Every finding on record at The Healthcare Resort of Kansas City

Based on observation, record review, and interview, the facility failed to ensure residents remained free from staff-to-resident verbal and/or mental abuse when Resident (R)9 reported during the resident council meeting attended by staff in 11/2025 that Licensed Nurse (LN) K and Certified Nurse Aide (CNA) QQ made fun of him. The abuse resulted in feelings of shame, sadness, and anger for R9, who further felt fear of retaliation from staff for bringing up the abuse. Findings included:- The Electronic Medical Record (EMR) for R9 documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), blindness in the right eye, posttraumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), major depressive disorder (major mood disorder that causes persistent feelings of sadness), schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition for R9. The MDS documented R9 had an impairment to both sides of his upper extremities and used a wheelchair for mobility. The MDS documented R9 was independent with all activities of daily living (ADL). The MDS documented R9 had active diagnosis of DM, schizophrenia, anxiety, and depression. R9's Care Plan documented:02/18/21- R9 was at risk for re-traumatization related to the diagnosis of PTSD; R9 was abandoned by his father as a child and suffered physical and emotional abuse from his mother.02/18/26- Staff to monitor R9 for side effects and adverse reactions of psychoactive medication.05/15/25 (after the event was identified)- R9 was seen by psychologists for supportive one-to-one service as needed. Review of the Resident Council Minutes dated 11/19/25 documented in the Miscellaneous section that some residents did not like to speak about things going on in the facility, as they feared the nurses and nurse aides would treat them worse because they told on them. The minutes documented education was provided to the resident council in attendance, which explained that the residents had the right to express or file a grievance or complain about anything that they felt was not right, without the fear of being mistreated, and to let someone know if they were being mistreated. The minutes recorded by one resident, R9, stated that the night nurse, LN K, makes fun of him, but he did not like to say anything because he thought the facility staff would retaliate. Review of R9's clinical record lacked evidence the above allegation was followed up on, and lacked evidence of resolution, psychosocial monitoring, and further actions related to the abuse allegation. Upon request, the facility was unable to provide an investigation dated prior to the survey that addressed the abuse allegation. A Facility Internal Investigation report dated 05/13/26, documented during the annual state survey, surveyors identified from the November 2025 resident council notes that LN K made fun of R9. R9 did not like to say anything because he thought there would be retaliation. The investigation also noted that on 01/21/26, Certified Nurse Aide (CNA) QQ yelled at a couple of the residents. The facility documented they changed Administrators in 03/2026 and the Director of Nursing in 04/2026, due to ongoing issues in the facility. The investigation also documented the current administration was not aware of the issues in the resident council minutes. Once the facility became aware of the situation, the facility immediately interviewed R9, who made the allegation about LN K. Administrative Staff A and Administrative Nurse D met with R9 for approximately 20 minutes. At that time, R9 reiterated several times that he felt safe, and although a few months ago he felt like LN K was laughing at him, he did not feel any tension between them now. R9 stated LN K gave him his medication on time and rubbed cream on his shoulder. The facility notified R9's representative of the situation and investigation. The facility also called LN K and placed her on a 72-hour leave pending investigation. The facility continued the process of interviewing residents on the west side to ensure they felt safe and free of abuse. CNA QQ was terminated from employment on 02/2026 for yelling at two residents, though the facility was uncertain which two residents. On 05/13/26 at 02:30 PM, Activities Director Z stated she did not remember the incident with R9 reporting abuse by LN K. She stated if there were any concerns at the resident council meetings, she would take each concern to the department the residents had concerns about. Activities Director Z stated each department was given a sheet of paper to address the concerns on, and that paper was returned to her. She stated she went over the responses with the residents at the following meeting. Activities Director Z stated if there was a concern of abuse or neglect, she would take that concern not only to the director of nursing, but also to the administrator. On 05/14/26 at 07:40 AM, R9 stated the facility administrative staff came to talk to him about the incident with LN K. He stated that it was the first time anyone had visited him about the incident. R9 stated LN K and another staff member named [CNA QQ] would make fun of him. He stated they would tell him he could be a baby momma because he had a very big abdomen. R9 stated LN K and CNA QQ would make fun of his speech, and he explained he came from a family that did not speak English. R9 stated he had to learn English on his own, and he knew he had an accent, but he tried to speak good English. R9 stated when LN K and CNA QQ made fun of him, it made him feel sad and mad. He stated that since CNA QQ no longer worked at the facility, LN K had been on good behavior. On 05/14/26 at 07:35 AM, Administrative Staff C stated the facility began an investigation of the allegation, and LN K had been suspended. Administrative Staff C stated Administrative Staff A and Administrative Nurse D spoke to R9 and other residents to ensure the residents were safe and felt safe. Administrative Nurse D stated all staff were educated. She stated the facility did not look at the past resident council minutes and should have ensured resident concerns were followed up on. She stated the facility had a plan in place and would follow up with the resident council each month. On 05/14/26 at 01:59 PM, Certified Nurse Aide (CNA) N stated she had Abuse and Neglect training on 05/13/26, during the survey. She stated she had never heard any staff member yell or make fun of a resident. CNA N stated if she heard or witnessed abuse, she would call her administrator at that moment. On 05/14/26 at 02:51 PM, LN J stated she received Abuse and Neglect training on 05/13/26, during the survey. She stated she had not heard a staff member yell or make fun of a resident. She stated she would call the director of nursing and the administrator and report the incident. On 05/14/26 at 02:51 PM, Administrative Nurse D stated she did not follow up on the resident council minutes prior to when she became the director of nursing. She stated that when the nursing department heads were put in place, the department heads picked five of what they felt were the most important care areas to work on. She stated the department heads should have read the resident council minutes and followed up. The facility's Abuse: Prevention of and Prohibition Against dated 04/26 documented that it was the policy of the facility that each resident had the right to be free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. It was also the policy of the facility to recognize the residents' right to personal privacy and confidentiality of their physical body, personal care, and personal space or accommodations. This included, but was not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the residents' medical symptoms. This also includes taking, keeping, using, or distributing photographs or video recordings of residents in any manner that would demean or humiliate a resident, regardless of consent provided or the resident's cognitive status.

Based on record review and interview, the facility failed to ensure staff reported Resident (R)9's allegation of verbal/mental abuse to the administrator and State Agency (SA) as required, leaving R9 and all the other residents at risk for ongoing abuse. (Refer to F600 and F610) Findings included:- Review of the Resident Council Minutes dated 11/19/25 documented in the Miscellaneous section that some residents did not like to speak about things going on in the facility, as they feared the nurses and nurse aides would treat them worse because they told on them. The minutes documented education was provided to the resident council in attendance, which explained that the residents had the right to express or file a grievance or complain about anything that they felt was not right, without the fear of being mistreated, and to let someone know if they were being mistreated. The minutes recorded by one resident, R9, stated that the night nurse, Licensed Nurse (LN) K, makes fun of him, but he did not like to say anything because he thought the facility staff would retaliate. Review of R9's clinical record lacked evidence the above allegation was followed up on, and lacked evidence of resolution, psychosocial monitoring, and further actions related to the abuse allegation. Upon request, the facility was unable to provide an investigation dated prior to the survey that addressed the abuse allegation and could not provide evidence the allegations were reported to the SA. A Facility Internal Investigation report dated 05/13/26, documented during the annual state survey, surveyors identified from the November 2025 resident council notes that LN K made fun of R9. R9 did not like to say anything because he thought there would be retaliation. The investigation also noted that on 01/21/26, Certified Nurse Aide (CNA) QQ yelled at a couple of the residents. The facility documented they changed Administrators in 03/2026 and the Director of Nursing in 04/2026 due to ongoing issues in the facility. The investigation also documented that the current administration was not aware of the issues in the resident council minutes. Once the facility became aware of the situation, the facility immediately interviewed R9, who made the allegation about LN K. Administrative Staff A and Administrative Nurse D met with R9 for approximately 20 minutes. At that time, R9 reiterated several times that he felt safe, and although a few months ago he felt like LN K was laughing at him, he did not feel any tension between them now. R9 stated LN K gave him his medication on time and rubbed cream on his shoulder. The facility notified R9's representative of the situation and investigation. The facility also called LN K and placed her on a 72-hour leave pending investigation. The facility continued the process of interviewing residents on the west side to ensure they felt safe and free of abuse. CNA QQ was terminated from employment on 02/2026 for yelling at two residents, though the facility was uncertain which two residents. On 05/13/26 at 02:30 PM, Activities Director Z stated she did not remember the incident with R9 reporting abuse by LN K. Activities Director Z stated if there was a concern of abuse or neglect, she would take that concern not only to the director of nursing, but also to the administrator. On 05/14/26 at 07:40 AM, R9 stated the facility administrative staff came to talk to him about the incident with LN K. He stated that it was the first time anyone had visited him about the incident. On 05/14/26 at 07:35 AM, Administrative Staff C stated the facility had just begun an investigation of the allegation, and LN K had been suspended. She stated the facility did not look at the past resident council minutes and should have ensured resident concerns were followed up on. On 05/14/26 at 02:51 PM, Administrative Nurse D stated she did not follow up on the resident council minutes prior to when she became the director of nursing. She stated that when the nursing department heads were put in place, the department heads picked five of what they felt were the most important care areas to work on. She stated the department heads should have read the resident council minutes and followed up.The facility's policy Abuse: Prevention Of and Prohibition Against dated 04/2026 documented all allegations of abuse, neglect, misappropriation of resident property, or exploitation should be reported immediately to the Administrator. Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations. The Facility will ensure that all individuals who are involved in the reporting or investigation process are free from retaliation or reprisal.

Based on record review and interview, the facility failed to investigate an allegation of verbal/mental abuse and further failed to implement protective measures after Resident (R) 9's alleged Licensed Nurse (LN) K verbally and mentally abused him, which permitted LN K to continue to have access to R9 and all residents in the facility. (Refer to F600 and F609). Findings included:- Review of the Resident Council Minutes dated 11/19/25 documented in the Miscellaneous section that some residents did not like to speak about things going on in the facility, as they feared the nurses and nurse aides would treat them worse because they told on them. The minutes documented education was provided to the resident council in attendance, which explained that the residents had the right to express or file a grievance or complain about anything that they felt was not right, without the fear of being mistreated, and to let someone know if they were being mistreated. The minutes recorded by one resident, R9, stated that the night nurse, Licensed Nurse (LN) K, makes fun of him, but he did not like to say anything because he thought the facility staff would retaliate. Review of R9's clinical record lacked evidence the above allegation was followed up on, and lacked evidence of resolution, psychosocial monitoring, and further actions related to the abuse allegation. Upon request, the facility was unable to provide an investigation dated prior to the survey that addressed the abuse allegation. A Facility Internal Investigation report dated 05/13/26, documented during the annual state survey, surveyors identified from the November 2025 resident council notes that LN K made fun of R9. R9 did not like to say anything because he thought there would be retaliation. The investigation also noted that on 01/21/26, Certified Nurse Aide (CNA) QQ yelled at a couple of the residents. The facility documented they changed Administrators in 03/2026 and the Director of Nursing in 04/2026, due to ongoing issues in the facility. The investigation also documented that the current administration was not aware of the issues in the resident council minutes. Once the facility became aware of the situation, the facility immediately interviewed R9, who made the allegation about LN K. Administrative Staff A and Administrative Nurse D met with R9 for approximately 20 minutes. At that time, R9 reiterated several times that he felt safe, and although a few months ago he felt like LN K was laughing at him, he did not feel any tension between them now. R9 stated LN K gave him his medication on time and rubbed cream on his shoulder. The facility notified R9's representative of the situation and investigation. The facility also called LN K and placed her on a 72-hour leave pending investigation. The facility continued the process of interviewing residents on the west side to ensure they felt safe and free of abuse. CNA QQ was terminated from employment on 02/2026 for yelling at two residents, though the facility was uncertain which two residents. On 05/13/26 at 02:30 PM, Activities Director Z stated she did not remember the incident with R9 reporting abuse by LN K. Activities Director Z stated if there was a concern of abuse or neglect, she would take that concern not only to the director of nursing, but also to the administrator. On 05/14/26 at 07:40 AM, R9 stated the facility administrative staff came to talk to him about the incident with LN K. He stated that it was the first time anyone had visited him about the incident. On 05/14/26 at 07:35 AM, Administrative Staff C stated the facility had just begun an investigation of the allegation, and LN K had been suspended. She stated the facility did not look at the past resident council minutes and should have ensured resident concerns were followed up on.On 05/14/26 at 02:51 PM, Administrative Nurse D stated she did not follow up on the resident council minutes prior to when she became the director of nursing. She stated that when the nursing department heads were put in place, the department heads picked five of what they felt were the most important care areas to work on. She stated the department heads should have read the resident council minutes and followed up.The facility's policy Abuse: Prevention of and Prohibition Against dated 04/2026 documented after receiving the allegation, and during and after the investigation, the Administrator will ensure that all residents are protected from physical and psychosocial harm. A licensed nurse will immediately examine the resident upon receiving reports of alleged physical or sexual abuse. The findings of the examination shall be recorded in the resident's medical record. If an allegation of abuse, neglect, misappropriation of resident property, or exploitation is reported, discovered or suspected, the Facility will take the following steps to protect all residents from physical and psychosocial harm during and after the investigation: Make room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator and protect the involved persons from retaliation.

