressing and placed in the trash can sitting by the foot of his bed. The dressing contained a moderate amount of serosanguinous drainage. Foul odor was noted. There was no date visible on the dressing. Continued observation revealed an open area of approximately 5 centimeters in diameter. The ADON then cleansed the pressure wound with the Normal saline solution x1. ADON removed her soiled gloves without washing or sanitizing her hands and said, I need to go get gauze and went to her cart. She returned a few seconds later and sanitized her hands, donned clean gloves, and cleansed the pressure wound with Normal saline solution x1. Applied Santyl to the wound bed. Removed her soiled gloves, without washing or sanitizing her hands and said, I need to go get Silver Alginate and went to her cart. Returned in few second sanitized her hand, donned clean gloves then applied Silver Alginate to the wound bed. Covered with Kerlix super sponges measured 6x6-3/4 and hypafix adhesive non-woven fabric band. (The ADON failed to apply Bactroban and Alginate as per physician orders -wound evaluation dated 1/11/24). Resident #3's foley was on the bed while the ADON provided wound care. Interview on 1/14/2024 at 2:45p.m. with the ADON. The Interviewer reviewed Resident #3's physician's order with the ADON. The ADON said she did not see the order for Bactroban and Calcium Alginate for Right buttock wound in the Matrix. The ADON said she did not have Bactroban in the wound care nurse's cart. The ADON said she was unable to find the border dressing in the wound care cart. She said, I don't know where the wound care nurse kept the dressing. Therefore, I made my own dry dressing using the gauze and tape. The ADON said the foley should have been placed below and not on the bed with the Resident #3 during wound care. She said the risk would be contamination and back flow of urine. Follow-up interview on 1/14/2024 at 4:28p.m. with ADON A and ADON B., ADON A said the Wound Care Doctor rounded with the Wound Care Nurse every Thursday and sent over the wound evaluation to the facility on Friday. The ADON said the Wound Care Nurse would then go over the wound evaluation for new order, recommendation, etc. She said the DON was assisting the Wound Care Nurse with entering new orders from the wound evaluation in the Matrix . She said she did not get a chance to look over 1/11/24 recent wound evaluations. She said the Administrator sent the wound evaluation to the Interviewer on yesterday (1/13/24) and she forwarded the same email to the Interviewer today (1/14/24). She said the new orders were not entered from the last Wound Care Doctor's visit on 1/11/24. Therefore, she was not aware Resident #3 had an order for Bactroban. She said Bactroban was used to treat infections. She said it was important to follow physician's order for proper wound care. The Interviewer shared Resident #3's Wound Care from earlier that day (1/14/2024) during the wound care treatment. The ADON said she should have washed/sanitized her hands after cleaning the wound, dirty to clean and prior to placing the clean dressing on the wound. The ADON she was waiting for the Wound Care Nurse to get to the facility. She said when she found out that Wound Care Nurse quit on them today 1/14/2024, she had to take care and to the wound care for the Surveyor. She said there was no border dressing in the wound care nurse cart. So, I made my own . It's clean environment. The gauze did not have to be sterile. Interview on 1/14/2024 at 5:04p.m. with the Wound Care Doctor, he said in the past he had concerns with Resident #3's wounds with infections. Resident #3 was placed on systemic antibiotics. He said he ordered Bactroban prophylactic last Thursday's visit (1/11/24) because the Resident #3 was incontinent of bowel. The Wound Care Doctor said, it's unorthodox using gauze. He said gauze did not have absorption capability like a typical boarder dressing. He said giving the fact the facility is in short supply. He said it would affect the wound if no proper infection control was used during wound care. Observation and interview on 1/15/2024 beginning at 4:28p.m. with Resident #3 revealed him lying in bed watching television. He said staff came in this morning and gave him a new dressing. He said he was feeling fine. Observation and interview on 1/18/2024 beginning at 1:58p.m revealed Resident #3 lying in bed with a blanket covering him up to his chest. He had the television on and a bed tray over his bed. He said staff has been working on his wound and has been covering it properly. He said they changed his dressing daily and he was in no pain. Resident#4 Resident #4's face sheet revealed he was a [AGE] year-old woman, admitted to the facility on [DATE]. Her diagnosis is dementia, muscle weakness, pressure ulcer of right hip stage 3, dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus ., hypertension, and contracture right hand (an abnormal thickening of tissues in the palm of the hand. Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed a BIMS score of 99, indicating resident was unable to complete interview. Further review of Resident #4's MDS revealed she was needed extensive assistance and one-person physical assistance for bed mobility, total dependence and two persons physical assistance for transfer and total dependence and one-person physical assistance for eating and toilet use. Record review of Resident #4's care plan dated 8/3/2023 revealed Resident #4's problem was pressure ulcer/injury. Resident #4 was at risk for skin breakdown. Long term target date: 12/8/2023, skin will remain clean, dry, and intact without evidence of breakdown through the nest review date. Approach: monitor for incontinence per routine rounds and prn change promptly, monitor for skin breakdown report to M.D. and R.P. Record Review of Resident #4's physician orders dated 1/11/2024 revealed, wound number: 2, wound location: right hip, wound type: stage 3 pressure injury. Clean wound with normal saline, fill wound with iodoform, cover wound with dry absorptive dressing, change dressing daily, reposition per facility protocol, and off load wound. Observation on 1/13/2024 1:45p.m. with Resident #4, revealed her lying asleep in bed. The bed was in a low position. There is a floor mat on the right side of the bed. There is a blue blanket covering resident up to her chest. There is a wheelchair in her room. The television was on and there are pillows on the resident's right side. Observation on 1/13/2024 at 4:23p.m. with Resident #4 revealed her with a border gauze on her buttocks. It is a small patch. The Wound care Nurse said she used the last border gauze on the Resident #4 and tonight she will have to use something else to substitute for the dressing. Observation on 1/15/2024 at 4:03p.m. with Resident #4 revealed her lying asleep in bed. She has a blanket covering her up to her chest. The call light is on top of the blanket. The television was on and the bed was in a low position. Floor mat was on the left side of the bed. Interview on 1/13/2024 at 1:00p.m. with Family Member A said, she spoke to the Wound Care Nurse and informed her that Resident #4, did not have a dry dressing on her wound. She said she asked the ADON and the Social Worker to look at the wound. She said they looked at the wound and they were baffled when they notice there was not a dry dressing covering Resident #4's wound. She said they told her they would train their CNAs better. She said staff lied about having medical supplies. She said for two weeks or more there were no medical supplies to treat the resident's wounds. She said the ADON apologized to her on 1/11/2024 for not having supplies. She said it was also verified by the medical records department that they were out of supplies. She said she had copies of the grievances she made concerning Resident #4's wounds. She said she comes to visit Resident #4 every day. She said Resident #4's other family comes to visit her at night. Family Member A said she sanitized the walls and doors in Resident #4's room. She said Resident #4 cannot do anything for herself. She said would like for Resident #4 to be treated with dignity and loyalty. Interview on 1/13/2024 at 2:40p.m. the Wound Care Nurse said she had been working at the facility for 6 months. She said she changed the resident's dressings daily. She said she did admissions skin checks, and readmission from the hospital. She said she did treatments for skin and wounds. She said she used sacral dressings, 4X4 border gauze, and waterproof dressings to treat the wounds. She said normally she would have what she needed to treat the resident's wounds, but lately she did not have what she needed. She said she had been using ABD pads and Kerlix in place of the dressings. She said she had been using those items because she did not have the normal dry dressings that she normally used. She said the facility is low on supplies. She said the Central Supply person who oversees the ordering of the supplies, could not put in the orders because she had to receive permission from the Administrator. She said the Central Supply person was told by the Administrator not to order the supplies due to budget. She said the DON told her to put in an order and she put in an order last week, but when shipment came it was not on the order list. She said she was not sure if they will have supplies next week. She said the facility had been without supplies for a month now. Observation on 1/13/2024 at 3:36p.m. revealed, on the wound care cart, there was only Alginate strips (absorb wound fluid resulting in gels that maintain a physiology moist environment) on the cart. There were no other supplies available on the wound care cart. There was an empty box of border gauze. Interview on 1/13/2024 at 3:40p.m. with the Wound Care Nurse, said she ran out of border gauze weeks ago. She said had to use abdominal pads and tape in place of the regular dressings. Follow-up interview on 1/13/2024 at 4:50p.m. with the Wound Care Nurse said she informed the Doctor that the facility ran out of supplies, and they have been substituting the dressings with ABD (abdominal gauze) pads. She said she told him they have not ordered wound care supplies. She said the Doctor told her he has never heard of that before. She said he told her that the facility needs to get supplies. Interview on 1/14/2024 at 11:50a.m. with the Wound Care Doctor , he said the Wound Care Nurse left a message regarding the shortage of supplies at the facility. He said the dry dressings and the border gauze are primary dressings and secondary dressing would be the abdominal pads. He said primary dressings are more important. He said Resident #4's wound was not doing well. He said Resident #4's wound was a medical copiability. He said wounds are stable for most residents. He said ABD pads were okay to use as a secondary dressing. He said he preferred the facility to use border gauze which is the primary dressing and order more supplies. Observation on 01/14/24 at 3:13p.m. revealed the ADON provided wound care for Resident #4. The ADON was assisted by CNA A. The ADON gathered the supplies at the treatment cart in the hallway before bringing them into Resident #4's room. Prior to initiation of the treatment, Resident #4 was assisted onto her left side. The ADON removed the Resident #4's soiled right hip area wound dressing and placed it in the trash can, sitting by the foot of her bed. The dressing contained a moderate amount of serosanguinous drainage. No foul odor was noted. The dressing was dated 1/13/24. Continued observation revealed an open area of approximately 0.3 centimeters in diameter. The ADON then cleansed the pressure wound with the normal saline solution x2, filled wound with iodoform and covered with 6x6-3/4 gauze and tape. The ADON said, the tape is not staying I will have to re-do the wound care. Observation on 1/14/24 at 3:40p.m. revealed CNA A provided Resident #4 with incontinence care. CNA A removed Resident #4's brief and tucked it under the resident's buttocks. CNA A did not spread Resident #4's labia to thoroughly clean the area and the resident's urinary meatus. CNA A assisted Resident #4 to turn onto her right side to clean her buttocks. CNA A, without removing her soiled gloves, tucked clean brief under the Resident 4's buttocks. CNA A opened Resident #4's side drawer and looked for wipes. With soiled gloves, CNA A applied (Vaseline-per family's request) on the Resident #4's buttocks. Then, removed her right-hand soiled glove (left-hand soiled glove on) and fasten the brief. CNA A completed perineal care and with the same soiled gloves on, touched the Resident #4's clean shirt, brief, sheet, and blanket. Observation on 1/14/2024 at 3:46p.m., ADON removed the gauze and tape recently placed on Resident #4's Right hip wound and placed a boarder dressing dated 1/14/24. The ADON said, We were able to find 3 boxes of the boarder dressings in the Hall 100's nurses' cart. Interview on 1/14/24 at 3:55p.m. with CNA A, she said she had been working at the facility for 3 years as a full-time employee. CNA A said she did not spread Resident #4's labia and clean her meatus during incontinent care. She said, I should have cleaned her properly. I got nervous. She said the failure placed Resident #4 at risk for infections. She said she could not recall doing CNA competency checks for incontinent care at the time of hire. She said she received training from school on how to perform incontinent care. She said she did not recall receiving training on proper incontinent at this facility at the time of hire. CNA A said she had not performed hand hygiene during the delivery of incontinent care to Resident #4, I was nervous. CNA A said her actions in not performing hand hygiene while changing gloves could result in cross contamination. She said she had completed in-service on infection control 2 to 3 months ago and could not recall the exact date. Interview on 1/15/2024 at 4:33p.m. with the Administrator, she said wound care supplies came in earlier in the day on 1/15/2024 from the company they order supplies from. Observation on 1/15/2024 at 4:39p.m. there were no supplies in the wound care office and there were no supplies on the wound care cart. Observation on 1/15/2024 at 4:45p.m. in central supply room, revealed border dressings: 16 boxes, sacral dressings - 0, Opti foam gentle-silicone faced foam boarder dressings: 4 boxes, alginate: 2 large boxes, 3 small boxes, and 8 strips. Kerlix: 13 super sponges and 13-25 comes in pack. Interview on 1/15/2024 at 4:51p.m., the Central Supply person said, she ordered supplies every week. She said she ordered whatever the wound care nurse told her to order. She said no one came to her and informed her that border gauze and sacral dressings were needed. She said she would leave a sheet of paper for staff to fill out if they were low on supplies. She said she would also put it in the nurse's station. She said she never told anyone that she was unable to order supplies due to budget. She said she had been working at the facility since May. Interview on 1/15/2024 at 5:03pm with the Administrator, she said the Central Supply person gets with the Wound Care Nurse and the DON to go over the order list and discuss what supplies are needed. She said before it is ordered the DON will review it. She said no one has come to her in months to tell her that they were low on supplies. She said not even the DON. She said there was a concern about supplies that was expressed by a family member. She said she went to the ADON and asked if they had supplies and the ADON checked to see if they had supplies and she said the supplies were there. Interview on 1/16/2024 at 5:05p.m., DON said she looked at orders that were given to her by the Central Supply person and the Wound Care Nurse would write down what supplies were needed. She said she would print the list and bring it to the morning meetings to confirm the orders. She said the Central Supply person would give the order list to the Administrator for submission. She said the last time an order was placed was on 1/12/2024. She said she did not notice that she was low on supplies. She said she went on vacation December 2023 and came back 1/3/2024. She said when she returned from vacation, the Central Supply person told her she was instructed not to order supplies by the Administrator. She said she told her to go ahead and order the supplies and if there was any blow back , like any repercussions, it was on her. She said had she known they were low on supplies, she would have ordered it before she left for vacation. Interview on 1/16/2024 at 5:21p.m. with the ADON, she said the Wound Care Nurse would sit with the Central Supply person and the Central Supply person would give the order to the Administrator and the Administrator would submit the order. She said the DON would ask the Central Supply person if she needed wound care supplies. She said the Central Supply person told the DON they had just enough supplies until a new order came in. She said when the DON returned from vacation they were out of supplies. Observation and interview on 1/16/2024 beginning at 5:30p.m. with the ADON. In the central supply room, revealed 3 boxes of sacral dressings, 5 dressings in each box. The ADON said they did not order many sacral dressings due to budget. She said there was a process of ordering sacral dressings. She said the order was placed on Friday and it may come in on Tuesday. Follow-up interview on 1/17/2024 at 1:52p.m. with the DON, she said she was trained on 1/16/2024 and she is now responsible for ordering wound care supplies and will make sure they have enough supplies for the facility. She said she will take the invoice and compare it to the order, to make sure everything was delivered, and nothing was on back order. She said she was going to make sure supplies are available and would make sure the proper care was provided per the physician's order. She said if the supplies are not available, she said it could be an adverse reaction to the resident if they don't have what the physician ordered. Interview on 1/17/2024 at 2:06pm, with the Environmental Services Supervisor over housekeeping and laundry. She said she had ordered supplies at the facility in the past. She said the last time she ordered for central supplies was either march or April of 2023. She said she had not ordered anything recently. She said the Central Supply person took over her position when she was promoted as a supervisor over laundry. She said when she first started working with laundry there were a few items she needed that was not available, but she said that was only for less than a week. She said when she was short, she went to another building and restocked the supplies. Record Review of the facility's policy titled Pressure Ulcers, dated 1/18/2017, read in part, .Pressure ulcers will be evaluated and treated in accordance with professional standards of practice to heal and prevent pressure ulcers unless clinically unavoidable. Evaluate the pressure ulcer initially for location; stage (see specific policy), size (in em's), sinus tracts, undermining, tunneling, exudate (type, odors), necrotic tissue, and the presence and or absence of granulation tissue and epithelialization. Determine and record the date of onset for each pressure ulcer identified as Stage II or greater. The date of onset is included in the information for the wound on the weekly wound tracking sheet and carried over week to week until healed. If a wound deteriorates to a higher stage, the original onset date is retained. For example, a Stage II pressure ulcer with an onset date of August 1 of this year that deteriorates to a Stage III or Stage IV, will continue to be tracked with an onset date of August, the concern is with the original date of the insult to the skin. Re-evaluate pressure ulcers at least weekly. If the patient's/resident's condition or the condition of the wound deteriorates, or if there is no significant progress within a reasonable time frame (2 weeks), the treatment plan should be re-evaluated. If the treatment plan is not changed, documentation should be provided as to why current treatment plan is being maintained . This was determined to be an Immediate Jeopardy (IJ) on 01/15/24 at 3:011 PM. The Administrator was notified. The Administrator was provided the Immediate Jeopardy template on 01/15/24 at 3:12 PM. The following Plan of Removal was submitted and accepted on 01/16/24 at 2:00 PM. Plan of Removal January 16, 2024 Immediate action: Other residents affected: o F686-- The facility failed to ensure Resident #1, Resident #2, and Resident #3, received adequate treatment services to heal pressure ulcers. o The facility failed to ensure supplies were available to provide adequate wound care treatment. o The facility failed to follow the doctor's order while providing wound care treatment. o Resident #1, Resident #2 and Resident #3's wound care orders were confirmed with wound physician to validate accuracy and needed supplies on 1/16/24. Nursing Management will validate proper medicine and supplies are being used by visual inspection on 1/16/24. o An audit of notes from the wound physician's current resident list will be completed by The Director of Nursing/Designee on 1/15/24 to identify new physician orders. Any orders identified will be implemented at time of discovery. o A physician order audit will be completed by the Director of Nursing/Designee on current residents with pressure wounds to validate appropriate supplies are available. If supplies are not available, physician will be notified for additional orders until supplies can be obtained from supplier. Supplies will be ordered and delivered to facility by 1/16/24. o Assistant Director of Nursing/designee will complete assessments on current