Based on record review and interview, the facility failed to ensure four of the four Certified Nurse Aide (CNA) and one Certified Medication Aide (CMA) staff reviewed had yearly performance evaluations completed. Findings included:- A review of the facility's staffing list revealed the following CNAs and CMAs were employed with the facility for more than 12 months: CNA MM, hired 06/05/24, had no yearly performance evaluation upon request.CNA NN, hired 02/05/25, had no yearly performance evaluation upon request.CNA 00, hired 06/03/21, provided a yearly performance evaluation which lacked a date and signature.CMA S, hired 03/27/25, had no yearly performance evaluation upon request.On 05/14/26 at 01:23 PM, Administrative Staff B stated each of the department heads were responsible for ensuring the yearly evaluations were completed. Administrative Staff B stated she would assist with tracking the due dates for the employees' yearly evaluations.The facility was unable to provide a policy related to yearly performance evaluation as requested on 05/14/26.

Based on record review, observations, and interviews, the facility failed to implement adequate infection control practices when staff failed to store Resident (R)13's nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) in a sanitary manner when not in use. The facility failed to ensure wet briefs were not left in R28's trash can and failed to ensure clean linen was not placed on a Personal Protective Equipment (PPE) cart. The facility failed to ensure dirty laundry bags were not placed on the residents' floor and failed to ensure a sanitary barrier was placed under a blood glucose monitor. The facility failed to ensure R86's nasal canula was stored in a sanitary manner when not in use. The facility further failed to ensure clean laundry was stored in a sanitary manner. Findings included:- On 05/12/26 at 07:45 AM, during the initial walk-through of the facility, R13's nebulizer mask laid on his windowsill, R13's nebulizer mask was not stored in a sanitary container.A wet brief laid open, wet with urine in the trash can next to R28's bed.Clean linen laid on a PPE cart directly on top of a box of opened gloves in the west hallway. Certified Nurse Aide (CNA) O placed soiled linen from the floor into a plastic bag and then placed soiled incontinent products off the floor into another plastic bag.On 05/13/26 at 07:53 AM, CNA O placed a bag of soiled linen and a bag of trash into the soiled utility room. CNA O exited the soiled utility without performing hand hygiene. CNA O entered the clean linen room, removed clean sheets from the room, and walked down the hallway without performing hand hygiene.On 05/12/26 at 08:17, Licensed Nurse (LN) I placed a blood glucose monitor on the bottom bed rail in R9's room. LN I did not have a clean barrier on the bed rail. LN I obtained R9's blood glucose reading, and laid the monitor back on the bottom bed rail.On 05/12/26 at 9:26 AM, R86's wheelchair had a portable O2 tank, and her nasal canula tubing was laying in the seat of the wheelchair. R86's nasal cannula was not stored in a sanitary container.05/14/26 at 01:59 Certified Nurse Aide (CNA) N stated nasal cannulas were to in a dated bag when not in use. She stated wet briefs should be taken out of resident's rooms when staff leave the room. CNA N stated hand hygiene should be performed when going from clean to dirty, or dirty to clean. She stated laundry, even if its dirty should not be placed on the floor. On 05/14/26 at 02:25 PM, LNJ stated all respiratory equipment should be placed in a dated bag when not in use. She stated staff should not lay clean linens on a PPE cart. LN J stated hands should be washed anytime you leave a resident's room, when taking trash, from clean to dirty, and dirty to clean. She stated nursing should have laid a paper towel down before laying down the glucose monitor in a resident's room. She stated staff should always take wet briefs out of a resident's room.On 05/14/26 at 02:51 PM, Administrative Nurse D stated respiratory equipment should be placed in a bag with the date. She stated hands should be washed or use sanitizer between clean and dirty, and clean linens should not be left on a PPE cart. Administrative Nurse D stated dirty linens should not be placed on the floor. She stated nursing should sanitize the glucose monitor and use a sanitary barrier in residents' rooms. The facility's Infection Prevention and Control Program dated 04/26 documented the infection prevention and control program was a facility -wide effort involving all disciplines and individuals, and was an internal part of the quality assurance performance improvement program the elements of infection prevention and control program consist of coordination, oversight, surveillance and data analysis.The facility's Hand Hygiene dated 02/26 documented it was the policy of the facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene, which was one of the most effective measures to prevent the spread of infection, based on accepted standards.The facility's Oxygen Equipment policy dated 01/26 documented it was the policy of the facility to maintain all oxygen therapy equipment in a clean and sanitary manner and to use humidifiers, tubing, masks, and cannulas for residents receiving oxygen. The equipment was to be discarded after use by a resident. The facility would maintain clean tanks, connectors and concentrators.

Based on record review and interviews, the facility failed to ensure agency staff received the required communication training. Findings included:- On 05/14/26 at 10:40 AM, a review of the training provided by the facility for agency Certified Nurse Aide (CNA) P, CNA Q, and Licensed Nurse (LN) K revealed the following:The facility was unable to provide documentation that CNA P had completed the communication training.The facility was unable to provide documentation that CNA Q had completed the communication training.The facility was unable to provide documentation that LN K had completed the communication training.On 05/14/26 at 01:23 PM, Administrative Staff B stated she was responsible for scheduling the agency staff. Administrative Staff B stated the facility expected the agency had provided the required training and in-services to their agency staff prior to scheduling the staff at the facility. The facility was unable to provide a policy related to staff required in-services as requested on 05/14/26.

Based on record review and interviews, the facility failed to ensure agency staff received the required resident rights training. Findings included:- On 05/14/26 at 10:40 AM, a review of the training provided by the facility for agency Certified Nurse Aide (CNA) P, CNA Q, and Licensed Nurse (LN) K revealed the following:The facility was unable to provide documentation that CNA P had completed the resident rights training.The facility was unable to provide documentation that CNA Q had completed the resident rights training.The facility was unable to provide documentation that LN K had completed the resident rights training.On 05/14/26 at 01:23 PM, Administrative Staff B stated she was responsible for scheduling the agency staff. Administrative Staff B stated the facility expected the agency had provided the required training and in-services to their agency staff prior to scheduling the staff at the facility. The facility was unable to provide a policy related to staff required in-services as requested on 05/14/26.

Based on record review and interviews, the facility failed to ensure agency staff received the required behavioral health training. Findings included:- On 05/14/26 at 10:40 AM, a review of the training provided by the facility for agency Certified Nurse Aide (CNA) P revealed the following:The facility was unable to provide documentation that CNA P had completed the behavioral health training.On 05/14/26 at 01:23 PM, Administrative Staff B stated she was responsible for scheduling the agency staff. Administrative Staff B stated the facility expected the agency had provided the required training and in-services to their agency staff prior to scheduling the staff at the facility. The facility was unable to provide a policy related to staff required in-services as requested on 05/14/26.

Based on observation, record review, and interview, the facility failed to ensure the facility provided a safe and clean homelike environment for the residents when staff failed to ensure the walkway/sidewalk into the building did not have missing tiles/blocks on the walkway. The facility failed to ensure the east resident dining area was free from ants. The facility failed to ensure the ceiling light in Resident (R) 19's room was working properly. Findings included:- On 05/12/26 at 07:29 AM, observation revealed several red tiles/bricks with raised dots were missing from the walkway into the building entrance.On 05/12/26 at 09:47 AM, observation revealed ants crawling across the table in the east dining room. Dietary Staff BB stated she had reported there had been ants noted on the table.On 05/12/26 at 10:44 AM, R19 stated the light above his bed had not worked since he was admitted to the facility on [DATE].On 05/13/26 at 01:30 PM, Maintenance U stated the facility had a TELS system (a building management platform designed for senior living with integrated asset management, life safety, and maintenance solutions) to report items that needed replaced or fixed. Maintenance U stated there was also a dry-erase board in the maintenance office to write things on as well. Maintenance U stated that pest control came out the previous day after the ants were reported and there was a work order placed for the repair of the bricks to the walkway. Maintenance U stated that they had not been informed of the light not working above R19's bed but said staff would get it repaired.The facilities Safe and Homelike Environment undated policy documented it was the policy of this facility to ensure that resident's that reside here were provided the right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and support for daily living safely. The facility would provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; adequate and comfortable lighting levels in all areas (adequate lighting means levels of illumination suitable to tasks the resident chooses to perform or the facility staff must perform).

Based on observation, record review and interview, the facility failed to ensure residents received the necessary activities of daily care (ADL) care needed when staff failed to provide consistent bathing to dependent Residents (R) 47, R6, and R77. Finding included:- 1. R47's Electronic Medical Record (EMR) documented diagnoses of quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), central cord syndrome (the spinal cord's ability to transmit some messages to or from the brain is damaged or reduced below the site of injury to the spinal cord).R47's admission Minimum Data Set (MDS) dated [DATE] documented at Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. R47 had functional limitation in range of motion on both sides of his upper and lower extremities. R47 used a wheelchair to assist in mobility. R47 was dependent on staff for shower/bathing.R47's Functional Abilities Care Area Assessment (CAA) dated 03/25/26 documented he was at risk for more contractures (abnormal permanent fixation of a joint or muscle), pain, impaired seated balance, impaired skin integrity, malnutrition, and fluid deficit. R47 had difficulty grasping objects with his hands. R47 is currently receiving physical and occupational therapy to address his risks.R47's Care Plan, dated revised on 04/06/26, directed staff he required assistance with bathing to allow R47 time to answer questions and to verbalize his feelings, perceptions, and fears; staff was to encourage him to make choices in his daily care routine. The Care Plan lacked staff direction on R47's preferred bathing day/time.R47's March 2026 Documentation Survey Report in the EMR documented his scheduled bathing time was on Wednesday and Saturday evenings. The report documented one shower given on 03/23/26. R47 refused a shower/bath on 03/19/26, 03/22/26, and 03/25/26. The report documented not applicable NA on 03/18/26, 03/19/26, 03/20/26, 03/21/26 and 03/28/26.R47's April 2026 Documentation Survey Report in the EMR documented his scheduled bathing time was on Wednesday and Saturday evenings. The report documented NA on five of nine bathing opportunities. R47 refused bathing on three of nine bathing opportunities. The report documented no shower or bath given to R47 in the month of April.R47's May 2026 Documentation Survey Report in the EMR documented his scheduled bathing time was on Wednesday and Saturday evenings. The report documented a shower given on 05/06/26. The report documented NA on three of four bathing opportunities reviewed.On 05/12/26 at 08:45 AM, R47 laid in his bed, resting his hair and beard had a dirty appearance.On 05/13/26 at 09:38 AM, Certified Nurse Aide (CNA) PP gathered bathing towels and clean linen for R47. CNAPP stated she was going to give him a bath since he agreed to it this morning. CNA PP stated R47 refused to bathe at times. - 2. R6's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following a nontraumatic intracerebral hemorrhage (a spontaneous, emergency bleeding within the brain) affecting the left non-dominant side, vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), contracture of left forearm, and left hand, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness, and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness).The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of six, which indicated severely impaired cognition. The MDS documented R6 had an impairment on one side of his upper and lower body. The MDS documented R6 needed set up or clean up assistance with eating and was dependent on staff for toileting and oral hygiene.R6's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 10/01/26 documented for R6 was dependent on staff for all self-care and mobility tasks except eating.R6's Care Plan documented:12/17/18-Sometimes R6 refuses baths or showers. Encourage R6 to allow bathing.01/04/24-Provide R6 with clear, concise instructions. Repeat as needed. Ask R6 to voice understanding.Limit R6's choices but provide chances for R6 to choose in my daily care routine.R6 EMR under Task documented R6's preferred days for bathing were Wednesday and Saturday evenings. R6's Bathing documented R6 was given a shower on 04/22/25 and a shower on 05/09/25.R6's EMR under Documents revealed the last scanned bath sheet was 12/10/25, documenting a shower was given.On 05/12/25 at 10:25 AM, R6 sat in his room in his Broda chair (specialized wheelchair with the ability to tilt and recline). R6 had grey whiskers on his face, and his hair was matted down. R6 had brown substances under his fingernails. - 3. R77's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of respiratory failure (the lungs cannot adequately supply oxygen to the blood (hypoxemia) or remove carbon dioxide, congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), sleep apnea (a disorder of sleep characterized by periods without respirations), cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and pneumonia (an infection in the lungs).The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R77 had an impairment of the extremities on one side of her upper body and both sides of her lower extremities. The MDS documented R77 was dependent on staff for oral hygiene and needed substantial/maximal assistance with bathing and toileting. R77's Urinary Incontinence/Indwelling Catheter dated 12/18/25 documented R77's frequent incontinence was noted in the lookback period. The CAA documented R77's risk factors, which included CHF, increased pain, and need for assistance with personal care. The CAA documented staff were to monitor and report concerns to physicians. R77's Care Plan documented:12/15/25-R77 was incontinent, staff were to wash, rinse, and dry perineum, and change clothing after incontinent episodes.Staff were to encourage R77 to make choices in her daily routine.01/29/26-R77 was dependent on staff for bathing and shower transfers.R77's EMR under Task under Bathing documented R77 preferred days for showers were Monday and Wednesday in the morning. R77's Bathing for the months of April and May of 2026 revealed R77 received three full sponge baths on 04/02, 04/06, 04/13, and three sponge baths on 04/20, 04/23, and 04/30, and R77 received one shower on 05/09, and one sponge bath on 05/11.R77's Documents revealed one bath sheet on 02/21/26.On 05/12/26 at 08:22 AM, R77 laid on her bed on her back. R77 had her nasal cannula oxygen in place. R77's fingernails had been polished. R77 had a brown substance under her fingernails.On 05/12/25 at 08:22 AM, R77 stated she did not have a scheduled shower day. She stated she had not had a shower since she had come to the facility. R77 stated she would like a shower. She stated staff stated they were always short of help, and that staff had a lot of residents that needed more care. R77 stated the staff would just come in when they had a minute to wash her. She stated the staff would use a washcloth and an emesis basin or just wipes for her bed bath.On 05/14/26 at 09:22 AM, Certified Nurse's Aide (CNA) M stated he was not sure of the R77's bathing schedule. He stated when he answered her call light, she asked if she could have a shower today. CNA M stated he was an agency and did not work at the facility. He stated if a resident wanted a shower, he would give the resident a shower.On 05/14/26 at 01:59 PM, Certified Nurses Aide (CNA)N stated she was unsure if bathing had been done on the evening shift. She stated she had talked to management and voiced her concerns about a bath aide to help with bathing for the residents. CNA N stated a bath sheet was done on each resident on the days the resident was to have a shower, and signed by the nurse if the resident refused.On 05/14/26 at 08:15 AM, Licensed Nurse (LN) I stated that residents had scheduled bath days/times per their preference. LN I stated that R47 did have scheduled bathing days and preferred them in the evening, but would frequently refuse.On 05/14/26 at 02:51 PM, Administrative Nurse D stated what was supposed to happen was the CNA was to give the shower, fill out a shower sheet, then sign the shower sheet after the shower was given. She stated if the resident refused the shower, the nurse was to talk to the resident later to see if another time worked better for the resident. Administrative Nurse D stated she would expect the nurse to chart in the residents chart if a shower was refused or offered. Administrative Nurse D stated the facility was aware there were problems with bathing. She stated staff have been educated about the importance of bathing. Administrative Nurse D stated that NA should not be used when documenting a shower or bath.The Facility's Activities of Daily Living (ADL), Services to carry out policy dated March 2026 documented it was the policy of this facility that residents were given the appropriate treatment and services to maintain or improve his/her abilities. Residents who were unable to carry out ADLs would receive necessary services to maintain: good nutrition; grooming; personal hygiene; and oral hygiene.

Based on observation, interviews, and record reviews, the facility failed to ensure the medication error rate did not exceed five percent (%) when staff administered seven of Resident (R) 1's 14 medications outside of the 60 minutes before or 60 minutes after window. This resulted in a medication error rate of 21.88%. Findings included:- On 05/13/26 at 09:35 AM, Certified Medication Aide (CMA) R had R1's Medication Administration Record (MAR) pulled up on his laptop on the medication cart. A couple of R1's medications had a pink background to indicate that the medication was late. CMA R began popping R1's medications out of their bubble pack card into a medication cup. CMA R entered R1's room to administer the medications to R1. CMA R hand R1 the medication cup and R1 took her medications without difficulty.On 05/14/26 at 08:31 AM, an Administration History Report was requested for R1's medication administrations from 05/13/26. The report revealed that seven morning medications were administered outside of the time window of one hour before and one hour after the scheduled time.1. Ascorbic Acid (vitamin c) 500 milligram (mg) chewable tablet, give one tablet by mouth once a day for Vitamin C. The scheduled administration time was 08:00 AM, the medication was administered late at 09:48 AM.2. Buspirone HCl (a medication used to treat anxiety) 10 mg tablet by mouth every 12 hours. This medication was scheduled to be given at 08:00 AM, and the medication was administered late at 10:11 AM.3. Hydralazine HCl (a medication used to treat high blood pressure) oral tablet 25 mg to be given between 07:00 AM and 09:00 AM. The medication was given late at 10:11 AM.4. Pantoprazole sodium (a medication used to reduce acid in the stomach), delayed release of 40 mg tablet by mouth in the morning before breakfast. The medications scheduled time was 07:00 AM to 09:00 am, the medication was given late at 10:11 AM.5. Baclofen (a medication used to relax muscles of the body) 15 mg tablet by mouth three times a day. The medication was scheduled to be given between 07:00 AM and 09:00 AM and was given late at 10:11 AM.6. Systane ophthalmic solution 0.6% (eye drops used to prevent tear evaporation), one drop in both eyes three times a day. The eye drops were scheduled for 07:00 AM to 09:00 AM, the eye drops were given late at 10:11 AM.7. Ipratropium bromide nasal solution 0.03% (a nasal spray used for relief of a runny nose due to allergies), two sprays in each nostril two times a day. This medication was scheduled to be administered from 07:00 AM to 09:00 AM but was not administered until 10:11 AM.On 05/13/26 at 09:35 AM, Certified Medications Aide (CMA) R stated he was running behind that day and trying to get the residents' medications given correctly and efficiently. CMA R stated that a couple of R1's medications.

Based on observation, record review, and interview, the facility failed to keep the facility free from pests and maintain an effective pest control program when ants were seen in the east dining room. Findings included:- On 05/12/26 at 09:47 AM, an observation noted ants crawling across the table in the east dining room. On 05/12/26 at 09:47 AM, Dietary Staff BB stated she had reported to maintenance that there had been ants noted on the table in the east dining room. On 05/13/26 at 09:15 AM, Administrative Staff C stated pest control came to the facility monthly and as needed when pests were noted in between the visits. Administrative Staff C stated an order was put in the TELS (a building management platform designed for senior living with integrated asset management, life safety, and maintenance solutions). On 05/13/26 at 01:30 PM, Maintenance U stated that he had been notified by a resident in the dining room and by staff of the ants yesterday. Maintenance U stated pest control came to the facility monthly and as needed. The pest control was called and would be coming tomorrow to spray for the ants in the dining room and to look for any other pests in the areas. Maintenance U stated it was spring, and the ants were looking for food, and it was possible for them to get inside the building.The facility's Pest Control policy dated March 2026 documented it was the policy of this facility to provide an environment free of pests. The facility would have a pest contract that provided frequent treatment of the environment for pests. It would allow for additional visits when a problem was detected. Monitoring of the environment would be done by the facility's staff.

Based on observation, record review, and interview, the facility failed to ensure Resident (R)6 and R43's call light was within his reach to enable him to call for staff assistance. Findings included:- R6's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following a nontraumatic intracerebral hemorrhage (a spontaneous, emergency bleeding within the brain) affecting the left non-dominant side, vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), contracture of left forearm, and left hand, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness, and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness).The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of six, which indicated severely impaired cognition. The MDS documented R6 had an impairment on one side of his upper and lower body. The MDS documented R6 needed set up or clean up assistance with eating and was dependent on staff for toileting and oral hygiene.R6's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 10/01/26 documented R6 was dependent on staff for all self-care and mobility tasks except eating.R6's Care Plan documented the following:09/28/22-R6 was provided with a soft touch call light for ease of use.01/18/23-R6 was to have brightly colored tape to his soft touch call light to remind R6 to use his call light to get out of bed.On 05/12/26 at 01:26 PM, R6 sat in his Broda chair (specialized wheelchair with the ability to tilt and recline) chair, positioned on the side of his bed. R6 was yelling out Help. R6's soft touch call light was laid in the middle of his bed. R6 was grabbing for the blankets on the bed, though he was unable to pull the blankets close enough to him to reach his call light.On 05/13/26 at 02:10 PM, R6 sat in his Broda chair, next to his bed. R6's soft touch call light was placed behind R6 on his bedside table. R6 was unable to reach his call light.2. R43's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of aphasia (condition with disordered or absent language function), gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach), and cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain).The admission Minimum Data Set (MDS) dated 01/27/26 documented severely impaired cognition. The MDS documented R43 had limited range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension) on upper and lower extremities on one side of her body. The MDS documented R43 was dependent on staff assistance for all of activities of daily living. R43's Cognitive Loss/Dementia Care Area Assessment (CAA), dated 02/03/26, documented she had impaired memory.R43's Care Plan documented the following interventions:01/22/26-Be sure the call light is within reach and encourage R43 to use it to call for assistance as needed.On 05/13/26 at 2:37 PM, R43 laid on the bed with the head of her bed only elevated slightly. R43's gastrostomy feeding (the introduction of a nutrient solution through a surgically inserted tube into the stomach through the abdominal wall) was patent. R43's call light was attached to her bed and the call light cord and button hung behind her bed. R43's bilateral heels rested directly on the mattress.On 05/14/26 at 01:59 PM, Certified Nurse Aide (CNA) N stated the call light should always be within the residents reach.On 05/12/26 at 01:30 PM, Licensed Nurse (LN) G stated R6 and R43's call light should be within their reach. LN G stated R6 was unable to reach his call light.On 05/14/26 at 02:51 PM, Administrative Nurse D stated call lights should always be within the reach of the resident. The facility's Accommodation of Needs policy dated 08/25 documented it was the policy of the facility to assure that a resident had the right to reside and receive services in the facility with reasonable accommodation of individual needs and preferences, except when the health or safety of the individual or other resident would be endangered.

Based on interviews, observation, and record review, the facility failed to ensure a discharge summary was completed and a recapitulation of Resident (R) 83's stay at the facility. The facility also failed to notify the state ombudsman of his discharge from the facility. Findings included:- R83's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of chronic pain and chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing).R83's EMR revealed a Nursing Note: dated 04/10/26 at 03:06 PM, that documented R83 was to be discharged home with his medications and all his personal belongings. Discharge instructions were reviewed with R83 and voiced no concerns.The Facility provided the Ombudsman notification for the past three months. Review of the items provided by the facility revealed the facility had sent copies of the bed-hold and hospital transfers to the state ombudsman's office.On 05/13/26 at 09:25 AM, Administrative Staff C stated she was unable to locate a discharge summary to have R83's recapitulation of his stay.On 05/14/26 at 11:10 AM, Social Services X stated she had only sent the list of residents who had transferred to the hospital.On 05/14/26 at 02:51 PM, Administrative Nurse D stated social services would start the discharge process and open the discharge summary form in the resident's EMR. Administrative Nurse D stated the charge nurse on duty would complete the discharge summary at the time of the discharge.The facility's Admission, Transfer, and Discharge policy dated 03/03/26 documented it was the policy of the Facility that each resident would remain in the Facility and not be transferred or discharged unless the discharge or transfer was appropriate as per the existing criteria. When the Facility transferred or discharged a resident, the Facility would ensure that the transfer or discharge was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider.

Based on observation, record review, and interview, the facility failed to implement and activities program to support Resident (R)6's social needs with involvement in both individual and group activities in order to support his highest psychosocial wellbeing when staff failed to offer and provide one on one activity or diversions from his red bag of activities in his room. Findings included:- R6's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following a nontraumatic intracerebral hemorrhage (a spontaneous, emergency bleeding within the brain) affecting the left non-dominant side, vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), contracture of left forearm, and left hand, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness, and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness).The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of six, which indicated severely impaired cognition. The MDS documented R6 had an impairment on one side of his upper and lower body. The MDS documented R6 needed set up or clean up assistance with eating and was dependent on staff for toileting and oral hygiene.R6's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 10/01/26 documented for R6 was dependent on staff for all self-care and mobility tasks except eating.R6's Care Plan documented:12/17/18-R6 was dependent on staff assistance with activity participation due to cognitive impairment and left side hemiplegia.Staff to invite R6 to schedule activities.09/03/19-R6's preferred activities were happy hour, ice cream socials, baking buddies, bingo, and going outside.10/01/25-R6 needed one to one bedside visits and activities in his room if he was unable to attend out of the room events.02/25/26-R6 was to be given as many choices as possible about care and activities.R6 had a red activity bag in his room hanging on his wall. The sign above the red activities bag stated give R6 something from his activities bag if he needs redirection.R6's EMR under Progress Notes under Activities Notes dated 09/25/25 documented R6 attended a group activity.On 05/12/26 at 08:55 AM, R6 sat in the dining room at a table by himself and ate his breakfast. R6 was pushed to his room, and his Broda chair was backed next to his bed. R6 was not provided one to one time and was not offered anything from his red activities bag.On 05/12/26 at 11:10 AM, R6 was pushed back to the dining room and sat in the corner eating his lunch. R6 was pushed back to his room at 01:15 PM. R6 was backed into his room next to his bed. R6 was not provided one to one and was not offered anything from his red activities bag.On 05/13/26 at 09:55 AM, R6 sat in the dining room at a table by himself and ate his breakfast. R6 was pushed to his room, and his Broda chair was backed next to his bed. R6 was not provided one to one and was not offered anything from his red activities bag.On 05/13/26 at 11:44 AM, R6 was pushed back to the dining room and sat in the corner eating his lunch. R6 was pushed back to his room when he finished his lunch. R6 was backed into his room next to his bed. R6 was not provided one to one and was not offered anything from his red activities bag.On 05/14/26 at 08:15 AM, R6 sat in the dining room at a table by himself and ate his breakfast. R6 was pushed to his room, and his Broda chair was backed next to his bed. R6 was not provided one to one time and was not offered anything from his red activities bag.On 05/14/26 at 01:15 PM, Activities Director Z stated she ensures all residents have an activities calendar in their rooms. She stated R6 was very disruptive in activities, and if he does come to activities, a staff member would have to come with him. She stated he had not been to many activities. Activities Director Z stated she had placed a red bag in R6's room. She stated staff could give him anything in the bag to occupy him. She stated she had not had a lot of time to do one-to-one activities with residents, because it was just her. Activities Director Z stated the facility was looking to get her an assistant.On 05/14/26 at 01:59 PM, Certified Nurses Aide (CNA) N stated R6 did not come out of his room for many activities. She stated he had behaviors when he was at activities. She was unsure who would do one to one activities with the residents, she thought that would be activities. CNA N stated she knew R6 had a red bag of things he could be given to keep him busy. She stated she knew her co-worker had given him something from the bag once.On 05/14/26 at 02:25 PM, Licensed Nurse (LN) J stated any staff can take a resident to activities. She stated the residents' preference for activities should be on the care plan. LNJ stated if a resident had an activity bag in their room, staff should make sure the resident had something from the bag.On 05/14/26 at 02:51 PM, Administrative Nurse D stated staff should be interacting with all residents. She stated she knew R6 had behaviors while he was at activities. She stated R6 should still be offered activities and interactions. Administrative Nurse D stated staff should be giving R6 something from his red bag for distractions if he was not going out to activities. The facility's Care of Dementia dated 03/25 documented It was the policy of the facility that all residents would have an individualized plan of care and have the least restrictive approaches to care. Staff were offered specialized training in the care of the dementia population, appropriate approaches to care, and managing behaviors.