residents with pressure wounds to identify signs and symptoms of infection on 1/15/24. If signs and symptoms of infection are present, physician will be notified upon discovery and additional orders obtained if directed. No additional residents with signs and symptoms of infection identified. One resident is being treated for infection since 1/3/24. Facilities Plan to Ensure Compliance and Monitoring: o Director of Nursing educated the wound physician on 1/16/24 to ensure a verbal exit with the Director of Nursing/Designee occurs prior to the physician leaving the building ensuring new orders are identified, carried out timely and supplies are available. o Licensed nurses were re-educated by the Director of Nursing/Designee on the exit process for the wound physician on 1/15/24 that includes ensuring a verbal exit is completed with the Director of Nursing/Designee prior to the physician leaving the building to ensure new are orders are identified, carried out timely and supplies are available. o Central Supply Person was reeducated by the Administrator/Designee on need for wound care supplies to be ordered timely and as needed per physician orders on 1/15/24. o Central Supply person will be provided a list of the current wound care case load and supplies needed by the Director of Nursing/Designee by 1/16/23. o Central Supply person will attend morning meeting to identify additional supplies needed through new orders or any supply issues. o Central Supply will order supplies per facility process weekly to ensure wound supplies are available for wound care. Any issues with supplies or anticipated issues with supplies will be discussed with the Director of Nursing upon notification so additional arrangements can be made to obtain supplies or physician notified for recommendations. o Licensed nurses will receive reeducation on wound care by the Director of Nursing/Designee by 1/16/24 including: o Providing treatment and care per physician's order o Validating supplies are available. If supplies are not available, notifying the physician for additional orders and notifying the Director of Nursing of need for supplies. o Licensed Nurses not receiving this education 1/15/24 will receive prior to their next scheduled shift and this will be completed in New Hire and agency orientation. o Licensed Nurses will have wound care competencies completed by the Director of Nursing/Designee including following physician order for supplies to be used and documentation with description of any observed changes in wound or skin integrity. o These competencies will be completed by 1/16/24. Licensed nurses who have not completed a competency by this date will receive prior to their next scheduled shift and this will be completed in New Hire and agency orientation. o Ad Hoc QAPI will be held on 1/15/24. o The Medical Director was notified of the Immediate Jeopardy on 1/15/24. Surveyor Monitored the plan of removal as follows: Observations were started on 01/15/2024 and continued through 01/18/24. Observation of Resident (#1, #2, #3, #4, #5, #6, #7, #8,) revealed residents receive [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure 1 resident (Resident #1) of 5 residents reviewed for medications was free of any significant medication errors, in that: -Resident #1's Lacosamide (anticonvulsant) medication was not refilled when needed. -Resident #1's Lacosamide medication ran out. -Resident #1 missed 9 doses of Lacosamide (anticonvulsant medication) that lead to Resident #1 having a tonic-clonic seizure (uncontrolled tightening and loosening of muscles that cause convulsions) and resulted in hospitalization . An Immediate Jeopardy (IJ) was identified on 11/13/2023. While the IJ was removed on 11/14/2023, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm, due to the need to evaluate the effectiveness of the corrective systems. Findings include: Record review of the Face Sheet (undated) for Resident #1 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, epilepsy (a brain condition that causes recurring seizures, cognitive communication deficit), and lack of coordination. Record review of the Quarterly MDS assessment dated [DATE] revealed Resident #1 scored 15/15 on the BIMS, indicative of intact cognition. Record review of the Care Plan (edited 10/11/2023) for seizure disorder revealed .Administer medications as ordered per MD. Record review of the Physician's Order Report dated 10/07/2023 to 11/10/2023 revealed Resident #1 was to receive Lacosamide, 10 mg/ml, 20 ml via his gastrostomy tube twice daily for seizure activity. Record review of the November 2023 MAR for Resident #1 revealed he was not administered Lacosamide once on 11/02/2023, and both doses on 11/03/2023 - 11/06/2023, a total of 9 missed doses. Record review of the PN dated 11/06/2023 at 10:34 p.m., written by * revealed Resident #1 was noted to be aphasic (unable to talk) and was staring off into space. The PN reflected the resident had drooping to one side of his mouth, and his face exhibited uncontrollable twitching. Resident #1 was sent to the hospital via 911. In an interview on 11/10/2023 at 2:28 p.m. the DON said Resident #1, while in the hospital, had said he did not receive his medication while at the facility. She said that prompted her to review the MAR. She said she discovered he had missed four days of the Lacosamide. She said she interviewed the nurses. She said that on 10/31/2023 LVN A tried to refill the prescription, but the pharmacy said it was a controlled medication, and it required a prescription. She said the pharmacy did not receive the refill prescription. She said the resident missed three days of the medication. In an interview on 11/10/2023 at 3:55 p.m., LVN A said she re-ordered Resident #1's Lacosamide before it ran out. She said she had ordered it on 11/30/2023 through the portal. She said they were supposed to send an e-script (electronic prescription). She presented a screenshot of the e-script that showed she sent the e-script to the NP on 10/30/2023 at 1:39 p.m. She said the resident had enough Lacosamide to last until 11/02/2023. She said she called the doctor's office on 11/02/2023, and they said they would send the e-script to the pharmacy. She did not recall who she spoke with. She said she passed on in her report that the medication should be arriving. She said she worked on 11/03/2023. When the pharmacy delivered, Resident #1's Lacosamide was not delivered. She said she intended to call the physician, but got busy with other duties. She said she was off duty the next three days. When she returned on 11/07/2023, Resident #1 had already been sent to the hospital. Record review of Resident #1's hospital (Hospital #1) record Emergency Department Triage dated 11/06/2023 at 10:55 p.m. revealed the Chief Complaint was Resident #1 was having stroke-like symptoms when EMS arrived, but was having a tonic-clonic seizure episode in the ED. The active diagnosis was reflected as 'seizure.' Record review of Resident #1's hospital (Hospital #1) record ED Final Report dated 11/07/2023 at 2:35 a.m. revealed he presented with seizure activity and was administered Versed 10 mg to resolve the seizure. The report reflected Resident #1 was moaning with pain and his level of consciousness was 'stuporous.' The Critical Care Note read in part .The patient presents with an illness or injury that acutely impaired one or more vital organ systems. There was a high probability of imminent or life-threatening deterioration in the patient's condition during their evaluation in the ED . The resident was transferred to the ICU at Hospital #2 on 11/07/2023. Observation and interview on 11/12/2023 at 9:50 a.m. revealed Resident #1 was in Hospital #2. He was awake and alert, lying in bed. He said he had a seizure but did not recall anything about missing medications. An attempt to contact the physician and the NP on 11/13/2023 at 10:28 a.m. was unsuccessful. An Immediate Jeopardy (IJ) was identified on 11/13/2023 at 1:35 p.m., due to the above failures. The Administrator and the DON were notified. The Administrator was provided the IJ Template at 1:40 p.m. The following Plan of Removal was submitted by the facility, and was accepted on 11/13/2023 at 5:48 p.m.: Plan of Removal POR 11/13/23 F760 Medication Error The identified resident no longer resides in the facility. A review of the medication administration compliance report was completed by the Director of Nursing/designee to identify any medications not available. No residents were identified with medications not available. MAR to cart audit, validating that there is a medication available in the medication cart for each physician's order will be completed by 11/13/23 to validate that there is a medication for any physician's order. This will be accomplished by the Director of Nursing or designee. Nursing Management will be re-educated on the following by the Clinical Consultant by 11/13/23 the following: Reviewing Medication Administration compliance report Monday - Friday in clinical morning meeting to review and resolve any issues regarding missed / unavailable medications. The RN weekend supervisor will review the Medication Administration Compliance report on the weekend to review and resolve any issues regarding missed/unavailable medications. Addressing unavailable medications when licensed nurses and/or Certified Medication Aides report that medications are not available. This will be documented by the licensed nurse or Certified Medication Aide on the 24-hour report for review by nursing management. The Director of Nursing will then document the clinical morning meeting agenda for tracking until resolved. Nurse Leadership hired after this date will complete this education presented in orientation by Clinical Consultant or designee. Nursing Management on personal time off will be educated prior to returning to work by the Clinical Consultant Licensed nurses and Certified Medication Aides will be re-educated on medication management by the Director of Nursing/designee on 11/13/23. Any licensed nurse or Certified Medication Aide on personal time off or not receiving this education by this date will receive prior to their next scheduled shift. This will be presented in new hire orientation and to agency personal. The following process for medication management will be implemented beginning 11/13/23 if a medication is not available: 1. The Licensed Nurse upon identification of a needed medication will Check the E-Kit inventory kit list to see if the medication needed is in the E-Kit and obtain and administer if it is included and then follow the re-order process. 2. The Licensed Nurse will then call the pharmacy and ask for the medication to be delivered within 4 hours, or the after-hours pharmacy number and ask for the med to be delivered within 4 hours. If the med will be delivered and will result in a late medication administration, the Doctor MUST be notified upon discovery and order written to be given when arrives from the pharmacy. 3. If a reordered medication requires a physician signature prior to dispensing, the Licensed Nurse will contact the on call provider upon discovery to request the required signature. The Licensed Nurse will call the pharmacy after 1 hour of speaking to the physician to verify the required signature for the medication has been received. 4. The Director of Nursing/designee MUST be notified by the licensed nurse upon discovery that required signature has not been received by the pharmacy, but no later than the end of shift. 5. Medication re-ordering process to prevent medication unavailability concerns. a. Medication aides and nurses will reorder medications when there is a four -to- five- day supply of medication remaining using the resupply button in Matrix to communicate with the pharmacy a refill is needed. The Director of Nursing will supervise the process implemented for medication not available Monday - Friday in Clinical Morning Meeting and the RN supervisor will supervise the process on the weekend. This re-education will be completed by 11/13/23. Any licensed nurse or Certified Medication Aide not receiving by this date will receive prior to the next scheduled shift. This will be presented to agency personnel and in new hire orientation. Licensed nurses and certified medication aides will not be able to work or administer medication until they receive this training. This will be accomplished by the Director of Nursing or designee. Medication compliance report to be reviewed daily Monday - Friday as part of the clinical morning meeting process beginning 11/14/23 in the clinical morning meeting. This will be an ongoing practice. Any concern will be addressed at the time of discovery. This will be accomplished by the Director of Nursing or designee. A MAR to Cart audit will be completed weekly for 4 weeks, or until substantial compliance is achieved to validate that medications are available for physician's orders. This will be accomplished by the Director of Nursing or designee. This practice will start on 11/13/23. Medical Director was notified of the Immediate Jeopardies and the contents of this plan on 11/13/23 by the Administrator. Monitoring for implementation of the POR was conducted on 11/14/2023: In an interview on 11/14/2023 at 1:13 p.m. MA B said she had received an in-service regarding medication re-ordering. She said she was to notify the ADON if the medication was not available. She said she was to check the medication room. In an interview on 11/14/2023 at 1:15 p.m., Agency nurse LVN C said she had received the in-service regarding medications. She said if a medication was not available, she was to check the E-kit, notify the DON, and call the pharmacy. In an interview on 11/14/2023 at 1:18 p.m., MA D said she received the in-service regarding medications. She said if a medication was not available, she was to alert the Charge Nurse. She said she or the Charge Nurse would see if the medication was available in the medication room. The Charge Nurse was then to call the pharmacy. In an interview on 11/14/2023 at 1:20 p.m., LVN A said she had received the in-service regarding medications. She said if a medication was not available, first check the cart. If it was not available in the facility call the pharmacy. Notify the DON and ADON. She said if the medication required a signature, make sure the pharmacy received the e-script. She said she would also check the E-kit. In an interview on 11/14/2023 at 2:15 p.m., ADON E said the ADONs were to review the Medication Administration Compliance Report daily. He said the report was not part of the MAR but had data to show when medication administrations were missed and new medication orders. He said on the weekends the Weekend Supervisor was to check the report, and the ADONs review the weekend activity on Monday mornings. In an interview on 11/14/2023 at 2:40 p.m. ADON F said the ADONs review the Medication Administration Compliance Report daily. She said she has been reviewing the report twice daily. She said the Weekend Supervisor reviews the report on the weekends. She said the nurses are now attending the morning meetings, and missed medications are reviewed. She said she or ADON E would be conducting new hire training. Record review confirmed the medication carts were audited as noted in the POR. Record review confirmed the Medication Administration Compliance Reports were being reviewed. Record review of the in-service Med Mgmt (Medication Management) Refills initiated 11/13/2023 revealed 8 nurses and 2 MAs with medication administration duties had attended. In an interview on 11/14/2023 at 3:10 p.m. the Administrator said the nurse should have notified the DON and the ADONs. The staff should have been more persistent. She said now they have been trained to notify Nurse Management. Record review of the facility in-service entitled Pharmacy Services Policies and Procedures, Section 7 - Medication Procurement (in-service date 09/27/2023) revealed .1. A clarification order must be written to edit an existing order . The policy read, in part, .2. Examples of orders that may need clarification include, but are not limited to the following J. Other orders that are unclear or questioned by the pharmacist . The Policy also read, in part, .The facility should contact the Physician/Prescriber when staff is notified by the Pharmacy of an order requiring clarification . The Administrator was informed the Immediate Jeopardy was removed on 11/14/2023 at 2:40 p.m. However, the facility remained out of compliance at a scope of isolated and severity level of actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 resident (Resident #1) of 5 residents reviewed for pharmacy services, in that: -Resident #1's Lacosamide (anticonvulsant) medication was not refilled when needed. -Resident #1's Lacosamide medication ran out. -Resident #1 missed 9 doses of Lacosamide (anticonvulsant medication) that lead to Resident #1 having a tonic-clonic seizure (uncontrolled tightening and loosening of muscles that cause convulsions) and resulted in hospitalization . An Immediate Jeopardy (IJ) was identified on 11/13/2023. While the IJ was removed on 11/14/2023, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm, due to the need to evaluate the effectiveness of the corrective systems. Findings include: Record review of the Face Sheet (undated) for Resident #1 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, epilepsy (a brain condition that causes recurring seizures, cognitive communication deficit), and lack of coordination. Record review of the Quarterly MDS assessment dated [DATE] revealed Resident #1 scored 15/15 on the BIMS, indicative of intact cognition. Record review of the Care Plan (edited 10/11/2023) for seizure disorder revealed .Administer medications as ordered per MD. Record review of the Physician's Order Report dated 10/07/2023 to 11/10/2023 revealed Resident #1 was to receive Lacosamide, 10 mg/ml, 20 ml via his gastrostomy tube twice daily for seizure activity. Record review of the November 2023 MAR for Resident #1 revealed he was not administered Lacosamide once on 11/02/2023, and both doses on 11/03/2023 - 11/06/2023, a total of 9 missed doses. Record review of the PN dated 11/06/2023 at 10:34 p.m., written by * revealed Resident #1 was noted to be aphasic (unable to talk) and was staring off into space. The PN reflected the resident had drooping to one side of his mouth, and his face exhibited uncontrollable twitching. Resident #1 was sent to the hospital via 911. In an interview on 11/10/2023 at 2:28 p.m. the DON said Resident #1, while in the hospital, had said he did not receive his medication while at the facility. She said that prompted her to review the MAR. She said she discovered he had missed four days of the Lacosamide. She said she interviewed the nurses. She said that on 10/31/2023 LVN A tried to refill the prescription, but the pharmacy said it was a controlled medication, and it required a prescription. She said the pharmacy did not receive the refill prescription. She said the resident missed three days of the medication. In an interview on 11/10/2023 at 3:55 p.m., LVN A said she re-ordered Resident #1's Lacosamide before it ran out. She said she had ordered it on 11/30/2023 through the portal. She said they were supposed to send an e-script (electronic prescription). She presented a screenshot of the e-script that showed she sent the e-script to the NP on 10/30/2023 at 1:39 p.m. She said the resident had enough Lacosamide to last until 11/02/2023. She said she called the doctor's office on 11/02/2023, and they said they would send the e-script to the pharmacy. She did not recall who she spoke with. She said she passed on in her report that the medication should be arriving. She said she worked on 11/03/2023. When the pharmacy delivered, Resident #1's Lacosamide was not delivered. She said she intended to call the physician, but got busy with other duties. She said she was off duty the next three days. When she returned on 11/07/2023, Resident #1 had already been sent to the hospital. Record review of Resident #1's hospital (Hospital #1) record Emergency Department Triage dated 11/06/2023 at 10:55 p.m. revealed the Chief Complaint was Resident #1 was having stroke-like symptoms when EMS arrived, but was having a tonic-clonic seizure episode in the ED. The active diagnosis was reflected as 'seizure.' Record review of Resident #1's hospital (Hospital #1) record ED Final Report dated 11/07/2023 at 2:35 a.m. revealed he presented with seizure activity and was administered Versed 10 mg to resolve the seizure. The report reflected Resident #1 was moaning with pain and his level of consciousness was 'stuporous.' The Critical Care Note read in part .The patient presents with an illness or injury that acutely impaired one or more vital organ systems. There was a high probability of imminent or life-threatening deterioration in the patient's condition during their evaluation in the ED . The resident was transferred to the ICU at Hospital #2 on 11/07/2023. Observation and interview on 11/12/2023 at 9:50 a.m. revealed Resident #1 was in Hospital #2. He was awake and alert, lying in bed. He said he had a seizure but did not recall anything about missing medications. An attempt to contact the physician and the NP on 11/13/2023 at 10:28 a.m. was unsuccessful. An Immediate Jeopardy (IJ) was identified on 11/13/2023 at 1:35 p.m., due to the above failures. The Administrator and the DON were notified. The Administrator was provided the IJ Template at 1:40 p.m. The following Plan of Removal was submitted by the facility, and was accepted on 11/13/2023 at 5:48 p.m.: Plan of Removal POR 11/13/23 F760 Medication Error The identified resident no longer resides in the facility. A review of the medication administration compliance report was completed by the Director of Nursing/designee to identify any medications not available. No residents were identified with medications not available. MAR to cart audit, validating that there is a medication available in the medication cart for each physician's order will be completed by 11/13/23 to validate that there is a medication for any physician's order. This will be accomplished by the Director of Nursing or designee. Nursing Management will be re-educated on the following by the Clinical Consultant by 11/13/23 the following: Reviewing Medication Administration compliance report Monday - Friday in clinical morning meeting to review and resolve any issues regarding missed / unavailable medications. The RN weekend supervisor will review the Medication Administration Compliance report on the weekend to review and resolve any issues regarding missed/unavailable medications. Addressing unavailable medications when licensed nurses and/or Certified Medication Aides report that medications are not available. This will be documented by the licensed nurse or Certified Medication Aide on the 24-hour report for review by nursing management. The Director of Nursing will then document the clinical morning meeting agenda for tracking until resolved. Nurse Leadership hired after this date will complete this education presented in orientation by Clinical Consultant or designee. Nursing Management on personal time off will be educated prior to returning to work by the Clinical Consultant Licensed nurses and Certified Medication Aides will be re-educated on medication management by the Director of Nursing/designee on 11/13/23. Any licensed nurse or Certified Medication Aide on personal time off or not receiving this education by this date will receive prior to their next scheduled shift. This will be presented in new hire orientation and to agency personal. The following process for medication management will be implemented beginning 11/13/23 if a medication is not available: 1. The Licensed Nurse upon identification of a needed medication will Check the E-Kit inventory kit list to see if the medication needed is in the E-Kit and obtain and administer if it is included and then follow the re-order process. 