Based on observations, record review, and interviews, the facility failed to provide adequate care and services to promote the healing of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) for Resident (R) 4, and R43 when staff failed to provide their heel boots. Findings included: - R4's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), aphasia (condition with disordered or absent language function) following cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), pressure ulcer and Stage 4 (a deep pressure wound that reaches the muscles, ligaments, or even bone) to right and left heels. The Modification of Quarterly Minimum Data Set (MDS) for R2, dated 04/06/26, recorded a Brief Interview for Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R4 had an impairment on both sides of her upper and lower extremities of her body. The MDS documented R4 was dependent on staff for all activities of daily living (ADLs). The MDS documented R4 received intravenous (into a vein) (IV) medications during the observation period. The MDS documented R4 was at risk for developing a pressure ulcer/injury. The MDS documented R4 had one unhealed pressure ulcer/injury. R4's MDS documented R4 had two Stage 2 (partial-thickness skin loss into but no deeper than the dermis, including intact or ruptured blisters), and two unstageable (depth of the wound is unknown due to the wound bed being covered by a thick layer of other tissue and pus). R4's Pressure Ulcer/Injury Care Area Assessment (CAA) dated 10/05/25 documented a pressure ulcer Stage 3 (full-thickness pressure injury extending through the skin into the tissue below) was noted to the sacrum, and left foot had unstageable wounds. The CAA documented R4 had multiple areas of moisture-associated skin damage (MASD- inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucous), related to contracture (abnormal permanent fixation of a joint or muscle), the need for assistance with personal care, and urinary incontinence. R4's Care Plan documented the following: 09/30/25- R4 was at risk for impaired skin integrity related to limited mobility, contractures, and incontinence 10/03/25- R4 should always have pressure relieving ankle foot orthosis (Prafo) boots on both feet at times. 05/12/26- Staff to provide treatment to R4's site of resolved pressure injury on left heel as ordered for prevention. R4's EMR under the Orders tab revealed the following physician orders: Low air loss mattress for skin maintenance every shift for skin integrity, ensure low air loss mattress was functioning and set per manufacturer settings dated 04/29/26. Wound treatment: cleanse right heel with wound cleaner, pat dry, apply a small amount of Santlyl (ointment used to actively break down and remove dead tissue from severe burns and chronic skin ulcers) directly to the wound bed, cut and apply HBlue (antimicrobial foam dressing), then wrap with Kerlix (stretchy gauze bandage) every day and as needed dated 04/28/26. Wound treatment: apply Skin-prep (liquid skin protectant) to left heel, then cover with Foam Secure (an absorbent, breathable medical bandage), change every day and as needed if wound dressing was not intact for protection every shift. Report redness, increased drainage, odor, warmth, signs of infection, decline or lack of improvement in wound to physician dated 04/28/26. On 05/12/26 at 08:44 AM, R4 laid on her bed, on her back. R4 had her eyes closed. R4's tube feeding (administration of nutritionally balanced liquefied foods or nutrients through a tube) was running. R4 had a boot on her right heel, R4's left heel laid directly on the mattress. R4 did not have her boot on her left heel as care plan was documented. On 05/14/26 at 01:59 PM, Certified Nurses Aide (CNA) N stated the CNA's put the residents' boots on and ensure the if a resident needed their heels floated, they would also do that. She stated she would know if a resident needed. CNA N stated she had a place on shift documentation to mark if she floated a resident's heels or applied a boot to the residents' heels. CNA N stated when she worked in the R4's hall she made sure her boots were on her heels. On 05/14/26 at 02:25 PM, Licensed Nurse (LN) J stated R4 should always have both of her boots on her heels. She stated the CNAs apply the residents' boots; it was also the nurse working that halls responsibility to ensure residents have what was ordered. LN J stated she was not sure if R4 should have boots, she would check R4's care plan and physicians orders. On 05/14/26 at 02:51 PM, Administrative Nurse D stated if a resident's care plan stated the resident should have boots, the CNA and the LN should ensure the resident should have her boots on. The facility's Skin and Wound Monitoring and Management policy dated 03/26 documented a resident who entered the facility without pressure injury does not develop a pressure injury unless individuals' clinal condition or other factors demonstrate that a developed pressure injury was unavoidable; and a resident having pressure injury receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing. - 2. R43's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of aphasia (condition with disordered or absent language function), gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach), and cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The admission Minimum Data Set (MDS) dated 01/27/26 documented severely impaired cognition. The MDS documented R43 had limited range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension) on upper and lower extremities on one side of her body. The MDS documented R43 was dependent on staff assistance for all of activities of daily living (adls). The MDS documented R43 was at risk for development of pressure ulcer injury. The MDS documented R43 had an unhealed pressure injury. The MDS documented a pressure reducing device was placed on her bed and in her chair. R43's Pressure Ulcer Care Area Assessment (CAA), dated 02/03/26, documented she was at risk of current wound becoming chronic and the development of new pressure related injuries. R43 was dependent on staff assistance for her ADLs. R43's Care Plan documented the following interventions: 01/22/26- requires pressure relieving/reducing device on the bed and wheelchair. Has a low air loss mattress. 01/23/26- Pressure reducing devices. 04/22/26- Prafo boots (special pressure-reducing heel protectors) as ordered. R43's EMR under the Orders tab revealed the following physician orders: Prafo boots on at all times, bilateral lower extremities dated 04/10/26. On 05/13/26 at 2:37 PM, R43 laid on the bed with the head of her bed only elevated slightly. R43's gastrostomy feeding (the introduction of a nutrient solution through a surgically inserted tube into the stomach through the abdominal wall) was patent. R43's call light was attached to her bed and the call light cord and button hung behind her bed. R43's bilateral heels rested directly on the mattress. On 05/14/26 at 09:23 AM, R43 laid on the bed with her bilateral heels resting directly on the mattress. - 3. R53's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of repeated falls, disorientation, diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), need for assistance with personal care, and multifocal motor neuropathy (a rare condition that causes muscle weakness due to nerve damage). R53's Quarterly MDS dated 03/30/26 documented he had a Brief Interview for Mental Status (BIMS)score of eight that indicated moderately impaired cognition. The MDS documented R53 was at risk for pressure ulcer development. R53 had a pressure-reducing device for his chair and bed. R53 was on a turning/repositioning program. R53's Pressure Ulcer Care Area Assessment (CAA), dated 02/23/26 documented he had no active pressure ulcers/injuries. His risk factors include a history of diabetes, incontinence, increased pain, and the need for assistance with cares. The staff was to monitor and report any concerns to the physician. R53's Care Plan documented the following: 07/20/25 – R53 was to have pressure reducing devices.R53 required a pressure relieving/reducing device on bed and wheelchair Turn and reposition as tolerated. R53's EMR under the Assessment tab revealed a Braden Scale dated 01/19/26, documenting R53 was at moderate risk for development of pressure related injuries. On 05/12/26 at 02:15 PM, R53 laid awake on his bed in the lowest position. R 53's wheelchair sat next to the bed with a Dycem (non-slip mat used for stabilization and gripping to prevent slipping) on the seat of his wheelchair, the wheelchair lacked a cushion and anti-tip device on the back of his wheelchair. R53 stated his buttocks would hurt after sitting in the wheelchair. On 05/13/2026 at 07:49 AM, R53 propelled his wheelchair down the hallway from the dining room to his room. The wheelchair lacked a cushion on the wheelchair seat and lacked anti-tip devices on the back of his wheelchair. R53 stated his bottom still hurt after sitting in the wheelchair.

Based on observation, record review, and interviews, the facility failed to provide care and services to prevent further decline in range of motion when staff failed to place Resident (R)6's hand splint on his left hand for contracture (abnormal permanent fixation of a joint or muscle) prevention. Findings Included:- R6's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following a nontraumatic intracerebral hemorrhage (a spontaneous, emergency bleeding within the brain) affecting the left non-dominant side, vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), contracture of left forearm, and left hand, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness, and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness).The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of six, which indicated severely impaired cognition. The MDS documented R6 had an impairment on one side of his upper and lower body. The MDS documented R6 needed set up or clean up assistance with eating and was dependent on staff for toileting and oral hygiene.R6's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 10/01/26 documented for R6 was dependent on staff for all self-care and mobility tasks except eating.R6's Care Plan documented the following:01/04/24- Staff to limit R6's choices and provide chances for R6 to choose in his daily care routine.01/08/25-Staff may offer a resting hand splint as tolerated for contracture prevention to left hand.R6's EMR under Orders revealed the following physicians' orders:May offer resting hand splint as tolerated for contracture prevention to left hand every shift, dated 07/09/24.R6's EMR under Treatment Administration Record (TAR) from 05/01/26-05/14/26 documented N for No form 05/01/26-05/14/26 for staff may offer a resting hand splint as tolerated for contracture prevention.R6's EMR lacks documentation R6's refusals for R6's resting hand splint.On 05/12/26 at 01:26 PM, R6 sat in his Broda chair (specialized wheelchair with the ability to tilt and recline), positioned on the side of his bed. R6 was reaching for his call light. R6 did not have a splint on his left hand. R6's fingers on his left hand were curled down onto the palm of his hand.On 05/13/26 at 02:10 PM, R6 sat in his Broda chair, next to his bed. R6 fingers on his left hand were curled down onto the palm of his hand.R6's room had a sign hanging which stated, Please help me put on my left hand brace every morning. Please remove before bed.On 05/14/25 at 01:59 PM, Certified Nurses Aide (CNA) N stated R6 had a sign hanging in his room to apply his brace. She stated she did not know who would put the brace on. She started nursing or therapy. CNA N stated she had never applied R6's brace to his left hand.On 05/14/25 at 02:25 PM, Licensed Nurse (LN) J stated it was the CNA's duty to apply R6's splint. She stated the LN working that hall should check to ensure R6 had his brace on.05/14/25 at 02:51 PM Administrative Nurse D stated if a resident should have a brace placed daily, that should be on the residents care plan. She stated it would be the CNA's responsibility to apply the splint. She stated the nurse should double check to ensure the brace was on the resident.The facility's Quality of Care policy dated 03/26 documented it was the policy of the facility that residents were given the appropriate treatment and services to maintain or improve his or her abilities.

Based on interviews, observation, and record review the facility failed to secure pressurized supplemental oxygen tanks in a safe, locked area, and out of reach of the cognitively impaired, independently mobile residents. The facility additionally failed to ensure fall interventions were in place for Resident (R) 53 and R16, which placed the residents at risk for preventable accidents and injuries. Findings included:- On 05/12/26 at 08:01 AM, during the initial walkthrough of the facility, an unsecured oxygen storage room revealed on the west hallway. The room contained 34 pressurized supplemental oxygen cylinder tanks stored in floor racks. The room had a key lock on the entry door.On 05/12/26 at 08;17 AM, an oxygen cylinder sat in the corner directly on the floor of R77's room. The oxygen cylinder cart was in R77's room. The oxygen cylinder was not placed in a cart. 1. R53's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of repeated falls, disorientation, diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), need for assistance with personal care, and multifocal motor neuropathy (rare condition that causes muscle weakness due to nerve damage).R53's Quarterly MDS dated 03/30/26 documented he had a Brief Interview for Mental Status (BIMS)score of eight that indicated moderately impaired cognition. The MDS documented R53 required supervision to touch assistance when moving from a sitting position to standing, and when he transferred from chair-to-chair transfers. The MDS documented that he was independent during a transfer on and off the toilet.R53's Falls Care Area Assessment (CAA), dated 02/23/26, documented he had two non-injury falls noted in the lookback period. His risk factors included a history of diabetes, a decline in cognition, incontinence, and the need for assistance with cares. The staff was to monitor and report concerns to the physician.R53's Care Plan documented the following:04/29/26- Staff would orient R53 to the location of the call light after each round. R53 was sent to the ER for further evaluation after his fall.05/7/26- Staff would apply anti-tippers to R53's wheelchair. On 05/12/26 at 02:15 PM, R53 laid awake on his bed in the lowest position. R 53's wheelchair sat next to the bed with a Dycem (non-slip mat used for stabilization and gripping to prevent slipping) was on the seat of his wheelchair, the wheelchair lacked a cushion and anti-tip device on the back of his wheelchair. R53 stated his buttocks would hurt after sitting in the wheelchair. On 05/13/2026 at 07:49 AM, R53 propelled his wheelchair down the hallway from the dining room to his room, The wheelchair lacked a cushion on the wheelchair seat and lacked anti-tip devices on the back of his wheelchair. R53 stated his bottom still hurt after sitting in the wheelchair. - 2. R16's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hypertension (HTN-elevated blood pressure), contracture (abnormal permanent fixation of a joint or muscle) of muscle, muscle weakness, and lupus (an autoimmune disease that damages the immune system, damages organs, and tissue throughout the body.The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14, which indicated cognition. The MDS document R16 needed set up or cleaned up for eating and substantial/maximal assistance with bathing and oral care, and was dependent on staff for toileting. The MDS documented R16 had no fall during the observation period.The Fall Care Area assessment dated [DATE] documented R16 was non-ambulatory and had bilateral hand contractures. The CAA documented R16 had not had a fall since 06/2025.R16's Care Plan documented the following:03/27/25-R16 was at risk for falls due to contractures, muscle weakness, and reduced mobility.06/26/25-Staff to use slide board with transfers to and from wheelchair for R16.06/27/25-Ensure call light was within R16's reach and encourage R16 to use call light for assistance.05/01/26 -Place bolsters on R16's bed to help define bed parameters R16's EMR under Progress Notes under Nursing Note documented on 05/01/26 at 03:03 PM R16 was found on the floor by a Certified Nurse Aide (CNA). R16 was on the floor with the bed sheet beneath him. R16 was assessed and assisted to bed. R16 denied pain.R16's EMR under Fall Risk Evaluation dated 12/06/25 documented a medium risk of seven.On 05/12/26 at 08:47 AM, R16 laid curled up on his bed. R16's bed was in a high position. R16's call light was wrapped around the right-hand side rail of his bed and dangling down. R16 stated he could not reach or find his call light, and he did not like his bed in a high position. R16 stated staff put his bed in a high position when doing his care.On 05/14/26 at 01:59 PM, Certified Nurse Aide (CNA) N stated call lights should always be within the resident's reach. She stated a resident's bed could be in a high position if the resident wanted the bed in a high position. CNA N stated R16 was a fall risk and his bed should be in a lower position.On 05/14/26 at 02:25 PM, Licensed Nurse (LN) J stated call lights should be within the resident's reach. She stated all residents' beds should be in a lower position. LN J stated R16 was a fall risk and staff should place his bed in a low position, if he was agreeable. LN J stated the oxygen storage room should always be kept locked and any oxygen cylinders should be stored on an oxygen cart. LN J stated everyone was responsible for ensuring fall interventions are in place to prevent future falls.On 05/14/26 at 02:51 PM, Administrative Nurse D stated call lights should be within the resident's reach. She stated beds should be in a low position. Administrative Nurse D stated oxygen should be stored behind a locked door when not in use and secured on an oxygen cart. Administrative Nurse D stated that it was everyone's responsibility to ensure fall interventions were in place. Administrative Nurse D stated, but ultimately, it was her responsibility.The facility's Fall Management System, dated 03/26, documented it was the policy of the facility to provide an environment that remains as free of accident hazards as possible. It was also the policy of the facility to provide each resident with appropriate assessment and interventions to prevent falls and minimize complications if a fall occurs.

Based on interviews, observation, and record review the facility failed to ensure Resident (R)43 received treatment and services for enteral nutrition (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew, or swallow food) to prevent complications or adverse consequences when staff did not position R43 to prevent potential aspiration. Findings included:- R43's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of aphasia (condition with disordered or absent language function), gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach), and cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain).The admission Minimum Data Set (MDS) dated 01/27/26 documented severely impaired cognition. The MDS documented R43 had limited range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension) on the upper and lower extremities on one side of her body. The MDS documented R43 was dependent on staff assistance for all activities of daily living (ADLs). The MDS documented R43 had coughing or choking during meals or when swallowing medications. The MDS documented R43 had received 51 percent or more of her total calories through tube feeding.R43's Feeding Tube Care Area Assessment (CAA), dated 02/03/26, documented she had suffered a CVA and was dependent on staff assistance for ADL and gastrostomy nutrition.R43's Care Plan documented the following interventions: 01/27/26- elevate R43's head of bed at least 30-45 degrees at all times during feeding.R43's EMR under the Orders tab revealed the following physician orders:Enteral feed orders every shift and elevate head of bed at least 30-45 degrees at all times during feeding and 1 hour after, dated 01/21/26.On 05/13/26 at 2:37 PM, R43 laid on the bed with the head of her bed only elevated slightly, but less than 30-45 degrees. R43's gastrostomy was infusing. R43's call light was attached to her bed, and the call light cord and button hung behind her bed. R43's bilateral heels rested directly on the mattress.On 05/14/26 at 09:25 AM, Administrative Nurse E stated R43's head of bed should be elevated at least 30 to 45 degrees at all times. The facility's Gastrostomy Tube Care and Management policy dated 04/2026 documented it was the policy of this facility to provide proper care and maintenance of gastrostomy tubes.

Based on observation, record review, and interviews, the facility failed to provide services consistent with the standards of care related to the care of Resident (R) 4's peripherally inserted central line (PICC-a thin, flexible tube that is inserted into a vein in the upper arm and threaded into a large vein above the heart) when staff failed to follow the physicians order for the in-facility removal of the PICC line when the intravenous antibiotic was finished for three days, failed to document the full removal of the line including the tip and failed to adequately monitor the site for complications after removal. Findings included: - R4's EMR from the Diagnosis tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), aphasia (condition with disordered or absent language function) following cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), and Stage 4 (a deep pressure wound that reaches the muscles, ligaments, or even bone) to right and left heels. The Modification of Quarterly Minimum Data Set (MDS) for R4, dated 04/06/26, recorded a Brief Interview for Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R4 had an impairment on both sides of her upper and lower extremities of her body. The MDS documented R4 was dependent on staff for all activities of daily living (ADLs). The MDS documented R4 received intravenous (IV-administered directly into a vein) medications during the observation period.R4's Pressure Ulcer/Injury Care Area Assessment (CAA) dated 10/05/25 documented pressure ulcer Stage 3 (full-thickness pressure injury extending through the skin into the tissue below) noted to the sacrum, and the left foot was unstageable (depth of the wound is unknown due to the wound bed being covered by a thick layer of other tissue and pus). The CAA documented R4 had multiple areas of moisture-associated skin damage (MASD- inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucous), related to contracture (abnormal permanent fixation of a joint or muscle), the need for assistance with personal care, and urinary incontinence.R4's Care Plan documented:09/30/25-Administer analgesia (medication for pain) as per orders.Staff to monitor for pain.R4's Care Plan did not address the PICC line or associated care.R2's EMR under the Orders tab revealed the following physician orders:Change PICC line dressing to the upper left extremity every day shift, every seven days, dated 03/31/26, discontinued on 05/12/26.Change PICC line caps weekly and as needed with each blood draw, every seven days or as needed dated 03/31/26, discontinued on 05/12/26.Daptomycin Sodium Chloride (antibiotic)Intravenous solution 500-0.9 milligrams (mg) per 50 milliliters (mls), use 600 mg intravenously in the evening for osteomyelitis (local or generalized infection of the bone and bone marrow) dated 04/29/26 until 05/08/26.Flush each port with 10ml of normal saline once daily before and after medication administration every day shift dated 03/31/26, discontinued on 05/12/26.R4's EMR under Nursing Notes dated 05/12/26 at 05:02 PM documented the PICC line removed this shift by RN on duty. Compression dressing applied. No complications noted. Resident tolerated well.R4's EMR under Nursing Notes dated 05/13/26 at 11:13 AM documented PICC line removed from left upper arm per physician's orders noted on 04/29/26 at 11:00 AM. R4 tolerated the removal with no issues. Nurse on duty instructed to monitor for abnormal bleeding or any other complications.R4's EMR under Orders lacked a physician's order to remove PICC line.R4's EMR under Documentation dated 04/29/26 continue Daptomycin/Cerftiax through 05/08/26 then remove PICC line and discontinue weekly labs, facility to follow up wound care and offload.R4's EMR lacked documentation related to inspection of the PICC line after removal to ensure the entire line, including the tip was removed without complications.On 05/13/26 at 09:34 AM, Administrative Nurse E stated she was in the facility when LN I stated R4's antibiotic had ended. Administrative Nurse E stated LN I had an order for the removal of R4's PICC line. She stated she should have charted the removal and what the site looked like. Administrative Nurse E stated she should do a late entry of charting for the removal of R4's PICC line removal.On 05/13/26 at 09:35 AM, Administrative Nurse D stated the office personnel had taken the order off the scanner. She stated the office personnel had sent the order out to all department heads. Administrative Nurse D stated nursing had not done anything with the order. She stated the office personnel scanned the order into R4's chart. Administrative Nurse D stated it should be the practice of the facility to document the removal of the PICC line, and any monitoring or complications.The facility's Quality of Care dated 03/26 it was the policy of the facility that residents were given the appropriate treatment and services to maintain or improve their abilities.