2. The Licensed Nurse will then call the pharmacy and ask for the medication to be delivered within 4 hours, or the after-hours pharmacy number and ask for the med to be delivered within 4 hours. If the med will be delivered and will result in a late medication administration, the Doctor MUST be notified upon discovery and order written to be given when arrives from the pharmacy. 3. If a reordered medication requires a physician signature prior to dispensing, the Licensed Nurse will contact the on call provider upon discovery to request the required signature. The Licensed Nurse will call the pharmacy after 1 hour of speaking to the physician to verify the required signature for the medication has been received. 4. The Director of Nursing/designee MUST be notified by the licensed nurse upon discovery that required signature has not been received by the pharmacy, but no later than the end of shift. 5. Medication re-ordering process to prevent medication unavailability concerns. a. Medication aides and nurses will reorder medications when there is a four -to- five- day supply of medication remaining using the resupply button in Matrix to communicate with the pharmacy a refill is needed. The Director of Nursing will supervise the process implemented for medication not available Monday - Friday in Clinical Morning Meeting and the RN supervisor will supervise the process on the weekend. This re-education will be completed by 11/13/23. Any licensed nurse or Certified Medication Aide not receiving by this date will receive prior to the next scheduled shift. This will be presented to agency personnel and in new hire orientation. Licensed nurses and certified medication aides will not be able to work or administer medication until they receive this training. This will be accomplished by the Director of Nursing or designee. Medication compliance report to be reviewed daily Monday - Friday as part of the clinical morning meeting process beginning 11/14/23 in the clinical morning meeting. This will be an ongoing practice. Any concern will be addressed at the time of discovery. This will be accomplished by the Director of Nursing or designee. A MAR to Cart audit will be completed weekly for 4 weeks, or until substantial compliance is achieved to validate that medications are available for physician's orders. This will be accomplished by the Director of Nursing or designee. This practice will start on 11/13/23. Medical Director was notified of the Immediate Jeopardies and the contents of this plan on 11/13/23 by the Administrator. Monitoring for implementation of the POR was conducted on 11/14/2023: In an interview on 11/14/2023 at 1:13 p.m. MA B said she had received an in-service regarding medication re-ordering. She said she was to notify the ADON if the medication was not available. She said she was to check the medication room. In an interview on 11/14/2023 at 1:15 p.m., Agency nurse LVN C said she had received the in-service regarding medications. She said if a medication was not available, she was to check the E-kit, notify the DON, and call the pharmacy. In an interview on 11/14/2023 at 1:18 p.m., MA D said she received the in-service regarding medications. She said if a medication was not available, she was to alert the Charge Nurse. She said she or the Charge Nurse would see if the medication was available in the medication room. The Charge Nurse was then to call the pharmacy. In an interview on 11/14/2023 at 1:20 p.m., LVN A said she had received the in-service regarding medications. She said if a medication was not available, first check the cart. If it was not available in the facility call the pharmacy. Notify the DON and ADON. She said if the medication required a signature, make sure the pharmacy received the e-script. She said she would also check the E-kit. In an interview on 11/14/2023 at 2:15 p.m., ADON E said the ADONs were to review the Medication Administration Compliance Report daily. He said the report was not part of the MAR but had data to show when medication administrations were missed and new medication orders. He said on the weekends the Weekend Supervisor was to check the report, and the ADONs review the weekend activity on Monday mornings. In an interview on 11/14/2023 at 2:40 p.m. ADON F said the ADONs review the Medication Administration Compliance Report daily. She said she has been reviewing the report twice daily. She said the Weekend Supervisor reviews the report on the weekends. She said the nurses are now attending the morning meetings, and missed medications are reviewed. She said she or ADON E would be conducting new hire training. Record review confirmed the medication carts were audited as noted in the POR. Record review confirmed the Medication Administration Compliance Reports were being reviewed. Record review of the in-service Med Mgmt (Medication Management) Refills initiated 11/13/2023 revealed 8 nurses and 2 MAs with medication administration duties had attended. In an interview on 11/14/2023 at 3:10 p.m. the Administrator said the nurse should have notified the DON and the ADONs. The staff should have been more persistent. She said now they have been trained to notify Nurse Management. Record review of the facility in-service entitled Pharmacy Services Policies and Procedures, Section 7 - Medication Procurement (in-service date 09/27/2023) revealed .1. A clarification order must be written to edit an existing order . The policy read, in part, .2. Examples of orders that may need clarification include, but are not limited to the following J. Other orders that are unclear or questioned by the pharmacist . The Policy also read, in part, .The facility should contact the Physician/Prescriber when staff is notified by the Pharmacy of an order requiring clarification . The Administrator was informed the Immediate Jeopardy was removed on 11/14/2023 at 2:40 p.m. However, the facility remained out of compliance at a scope of isolated and severity level of actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems.

40249 Based on observation, interview, and record review, the facility failed to ensure 1 resident (Resident #8) of 8 residents was free of any significant medication errors, in that: -Resident #8's thyroid medication was discontinued without a physician order. -Resident #8 missed 30 daily doses of the thyroid medication. The noncompliance was identified as past noncompliance (PNC). The Immediate Jeopardy (IJ) began on 08/23/23 and ended on 09/28/23. The facility corrected the noncompliance before the survey began. The failure led to Resident #8 having a TSH lab value that was Critical High. Findings include: Record review of the Resident Face Sheet for Resident #8 (no date) revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, cognitive communication deficit (decreased ability to speak and understand), hypothyroidism (disorder of the endocrine system in which the thyroid does not produce enough thyroid hormone), and dementia (a group of thinking and social symptoms that interferes with daily functioning). Record review of Resdient#8's Quarterly MDS assessment dated [DATE] revealed Resident #8's BIMS score was 3 out of 15 indicative of severely impaired cognition. The MDS reflected the resident had medically complex conditions that included anemia, heart failure, hypothyroidism (disorder of the endocrine system in which the thyroid does not produce enough thyroid hormone), and hypertension (high blood pressure). Record review of Resident#8's Care Plan initiated 03/22/2021 and revised on 08/17/23 revealed the following care plan: Problem: Resident#8 has a DX of Hypothyroidism. Goal: Resident#8 will have no unaddressed complications r/t hypothyroidism thru the next review date 11/17/2023. Approach(s): Monitor lab as per MD order, report result to MD. Administer medication as ordered per MD. Record review of the August 2023 and September 2023 MAR for Resident #8 revealed she received Levothyroxine, 100 mcg daily at 5:00 p.m. from 08/04/2023 to 08/22/2023. The Levothyroxine was not administered from 08/23/2023 to 09/23/2023. The Levothyroxine 100 mcg daily was administered from 09/24/2023 to the time of the end of the investigation (10/28/2023). Record review of Resident#8's Prescription Order dated 08/23/2023 revealed the Levothyroxine 100 mcg was discontinued by LVN E on 08/23/2023 at 1:35 p.m. The sheet reflected DC Created Date: 08/23/2023 at 01:35 PM. DC Verified By: LVN E. DC Sign Date 08/23/2023. DC Note: Per pharmacy. Order DC'D on 07/29/2023 . Record review of the current Levothyroxine order, dated 09/24/2023 revealed the resident was to receive 100 mcg of Levothyroxine nightly at 5:00 p.m. Record review of the lab result dated 09/27/2023 for Resident #8 revealed a TSH level of 54.592 ulU/ml, with the reference range of 0.450-5.330 ulU/ml. The 54.592 ulU/ml level placed the resident at risk for lethargy, weakness, and low heart rate. Record review of a Nurse Progress Note dated 09/27/2023 at 4:00 a.m. revealed an order was received to repeat the lab in four weeks. The repeat lab had not been drawn as of the exit of the investigation on 10/28/23. Record review of the Provider investigation report dated 09/26/23 written by the DON revealed read in part: .Call placed to NP to inquire if she had given any order to discontinue the residents Levothyroxine on 08/23/23. NP stated No and that she was notified on 09/24/2023, she gave order to restart medication at 100mcg and lab ordered, once resulted she could better determine if the level was therapeutic. She states she researched the issue as well when she received the information on 09/24/23 and found no order was given from their medical group to discontinue the medication . Record review of the facility's Medication Error worksheet in the PIR reflected the NP C was informed on 09/24/2023 at 5:22 p.m. that the resident had not been receiving the Levothyroxine. Record review of Resident#8's nurses note dated 9/26/23 at 11:14am revealed read in part: .Resident awake and alert at her normal baseline no verbal/nonverbal s/s distress, lethargy or hyperactivity observed, no goiter, sweating, abnormal tremors noted . Record review of SBAR for Resident#8 dated 9/24/23 read in part: .Situation: The change in condition, symptoms, or signs observed and evaluated is/are-No s/s missed thyroid meds. This started on 9/24/23. Things that make the condition or symptom worse are not providing medication per order. Things that make the condition or symptom better are therapeutic range of levels. Appearance: Resident is in her gerichair [reclining padded wheelchair] at her current baseline, talking with staff passing by as per usual, does not appear to be in distress. Review And Notify: NP on 9/24/23 at 5:10pm. Labs ordered CBC, BMP, TSH new orders pending lab results. Resident awake and alert at baseline since missed doses of levothyroxine, assessment reveals no change from prior condition. Absent of lethargy, hyperactivity, - goiter, sweating, no abnormal tremors . In an interview via telephone on 10/18/2023 at 4:45 p.m. a family member of Resident #8 said the resident did not receive her thyroid medication (Levothyroxine) for one month. She said she noticed differences in the resident's behavior. Resident was having panic attacks. Looking around. Something was off. It was so, so bad. Family member said she looked at the resident's medications and noticed the Levothyroxine was not being administered. The nurse went back through the med list. The latter part of September 2023 and the levothyroxine was not given for 4 weeks. In an interview on 10/19/2023 at 3:10 p.m., the DON said the Levothyroxine for Resident #8 had been reinstated. The DON said that a nurse had attempted to reorder the Levothyroxine when the resident's supply became low. The pharmacy said it had been discontinued. The nurse took the pharmacy's word and discontinued the medication. The DON said she spoke with NP C. NP C said not to discontinue it. NP C said to re-start the Levothyroxine at the same dose. A lab was drawn and the THS level was 'critical high (lab value that indicated the resident could be at risk of experiencing lethargy, weakness, or low heart rate).' She said she notified the MD and NP C. An order was received to continue with the current dose and redraw the lab. The facility reported the medication error to HHS (Intake #453991). She said an in-service was conducted. Before a medication is discontinued, a clarification order from the MD or NP must be obtained. Observation on 10/27/23 at 9:22a.m., revealed Resident#8 was setting on her gerichair. Resident mumbled for about 5 minutes while being interviewed and could not answer appropriately to the questions asked about her stay at the facility and medications. Record review and interview with the DON on 10/27/23 at 10:30a.m., she said Pt's family member brought it to nurse's attention on 9/24/23. Family member visited the Pt in the evenings and knew pt's medication regimen. Weekend Supervisor was in the facility when the pt's family member brought to their attention who then asked charge nurse to assess the resident and call the doctor. The DON said meds should not be discontinued unless an order was received by the MD/NP. She said Resident#8 was sent to the hospital on 7/29/23 and returned on 8/3/23. Resident resumed all her meds along with the thyroid med. Levothyroxine medication supply was running low. So, the charge nurse went to re-order the medication. The pharmacy sent notification via fax that med was d/c'd on 7/29/23. Instead of nurse calling to clarify the order the nurse d/c'd the order in Matrix (electronic medical record). She said Charge nurse LVN E discontinued the medication. The DON said LVN E went prn and then stopped coming. LVN E's last day of work was 9/28/23. This Surveyor reviewed Resident#8's progress notes with the DON. The Surveyor explained that there was no record review of the order/progress note related to the medication being discontinued or the communication with the pharmacy. The DON said nurses could check off the box to d/c med in matrix and write a reason for discontinuing the med. Or they can d/c the med and make a progress note. In this situation LVN E wrote the reason per pharmacy order dc'd and did not make a progress note. The DON said the orders were reconciliated by the physician at the beginning of the month. If the order was dropped off after then, the physician would not know until they came to see the resident. In a telephone interview on 10/27/23 at 10:58a.m., with NP C, she said the DON brought it to her attention on 9/24/23 that resident missed one month of thyroid med. NP C said risk to the resident would be hypothyroid symptoms such as increase weakness, lethargy, and low heart rate. She said the resident was not having symptoms. She said she ordered to resume med, check lab work, and follow up lab work in 4 to 6 weeks. She said NP/MD would not discontinue thyroid medication abruptly they would adjust the med dose according to the lab results. NP C said she and the physician visited Resident #8 once per month. At that time, they would assess the resident and check the orders. She said the resident was not showing any symptoms. She said they would have to wait for the lab results. In a telephone interview on 10/27/23 at 11:09a.m., with Pharmacy Tech, she said if the Pt stayed out of the facility for more than 24 hours then all the meds would be discontinued. She said when the Pt returned to the facility the nurses needed to re-admit all med orders. She said in her system it showed that the Pt was discharged from the facility on 7/29/23 therefore, the Levothyroxine order was discontinued on their end. She said the pharmacy received new order on 9/24/23. In a telephone interview on 10/27/23 at 11:18a.m., with LVN E, she said she had not worked at this facility for over 2 months and did not recall discontinuing any meds without clarifying or getting d/c order from the doctor. She said, the facility made up that documentation. In an interview on 10/27/23 at 1:03p.m., with the Business Office Manager, she said when the census line changes for example if the pt went to the hospital, discharged or had a room change. She waits couple of days and places resident on leave in their system. After the resident had been out of the facility for 3 midnights then she discharges the resident from the facility by back dating to the date the resident was sent to the hospital. She said when she discharges resident from her system. It discharges from the pharmacy system as well. She said the pharmacy asked for the census sometime weekly to check for the discrepancy to confirm when the resident went out. Record review of the facility in-service entitled Pharmacy Services Policies and Procedures, Section 7 - Medication Procurement (in-service date 09/27/2023) revealed .1. A clarification order must be written to edit an existing order . The policy read, in part, .2. Examples of orders that may need clarification include, but are not limited to the following J. Other orders that are unclear or questioned by the pharmacist . The Policy also read, in part, .The facility should contact the Physician/Prescriber when staff is notified by the Pharmacy of an order requiring clarification . It was determined these failures placed Resident #8 in an Immediate Jeopardy (IJ) situation from 08/23/2023 to 09/23/2023.The DON/Regional Nurse were notified and provided with the IJ template on 10/28/23 at 10:32am. The facility took the following action to correct the non-compliance on 09/28/2023. Record review of the facility's time sheet revealed LVN E worked on 8/23/23. LVN E's last day worked at this facility was 9/28/23. Record review of the facility's Inservice dated 9/27/23 revealed 16 nurses were in serviced by the DON/ADON on Clarification of orders. Record review of Admit/Discharge report audit from 8/1/23 to 9/30/23 was completed by ADON A, ADON B, Night charge nurse and oversight by the Regional Nurse. In an interview on 10/27/23 at 12:40p.m., with the DON, she said after it was brought to facility's attention. The ADONs, herself and the night charge nurse audited admit/discharge report from 08/01/23 to 9/30/23 to match meds with hospital discharge med list. She said moving forward residents who have been discharged and readmitted would have readmission orders reconciled against Matrix orders entered by the admitting nurse and notify MD/ NP for clarifications of any discrepancies, notify RP, any changes will also be documented in the medical record. Any pharmacy or ancillary orders that medications are discontinued will also be clarified with the MD/NP. The nurses were re-educated on Matrix physician order entry for accurate and complete order entry against the hospital readmission orders. clarification of order. The re-education was completed by 09/28/23. Any licensed nurse not receiving this re-education would receive prior to their next scheduled shift. The education would also be presented to new hires in the orientation process. Nurse management will validate administration compliance, admission/ readmission and new diabetic orders as part of the clinical meeting process and by charge nurse on the weekends including validation of accurate and complete entry into Matrix. The data will be reviewed in the quality assurance performance improvement committee meeting for three months for review and recommendations. Any concern identified will be addressed at time of discovery. Interviews were conducted on 10/27/23 and 10/28/23 with nurses on various shift they verified the understanding of in service/facility's protocol.

Based on observation, interview and record review, the facility failed to provide necessary treatment and services to promote healing and prevent worsening pressure sores for 1 of 6 resident (Resident #1) reviewed for pressure sores. - The facility failed to identify, obtain treatment to Resident #1's pressure ulcer to the top of his right foot extending to right medial (inner) foot. These failures could place resident at risk of development of new pressure sores, worsening of current sores, infection, amputation, pain, and suffering. Findings included: Review of Resident #1's face sheet dated 01/18/23, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of pressure ulcer of sacral stage 4 ( bedsore - a deep wound reaching the muscles ligaments or bones), metabolic encephalopathy ( problem in the brain cause by chemical imbalance in the blood), end stage renal ( medical condition which result in one's kidney cease functioning on a permanent basis leading to the long term use of dialysis), lack of coordination, insomnia, cough, anemia (low iron binding in the blood) chronic obstructive pulmonary disease ( disease that cause airflow blockage and breathing -related problem), muscle wasting and atrophy( decreased in size of a body part, cell, organ or other tissue ) abnormalities of gait and mobility, essential (primary) hypertension, fracture of coccyx( tailbone) Obesity (excess body weight), mixed, hyperlipidemia (high fat in the blood), pain in right shoulder and anxiety disorder Record review of Resident #1's admission MDS, dated [DATE], revealed a BIMS score of 08 out of 15, which indicated the resident's cognition was mildly impaired with stage 4. ( Section M - Skin Condition, F. Unstageable- slough and/or eschar). Resident #1's functional status revealed he required extensive assistance with bed mobility, transfer, dressing, and personal hygiene. Resident #1 was always of incontinent of bowel and continent of bladder. Record review care plan dated 03/27/23 problem started category: Pressure ulcer ( unstageable pressure ulcer at right hip, stage IV pressure ulcer at left lateral heel left buttock) goal : Skin will remain clean, dry and intact without evidence of breakdown thru the next review date Record review of Resident #1's physician's order dated 03/16/23 revealed he had a DTI to the right heel and an order to paint with betadine and LOTA, every shift. First 07:00 AM -07:00 PM. Record review of Resident #1's physician's order dated 04/06/23 revealed he had an unstageable (Full thickness tissue loss in which actual, depth of the ulcer is completely obscured by slough( yellow, tan, gray, green or brown and /or eschar ( tan, brown, or black) in the wound bed, at the right medial ankle and an order to paint with betadine and LOTA, every shift. First 07:00 AM -07:00 PM. Record review of Resident #1's physician's order revealed no new order for top right foot extending to medial foot measuring approximately 4cm (length) by 5 cm (width) with dark slough(skin peeling can have causes that aren't due to underlying disease) draining serous(excessive serous fluid could be a sign of too much unhealthy bacteria on the surface of the wound) foul odor fluid. Observation on 04/13/23 at 9:30 AM of RN A performing wound care for Resident #1 assisted from CNA C. RN A placed a box of gloves on the foot of the bed. RN A washed her hands and donned gloves, removed soiled dressing. Further observation revealed RN A did not wash her hands and donned gloves, used normal saline, poured it on a 4 by 4 gauze, then cleaned the pressure ulcer to right foot ankle. RN A cleaned the top right foot extending to the medial foot measuring approximately 4cm (length) by 5 cm (width) with dark slough draining serous foul odor fluid and the right heel with slough. The pressure ulcer had slough with a foul odor and serous drainage, RN A then doff gloves without washing hands applied betadine and taped In an interview on 04/13/23 at 10:10 AM, with RN A regarding physician's order to top of right foot ulcer extending to the medial side of the foot, with no physician's orders for the treatment. RN A said she was using the same order to the right heel. RN A said she was just helping the floor nurse and Resident #1 was not her regular resident. She said the facility wound care nurse quit last week, and she was very sorry and would notify the wound care doctor. RN A said she was trained to identify new ulcers and report them to the doctor. RN A knew not obtaining treatment order could result in sepsis and the ulcer should be identified by location and size. Interview with the wound care doctor on 04/13/23 at 12:39 PM, he said he visit the facility once a week on Thursday and RN A just told him of Resident #1's top of right foot ulcer extending to the medial side of the foot, and just debrided ( surgical removal) the slough, he said the wound was infected and will changed the treatment. Interview with the travel DON on 04/14/23 at 2:30 PM she said she was the DON and she was responsible for staff training about wound care. The DON said each ulcer should be identified and documented weekly. The DON said she started working with facility 4 days ago. She stated the nurse was also responsible for ensuring that any ulcer had treatment and documented on the weekly skin sheet log. The DON said the facility was in a process of hiring a new treatment nurse and she be in-servicing nursing staff on the identification of new pressure areas and time limits in which action must be taken. In an interview on 04/14/23 at 2:30 PM, the Administrator said nursing management would in-serviced on newly admitted residents to ensure there were no missing wound care, pressure ulcer or medication orders. The Administrator said all identified discrepancies were addressed. Record review of the facility's weekly wound tracking worksheet dated 4/6/23 revealed Resident #1's skin assessment was not listed on the wound sheet and further review of Resident #1's physican's orders on 4/14/23 revealed no documentation of new Physician's order. On 4/14/23 requested for Resident #1's physician's orders for top of right foot ulcer extending to the medial side of the foot treatment, none was provided. Record review of the facility policy titled Pressure Ulcers revised 9/23/17 reveled, 2- Determine and record the date of onset for each pressure ulcer identified as state 2 or greater. The date of onset is included in the information for the wound on the weekly wound tracking sheet and carried over week to week until healed .6- re-evaluate pressure ulcers at least weekly. If the patient/resident's condition or the condition of the wound deteriorates, or if there is no significant progress within a reasonable time frame (2 weeks), the treatment plan should be re-evaluated. 7- if the treatment plan is not changed, documentation should be provided as to why current treatment plan is being maintained. Record review of the facility policy titled Physician and Other Communication/Change in Condition revised 10/16/2017 revealed, 3- Notify the physician of the change in medical condition. (The physician notification grid may be used as a reference tool regarding the acceptable notification timeframe.) The nurse will document all assessments and change in the patient's/resident's condition in the medical record. Record review of the facility policy Admission Orders revised 11/01/17 revealed, Policy: The facility's leadership and designated licensed staff, at the time of patient/resident admission, will obtaining physician orders for the patient/resident's immediate care. Procedures- On or before the patient/resident is admitted , the physician provides the facility with the following written information, which includes but is not limited to: . e- written treatment orders that are necessary to maintain or improve the patient/resident's functional abilities.

Based on observation, interview and record review, the facility failed to provide necessary treatment and services to promote healing and prevent worsening pressure sores for 1 of 6 resident (Resident #3) reviewed for pressure sores. - The facility failed to timely identify, treat and prevent the development of Resident #3's pressure ulcer, resulting in the resident developing osteomyelitis (a bone infection). - The facility failed to perform wound care on Resident #3's right ankle pressure ulcer as per physician's orders - The facility failed to administer Medication to Resident #3 for treatment of her osteomyelitis. On 10/26/22 at 2:30 PM an immediate Jeopardy (IJ) was identified. While the IJ was removed on 11/02/22, the facility remained out of compliance at a severity level of actual harm and scope isolated due the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place resident at risk of development of new pressure sores, worsening of current sores, infection, amputation, pain and suffering. Findings included: Record review of Resident #3's face sheet revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: dementia, anxiety, muscle wasting and atrophy, left hand contracture, seizures, depression and hemiplegia and hemiparesis. The resident discharged to the hospital on 10/07/22 and returned to the facility on [DATE]. Record review of Resident #3's admissions MDS dated [DATE] revealed use of corrective lenses and moderately impaired cognition as indicated by a BIMS score of 8 out of 15. The Resident required extensive assistance and 2 + person physical assist for bed mobility, transfer and dressing as well and total dependence for bathing, used a wheelchair. The resident was always incontinent of both bladder and bowel, was at risk of developing pressure ulcers/injuries, required a pressure reducing device for bed, did not admit to the facility with any unhealed pressure ulcers/injuries and required applications of ointments/medications. Record review of Resident #3's care plan revised 10/13/22 revealed, Problem- Pressure Ulcer; Goal- Heel protectors given to resident and heel off loaded; Approach- Offload heel and ensure heel protectors in place. Problem- risk for skin breakdown related to impaired cognition, impaired mobility and incontinence of bowel and bladder; Goal- skin will remain clean, dry and intact without evidence of breakdown through the next review date; Approach- monitor for skin breakdown, report to MD and RP, provide pressure relieving and positioning devices as needed, assist with repositioning as needed. Record review of Resident #3's Progress Notes dated 08/05/22 at 4:35 PM revealed, Head to toe skin assessment performed . skin without cracks or opening. No bruising, no lesions or disruptions in skin. Record review of Resident #3's Observation Report dated 8/5/22 at 4:37 PM revealed, resident was at risk for pressure ulcers as indicated by a Braden Scale Score of 17. Record review of Resident #3's TAR for 08/2022 through 09/2022 revealed, the resident had no orders for repositioning/turning or off loading or ensuring pressure relieving devices were in place. Record review of Resident #3's Observation Report dated 9/14/22 at 10:59 PM revealed, Resident #3 did not have any skin issues. Record review of Resident #3's Observation Report dated 9/21/22 at 9:43 PM written by LPN Q revealed, Skin- comments: redness under left breast/abrasion to rt. Thigh and pressure area to right foot. Record review of Resident #3's Progress Notes dated 09/21/22 at 11:02 PM revealed written by LPN Q, resident noted with pressure area to right foot and redness under breast. The note did not contain information of nursing management, NP, MD or RP notification of the resident's right ankle pressure area. Record review of Resident #3's Therapy Screening Form dated 09/22/22 at 10:55 AM completed by OT A revealed, observation details- other ulcer to R foot . comments: Resident has an ulcer to the R foot. Resident currently on skilled therapy services. Record review of Resident #3's Observation Report dated 9/29/22 at 11:57PM written by LPN Q revealed, Skin-comments: redness under bilateral breast/treatment in place, abrasion back of right upper thigh and open area to the right ankle. Record review of Resident #3's Progress Notes dated 09/30/22 at 3:13 PM written by ADON A revealed, Noted 2.5X2.5 to Right ankle with minimal yellow slough and minimal drainage. Notified Wound Care MD for wound care notification and orders. New orders: Santyl and Alginate daily. Left Message for RP. Wound Care Nurse notified. Record review of Resident #3's Physician's Orders for 09/30/22 revealed, Clean R ankle with NS, Pat Dry, Apply Santyl and Calcium with Alginate daily and wrap with Kerlix. Record review of Resident #3's Wound Care Administration History TAR for 10/01/22 to 10/19/22 revealed, Resident #3 did not receive wound care on 10/17/22 or 10/19/22. Record review of Resident #3's Physician's Orders dated 10/13/22 revealed, order for offload heel and ensure heel protectors in place every shift. Record review of Resident #3's Observation Report dated 10/04/22 at 3:13 AM written by LPN Q revealed, patient at high risk for pressure ulcer. Record review of Resident #3's Observation Report dated 10/05/22 at 6:35 PM written by LPN Q revealed, comments: right foot wound treatment in place. Record review of Resident #3's Wound Assessment Details dated 10/06/22 written by the Wound Care MD revealed, Wound Status: Wound Location- right, lateral ankle; Wound Type- Pressure Ulcer; Date Acquired- 09/30/22; Acquired at Facility-Yes. Wound Descriptions: Wound Encounter- initial; Wound Progress- Initial Exam; Stage- Unstageable Pressure Injury Obscured full thickness skin and tissue loss. Wound Orders: Cleanse wound with normal saline . apply Santyl (collagenase), apply Bactroban, apply alginate, cover wound with dry absorptive dressing, change dressing daily, float heels with pillows. Record review of Resident #3's Hospital Wound Care Notes dated 10/09/22 revealed, Pressure Injury Prevention Measures- 1- turn and reposition every 2 hours and PRN. 2- Use of protective dressings and offloading devices to prevent injury. Record review of Resident #3's Hospital Discharge Record dated 10/13/22 revealed, the resident was discharged to the hospital on 10/07/22 due to Dilantin toxicity and readmitted to the facility on [DATE] Record review of Resident #3's Hospital Case Management Consult dated 10/13/22 revealed, Special Instructions Patient will require 6 weeks of antibiotics including meropenem 1 g IV every 8 hours as well as oral Doxycycline 100 mg twice a date. Record review of Resident #3's Hospital Discharge Records printed 10/13/22 at 13:28 PM revealed, ongoing problem- resistance pseudomonas, wound of right ankle. Take the antibiotics Meropenem which is an IV medication and Doxycycline which is an oral medication to trat bone infection in the ankle. Record review of Resident #3's Observation Report dated 10/13/22 at 6:15 PM written by ADON B revealed, Resident #3 had a 5 cm X 3 cm, 0.1 cm deep stage III pressure ulcer, with loss of epidermis. The wound was located on Resident #3's R ankle. Record review of Resident #3's Physicians Orders dated 10/19/22 revealed, no orders for IV meropenem antibiotics or orders to maintain the resident's central line or change the dressing covering the central line. Record review of Resident #3's facility Physician's Orders for 10/2022 revealed, no orders for repositioning/turning until 10/20/22. Record review of Resident #3's Physician Orders dated 10/20/22 run at 09:43 AM revealed Turn and Reposition every 2 hours and as needed Every Shift First 07:00 AM - 03:00 PM, Second 03:00 PM - 11:00PM, Third 11:00 PM - 07:00AM. Record review of Resident #3's TAR run on 11/02/22 revealed, Resident #3 received her first dose of Meropenem 1 g Intravenously every 8 hours for 6 weeks on 10/20/22 at 2 PM. Record review of Resident #3's Pressure Ulcer Healing Chart dated 11/02/22 revealed, the only entry for Resident #3's right ankle ulcer was entered by ADON B on 10/07/22 at 12:53 PM. An observation and interview on 10/19/22 at 9:27 AM revealed, Resident #3 lying in bed with no pressure relieving device on her right foot. The resident had an undated transparent dressing covering a central line (a line placed in the upper chest to administer medication via IV) that was dirty, dark brown old blood was observed under the transparent dressing and the edges of the dressing were lifting off the patient's skin and appeared yellow in color. Resident #3 said she had a central line located under the dressing that she received at the hospital to get IV medication, but she had not received any since arriving at the facility. She said since she readmitted to the facility nursing staff had not cleaned the area under the dressing or provided any care to her central line. In an interview on 10/19/22 at 10:00 AM, RN G said she did not know why Resident #3 had a central line. She said the resident returned from the hospital with the central and normally such lines were used to administer IV medications. RN G reviewed Resident #3's chart and said that the resident had no orders for IV medications or orders to maintain the central line. She said the dressing on the central line appeared to be from the hospital because the dressing on the central line was different from what was used at the facility. RN G said normally when a resident had a central line or a PICC line there should be orders to flush the line daily as well as a weekly dressing change. She said on her recent shifts she had not personally cared for the Resident #3's central line and there was nothing in the resident's EMR that indicated any other staff cared for the resident's line. RN G said the admitting nurse was responsible for ensuring all central/PICC lines were documented and orders for care/use are entered. She said she was not the admitting nurse so she could not tell why Resident #3 was missing orders for her central line, but she would escalate it to her DON. In an interview on 10/19/22 at 11:00 AM, ADON B said that when a resident arrives with a central line, the admitting nurse reconciles the medications/orders and completes a skin assessment. She said if a resident had a central/PICC line, the nurse would remove the hospital dressing to examine in and redress it including a label of the date and signature. She said dressing covering IV access sites were expected to be changed every 7 days. ADON B said if a resident's EMR did not contain an IV order, a task would not appear on the TAR, but nurses should use their professional judgement to ensure that care was provided to the access site and the dressing was changed. She said resident's that admit with IV access that was not going to be administered any antibiotics should be assessed for discontinuation of the line by escalating the issue to the physician. ADON B said that Resident #3 readmitted to the facility with a central line, but she was not on any IV antibiotics. She said she did not know why Resident #3 had a central line. In an interview on 10/19/22 at 1:04 PM, the MD said that she was unaware that Resident #3 had a central line and had no knowledge of her requiring medication to be administered via IV. She said normally when a resident admits with an IV line the MD and the nursing staff would assess