The facility identified a census of 66 residents. The sample included 19 residents with six reviewed for nutrition. Based on observation, record review, and interviews, the facility failed to monitor weights consistently in order to identify loss and immediately involve the registered dietician and physician to evaluate if nutritional needs were met for Resident (R) 27's enteral nutrition regimen (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew or swallow food) to prevent a significant, unplanned weight loss of 11.74 percent (%) within two months. Findings Included: - The Medical Diagnosis section within R27's Electronic Medical Records (EMR) included diagnoses of aphasia (condition with disordered or absent language function) muscle weakness, dysphagia (difficulty swallowing), hemiplegia/hemiparesis (weakness and paralysis on one side of the body), and cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). R27's Admission Minimum Data Set (MDS) completed 06/09/24 noted a Brief Interview for Mental Status (BIMS) assessment could not be completed due to severe cognitive impairment. The MDS indicated she was dependent on staff for bed mobility, transfers, dressing, bathing, and personal hygiene. The MDS indicated she received enteral nutrition through a feeding tube. The MDS indicated she weighed 155 pounds (lbs.) upon admission. R27's Functional Abilities Care Area Assessment (CAA) completed 06/13/24 indicated she admitted to the facility for therapy services related to her medical diagnoses. The CAA indicated she was dependent on staff for all her activities of daily living (ADL). R27's Feeding Tube CAA completed 06/13/24 indicated she was unable to swallow or chew her food safely. The CAA noted she had a percutaneous endoscope gastrostomy tube (PEG-a tube inserted through the wall of the abdomen directly into the stomach) for all nutritional intake and was on a nothing by mouth diet (NPO). The CAA indicated she was at risk for complication related to her PEG tube. The CAA indicated the enteral nutrition will be monitored by the registered dietician and medical provider. R27's Nutrition CAA was not triggered upon her admission. R27's Care Plan initiated 06/04/24 indicated she was at risk for alterations with her functional abilities related to her medical diagnoses. The plan noted she was dependent on staff for transfers, dressing, bed mobility, toileting, dressing, bathing, and personal hygiene. The plan indicated she was at risk for altered nutrition and had a PEG tube for enteral nutrition. The plan instructed all medications and nutrition would be administered via her PEG tube. The plan instructed staff to administer her enteral feeding and water flushes per her provided orders. The plan instructed staff to check tube placement and gastric residual volume. The plan instructed staff to hold her enteral feedings if the residual amount was greater than (>) 100 cubic centimeters (cc). R27's EMR under Registered Dietician Note indicated R27 was seen by the Registered Dietician (RD) on 06/10/24. The note indicated R27's current body weight was 155.1 lbs. The note indicated R27's diet was NPO and she received enteral nutrition. R27's EMR under Physician's Progress Note indicated the medical provider met with R27 and her resident representative on 06/14/24. The note indicated R27's representative reported R27 had a five-pound weight loss to the medical provider. The note indicated her family was concerned about her nutritional intake and weight loss. The note instructed nursing staff to reweigh R27 accurately and discuss further weight management. The EMR lacked follow-up documentation from the medical provider. R27's EMR under Physician's Orders revealed an order dated 06/04/24 for her to be weighed weekly for four weeks. The order was discontinued on 07/02/24. R27 had no other orders for weight monitoring. R27's EMR under Physician's Orders revealed an order (started 06/03/24) for staff to administer Jevity 1.5 Liter (liquid nutritional supplementation) via PEG tube, twice daily at 55 milliliters (ml) continuously from 08:00 PM to 11:00 AM. The order instructed staff to provide 60 ml water flushes every four hours, prior to enteral feedings. The order was discontinued and reentered on 06/16/24 with no nutritional changes. R27's EMR under Physician's Orders revealed an order (started 06/03/24) for staff to administer 150 ml bolus feedings of Jevity twice daily. The order was discontinued and reentered on 06/16/24 with no nutritional changes. R27's EMR under Weight History between 06/03/24 to 07/09/24 revealed her weight upon admission was 155 lbs. on 06/03/24. The EMR revealed her weight decreased to 143.6 lbs. on 06/11/24, indicating a 7.35% weight loss since her admission to the facility (eight days). R27's EMR indicated her weight decreased to 142.4 lbs. on 06/20/24, indicating an 8.13% weight loss since her admission (17 days). R27's EMR noted her last recorded weight was 145.2 lbs. on 07/01/24. R27's EMR lacked documentation showing the medical provider or the registered dietician were notified of R27's continued weight loss. Observation on 07/09/24 at 07:04 AM, revealed R27 slept in her bed. The head of R27's bed was propped upward and her nutritional pump was set to 55 ml, with no leaks or spills noted. On 07/10/24 at 08:00 AM staff weighed R27 upon request. She weighed 136.8 lbs. indicating an 11.74% weight loss since her admission (37 days). On 07/10/24 at 09:21 AM R27's representative reported she had concerns related to R27's weight loss. She stated she reported her mother's initial weight loss to the medical provider but had not heard back about what interventions would be put in place or if additional supplementation was needed. She stated the facility had not increased R27's supplementation and feared more weight loss occurred. She stated she didn't feel the current feeding regimen was enough to prevent R27's weight loss and nothing has changed since then. On 07/10/24 at 08:43 AM Licensed Nurse (LN) H stated residents with enteral nutrition should be weighed weekly due to the risk of malnutrition. He stated R27 had a major weight loss identified earlier in the morning and the physician was notified. He stated an order for speech therapy was placed to evaluate her. He stated staff were expected to notify the medical provider and RD upon suspected weight loss. He stated the communication should be documented in the progress notes. He stated resident with enteral nutrition and weight loss should be evaluated to ensure their supplemental nutrition needed to be increased or adjusted. He stated the dietician was at the facility weekly and should evaluate R27's needs if she was at risk. On 07/10/24 at 02:55 PM Administrative Nurse D stated staff should weigh enterally fed residents weekly and report weight loss to the registered dietician. She stated the facility's dietician was on maternity leave and they utilized a temporary RD. She stated the RD came in weekly and should see all residents at risk for weight loss. She stated the RD notes should be charted in the EMR under Progress Notes. On 07/11/24 at 09:25 AM Consultant GG stated she had concerns with the facility's communication related to concerns with weight loss and issues with enteral feedings not being reported to her from staff. She stated she recently met with the facility's management to ensure she was being notified about any dietary concerns reported by staff. She stated she intended to increase R27's enteral feed rate from 55 ml to 65 ml. She stated she expected staff to notify her immediately of findings of significant weight loss. She stated she asked the facility to reweigh R27 yesterday after being notified of the weight loss identified but the facility had yet to notify her of the results. The facility's Nutrition Status Management policy revised 12/2023 indicated the facility was to assess each resident's nutritional needs to ensure their nutritional needs were maintained within acceptable parameters. The policy noted the facility will identify the resident's ideal body weight, associated condition, nutritional preferences, psycho-social needs, and risks. The policy noted at risk resident's will be weighed weekly and reviewed by the dietician. The facility failed to monitor weights and adjust R27's enteral nutrition regimen before a significant weight loss occurred. As a result of the deficient practices, R27 had a significant unplanned weight loss of 11.74% within two months.

The facility identified a census of 55 residents. The sample included three residents reviewed for foot care. Based on record review and interviews, the facility failed to ensure Resident (R) 1, who had a history of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made or the body cannot respond to the insulin) and amputations of his right leg and his left fifth toe related to DM, received appropriate wound care and services to prevent complications from his medical conditions. As a result, R1's toe wound became progressively worse and infected and ultimately required surgical removal. This also placed R1 at risk for increased pain and decreased mobility. Findings included: - R1 admitted to the facility on [DATE] and transferred to the hospital on 03/14/24. The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses of DM, unsteadiness on feet, peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), acquired absence of right leg below the knee, dementia (a progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance, and amputation of the right leg below the knee. R1's Admission Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of three, which indicated severe cognitive impairment. The MDS recorded R1 had no behaviors and no rejection of care. R1 had impairment on one side for upper and lower extremities and required substantial/maximal assistance with bathing. R1 required supervision with upper body dressing and partial/moderate staff assistance with lower body dressing and with his footwear. R1 required partial/moderate assistance from staff to walk 10 feet. The MDS recorded R1 had medically complex conditions that included DM but did not have a terminal (a life expectancy of less than six months) diagnosis. R1 had skin tears and moisture-associated skin damage (MASD- inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucous) but no vascular wounds. R1 did not receive treatments or ointments for his feet during the assessment period. The Pressure Ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction)/Injury Care Area Assessment (CAA) dated 02/17/24, documented R1 had an alteration in functional abilities and required assistance from staff. R1 had a risk of an alteration in his skin integrity. The CAA documented R1 had redness and MASD to his groin and skin tears to bilateral knees and left forearm. The CAA indicated staff would assess R1's skin as ordered and report to the physician as needed. R1's Care Plan dated 02/05/24 and revised on 02/22/23 documented R1 had an alteration in functional abilities due to DM, PVD and R1 had a right below knee amputation with a prosthesis (artificial body part). The plan directed staff R1 required partial/moderate assistance from staff for walking short distances, transfers, lower body dressing, and putting on/taking off footwear. The plan recorded an intervention dated 02/23/24 that directed R1 to wear a left foot ankle-foot orthosis (AFO- a hard brace worn on the lower leg that improves overall walking safety and efficiency). R1's Care Plan dated 02/05/24 and revised 02/22/24, documented R1 was at risk for alteration in skin integrity related to DM and PVD. The Care Plan documented interventions, with a start date of 02/05/24, that directed R1 needed monitoring, reminding, and assistance to turn and position; staff notified the nurse of any new areas of skin breakdown. The plan directed staff to perform a skin assessment as ordered and reported to the physician as needed (initiated on 02/05/24 and revised on 02/23/24). The plan recorded an intervention dated 02/22/24 that directed staff to administer antibiotics to a left toe infection as ordered and monitor and report adverse effects. An intervention dated 02/22/24 documented treatment to the left foot as ordered and report to the physician for increased signs and symptoms of infection. An intervention dated 02/29/24 documented R1 was followed by a wound specialist. R1's Care Plan dated 02/23/24 documented R1 had DM with neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet) and listed a goal that R1 would have no complications related to his DM. The plan directed staff to administer his DM medication as ordered and monitor his blood glucose levels as ordered. The plan directed staff to monitor the insulin (a hormone that lowers the level of glucose in the blood) injection sites and monitor and report signs of hypoglycemia (low blood glucose level) or hyperglycemia (high blood glucose level). The plan lacked direction to staff regarding care for R1's foot. R1's EMR recorded a Physician Order dated 02/05/24 that directed the wound specialist may evaluate and treat for wound care. R1's Physical Therapy Treatment Encounter Notes documented a summary of services dated 02/07/24 which noted the therapist instructed R1 in skilled intervention to address gait training focused on facilitation of toe clearance at swing limb advancement and directional changes to improve R1's safety with independent ambulation. R1's Physical Therapy Treatment Encounter Notes dated 02/15/24 lacked mention of any issues identified or brought to nursing. R1's EMR recorded a Nursing note on 02/15/24 at 03:28 PM that documented Pt came to nurse and asked her to look at his toe. R1's second toe on his left foot had moist, loose skin. Staff cleaned the toe and wrapped it with gauze. The note documented that the toe needed followed up with by the doctor. A Nurse Practitioner (NP)/Physician Assistant (PA) Progress Note on 02/15/24 at 04:29 PM by Consultant GG documented R1 had a foot ulcer as a current medical problem. R1's skin color was appropriate for race, warm, and visible skin intact. The note documented a plan, but the plan did not address R1's foot. A review of R1's EMR lacked evidence staff monitored R1's left foot after placing gauze on the second toe on 02/15/24, lacked evidence of treatment orders obtained, physician notification, and lacked a formal assessment of the area until 02/21/24. A Daily Skilled Note on 02/21/24 at 02:53 AM documented R1 had a skin tear located on his left middle toe, R1 was compliant with treatment, and the skin condition was not a new onset. The note did not indicate which toe was referred to as the middle toe (R1 only had four toes due to a fifth toe amputation). A Physician Progress Note on 02/21/24 at 12:55 PM documented R1 was seen at the nurse's station for a new open area to the third left toe with a possible infection. The note directed to start Bactrim (antibiotic medication used to treat infections) 800 milligrams (mg)- 160 mg twice daily for 14 days and lactobacillus (probiotic supplement used to replace good bacteria in the gut) daily for 14 days with directions to see wound care orders for treatment plan of care. A Nursing note on 02/21/24 at 03:32 PM documented R1 was seen by the NP related to a new diabetic ulcer to the third toe of the left foot. The wound bed was discolored with some drainage and some moisture was noted to the bottom of the toe. There was dry skin to the top of the toe. The NP ordered Bactrim twice daily for 14 days, lactobacillus daily, and R1 should be on the wound care list for the next scheduled day. There was an order to cleanse the wound, apply triple-antibiotic ointment (TAO), and wrap it with gauze and tape. R1's EMR recorded a Physician Order dated 02/21/24 that directed to cleanse R1's third toe of the left foot with wound cleanser, apply TAO, and cover with gauze, and tape in place two times a day. The Silhouette Wound + Skin Assessment note signed on 02/27/24 documented an encounter to evaluate the chief complaint of an open wound/skin lesion. The note documented R1 was new to the wound specialty service. The note listed on 01/23/24 R1 was seen by podiatry prior to his admission at the facility on 02/05/24 and a toenail was removed completely. On 02/15/24 the patient asked staff to look at his toe and there was moist, loose skin that was cleaned and monitored. On 02/21/24 the area started to look necrotic (pertaining to the death of tissue in response to disease or injury). The note documented no X-ray was completed. The note recorded R1 had a history of a right below-knee amputation and a left fifth toe amputation. The note recorded an X-ray was ordered to evaluate for osteo (osteomyelitis - a local or generalized infection of the bone and bone marrow). R1's EMR recorded a Physician Order dated 02/29/24 that directed to cleanse the wound with wound cleanser, apply Santyl (a prescription enzyme used to help break up and remove dead skin and tissue from a wound), mupirocin (antibiotic ointment), and cover with bordered gauze every dayshift. R1's EMR recorded a Physician Order dated 02/29/24 that ordered a 3-view X-ray of the left foot. A Nursing note dated 02/27/24 at 11:53 PM and marked Late Entry documented R1 was seen by the wound care specialist due to a wound on the left third toe. The note indicated the wound was unable to be staged (a rating system used to rate wound severity for pressure injuries) and an X-ray was called to the X-ray vendor. The note indicated see wound report for dimensions. A Nursing note dated 02/29/24 at 01:43 PM documented staff spoke with a representative from the X-ray vendor regarding R1's profile to ensure R1's X-ray of his left foot was obtained. The note documented R1 was added at that time and the X-ray was scheduled with an estimated time of that day. A Nursing note dated 03/01/24 at 10:03 AM documented the X-ray obtained on 02/29/24 showed no evidence of osteomyelitis; staff informed the wound nurse. A LN-SKIN Ulcer Non-Pressure Weekly assessment in R1's EMR under the Assessment tab revealed an assessment dated [DATE] which documented an initial assessment of the left third toe. The assessment indicated the onset date was 02/15/24. The wound had 25 percent (%) slough (dead tissue, usually cream-colored or yellow), 50 % granulation tissue (new tissue formed during wound healing), and 25% epithelial tissue (new skin growing in a superficial wound). The wound measured 1.4 centimeters (cm) by 2 cm by 0.2 cm. The Silhouette Wound + Skin Assessment note with a service date of 03/13/24 documented the wound care specialist observed R1 in the company of the facility wound nurse. The wound care noted R1's left leg was visibly soiled and his Tubi-grips (elasticated tubular bandage designed to provide tissue support in treating strains, sprains, soft tissue injuries, general edema, and tissue protection) and dressing were saturated from weeping (slow leaking of fluid from the tissue). The note recorded there was a concern for the possibility of auto-amputation of the toe. The note recorded R1 was at higher risk due to a previous amputation of the fifth toe and a right leg amputation as well. The hospital Progress Notes, dated 03/14/24, documented R1 was from a facility with a history of 10 to 14 days of left foot redness, swelling, and a wound to his left third toe. R1's left lower extremity showed marked redness, warmth, and swelling of the foot and ankle; there was a wound on the tip of the third toe; and the fifth toe had been amputated. The hospital Master Treatment Plan (MTP), dated 03/15/24, documented R1's MTP was updated to reflect the toe amputation surgery. R1's had the third toe of his left foot amputated. Observation of three digital pictures dated 02/21/24, revealed R1's third toe on his left foot had a visible wound. The wound was located on the tip and pad of his third toe and had moist, yellow/white tissue with what appeared to be fibers or hair hanging off the wound. The anterior surface of R1's third toe had what appeared to be a brown, crusted residue. R1's second toe did not appear to have any moist or loose skin. On 03/28/24 at 11:38 AM, R1's representative stated R1 fell in January and ripped his toenail off. She stated she soaked R1's foot in hot water and did wound care on the toenail bed before he was admitted to the hospital in January. R1's representative stated when R1 admitted to the facility, the toenail bed had no signs of infection and was almost healed. R1's representative stated she told the admitting nurse about the toe. She stated the admitting nurse did a head-to-toe assessment when R1 admitted and looked at his toe. R1's representative stated when she came in on 02/21/24 and saw R1's third toe, it had a wound and it appeared as though some of the bandage was left behind on the toe. R1's representative stated when R1 transferred to the hospital on 03/14/24, his third toe was black. On 03/28/24 at 01:57 PM, Licensed Nurse (LN) G stated the first time she saw an issue with R1's left foot was when therapy told her he had bumped his toe. She stated she had put a bandage on it on 02/15/24 and then went in later that day because the toe felt boggy (abnormal texture of tissues characterized by sponginess, usually because of high fluid content) so she cleaned it and wrapped it with gauze. LN G stated she called the doctor but did not document it and she knew the doctor saw the toe before 02/21/24 because she was with them. She stated R1 was started on Bactrim on 02/21/24. LN G stated when a new skin issue was found, she made a note and put a wound care order in, then notified the doctor and Administrative Nurse D. She stated she was not good at documenting all of the notifications. She was unable to find an order in place to monitor R1's toe on 02/15/24 until he was seen by the provider on 02/21/24. On 03/28/24 at 03:05 PM, Administrative Nurse D stated when the open wound was noticed, the facility immediately got treatment for it. She stated 02/21/24 was the day it was documented as found and 02/15/24 was when the nurse documented there was something wrong with his toe. Administrative Nurse D stated she did not remember being notified of the skin condition on 02/15/24. She stated if there were new skin issues, a treatment was initiated, documentation was completed, and notification was made to the provider and her. She stated the note on 02/15/24 did not specifically say the provider was notified but the provider came in Monday, Wednesday, and Friday so they would have followed up the next day. Administrative Nurse D stated the provider saw him on 02/15/24 and documented he had a foot ulcer, but she did not know why the NP would put ulcer when there was no treatment on 02/15/24 for it. She stated the nurse described the toe as moist and loose and sometimes if there was no bleeding or drainage, the nurse put gauze on it to pad the area, but it was not necessarily a treatment. Administrative Nurse D stated if a nurse adhered something to the skin, she expected nursing to follow up on the area and she expected the nurse to report it to the physician. On 03/29/24 at 11:34 AM, Administrative Nurse E stated R1 originally had moist skin on his third toe with gauze used to keep it dry and the nurse completed that daily. She stated on 02/21/24, R1 hit the third toe in therapy and had a skin tear that was cleaned and wrapped. Administrative Nurse E stated on 02/15/24 R1 had moist skin on the same toe that was kept dry with gauze. She stated she saw that R1 had a bandage on his toe on 02/21/24 and he had new orders from the NP that day. Administrative Nurse E stated she was told about the moist toe and the nurse showed her then the gauze was put on the toe to absorb the moisture. She stated since it was not an open wound, she did not think there was an order, but it should have been followed up on. She stated up until 02/21/24, R1 only had moisture on his toe. She stated moisture could break down the skin. On 04/09/24 at 10:54 AM Consultant GG stated R1 usually had his shoes on when she saw him and stated the facility had not informed her of the toe issue on 02/15/24 so she did not look at R1's foot on that date. The facility's Skin and Wound Monitoring and Management policy revised 12/2023 documented a licensed nurse will assess/evaluate each pressure injury and/or non-pressure injury that exists on the resident. This assessment/evaluation should align with the scope of practice and include but not be limited to: 1. Measuring the skin injury. 2. Staging the skin injury (when the cause is pressure). 3. Describing the nature of the injury (e.g., pressure, stasis, surgical incision). 4. Describing the location of the skin alteration. 5. Describing the characteristics of the skin alteration. Areas of breakdown, excoriation, discoloration, or other unusual findings (either initially identified at the time of admission or as new findings) must be documented in the nursing notes or on the appropriate weekly assessment form. A licensed nurse will assess/evaluate at least weekly each area of alteration/injury, whether present on admission or developed after admission, which exists on the resident. This assessment/evaluation should include but not be limited to items 1 through 5 above, and the following: 6. Describing the progress with healing, and any barriers to healing that may exist. 7. Identifying any possible complications or signs/symptoms consistent with the possibility of Infection. Once an area of alteration in skin integrity has been identified, assessed, and documented nursing. shall administer treatment to each affected area as per the Physician's Order. Treatments per physician order, should be documented in the resident's clinical record at the time. they are administered. The facility failed to ensure R1, who had a history of DM and amputations was closely monitored and assessed for complications after a concern was noted on 02/15/24 on a toe on his left foot. R1's foot and toe later became infected and required surgical removal. This also placed R1 at risk for increased pain and decreased mobility.