the line and then discontinue it if there was no need for it. She said IV lines should be cared for per the facility nursing protocol and that all dressings should be dated and signed on the day they were placed. The MD said she was unaware if Resident #3 was supposed to be on IV antibiotics for her osteomyelitis or that the medication was not being administered. In an interview on 10/19/22 at 1:43 PM, the NP said that she identified a discrepancy on 10/14/22, the day after the resident readmitted from the hospital, that showed the resident should be receiving IV meropenem for treatment of her bone infection but there were no orders for it. The NP said she had an unknown nursing staff contact the hospital infection disease doctor to get clarification on the missing antibiotic. The NP said she didn't know that care was not being provided to the resident's central line and that her expectation was for the facility to follow nursing protocol in entering orders and providing care. In an interview on 10/19/22 at 2:09 PM, LVN J said she was new and was training with ADON B on the day Resident #3 readmitted to the facility and ADON B was the admitting nurse even though she wrote the note in the EMR. She said she completed the head-to-toe assessment for Resident #3 and ADON B was responsible for the rest. In an interview on 10/19/22 at 2:20 PM, ADON B said she was not the admitting nurse for Resident #3, and she didn't even work on that day. She said she was unaware of a missing IV antibiotic or the resident's diagnosis of osteomyelitis. In an interview on 10/19/22 at 2:32 PM, ADON A said ADON B was the admitting nurse on 10/13/22 when Resident #3 returned to the facility. She said Resident #3 was originally on her unit, but the hospital nurse gave a report stating the resident has ESBL (resistant bacteria) in her urine, so she required isolation and only ADON B's unit had single rooms available. ADON A said LPN I took the call from the hospital noted that Resident #3 had a central line, ESBL in the urine and required IV antibiotics. She said LPN I personally provided a verbal and physical report to ADON B about Resident #3's needs upon readmission. In an interview on 10/19/22 at 2:36 PM, LPN I said she received report from the hospital over the phone that Resident #3 had a central line, required IV meropenem for osteomyelitis and had ESBL in her urine. She said since Resident #3 required isolation, only ADON B's unit could readmit the resident since she required a single room. LPN I said she gave a verbal and paper report to ADON B regarding Resident #3's central line, isolation and IV antibiotic needs. In an interview on 10/19/22 at 2:42 PM, ADON B said that she was Resident #3's admitting nurse on 10/13/22 but she doesn't remember the details on Resident #3's admission to her unit. She said she had so many patients and received a lot of reports so she couldn't keep track of everything. ADON B said she could not locate the physical report given to her by LPN I about Resident #3. In an interview on 10/19/22 at 3:00 PM, the Administrator said she and the nursing staff were aware that Resident #3 would be readmitting with an order for IV meropenem. She said prior to returning to the facility the hospital contacted her to discuss Resident #3's need for IV antibiotics and weekly labs to ensure the facility could provide it before discharging her. The administrator said she assured the hospital that the facility could administer the IV medication and complete the weekly labs for Resident #3. The Administrator said when a resident admits to the facility the admitting nurse was responsible for reconciling any medication or care orders, communicating it to the physician who approves and then the admitting nurse enters the orders into the EMR. She said ADON B was responsible for ensuring Resident #3's IV antibiotic and central line care orders were entered into the EMR. An observation and interview on 10/20/22 at 5:10 PM with LPN U revealed, Resident #3 well dressed, well fed, in no immediate distress lying in bed. The resident's right ankle had a wound the approximate size of a golf ball, with a red appearance and missing the outer layer of skin. The resident's leg was not in a protective device, the wound was open with no dressing laying on a towel and pink drainage was observed. As LPN U raised the resident's foot in order to visualize the wound, the towel fibers were observed to adhere to the wound and Resident #3 grimaced as the fibers detached from the open wound. After reviewing Resident #3's EMR, LPN U said the resident was supposed to have a wound dressing that was wrapped with Krelex and the last time a dressing change was documented was 10/18/22 at 8:51 AM, but the resident had orders for daily dressing changes/wound care. LPN U said she was not Resident #3's nurse and was just covering for the assigned nurse who was on a meal break, so she did not know why there was no dressing on the resident's right ankle wound or why wound care was not performed since 10/18/22. LPN U said for wounds like those on Resident #3's ankle she would not recommend taking off the dressing prior to baths since it was open, and the resident had a organism but instead change the dressing after a bath if it became wet. She said at the very least Resident #3's wound should have been redressed immediately after her bath that occurred prior to 2:30 PM. In an interview on 10/20/22 at 5:17 PM, CNA T said that Resident #3's dressing was removed prior to a bath that occurred before 2:30 PM that day. She said Resident #3's nurse removed the dressing so it wouldn't get wet during the bath, and she elevated Resident #3's leg to ensure water/soap did not enter the wound during the bath. CNA T said Resident #3's nurse was responsible for redressing the wound after the shower and she did not know why it had not occurred. In an interview on 10/26/22 at 10:07 AM, Wound Care Nurse #2 said she just started in her position within the last week. She said she didn't know the prior history of Resident #3's right ankle pressure ulcer. She said currently the wound was an open circular spot that was pink/red, with slight red drainage, no pus or signs of infection and appeared to be healing. In an interview on 10/26/22 at 10:09 AM, the ADON said Resident #3's pressure ulcer was first identified on 09/30/22 and when once she was notified, she immediately notified the physician and got orders for treatment of Resident #3's wounds. She said pressure ulcers were initially observed as redness in pressure points and to prevent their development pressure relieving practices were put in place. After reviewing Resident #3's weekly observations, ADON A said on 9/21/22 LPN Q documented a pressure area to the right ankle but she did not see any documentation that care was provided to the area, pressure relieving devices were put in place or notification was made to the RP/DON or MD. She said once the area of concern was identified on 9/21/22 by LPN Q there should have been notification to the MD/RP and DON as well as continuous monitoring/evaluation of the area to ensure there was no deterioration to the patient's skin. In an interview on 10/26/22 at 10:56 PM, the NP said she was never informed of the pressure area on Resident #3's right ankle prior to discharge to the hospital on 10/07/22 and readmission to the facility on [DATE]. In an interview on 10/26/22 at 11:04 PM, Wound Care Nurse #1 said he was notified by ADON A on an unknown dated of the pressure area, and he observed it to be a red open skin area to the right ankle, so he completed an SBAR and performed wound care as ordered. Wound Care Nurse #1 said there were a lot of complaints from residents and other nursing staff that wound care was not being performed as ordered or sometimes at all. In an interview on 10/26/22 at 11:54 AM, LPN Q said when she first identified the pressure area on Resident #3, she noted it in her weekly skin observation form and informed ADON A. She said when she assessed Resident #3 the next time, she did not observe any wound care on the resident's ankle, there were no orders for wound care and there was no documentation to show any action was taken. LPN Q said after establishing action was not taken about her previous notification of Resident #3's pressure area she informed ADON A again as well as documented in the physician communication binder and notified the wound care doctor. In an interview on 10/26/22 at 2:18 PM, LPN Q said the first time she saw Resident #3's pressure area, it was purple intact skin that was about the size of a quarter but the next time she saw the wound it was open and bigger. She said the resident did not complain about any pain, but she immediately escalated the issue to ADON A again and Wound Care Nurse #1 took care of it immediately. In an interview on 11/03/22 at 10:58 PM, the Wound Care MD said that he first saw Resident #3's pressure ulcer on 10/06/22 but he was unable to stage it due to the presence of slough. He said he saw the resident on 10/20/22 and 10/28/22 and per his notes the resident's wound was improving. The Wound Care MD said he was never informed that Resident #3 did not receive the IV antibiotic required to treat her osteomyelitis and the expectation was that he should have been informed of such situations. He said wound care orders for medication and physical treatment must be followed by nursing staff and failure to do so could result in worsening of the wound or infection. In an interview on 11/03/22 at 12:00 PM the Mobile DON said that when a CNA notifies a change in a resident's skin, they must immediately notify the charge nurse and the charge nurse should assess the resident, notify the resident's physician, family, DON, and administrator. She said if the wound care nurse was present at the time they could also complete the assessment, but ultimately the charge nurse was responsible that action was taking on any newly identified wounds. She said once the resident's physician was notified the nurse should receive any new orders and enter them into the EMR and from there care should be provided as ordered. She said the risk of not timely identifying a new pressure area and providing wound care as ordered was delay in treatment and potentially a decline in status. Record review of the facility policy titled Wound Documentation revised 6/01/15 revealed, Policy- documentation of wounds will be performed consistently using approved forms 6- tracking of all wounds will be completed weekly on the wound tracking worksheet. Record review of the facility policy titled Wound Evaluations revised 06/01/15 revealed, evaluation results are communicated to the members of the care team through documentation, care plan meetings, and care planning. Record review of the facility policy titled Dressing Change Wound Evaluation revised 06/01/15 revealed, with each dressing change the clinician should observe and document the following: general appearance, drainage, surrounding skin and wound odor. Document all procedures performed and resident response (including pain/discomfort to the resident) on the appropriate form. Record review of the facility policy titled Licensed Nurse Skin Checks revised 06/01/15 revealed, Weekly, the licensed nurse performs a head-to-toe check of the resident's skin paying attention to . bony prominences. Observing for: redness, rashes, bruising, open areas . document the actions taken in the nurses note along with a summary of all persons who were notified and their responses. Record review of the facility document titled Physician Communication Grid revised 7/01/16 revealed, Condition-Pressure ulcer; Treatment required within 4 hours- New stage III or higher, any break in skin associated with fever or signs of infection; Routine Physician Notification (within 24 hours)- New Stage II or less. Record review of the facility document titled Practice Guidelines for Prevention and Management of Pressure Ulcers revised 9/07/17 revealed, Ongoing Evaluations: Patients/residents at risk for pressure ulcer development and those with wounds should be monitored daily for changes in their skin condition. This may occur during the course of the resident's daily care and/pr bathing. The CNA should perform a head-to-toe check of the resident's skin paying attention to: surfaces that come in contact with the bed and chair. Bony prominences . Any abnormal findings/changes (redness, rashes, bruises, open areas etc.) should be documented on appropriate facility forms (if utilized) and reported to licensed nurse assigned to the resident for evaluation and Follow up. Abnormal findings/changes should be reported to the resident's primary care provider and family/RP by the licensed nurse per facility protocol Movement or Management of Tissue Load- The care plan for a resident at risk or friction Record review of the facility policy titled Pressure Ulcers revised 9/23/17 reveled, 2- Determine and record the date of onset for each pressure ulcer identified as state 2 or greater. The date of onset is included in the information for the wound on the weekly wound tracking sheet and carried over week to week until healed .6- re-evaluate pressure ulcers at least weekly. If the patient/resident's condition or the condition of the wound deteriorates, or if there is no significant progress within a reasonable time frame (2 weeks), the treatment plan should be re-evaluated. 7- if the treatment plan is not changed, documentation should be provided as to why current treatment plan is being maintained, Record review of the facility policy titled Physician and Other Communication/Change in Condition revised 10/16/2017 revealed, 3- Notify the physician of the change in medical condition. (The physician notification grid may be used as a reference tool regarding the acceptable notification timeframe.) The nurse will document all assessments and change in the patient's/resident's condition in the medical record. Record review of the facility policy Admission Orders revised 11/01/17 revealed, Policy: The facility's leadership and designated licensed staff, at the time of patient/resident admission, will obtaining physician orders for the patient/resident's immediate care. Procedures- On or before the patient/resident is admitted , the physician provides the facility with the following written information, which includes but is not limited to: . e- written treatment orders that are necessary to maintain or improve the patient/resident's functional abilities. This was determined to be an Immediate Jeopardy (IJ) on 10/25/22 at 03:30 PM. The Administrator was notified. The Administrator was provided with the IJ template on 10/26/22 at 11:38 AM. The following plan of removal was submitted by the facility and was accepted on 10/28/22 at 2:27 PM. - Resident #3 started receiving treatment for her pressure ulcer per her Physician's order. - Resident #3 started receiving IV antibiotics per physician's order for her osteomyelitis and was improving. - The facility completed a skin sweep on residents residing in the facility beginning on 10/26/22. The Skin sweep identified 4 additional residents with previously unidentified skin issues, treatments were initiated per physician's orders and the resident's care plans were updated accordingly. This was completed on 11/01/22. - The facility's Practice Guidelines for Prevention and Management of Pressure Ulcers revised on 2017 was reviewed by clinical consultants, the DON and Administrator and no need for revision were identified. - The facility completed in-services training on reporting, identification, and treatment of newly identified pressure ulcer with CNAs and Nursing. This was started on 10/26/22 and completed on 11/02/22. This training will be continuous for new hires as well as PRN staff. - The DON, ADON, Staff Development Coordinator and wound nurses were re-educated to review weekly skin observations/assessments in the clinical morning meetings. This was completed on 10/26/22 and new employee after this date would complete this education at orientation under the DON or designee. - The DON, Mobile DON, weekend nursing supervisors and wound care nurses reviewed the documented weekly resident skin observations in each resident's EMR to ensure that any new skin issues identified had an immediate measure implement to prevent deterioration and physician notification occurred as indicated. This was starting on 10/26/22 and continues on a daily basis. - Braden Scale for predicting pressure sore risks were completed for all facility resident's and appropriate interventions were verified and put in place for all resident's identified at risk of development of pressure ulcers. This was started on 10/26/22 and completed on 11/01/22. - Residents with identified wounds who were receiving wound care were EMR were audited to ensure all identified residents were receiving wound care as ordered. No discrepancies were identified. This was completed on 10/26/22. Monitoring An observation on 10/26/22 at 9:45 AM revealed, MAs passed medications, floor nurses completed treatments and CNAs providing care. No prolonged call bells, no injuries/incidents, no residents calling out for help. An observation on 10/27/22 at 7:18 AM revealed, MAs passed medications, floor nurses completed treatments and CNAs providing care. No prolonged call bells, no injuries/incidents, no residents calling out for help. Nursing staff An observation on 10/27/22 at 7:38 AM revealed, Resident #3 sleeping in bed. The resident appeared to be in no immediate distress with her right foot in a pressure relieving device. Resident #3's right ankle dressing was not visible to the surveyor. An observation on 10/28/22 at 07:12 AM revealed, MAs passed medications, floor nurses completed treatments and CNAs providing care. No prolonged call bells, no injuries/incidents, no residents calling out for help. Resident #3 appeared to be in no immediate distress, lying in bed with both legs in pressure relieving devices. An observation on 10/29/22 at 1:14 PM revealed floor nurses completed treatments and CNAs providing care. No prolonged call bells, no injuries/incidents, no residents calling out for help. Resident #3 was well dressed in no immediate distress and responsive. She said she was doing well, and she had not yet received wound care today. The resident's central line dressing and right ankle dressing were labeled with the date 10/28/22, appeared to be clean and dry. An observation on 10/30/22 at 1:01 PM revealed, MAs passed medications, floor nurses completed treatments and CNAs providing care. No prolonged call bells, no injuries/incidents, no residents calling out for help. Resident #3 appeared to be in no immediate distress with both legs in pressure relieving devices. Resident #3 stated she was feeling better, and her wound care was performed daily. An observation on 10/31/22 at 10:10 AM revealed, MAs passed medications, floor nurses completed treatments and CNAs providing care. No prolonged call bells, no injuries/incidents, no residents calling out for help. Resident #3 was sleeping in bed and appeared to be in no immediate distress. An observation on 11/01/22 at 9:23 AM revealed, MAs passed medications, floor nurses completed treatments and CNAs providing care. No prolonged call bells, no injuries/incidents, no residents calling out for help. Resident #3 was not available for observation. An observation on 11/02/22at 9:39 AM revealed, MAs passed medications, floor nurses completed treatments and CNAs providing care. No prolonged call bells, no injuries/incidents, no residents calling out for help. Resident #3 was sleeping in bed in no immediate distress with both lower legs in pressure relieving devices. In an interview on 10/27/22 at 7:25 PM, LVN J said she had not received any additional/new in-servicing or training on identification and treatment of pressure ulcers. In an interview on 10/27/22 at 07:27 AM, LVN I said he had not received any additional/new in-servicing or training on identification and treatment of pressure ulcers. In an interview on 10/27/22 at 07:27 AM, CNA D said she had not received any additional/new in-servicing or training on reporting any newly identified skin areas of concern. In an interview on 10/28/22 at 07:25 AM, LVN T said he had not received any additional/new in-servicing or training on identification and treatme [TRUNCATED]

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 10 residents (CR #1) reviewed for quality of care. -The facility failed to obtain stat orders for UA C & S, CBC, and BMP that was ordered on [DATE] by the NP. CR #1 had begun to complain of a burning sensation when urinating on [DATE]. CR #1 was found unresponsive and was sent to the hospital on [DATE]. CR #1 was intubated and transferred to ICU where he later passed away on [DATE], discharge diagnosis of acute community cardiac arrest (sudden loss of heart function, breathing, and consciousness), MRSA carrier (a bacteria resistant to treatment with usual antibiotics), chronic right lower lobe infiltrate (substance denser than air such as blood, pus, protein within the lungs), chronic left hydronephrosis (excess fluid in a kidney due to a backup of urine) and hyroureter (abnormal enlargement of the ureter caused by any blockage that prevents urine from draining into the bladder), and chronic prostatomegaly ( prostate enlargement). On [DATE] at 1:00pm an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE] at 3:00 p.m., the facility remained out of compliance at a severity level of a J and a scope of J due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place all facility residents at risk of not receiving timely care when experiencing a change in condition that can lead to hospitalization and death. Findings included: Record review of CR #1's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: dementia (memory loss and judgement), difficulty walking, macular degeneration (eye disease that causes vision loss), hypertension (high blood pressure), chronic kidney disease, hyperlipidemia (high cholesterol) legal blindness, unstable angina (chest pain), atherosclerosis (harden of the arteries) coronary artery (arteries that surrounds and supply the heart) of transplanted heart, and benign prostatic hyperplasia (prostate enlargement). Record review of CR #1's MDS dated [DATE] revealed CR #1 had a BIMS score of 10 indicating cognition level being moderately impaired. CR #1's functional status revealed he required extensive assistance with bed mobility, dressing, and personal hygiene. CR #1 required limited assistance with transfer and toilet use. Further review revealed that CR #1 was always incontinent of bowel and bladder. Record review of CR #1's Care Plan dated [DATE] and revised [DATE] revealed that CR #1 was being care planned for risk for decreased cardiac output due to increase cardiac load related to chronic kidney disease with an intervention to monitor labs as ordered and report abnormalities to MD. Record review of CR #1's Physician Orders dated [DATE] revealed an order for UA (test of the urine) with C & S (a test to find germs such as bacteria in the urine) to be collected on Sunday night. Further review revealed a stat order (to done right way) dated [DATE] for UA C & S, CBC (blood test to evaluate the overall health and detect a wide range of disorders), and BMP (blood test checking for the levels of different substances in the blood). Record review of CR #1's lab report at 10:59am for UA C & S collected on [DATE] revealed urine culture: three or more organisms are present. This culture is considered mixed and will not be processed any further. Such a urine culture does not meet the NHSN criteria . Record review of CR #1's Nursing Progress Notes dated [DATE] documented by LPN E at 3:21pm revealed in part: .C & S result shows specimen contaminated, notified the NP, resident c/o pain and burning with urination, received new order to recollect UA with C & S stat and CBC, BMP .attempted to recollect urine, unsuccessful at this time, resident unable to urinate at this time, encouraged fluids, report given to oncoming nurse . Record review of the NF's 24hour report revealed that CR #1 C & S pending with no date on the 24hour report. Further review revealed a sheet dated [DATE] with no documentation regarding CR #1 stat labs and another sheet read UA C & S pending, not dated. Further review of the 24hour record dated [DATE] with no documentation regarding the status of CR #1 stat labs. Record review of the NF staffing schedule dated [DATE] for the evening shift revealed that LVN T was assigned to room [ROOM NUMBER], where CR #1 was residing. Record review of CR #1's NP Progress Notes dated [DATE] revealed in part: .Chief Complaint: Dysuria .UA was contaminated with no results. Repeat stat UA and culture and labs ordered pending. Patients seen awake in bed. He remains afebrile. Encouraged to increase po fluids, proper perineal care. Staff to report labs once they return . Record review of CR #1's Nursing Progress Notes dated [DATE] documented by RN F at 10:36am revealed in part: .Writer enters resident's room at approximately 8:13am as CNA was attempting to arouse resident with verbal stimuli . Writer applying sternal pressure with no response, not able to detect a pulse. Primary nurse at bedside checking blood glucose (400's), writer called for the crash cart, continued to get BP, NC increased to 12 liters, and placed call to HFD via 911 for medical support resident having some agonal respirations. NC replaced with 100% NRB mask .As board was being placed, writer was informed that resident was a DNR and at that time, resident begin to moan and was beginning to arouse. First HFD arrived at approximately 8:20am, assessed resident and preparing for transport and left the facility at 8:37am .RP was informed of planned transport to hospital . Record review of CR #1's hospital ER records dated [DATE] with a discharge date of [DATE] revealed in part: .Patient was admitted to the ED on [DATE] at 8:57am chief complaint possible STEMI .presenting with generalized weakness that started 1 weak ago prior to arrival .Brought in by HFD who noted heart rate in the 120's dropping to rate in the 40's before arriving to the ED .A EKG was taken on route showing possible STEMI .Patient endorsing UTI having burning sensation .Once in the ED patient actively vomiting with shortness of breath before coding .CPR was started, and shock was administered when CR #1 went into v-tach (abnormal heart rhythm) .Severity is severe .Patient was intubated . clinical impression cardiac arrest, acute myocardial infarction, and acute anemia . Further review of CR #1's ER records revealed the following: RBC: 2.38 (normal 4XXX,d+[DATE]) Hgb: 6 (normal ,d+[DATE]) Lymphocytes: 67 (normal ,d+[DATE]) AST: 504 (normal ,d+[DATE]) ALT: 486 (normal ,d+[DATE]) Troponin: 249 (normal ,d+[DATE]) WBC: 40.74 (normal 4XXX,d+[DATE]) Interview on [DATE] at 8:15am with an individual regarding CR #1, said that CR #1 passed away in the hospital and would have to look at the date. The individual said the doctor at the hospital said CR #1's death was due to negligence. The individual said the doctor at the hospital said when CR #1 arrived at the hospital, his condition was critical and that his condition had gotten too bad to treat. The individual said the doctor had asked what the NF was giving CR #1 to treat his infection. The individual said she spoke to the previous DON whom she had learned stopped working at the NF on [DATE]. The individual said when the previous DON reviewed CR #1 records, she began to cry saying that the NF had failed CR #1 because they did not follow-up with CR #1's labs. The individual said the previous DON kept apologizing. Attempted interview on [DATE] via phone at 12:17pm with previous DON, no answer, left voicemail with a call back number. Interview on [DATE] at 2:38pm the Administrator said the ADON assisted the DON in helping with monitoring resident's clinical systems but did not know what systems in specific. Interview on [DATE] at 3:00pm with RN G via phone said she worked at the NF full time 7am-7pm shift. RN G said she remembered CR #1 who resided in room [ROOM NUMBER]. RN G said she did not remember any pending labs on CR #1. RN G said she was the nurse that collected the UA C & S for CR #1 on [DATE]. RN G said she normally worked the 300-hall. RN G said on [DATE] Hall 200 needed a nurse. RN G said she collected the UA C & S for CR #1 by having CR #1 clean his penis, void, and midway, resident emptied the rest of the urine in the specimen container. RN G said when the urine specimen was collected, she placed the container specimen in the fridge to be picked up. RN G said the lab picked up CR #1's UA C & S the same day she collected the urine specimen because the lab technician was already at the NF. RN G said she did not know why the urine specimen was not collected sooner. RN G said she was just told on [DATE] that the UA needed to be collected. RN G said if a resident was not able to void or urinate, she would have placed a call to the doctor to see if she could get an order for a straight catheter to obtain the urine specimen. Interview on [DATE] at 3:26pm with the DON, she said it was the Unit Nurses that was responsible in ensuring labs were being done and the ADON and herself to monitor that it was being done. The DON said she always double checked and discussed in her morning meetings with the nursing staff regarding resident clinicals at her other place of work. The DON said she could not speak for the NF previous DON. Further interview with the DON said if a nurse could not obtain a urine specimen with the resident voiding/urinating, the nurse should notify the doctor and get an order to straight cath the resident to obtain the specimen. The DON said when the doctor orders a UA C & S, they were looking for any infections or microorganisms. The DON said if an infection was present in the urine and left untreated, the infection could exacerbate, and the resident health will deteriorate. The DON said sepsis could occur which was very serious because the infection was in the blood stream. Interview on [DATE] at 3:47pm with LPN D, she said she worked on [DATE] on the 3pm-11pm shift and was the nurse for CR #1. LPN D said she did not collect a UA C & S for CR #1 and was not aware that a UA C & S needed to be recollected. LPN D said she never received in report that a urine specimen needed to be collected on CR #1 and most of the time it was the morning shift that collected the specimens. LPN D said she communicated with the nurse concerning resident condition or status through verbal reports. LPN D said she did hear that CR #1 was sent to the hospital after being found unresponsive. Interview on [DATE] at 4:00pm, the ADON said CR #1 went to the hospital but did not know why. The ADON said she later heard CR # 1 needed oxygen because he was experiencing shortness of breath. The ADON said it was herself and the DON who was responsible for monitoring the labs. The ADON said labs were also discussed in morning meetings and that she did hear that CR #1's urine had been collected but needed to be recollected due to specimen being contaminated. The ADON said by that time, CR #1 had already gone to the hospital. The ADON said she did not investigate what was going on with CR #1's urine specimen and that it was the previous DON that was involved with that and that was all she could remember about it. The ADON said the previous DON did tell her that CR #1 was in the hospital in ICU. The ADON said she done chart auditing for new admissions. The ADON said the NF did not have any specific person that done chart auditing on the rest of the residents residing in the NF. The ADON said she did remember asking LPN E about CR #1's urine being collected but she did not make sure that the order had been fully carried out and just trusted the nurses to do what they were supposed to do. Interview on [DATE] at 4:40pm the Administrator said the previous DON's last day to work at the NF was on [DATE]. The Administrator said she was told that CR #1 became unresponsive, and the nurse gave resident oxygen. The Administrator did not say when she was informed of CR #1's change in condition. The Administrator said the nurse was about to start CPR and about that time, CR #1 became aroused and was sent to the hospital. Interview on [DATE] at 11:47am via phone with RN F said she was the weekend supervisor. RN F said on [DATE] she was going to get a tray off the cart, when she heard CNA S calling CR #1's name 3 (three) times. RN F said it was then when she realized something was not right and therefore went to CR #1's room. RN F said she saw CNA S standing over CR #1. RN F said although CR #1 had agonal breathing (gasping for air), she could not palpate a pulse. RN F said other staff members were coming to CR #1's room and she told someone to bring the crash cart which was right down the hall and to get vital signs. RN F said she did not do any compressions and when the crash cart got to the room, she began to push the back board under resident back with force and that was when resident moaned. RN F said it was at that time that someone said resident was a DNR. RN F said she did not remember any oxygen being administered or if the time of day was in the morning or noon. RN F said CR #1 was sent out to the hospital right away. RN F said she had not seen CR #1 on [DATE] prior to change in condition nor was she aware of any stat or pending labs for CR #1. CR #1 said she believed the nurse that was caring for CR #1 on [DATE] was an Agency Nurse and that talk amongst the staff members saying the incident happen suddenly. Record review of the NF Policy on Resident Rights revised [DATE] revealed in part: .The facility provides equal access to quality care regardless of, diagnosis, condition, or payment source . Record review of the NF policy on Laboratory Testing revised [DATE] revealed in part: .To provide laboratory services that are accurate and timely, ensuring the utility of laboratory testing for diagnosis, treatment, prevention or assessment is maximized .Orders for diagnostic services will be promptly carried out as directed in the physician's order .The appropriate licensed individual will complete a telephone order electronically/or handwritten requisition, placed in laboratory requisition binder. The nurse or other licensed individual will document in the medical record .Note on 24-hour report .Should the attending physician order a blood test .cultures .they shall be obtained and completed as soon as practical .Critical/STAT test shall be reported to the physician as the results are obtain .Note in Nurses notes .note on 24-hour report . Record review of the NF policy on Reports: 24 Hour Reporting revised [DATE] revealed in part: .The nursing staff will complete a 24 Hour Report on each unit/floor, each shift, 7 days per week. The 24 Hour Report will include, among other things, any status changes in patient/resident conditions, appropriate notifications and the verifications of documentation of any changes .The nurse will note any new orders .The licensed nurse will check the boxes to identify appropriate Lab/X-Ray status each shift . An Immediate Jeopardy (IJ) was identified on [DATE] at 1:00PM, due to the above failures. The Administrator and DON was notified of the IJ and the IJ template was provided on [DATE] at 1:00 PM. Interview on [DATE] at 2:20pm, LPN E said she worked Monday through Friday from 7am to 3pm. LPN E said she only remembered that CR #1's UA C & S had to be recollected because the first specimen was contaminated. LPN E said CR #1 was very alert and oriented and was always inquiring about his lab results whenever labs were ordered on him. LPN E said she called the NP telling her what had happened regarding CR #1's UA C &S asking what she wanted to do. LPN E said the NP gave an order for STAT labs. LPN E said she called the lab but could never get an answer. LPN E said she waited on the phone for ,d+[DATE] minutes. LPN E said no one in the lab ever came to the phone. LPN E said it was at the end of her shift when she tried to get a UA C & S for CR #1, CR #1 was unable to void, and she therefore gave the oncoming nurse LVN T report to follow up on CR #1 stat labs telling LVN T she was unable to obtain a UA C & S. LPN E said LVN T witnessed her being on the phone trying to contact someone in the lab regarding CR #1's stat labs. LPN E said she told LVN T to follow-up on CR #1's stat labs. LPN E said when labs were ordered stat, the nurse was supposed to call the lab and get a confirmation number and document in the progress notes. LPN E said the labs were also put in the system under labs and the lab company could view the lab orders as well. LPN E said when she returned to work the next day, LVN T reported that he was able to collect the UA C & S. LPN E said she never got to review the results because CR #1 had gone to the hospital. LPN E said she never saw the stat CBC and BMP results for CR #1. LPN E said the nurses received report on the residents verbally at shift change and the 24-hour report sheet. Interview on [DATE] at 7:58am via phone, the NP said the NF had notified her of CR #1's UA C & S specimen was contaminated. The NP said she gave the NF a STAT order for UA C & S due to the delay in lab results and added the blood work CBC and BMP. The NP said she wanted to see if CR #1 urine had any WBCs in it and if CR # 1 was experiencing any kidney abnormalities. The NP said she could not speak for the NF as to why they did not collect the labs she had ordered. Interview on [DATE] at 9:50am with the Administrator, she said she did not know how the resident labs were being tracked to ensure that labs were being carried out per physician orders. Interview on [DATE] at 10:14am with the ADON said the NF was tracking labs by using a lab tracker online as well as on paper. The ADON said she could not answer what happened regarding CR #1's stat lab orders. The ADON said the previous DON was overseeing that the labs were being done and updated. The ADON said the nurses on the units communicated by doing verbal report and documenting on the 24-hour report to ensure the continuity of care. The ADON said she reviewed the 24-hour nursing report and the previous DON reviewed the final report in the morning meetings. The ADON said the previous DON would designate who was going to follow-up with any concerns such as abnormal labs or pending