The facility identified a census of 69 residents. The sample included three residents reviewed for falls. Based on record review, interview, and observations, the facility failed to provide adequate supervision and implement interventions aimed to prevent falls for Resident (R) 1, who was at high risk for falls and had a Brief Interview for Mental Status (BIMS) score of six indicating severe cognitive impairment. R1 admitted to the facility on [DATE] with a diagnosis of traumatic subdural (collection of blood on the surface of the brain due to injury) hemorrhage (an escape of blood from a ruptured blood vessel) due to a fall at home. On 07/14/22 R1 fell in the facility and staff implemented nonskid socks. No root cause analysis was conducted, and no plan of care developed to address R1's fall risk. On 07/15/22 R1 had an unwitnessed fall in her room, she complained of pain and was sent to the emergency room via Emergency Management Services (EMS). R1 was diagnosed with a proximal humerus (the upper arm bone close to the shoulder) fracture and her broken arm was placed in a sling. The facility did not implement any interventions at that time to prevent further falls or injuries. From 07/20/22 through 07/23/22 R1 had multiple falls. On 07/23/22 R1 slid from her wheelchair. A few minutes later, R1 fell in her room. The clinical record recorded R1 did not have nonskid socks and had no other preventative measures in place. R1 complained of pain in the right hip which required x-rays. On 08/01/22 and 08/02/22 R1 was observed on the floor mat in her room. The facility failed to identify and implement preventative measures to address falls, safety and supervision needs for R1 who had multiple falls including one which resulted in a fracture. This placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab recorded diagnoses of traumatic subdural hemorrhage without loss of consciousness, sprain of joints and ligaments of unspecified parts of neck, wedge compression fracture (when forced together bone surfaces caused a bone to break) of unspecified lumbar vertebra (back bones), muscle weakness, need for assistance with personal care, difficulty in walking, and dementia (progressive mental disorder characterized by failing memory, confusion). The Entry Minimum Data Set (MDS) dated [DATE] documented R1 admitted to the facility on [DATE]. Review of the Hospital Paperwork dated 07/06/22 documented R1 fell at home on 06/20/22 and could not fully turn her head to the right The paperwork further documented a subacute subdural hematoma (a solid swelling of clotted blood within the tissues), and lumbar (lower part of the back) three compression fracture. The Initial Admission Record assessment dated [DATE] completed 07/14/22 documented R1 used a walker for mobility and noted that R1 was ambulatory or self-mobile in a wheelchair. The Fall Risk Evaluation assessment dated [DATE] completed 07/15/22 documented R1 scored a 17 on the assessment, which indicated she was a high fall risk. The Initial Care Plan assessment dated [DATE], completed on 07/26/22, documented R1 was at risk for falls related to confusion, deconditioning, gait/balance problems, incontinence, poor communication/comprehension, and being unaware of safety needs. The assessment directed staff to be sure the call light was within reach and encourage R1 to use the call light for assistance as needed; keep bed in the lowest position; educate resident/family/caregivers about safety reminders and what to do if a fall occurs, and to keep floor mats at bedside. The Nursing Note dated 07/14/22 at 03:38 PM documented R1 fell at bedside. R1 stated she was trying to make her bed and fell . The note recorded staff added non-skid socks upon admission and R1 should have her call light within reach. The Risk Investigation dated 07/14/22 at 03:42 PM documented R1 was observed on the floor next to the bed, with her back against the wall. The investigation documented unidentified staff were with R1 just prior to the fall and R1 was in bed. Staff immediately looked over R1 and her range of motion (ROM) was within normal limits without signs or symptoms of pain or grimace noted. Staff assisted R1 to bed and therapy brought a wheelchair and began R1's evaluation immediately. The Neurological Flow Sheet dated 07/14/22 documented neurological checks were completed 03:30 PM, 03:45 PM, 04:00 PM, 04:15 PM, 04:30 PM, 05:30 PM 06:30 PM, 07:30 PM, 08:30 PM, 09:30 PM, 07/15/22 01:30 AM, and 05:30 AM. The Neurological Flow Sheet dated 07/14/22 lacked checks for 07/15/22 09:30 AM, 01:30 PM, and 05:30 PM. The Fall Risk Evaluation assessment dated [DATE] completed 07/16/22 documented R1 scored a 14 on the assessment, which indicated she was a high fall risk. The Nursing Note dated 07/15/22 at 07:16 AM documented R1 continued follow up fall. R1 was documented to have [CONDITION(S)] (difficulty sleeping) and was a high fall risk related to baseline confusion. Nursing staff documented one on one supervision for safety. The Nurse Practitioner/Physician's Assistant Progress Note dated 07/15/22 at 10:11 AM documented R1 sat at the nurse's station in her wheelchair. The Incident Note dated 07/15/22 at 09:00 PM documented R1 was found on the floor by staff and could not move her left arm. R1 remained on the floor until emergency services (EMS) arrived and moved her. The Nursing Note dated 07/15/22 at 09:07 PM documented staff found R1 on the floor in her room and could not move her left arm. R1 was removed from the floor by the ambulance staff. The Risk Investigation 1664 dated 07/15/22 at 09:00 PM documented R1 was found on the floor in her room with pain in her left shoulder and R1 could not move her arm. The ambulance was called. When asked what happened, R1 stated she was attempting to go to the bathroom and wanted help getting up. The immediate action was R1 was left on the floor with staff present until the ambulance arrived. The investigation lacked analysis of causative factors and identification of interventions to prevent future falls. The Risk Investigation 1665 dated 07/15/22 at 09:00 PM documented unidentified nursing staff found R1 on the floor and she could not mover her left arm. The ambulance was called to the facility to assist R1 from the floor and take R1 to the emergency department. The immediate action was the ambulance was called to remove R1 from the floor and transport to the hospital. The investigation lacked analysis of causative factors and identification of interventions to prevent future falls. The Hospital Visit Documentation dated 07/16/22 at 12:40 AM documented R1 had a shoulder fracture, closed fracture of left humerus. R1's clinical record lacked evidence interventions were added to R1's plan of care to address her safety needs, fall risks, and the need for the sling for her broken arm. The Nursing Note dated 07/17/22 at 04:45 AM documented R1 was unable to relax with an ice pack on her shoulder. The note documented R1 refused to keep the sling on her left arm. The Nursing Note dated 07/20/22 at 05:54 AM documented R1 sat on the floor next to the bed around 01:00 AM. Unidentified nursing staff walked past R1's room and noted R1 crawling on the floor. Upon assessment no new injuries were noted. R1's clinical record lacked evidence interventions were added to R1's plan of care to address her safety needs and fall risks; the record lacked evidence neurological checks were completed for the unwitnessed fall on 07/20/22. The Weekly Skilled Review Note dated 07/21/22 at 09:35 AM documented R1 had frequent falls, decreased safety, advanced dementia, decreased insight, and a new fracture to left humeral fracture with decreased compliance wearing the sling. The Risk Investigation 1670 dated 07/22/22 at 07:00 AM documented an unidentified nurse was notified by an unidentified CNA that R1 was found on the floor in R1's room, lying next to the bed. No immediate action was documented. The investigation lacked analysis of causative factors and identification of interventions to prevent future falls. The Risk Investigation 1671 dated 07/22/22 at 07:00 AM documented R1 found on the floor in R1's room by unidentified staff lying on the floor next to the bed. The immediate action taken was unidentified nurse notified, nurse assessment, vital signs and neurological checks obtained; peri-care (cleaning of the genitals) was provided. The facility was unable to provide evidence of neurological checks performed after the unwitnessed fall on 07/22/22. The Nursing Note dated 07/22/22 at 10:54 AM documented unidentified nursing staff reported R1 was on the floor in the room. R1 laid in supine position on the floor and yelled for help. The note documented R1 did not use the call light; non-skid socks were not on; no fall mat or perimeter mattress was in place; R1 was incontinent. The note further documented R1 slid out of her wheelchair at the nurse's station at 10:45 AM. R1 reported increased pain at left leg and new x-ray ordered for left hip and left femur. The EMR lacked a risk investigation for this fall. R1's clinical record lacked evidence the facility implemented interventions to prevent future falls. The facility was unable to provide evidence of neurological checks performed after the unwitnessed fall on 07/22/22. The Nursing Note dated 07/22/22 at 01:28 PM documented arthritic changes to R1's left hip, no obvious signs of fracture. The Nursing Note dated 07/23/22 at 05:57 AM documented R1 was on a low bed with a perimeter mattress in place next to the bed. R1 was crawling out of bed and was discovered by staff sitting on the perimeter mattress; two staff assisted R1 off the mattress on the floor with the use of a gait belt. The EMR lacked a risk investigation for this fall. The facility was unable to provide evidence of neurological checks performed after the unwitnessed fall on 07/23/22. The Nursing Note dated 07/23/22 at 06:18 PM documented an unidentified nursing staff found R1 on the fall mat next to her bed lying in a supine position on her back. The EMR lacked a risk investigation for this fall. The facility was unable to provide evidence of neurological checks performed after the unwitnessed fall on 07/23/22. The Nursing Note dated 07/24/22 at 11:59 PM documented R1 migrated from her low bed to sit on the perimeter mattress on the floor. The EMR lacked a risk investigation for this fall. The facility was unable to provide evidence of neurological checks performed after the unwitnessed fall on 07/24/22. The Weekly Skilled Review Note dated 07/28/22 at 09:38 AM documented R1 had frequent falls, decreased safety, advanced dementia, decreased insight, a left humeral neck fracture with decreased compliance with sling. R1 had an appointment scheduled with orthopedics (bone doctor), but due to R1 tested positive for COVID (highly contagious respiratory virus), the appointment needed rescheduled. The Nurse Practitioner Physician Assistant Progress Note dated 08/01/22 at 10:41 AM documented R1 laid on her floor mat and R1 reported that she wanted to get up for the day. Unidentified nursing staff reported that therapy would get her up. The plan of care for R1 was frequent rounding. The EMR lacked a risk investigation for this fall. The facility was unable to provide evidence of neurological checks performed after the unwitnessed fall on 08/01/22. On 08/02/22 at 02:45 PM Administrative Nurse D stated R1 had five falls total and that two did not make it into the risk system for investigation. Observation on 08/02/22 at 02:28 PM revealed R1 laid on the floor with her head facing the windows and her feet towards the doorway. R1 laid on her right side, parallel with the bed on the floor mat next to her bed. R1 hollered out come here, come here. On 08/02/22 at 02:30 PM Licensed Nurse (LN) G looked at R1 on the floor/mat and stated R1 was care planned to lay on the floor mat by her bed. Another[unidentified] nurse who stood at the medication cart stated, yes, she is care planned to be on the floor and neither nurse assessed R1 or assisted R1 off the floor. On 08/02/22 at 02:38 PM LN H stated R1 was very confused and was constantly up and down. LN H revealed when she worked, R1 would sit in a wheelchair at the nurse's station. LN H further revealed staff would do one on one with her when it was viewed as needed, in that moment, but one-to-one was not ordered. LN H stated when a resident fell , the resident was assessed, vital signs were checked, and staff attempted to figure out what happened or caused the fall. Staff completed the risk investigation paperwork, notified the appropriate individuals, and started neurological checks if the fall was unwitnessed, or the resident was confused. LN H stated she expected to see some type of intervention put into place. On 08/02/22 at 03:35 PM Certified Nurse Aide (CNA) M stated she picked R1 up from the floor/mat, and placed R1 back into her bed. She stated she did this at different times throughout her shifts as well. CNA M reported she picked R1 up from the floor/mat twice already that shift. She stated on 07/29/22, she picked R1 up from the floor/mat two or three times. CNA M further stated that she tells the charge nurse on duty about R1's falls. CNA M revealed she got R1 up off the floor mat without an assessment completed. CNA M further revealed R1 was restless and fidgeted frequently and would throw herself on the floor. CNA M doubted R1 could walk without assistance related to R1's fractured arm. On 08/03/22 at 11:05 AM Certified Medication Aide (CMA) R stated she know how to provide cares for R1 based on the care plan on the Kardex (a medical-patient information system). CMA R stated that when a resident fell , CMA R reported the fall to the nurse and CMA R sat with the resident until the nurse was able to assess the resident. CMA R further stated that interventions put into place related to a fall would go on the Kardex to alert floor staff. On 08/03/22 at 11:55 AM Administrative Nurse D stated she expected nursing staff to have the baseline care plan completed within 12 hours, but nursing staff had 24 hours to complete it. CNA/CMAs knew there was a JOT sheet (quickly written sheet of what the residents needed for cares) that was handed out for staff when a resident admitted and that initially told the staff how to care for the resident while staff completed the baseline care plan. Administrative Nurse D revealed without a Kardex or JOT sheet to direct cares, staff would not know how to keep R1 safe. The Fall Management System policy revised 06/2018 documented the facility would provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurred. It further documented residents with high risk factors identified on the Fall Risk Evaluation would have an individualized care plan developed to prevent falls by addressing the risk factors and would consider elements of the evaluation that put the resident at risk. When a resident sustained a fall, a physical assessment would be completed by a nurse, with results documented in the medical record, follow-up documentation would be completed for a minimum of 72 hours following the incident. The policy documented review of the fall incident would include an investigation to determine probable cause factors, a summary of the investigation and recommendations would be documented in the resident's clinical record and the residents care plan would be updated. The facility failed to provide adequate supervision and implement interventions aimed to prevent falls for R1, who was at high risk for falls and was cognitively impaired. The facility failed to identify and implement preventative measures to address falls, safety and supervision needs for R1 who had multiple falls including one which resulted in a fracture. The facility failed to assess R1's physical and neurological status after unwitnessed falls though R1 had a fall related head injury and fracture. These deficient practices placed R1 in immediate jeopardy. On 08/02/22 the facility implemented the following corrective actions to address the immediate jeopardy (IJ): The Medical Director was notified of lJ at 06:12 pm on August 2, 2022. R1 incidents were reviewed. Root cause was established, and interventions and care plan updated for R1 to include the following: Immediate 1:1 24/7 to ensure residents safety Perimeter Mattress Non-Skid Socks Fall mats to be placed at bedside at all times Comfort measures -repositioning Assessment of sling to ensure that arm is positioned comfortably Anticipate residents needs and offer foods/fluids frequently. Resident is always to be transferred with a gait belt. Bed at lowest position. Nursing staff has been in serviced on these interventions. Director of Nursing verified that the resident's interventions were in place. An Interdisciplinary Team (IDT) review of residents with frequent falls was completed 08/02/22. Interventions and care plans were updated as necessary. Review of all resident fall assessments was completed on 08/02/22. Resident designated as being at high risk for falls had their falls and plan of care reviewed for intervention effectiveness and care plan updated as necessary. DON and designees verified that interventions were in place. Education with floor staff regarding fall prevention, interventions and Resident specific education on plan of care for Resident #1 was initiated 08/02/22. After removal of the immediacy was verified, the deficient practice remained at a scope and severity of a G