labs, family concerns/follow ups, physician notifications, etc. The ADON said she had to admit there was a break in the NF system in communication because the communication was not consistent. The ADON said after she reviewed the 24hour reports, there was a lot of information missing such as dates or dates not being consistent, labs not reported if they were done or not, or if it was communicated with the following shift. The ADON said everything was running together, which made it hard to understand or follow. The ADON said the NF was going to have to do a lot of re-educating with the Nursing staff. The ADON said the NF utilized the 24hour report sheet to help guide them in the morning meetings regarding the resident's care. The ADON said the 24hour report sheet was also compared with the NF Activity Report which was basically another 24hour report sheet as a backup system discussing the resident care needs. The ADON said the previous DON was over both report systems. The ADON said with these two report systems, the NF could access a resident or all residents to review their medical records. The ADON said she assisted the DON with these reports. The ADON said she did not know why the staff did not obtain the UA C & S that was ordered on CR #1 on [DATE] and waited to [DATE]. The ADON said after reviewing CR #1's Nursing Progress Notes, the NF lab services came to the NF on Sunday, Monday, and Tuesday's unless the labs were STAT. The ADON said after further reviewing CR #1's medical records on [DATE], the nurse could have done 3 things: call the doctor and asked for a straight cath, get an order for an indwelling catheter, or ask to send CR #1 to the hospital. The ADON said the NF failed to communicate and document what was going on with resident labs. The following Plan of Removal was submitted by the facility and accepted on [DATE] at 12:35 p.m. PLAN OF REMOVAL Date:[DATE] Immediate action: Identified resident is not currently in facility as of [DATE]. Residents who reside in the facility and have physician orders for laboratory testing have the potential to be affected by the alleged deficient practice. An audit of physician ordered laboratory tests for the past 30 days for current residents was initially completed on [DATE] by the Director of Nursing / designee to identify root cause analysis for STAT labs not completed timely. Current lab audit in progress from [DATE] through [DATE] to validate current lab orders have been obtained and to validate results received and verified. To Facilities Plan for compliance: Licensed nurses will be re-educated by the Director of Nursing / designee on the following: Laboratory Testing Policy and Procedure with focus on orders given by the physician for laboratory testing are to be documented at the time the order is received and implemented timely. Lab tracking form implementation for daily audit of lab orders, collections, and results. This was implemented on [DATE]. Shift to shift report is to be given to oncoming nurse for effective communication regarding resident care and treatment; such as changes of condition, new orders, abnormal labs and any significant events. This was implemented on [DATE]. Change in Condition Policy and Procedure with focus on change in condition assessment, documentation, and reporting to primary care physician, Residents' responsible party, and orders to be carried out as a result of the change in condition such as routine and STAT labs, transfer to higher level of care, or any other Physician order changes. The Physician Notification/Change of Condition policy and Laboratory Testing Policy was reviewed by Clinical Consultant and facility leadership and no revisions recommended. Certified Nursing Assistants were re-educated regarding the expectation that if resident continues or complains of a symptom to report these changes immediately to charge nurse This re-education will be initiated on [DATE]. Any licensed nurse or Certified Nursing Assistant not receiving this training by [DATE] will receive prior to next scheduled shift. This information will be presented to licensed agency staff and in new hire orientation. The Director of Nursing / designee will review laboratory test results with utilization of the lab tracking form in the Clinical Morning meeting Monday through Friday and the charge nurse will review on the weekends to validate that any physician's order change as a result of abnormal or critical laboratory results was implemented timely. The Director of Nursing / designee will review the 24 hour report and will attend shift to shift report daily for 5 days or until compliance has been achieved to validate that communication is occurring related to the care and treatment of the residents. The Director of Nursing / designee will re-educate Medical Records regarding procedure for uploading laboratory results into the Electronic Medical Records for weekly review at long term care coordination meeting. The medical director was notified of the Immediate Jeopardy on [DATE]. An Ad Hoc Quality Assurance Performance Improvement meeting was held on [DATE] to discuss the contents of this plan. Policies were reviewed and used for training purposes. No revisions were necessary. Interview on [DATE] at 4:36pm with LVN T via phone, said he was not CR #1's nurse and could not remember anything regarding any stat labs for resident. _________________________________________ On [DATE] the surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: Interview with LPN I on [DATE] at 12:00pm, she said she was working Hall 200 and worked Monday through Friday 7am-3pm. LPN I said she had been in-serviced on the NF Laboratory Policy and documentation. LPN I said she was in-serviced on filling out the 24hour report sheet regarding a resident labs, pending labs, checking for results of labs, and notifying the physician of lab results. LPN I said when a lab order was received, it must be put in the computer under labs and checked whether it is a standard lab or stat lab. LPN I said she was in-serviced on the importance of communicating effectively to the oncoming nurse through verbal report and 24hour report so nothing was missed involving the residents care. Interview on [DATE] at 12:10pm with LVN J on the 300 Hall said she was a new nurse at the NF and had received a lot of in-services, one being Labs. LVN J said she had been in-serviced on checking physician orders in the system, following up on all labs ensuring there were no pending orders and if so follow up to see what was going on, communicating through verbal and 24hour reports, and reporting findings to the physician and ADON. Interview on [DATE] at 1:20pm with LVN K on Hall 100 said she worked at the NF part time on the 7am-3pm shift. LVN K said she had been in-serviced on lab orders and how to track lab orders. LVN K said when a lab order was received, the order must be placed in the computer under lab section specifying if the lab was a stat lab or standard lab. LVN K said if the order was a stat lab, she needed to call the lab. LVN K said she also had to document in the Nursing Progress Notes the step taken and document labs on the 24hour report sheet. LVN K said a copy was to be given to the ADON and a copy placed in the Physician Orders. LVN K said the nurse was also to follow up on the labs and communicate the results to the Physician or NP as well as the resident family. Interview on [DATE] at 1:30pm interview with CNA L said she worked Hall 100 during the 7am-3pm shift. CNA L said she had been in-serviced on testing for the COVID-19, N-95 mask, and Infection Control, and changes in resident condition such as vital signs, skin issues, bowel and bladder changes, pain, appetite, upset stomach, and report to the nurse right away. Interview on [DATE] at 1:40pm with CNA M said she worked on the 200 Hall during the 7am-3pm and had been in-serviced on infection control, dining room assignments, and reporting to the nurse immediately if notice any changes in a resident condition. Interview on [DATE] at 1:50pm with LVN O said she worked at the NF PRN, and she was working on the 400-Hall 7am-7pm. LVN O said she had received in-services on stat labs and standard labs. LVN O said stat labs had to be called in, input in the system under labs, documented in the Progress Notes, and on the 24hour report sheet. LVN O said critical labs had to be communicated to the doctor immediately. LVN O said a copy of the requisition had to placed inside of the lab book that was kept at the nurse station and that each nurse should be checking at the beginning of their shift the lab requisition book as well as all labs ordered in the computer. LVN O said this was done to ensure all labs were done or and if there were any pending labs to follow up on. Interview on [DATE] at 7:25am with LVN T via phone said he normally worked the night shift and had been in-serviced on the NF Lab Policy. LVN T said he was in-serviced on when receiving order from the doctor for labs, he had to enter lab order in the computer, call the lab, document in the progress notes and on the 24hour report sheet, give a verbal report to the oncoming nurse, watch for any pending labs, provide the lab results to the physician or NP. LVN T said this was done to ensure that no labs were missed and done in a timely manner. Interview on [DATE] at 7:33am with LVN P said she worked the 11:00pm-7:00am shift and had been in-serviced on how to process lab orders received from the doctor or NP. LVN P said the order must be put in the computer and documented in the Nursing Progress Notes as well as on the 24hour sheet. LVN P said this information also had to be communicated to the nurse in verbal report at the change of shift. LVN P said a stat lab had to be called in to the lab as well as put in the computer and documented in the progress notes. LVN P said the RP of the resident had to be notified of the physician orders, and to notify the physician of the lab results. LVN P said if she was unable to obtain the specimen ordered, she would have to notify the doctor or NP to see what steps the doctor wanted take. Interview on [DATE] 7:42am with RN F said she had been in-serviced on labs and the NF policy regarding labs. RN F said if the nurse was unable to collect the ordered specimen, the doctor needed to be called for any further orders. RN F said all labs were to be documented in the nurse progress notes and on the 24hour report sheet. RN F said would communicate in shift report what actions were taken regarding processing lab. RN F said a copy of the order was provided to the DON/ADON and copy was also in the resident records. RN F said she was also in-serviced on the SBAR being filled out when a resident had a change in condition. Interview on [DATE] at 8:17am with LPN Q said she worked the 3pm-11pm shift and had been in-serviced on all lab orders to place in the progress notes and discussed with the oncoming nurse in shift report. LPN Q said all lab orders were to be put in the computer and if a stat lab to call the lab in first documenting the actions taken. LPN Q said if a nurse did not have access to the labs, that nurse could still call the lab in whether the lab was a standard lab or stat lab and get a confirmation number. LPN Q said the nurses were to check the fax machine for incoming lab results and notifying the doctor of the lab results. Interview on [DATE] at 10:42am with LVN R said she had been in-serviced that all labs were put in the computer, documented on the 24hour report sheet, and communicated to the oncoming nurse during shift report. LVN R said the DON/ADON was provided a copy of the lab order to make sure the lab (s) was done. LVN R said the physician was to be notified of the lab results or if unable to get the lab or specimen so that further orders may be given. LVN R said the resident RP was notified as well. Interview on [DATE] at 12:pm with LPN E said she had been in-serviced on carrying out lab orders by taking the order and putting in the computer under the lab section, contacting the resident family regarding the new order, documenting in the nursing progress notes and on the 24hour report, and communicate at shift change in verbal report with the oncoming nurse. LPN E said once the order was signed off, she had to place the copy of the order in the ADON's box so she could have it at the morning meetings. LPN E said if a specimen was unable to be obtain, she would notify the physician or NP for further orders. LPN E said if the order was a stat lab, she would do everything the same as a standard lab except she would call the stat lab in to the lab company and get a confirmation number of the order lab. LPN E said she was also in-serviced on making sure the 24hour report sheets were completely filled out and dated with the resident (s) name and what was going with the resident and if the task had been completed. Interview on [DATE] at 10:30am, the Administrator said th [TRUNCATED]

Based on observation, interview and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #3) reviewed for supervision. -The facility failed to provide adequate supervision to Resident #3 during a bed bath by not holding the resident while she lie on her side resulting in the resident falling out of bed. Resident #3's fall caused a laceration to the forehead which required stitches and a femoral fracture. This failure could place residents at risk for major injuries due to inadequate supervision. Findings Included: Record review of Resident #3's face sheet revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: dementia, anxiety, muscle wasting and atrophy, left hand contracture, seizures, depression and hemiplegia and hemiparesis. Record review of Resident #3's admissions MDS dated [DATE] revealed use of corrective lenses and moderately impaired cognition as indicated by a BIMS score of 8 out of 15. The Resident required extensive assistance and 2 + person physical assist for bed mobility, transfer and dressing as well and total dependence for bathing, used a wheelchair and was always incontinent of both bladder and bowel. Record review of Resident #3's care plan revised 10/13/22 revealed, Problem- risk for falls related to impaired cognition, impaired mobility, incontinence and use of psychotropic meds. 8/17/22- resident fell from bed while care was being provided, sustained forehead laceration. Goal- Resident #3 will not experience injuries from falls, Approach- 2 person assist when ADLs are provided with bathing or incontinence care start date 8/17/22. Problem: Resident #3 requires assistance with ADLs related to impaired cognition, impaired mobility and incontinence created 8/16/22. Approach- Bathing: Total with 1 person assist, Bed Mobility- Extensive with 1-2 person assist, Dressing- Extensive with 1-2 person assist. In an interview on 10/19/22 at 08:40 AM, the Administrator said that Resident #3 was receiving a bed bath with only CNA F. When the resident was rolled to her side, the CNA removed her hands from the resident to wet the towel and the resident rolled off to the ground. She said the resident was bleeding from her head so CNA F immediately notified the nurse who immediately sent Resident #3 to the hospital for further evaluation. The Administrator said when Resident #3 returned from the hospital she was diagnosed with a femur fracture. She said at no point during a bed bath for a resident that requires a 2 person assist should the resident be left unattended or unsupported. The Administrator said even though it was accident, failure to properly support Resident #3 resulted in the fall and ultimately the resident's injury and hospitalization . An observation and interview on 10/19/22 at 9:27 AM revealed, Resident #3 lying in bed with 2 visible scars covering approximately 1/2 of the width of her forehead. Resident #3 said in August while receiving a bed bath she experienced a seizure and rolled off the bed onto the floor slashing her forehead, broke her leg and had to get stitches. She said during the bed bath the CNA rolled her onto her side but did not have hands on her/ support her which resulted in her fall. Resident #3 said she the CNA had not left the room but was not beside her when she fell . In an interview on 10/19/22 at 01:04 PM, the MD said that she was informed that Resident #3 had a fall while she was receiving care. She said the resident could not sit up by herself or reposition herself so she would not have been able to roll herself out of bed. The MD said the resident suffered a femur fracture from the fall but she was not aware that the resident reported she had a seizure. An attempt was made to interview CNA F on 10/19/22 at 02:08 PM. The surveyor was not able to get in touch with the staff. In an interview on 10/25/22 at 10:32 AM, the Administrator said that Resident #3's fall was due to the CNA failure to support the resident at all times during the bed bath. She said that in August after the resident's fall CNAs were re-educated on making sure that adequate support/supervision was provided to residents during ADL care. In an interview on 11/03/22 at 12:51 PM, the Mobile DON said that when performing care staff should provide the level of care as indicated in the resident's ADL profile. She said at no point during a bed bath should a resident be left unsupported or unsupervised. She said failure to provide adequate supervision during ADLs could place residents at risk for falls and injury. Record review of Resident #3's Progress Notes dated 8/17/22 at 9:31 AM by ADON A revealed, Staff was providing care for resident while in bed when resident rolled to the floor hitting her forehead. Resident sustained a laceration across her forehead. 911 notified. Gauze and Kerlix were provided to minimize bleeding with ice pack. Notified MD and RP. Resident transferred via 911 to the hospital. Record review of Resident #3's Hospital Discharge Instructions dated 8/21/22 at 4:21 PM revealed, Patient requires follow up with orthopedic surgery outpatient within 1 week to evaluate her new right femoral fracture during this hospitalization . forehead laceration, accidental fall from bed. Record review of Resident #3's Progress Notes dated 08/21/22 at 8:42 PM by RN G revealed, Resident #3 arrived from the hospital on a stretcher at about 5:56 PM with an admitting diagnoses of right femoral (thigh area) fracture that was braced. On assessment forehead seen with suture line of about 12 sutures. Dark purple color seen below the eyelids. Upper lips X 2 suture line. Resident needs 2 person assist with ADLS. Record review of the facility policy titled Fall Management revised 07/21/22 revealed, The facility provides assistive devices and/or therapies based on individual resident needs to facilitate mobility increase balance awareness, transfers, safe toileting, or other areas to assist the resident with fall prevention. The document did not address the level of assistance necessary for resident care/supervision and the prevention of accidents/incidents. Record review of the facility policy titled Activities of Daily Living Optimal Function revised 08/30/17 revealed, the document contained no specific instructions on how to complete ADLs or the level of assistance/supervision needed while completing ADLs.

Based on interview and record review, the facility failed to ensure services provided by the facility met professional standards of quality for 1 of 5 residents (Resident #3) reviewed for professional standards. - The facility failed to provide a bed bath to Resident #3 with 2 people as indicated in her MDS resulting in the resident falling out of the bed and sustaining a laceration to the forehead and a fracture. This failure could place resident at risk for falls and injuries. Findings Included: Record review of Resident #3's face sheet revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: dementia, anxiety, muscle wasting and atrophy, left hand contracture, seizures, depression and hemiplegia and hemiparesis. Record review of Resident #3's admissions MDS dated [DATE] revealed use of corrective lenses and moderately impaired cognition as indicated by a BIMS score of 8 out of 15. The Resident required extensive assistance and 2 + person physical assist for bed mobility, transfer and dressing as well and total dependence for bathing, used a wheelchair and was always incontinent of both bladder and bowel. Record review of Resident #3's care plan revised 10/13/22 revealed, Problem- risk for falls related to impaired cognition, impaired mobility, incontinence and use of psychotropic meds. 8/17/22- resident fell from bed while care was being provided, sustained forehead laceration. Goal- Resident #3 will not experience injuries from falls, Approach- 2 person assist when ADLs are provided with bathing or incontinence care start date 8/17/22. Problem: Resident #3 requires assistance with ADLs related to impaired cognition, impaired mobility and incontinence created 8/16/22. Approach- Bathing: Total with 1 person assist, Bed Mobility- Extensive with 1-2 person assist, Dressing- Extensive with 1-2 person assist. Record review of Resident #3's Progress Notes dated 8/17/22 at 9:31 AM by ADON A revealed, Staff was providing care for resident while in bed when resident rolled to the floor hitting her forehead. Resident sustained a laceration across her forehead. 911 notified. Gauze and Kerlix were provided to minimize bleeding with ice pack. Notified MD and RP. Resident transferred via 911 to the hospital. Record review of Resident #3's Hospital Discharge Instructions dated 8/21/22 at 4:21 PM revealed, Patient requires follow up with orthopedic surgery outpatient within 1 week to evaluate her new right femoral fracture during this hospitalization . forehead laceration, accidental fall from bed. Record review of Resident #3's Progress Notes dated 08/21/22 at 8:42 PM by RN G revealed, Resident #3 arrived from the hospital on a stretcher at about 5:56 PM with an admitting diagnosis of right femoral (thigh area) fracture that was braced. On assessment forehead seen with suture line of about 12 sutures. Dark purple color seen below the eyelids. Upper lips X 2 suture line. Resident needs 2 person assist with ADLS. In an interview on 10/19/22 at 08:40 AM, the Administrator said that Resident #3 was receiving a bed bath on 08/17/22 with only CNA F and when the resident was rolled to her side, the CNA removed her hands from the resident to wet the towel and the resident rolled off to the ground. She said the resident was bleeding from her head so CNA F immediately notified the nurse who immediately sent Resident #3 to the hospital for further evaluation. The Administrator said that when Resident #3 returned from the hospital she was diagnosed with a femur fracture. She said the facility investigation revealed that Resident #3's ADL profile did not specify how many staff were required for a bed bath , but her Bed Mobility indicated a 2-person assist was required. She said Resident #3's ADL profile was updated to match her bed mobility of 2 person assist. The Administrator said CNA F was no longer employed at the facility. An observation and interview on 10/19/22 at 9:27 AM revealed, Resident #3 lying in bed with 2 visible scars covering approximately 1/2 of the width of her forehead. Resident #3 said in August 2022 while receiving a bed bath, she experienced a seizure and rolled off the bed onto the floor slashing her forehead, broke her leg and had to get stitches. She said during the bed bath, the CNA rolled her onto her side but did not have hands on her/ support her which resulted in her fall. Resident #3 said she the CNA had not left the room but was not beside her when she fell . In an interview on 10/19/22 at 01:04 PM, the MD said that she was informed that Resident #3 had a fall while she was receiving care. She said the resident could not sit up by herself or reposition herself so she would not have been able to roll herself out of bed. The MD said the resident suffered a femur fracture from the fall, but she was not aware that the resident reported she had a seizure. An attempt was made to interview CNA F on 10/19/22 at 02:08 PM. The surveyor was not able to get in touch with the staff. In an interview on 10/25/22 at 10:32 AM, the Administrator said that Resident #3's fall was due to the CNA failing to provide care with 2 people as indicated by the resident's assessments. She said that in August after the resident's fall CNAs were re-educated on making sure that care was provided per the resident's profile and management audited all resident records to update ADLs to reflect the level of assist required for both bed mobility and bed baths. In an interview on 11/03/22 at 12:51 PM, the Mobile DON said that when performing care staff should provide the level of care as indicated in the resident's ADL profile. She said during turning and reposition of a person receiving a bed bath the resident's bed mobility level of care should be used an to ensure the safety of the resident. The Mobile DON said failure to provide care as required placed residents at risk of injury. Record review of the facility's in-service record titled 2-person Assist dated 08/17/22 revealed, Any bed transfers for a 2-person assist must have 2 people for showers, bed baths, dressing, grooming, repositioning. The training was completed by CNAs, RNs, and LVNs. Record review of the facility policy titled Activities of Daily Living Optimal Function revised 08/30/17 revealed, the document contained no specific instructions on how to complete ADLs or the level of assistance needed while completing ADLs.

Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for one (Resident #43) of three residents reviewed for wounds. 1. The failed to provide wound care treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Wound Care Nurse failed to transcribe and follow wound care orders for new facility acquired stage 3 pressure ulcer to R43's left posterior thigh ordered by the Wound Care Doctor on 6/23/22 3. Wound Care Nurse failed to transcribe and follow new order for Resident's Sacrum Stage 4 Pressure Ulcer ordered by the Wound Care Doctor on 06/16/22 and 6/23/22. Stage 4 Pressure Ulcer required debridement of dead tissue. These failures could place residents at risk for developing infections and deterioration of their wounds. Findings included: Resident #43 Record review of the admission sheet for Resident #43 revealed she was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling), altered mental status (a disruption in how your brain works that causes a change in behavior). Record review of Resident#43's Comprehensive MDS, dated [DATE] revealed a BIMS score 03 out of 15 indicating severely impaired cognition. She required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. Section M0300- Stage 4: - 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. Number of Stage 4 pressure ulcer- coded yes. Number of these stage 4 pressure ulcers that were present upon admission/entry or reentry: coded -1. Record review of Resident#43's Care plan initiated 4/12/22 and revised on 6/23/22 revealed the following: Problem: Resident#43 has a pressure ulcer to sacral area. Goal: Resident#43's ulcer will heal without complications. Target Date: 08/02/2022. Approach: Treatment per MD order. Record review of Resident#43's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Special instructions: Drainage: S=Saturated, M=Moist, D=Dry General Appearance; R=Red, Y=Yellow, B=Black, w=White, P=Pink, F=Firm, N=Normal as needed. Record review of Resident#43's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident#43's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 03:00 AM - 07:00 PM Record review of Resident#43's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident#43's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident#43's Laboratory result for wound culture read in part: .collected 6/21/2022 at 1:01pm Test Not Performed. Final-Approved 06/22/2022 5:04pm Order choice: wound culture was not performed due to specimen integrity/improper storage. Nurse N/A notified: will be collected next routines. 6/22/22 5:03pm . Record review of Resident#43's Laboratory result for wound culture read in part: .collected 6/21/2022 at 1:01pm Test Not Performed. Final-Approved 06/27/2022 4:03pm Order choice: wound culture was not performed due to Mislabeled/Missing info. Nurse N/A notified: will be collected next routines. 6/27/2022 4:02pm . Record review of Resident#43's Wound Care Evaluation dated 6/16/22 read in part: .Wound Number: 1, Wound location: sacral, Wound type: pressure ulcer, dated acquired: 5/14/21, Acquired at facility: No, Wound Measurements: Length (cm): 6.5, Width (cm): 9, Depth (cm): 2.7. Wound progress: No change. Odor: Mild. Wound Orders: wound #1 Sacral cleanse wound with ¼ strength Dakin's solution apply Santyl ([MEDICATION(S)]), apply [MEDICATION(S)], apply Alginate, apply -skin prep around wound edge, cover wound with dry absorptive dressing. Change dressing daily. Debridement performed for Assessment: Wound #1 Sacral. Post Debridement Measurements: Length: (cm)-6.5, Width: (cm)-9, Depth: (cm)-2.7 . Record review of Resident#43's Wound Care Evaluation dated 6/23/22 read in part: .Wound Number: 1, Wound location: sacral, Wound type: pressure ulcer, dated acquired: 5/14/21, Acquired at facility: No, Wound Measurements: Length (cm): 10, Width (cm): 9, Depth (cm): 2.3. Wound progress: No change. Odor: Mild. Wound Orders: wound #1 Sacral cleanse wound with ¼ strength Dakin's solution apply Santyl ([MEDICATION(S)]), apply [MEDICATION(S)], apply Alginate, apply -skin prep around wound edge, cover wound with dry absorptive dressing. Change dressing daily. Wound #6 Left, Posterior Thigh. Wound Number: 6, Wound location: Left, Posterior Thigh, Wound Type: Pressure Ulcer, Date Acquired: 6/23/2022, Acquired at facility: Yes. Wound Measurements Length: (cm)-5, Width: (cm)-6, Depth: (cm)-0.1. Wound encounter: initial, Wound progress: initial exam, Stage 3 pressure injury. Wound Order: cleanse wound with normal saline, apply Alginate, cover wound with dry absorptive dressing, change dressing daily . Observation and attempted interview on 6/29/22 at 12:04 p.m., revealed Resident #43 was resting on an air mattress. She was alert and well groomed. The resident mumbled for 5 minutes while being interviewed and could not make her self-understood and did not respond appropriately to asked questions about her pressure sore/injuries. Observation on 6/29/22 at 12:10p.m., revealed the Wound Care Nurse (WCN) provided wound care for Resident #43. The WCN was assisted by Certified Nurse Aide (CNA) O. The WCN gathered the supplies at the treatment cart in the hallway before bringing them into Resident #43's room. Prior to initiation of the treatment, Resident #43 was assisted on to her right side. WCN removed the resident's soiled sacral area wound dressing and placed in the trash can sitting by the foot of resident's bed. The dressing contained a moderate amount of serosanguinous drainage. Foul odor was noted. There was no date visible on the dressing. Continued observation revealed an open area of approximately 10 centimeters in diameter. The WCN then cleansed the pressure wound with the dakin's solution, pat dried, applied Calcium Alginate to the wound bed, covered with dry dressing. The WCN did not use skin prep, [MEDICATION(S)] and Santyl as ordered by the Wound Care doctor on 6/16/22 and 6/23/22. Further observation revealed WNC removed the resident's soiled left posterior thigh wound dressing and placed in the trash can sitting by the foot of resident's bed. An open area of approximately 5 centimeters in diameter noted. The WCN then cleansed the pressure wound with the dakin's solution, patted dry, applied Calcium Alginate to the wound bed, and covered with dry dressing. The left posterior thigh treatment order was not in resident's MAR/TAR. In an interview on 6/29/22 at 12:37p.m., with the WCN, she confirmed she forgot to put the skin prep and [MEDICATION(S)] prior to placing Calcium Alginate and dry dressing. She said the skin prep, protected the skin and helped reduce friction during removal of soiled dressing. This Surveyor reviewed resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . WCN said she forgot to apply skin prep, [MEDICATION(S)] and Santyl. She said she remember getting the new order from the wound care doctor for Santyl and left posterior thigh but got busy and forgot to transcribe the new treatment order in matrix. She said Wound Care doctor came once a week on Thursday and by the end of the day, he updated his notes. She said she printed those wound evaluation and updated the orders the same day. She said only she had access to the wound care doctor's notes. She said she performed wound care treatments Monday to Friday for the whole building. She said there was another nurse that performed wound care on the weekends. She said weekend WCN did not have access to wound care doctor's notes. When asked since she forgot to transcribe the new wound care orders from 6/16/22 and 6/23/22, how would the weekends nurse know the what the new orders were and if the dressing soiled/dislodge how would the floor nurses know the new treatment orders. WCN said, I was never orientated I was thrown in as a WCN. She said the no one from management spot checked her. She said the wound care doctor rounded with her every Thursday, but he did the wound care/debridement. She said he had not seen her do wound care treatment on residents. She said she was responsible for performing treatments, updating care plans, updating new wound care orders. In an interview on 6/29/22 at 2:24p.m., with the DON, this surveyor shared the observations from earlier. The DON said her expectation was for wound dressings to be changed daily and as needed if soiled or dislodged according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said wound care doctor came weekly on Thursdays and sent his notes by the end of day on Thursday. She said the WCN notified her of the wound care observations findings. She said she spoke to WCN and there was a plan in place now that she had to look though WCD's notes every Thursday. She needed to create a progress notes every Thursday stating if there were any new treatment orders were given, wound progress and any recommendation from the wound care doctor. She said she told WCN that the progress notes had to be consistent with the wound care doctor's rounds. She said she should be rounding once a week with WCN to make sure treatments were done accurately. But have not rounded with her. She said it was important to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . At that time the WCN skill competency check off was requested. Record review and interview on 6/30/22 at 11:40a.m., with the WCN of wound care evaluation dated 6/16/22, 6/23/22 and Resident's MAR/TAR/physician orders. She said she was not a certified wound care nurse, but had previous wound care experience from her other job. She said she started approximately 4 weeks ago as a WCN. She said she observed a new wound on Resident #43's left thigh on Wednesday (6/22/22) and the Wound care doctor saw it for the first time on Thursday (6/23/22) and gave new treatment orders. She said she transcribed left thigh wound care order yesterday after Surveyor's questionings. She said she looked though wound care doctor's notes and updated the orders yesterday (6/29/22) as there were discrepancy. She said, I have been behind on things and forgot to put the order in. This Surveyor reviewed wound care evaluation dated 6/16/22, 6/23/22 and Resident's MAR/TAR/physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order entered today was missing Santyl and [MEDICATION(S)] as ordered. She said she just gave access to DON to view Wound care doctor's notes online. She said Wound Care Doctor rounded with her this morning and asked for sacrum wound culture results and ordered stat sacrum x-ray. She said she followed up with the lab today and found out that the culture was mislabeled, and the lab was unable to run that culture. She said the culture was ordered on 6/21/22. The weekend wound care nurse collected the culture on 6/20/22 and placed it in the refrigerate and the lab said it should not be refrigerated. 2nd time weekend wound care nurse mislabeled the culture. She said she would re-collect the culture tomorrow because the wound care doctor had debrided (To remove dead, contaminated, or adherent tissue and/or foreign material) the wound and applied treatment this morning. She said she needed to enter an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . In a telephone interview on 6/30/22 at 12:29p.m., with the Wound Care Doctor, he said Resident #43 had history of bone infection and was on antibiotics. He said he had suspected bone infection and had ordered wound culture and an x-ray to restart antibiotics. He said he discussed with WCN that morning regarding the wound cultures, and she said the facility was waiting on the results. So he ordered a stat sacrum x-ray. In an interview on 6/30/22 at 1:08p.m., with the DON, she said there was no training needed for wound care nurse. Any nurse could do the treatment. Wound Care Nurse did not have to be certified. She said she was unable to find the competency check for WCN. She said she spoke with the Wound Care Doctor today and have asked him to send her and the WCN an email with progress notes after each visit on Thursdays. So, she could follow up to see if there was change or no change in wounds. She said she had also discussed with WCN that she needed to write a Progress notes saying she rounded with the wound care doctor weekly. At this time policy on pressure ulcers was requested. No policy on Pressure Ulcers was provided on exit. Record review of facility's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Policy: The qualified licensed nurse will obtain and transcribe orders according to facility practice guidelines. Medication/Treatment: 2. Transcribe the order onto the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of facility's Dressing Change Wound Evaluation policy (revision: 6/1/2015) read in part: .Policy: An evaluation will be performed with each dressing change. Procedure: The evaluation is the ongoing process of noting wound characteristic each time a clinician sees that wound. The evaluation is the basis of that clinician's opinion on wound progress. 1. With each dressing change the clinician should observe and document the following: A. General appearance. B. Drainage. C. Surrounding skin. D. Wound odor . Record review of facility's Documentation-Licensed Nursing policy (revision: 7/1/2016) read in part: .Policy: Documentation pertaining to the patient/resident will be recorded in accordance with regulatory requirement. Procedure: The nursing staff will be responsible for recording care and treatment, observations and assessments and other appropriate entries in the patient/resident clinical record.