The facility identified a census of 50 residents. The sample included seven residents identified at risk for elopement (when a cognitively impaired resident leaves the facility without staff knowledge). Based on record review, observation, and interview the facility failed to provide adequate supervision and appropriate interventions to prevent an elopement. Resident (R)1, who mobilized independently in a wheelchair, with poor cognition and identified at high risk for elopement, exited the facility on 12/12/21 at 5:50 PM without staff knowledge or supervision. A facility visitor alerted facility staff that R1 was outside the facility, alone in the parking lot. This deficient practice placed R1 in Immediate Jeopardy. Findings included: - R1's electronic medical record (EMR), under the Diagnosis tab, listed diagnoses of cognitive communication deficit (problems with communication with an underlying cause in a cognitive deficit rather than a language or speech deficit), asthma (a condition wherein a person's airways become inflamed, narrow and swell, producing extra [MEDICATION(S)], which makes it difficult to breathe), [CONDITION(S)] [CONDITION(S)] (a thickening and hardening of the hearts arterial walls caused by cholesterol deposits, and calcification) and stage three chronic kidney disease (a gradual loss of kidney function and the body's ability to filter blood). The Annual Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of two which indicated R1 had severely impaired cognition. The MDS documented the resident had instances of wandering behavior during the assessment period. R1 ambulated with the use of a wheelchair and received anti-depressant medication. The 10/27/21 Cognition Care Area Assessment (CAA) recorded R1 was hard of hearing, but could hear if the speaker raised their voice volume. The CAA recorded R1 continued to wander at times and could be easily redirected. The Elopement Risk Assessment on admission, dated 10/16/20 documented a score of 16 which indicated R1 was at high risk for elopement. The Elopement Risk assessment dated [DATE] documented a score of 11 which indicated R1 was at high risk for elopement. The resident's Care Plan dated 10/17/21 recorded R1's cognitive status, functional abilities, medication use, nutritional, and other care needs. It identified R1's risk status for falls and skin disruptions. The Care Plan lacked documentation to address R1 was at high risk for elopement and lacked interventions to prevent elopement. Review of the Nurses Progress Notes in R1's EMR documented R1 demonstrated exit seeking behavior on the following dates: 10/18/20 at 05:52 AM, 10/21/20 at 01:30 PM, and 08/28/21 at 12:33 AM. A Nurses Progress Notes dated 12/12/21 at 05:50 PM recorded (unidentified) facility staff were alerted a resident was outside in the parking lot. The unidentified staff responded and R1 was brought back into the facility. Staff informed R1's emergency contact person who expressed dissatisfaction and inquired when R1 exited the facility. The staff member informed R1's emergency contact person it was unknown at that time when R1 left the facility. Review of the Facility Report documented on 12/12/21 at approximately 05:50 PM, revealed an unidentified family member called the facility and reported there was a resident out in the front parking lot in a wheelchair and staff responded. The report noted R1 had a dinner plate with food on her lap. Camera footage revealed R1 was outside approximately three minutes. This same report documented the weather outside was between 50 and 55 degrees Fahrenheit (F). According to https://www.wunderground.com/history/daily/us/mo/kansas-city/KMCI/date/2021-12-12 the temperature on 12/12/21 at 05:53 PM was 45 degrees F. Review of the facility's video surveillance from 12/12/21 revealed the following timeline: 05:44 PM: a car pulled up or past the facility entrance. 05:45.54 PM Certified Medication Aid (CMA) P used a key card and entered the building. 05:46.10 PM R1 appeared in a wheelchair, moving slowly through the inner door to the outside foyer. 05:46.50 PM R1 passed thru the inner door, foyer, and outer door and was completely outside the facility. 05:49.15 PM an unidentified male entered the building. 05:50.02 PM facility staff exit the facility through the front door. 05:50.44 PM facility staff return withR1 to inside the facility. R1 was outside the facility without supervision for at least three minutes and 52 seconds. In an undated Witness Statement CNA N documented at 05:30 PM R1 sat by the door, like always. In an undated Witness Statement CNA O documented at 05:50 PM staff observed R1 leaving the dining room with her plate of food. R1 headed toward the front of the building. In an undated Witness Statement Licensed Nurse (LN) M documented at 05:50 PM staff were notified by a family member a wheelchair resident was in the parking lot. Staff immediately went outside and brought the resident back in. LN M spoke with R1's emergency contact, who was very upset. Further inquiry revealed a different (unidentified) staff member noted R1 by the receptionist desk at approximately 05:30 PM. R1 had been out of the facility, with her family, and had returned at 05:00 PM. Shortly after R1's family member left, R1 self-propelled her wheelchair in the hallway toward the facility dining room. On 12/15/21 at 08:30 AM observation of the facility parking lot, where R1 traveled, revealed numerous hazards such as changing slopes, concrete curbs, asphalt, shrubbery, landscape rock, and a drive-up entrance to the facility. There is also close proximity to a busy four lane roadway where traffic moved at 35 miles per hour. On 12/15/21 at 02:10 PM R1 sat in the dining room seated with another resident. Staff encouraged R1 to participate in a bingo game. On 12/15/21 CMA P was unavailable for interview. Interviewed on 12/15/21 at 12:54 PM Administrative Nurse D stated R1's main objective was not to exit the facility, but acknowledged that R1 did wander about the facility and liked to sit in the lobby near the reception desk. Administrative Nurse D could not say why R1's Care Plan did not have interventions for exit seeking behaviors prior to 12/15/21. She further stated preventative measures included photographs of elopement at risk residents placed at the nurse's desks and receptionists' desk and speaking to the families to develop alternate activities. Nurse D noted there was an agency nurse assigned to R1 at the time of elopement. Interviewed on 12/15/21 at 01:03 PM Administrative Staff A stated she expected staff to use the elopement risk assessment located in the computer software and develop a plan of care to address elopement risk, documented on the Care Plan. Administrative Staff A said she expected all staff on duty to be cognizant of, and accountable for, residents at risk for elopement. Review of the facilities Safety Program For Wandering Dementia Resident's policy dated December 2021 recorded: Each resident was to be assessed immediately upon admission for potential wandering or elopement. The elopement wandering UDA was to be completed and it was to be determined if the resident was a wandering/elopement risk . The facility failed to provide adequate supervision and appropriate interventions to prevent R1, who was identified at high risk for elopement and diagnosed with impaired cognition, from exiting the facility in the evening of 12/12/21. At approximately 05:50 PM R1 exited the facility, alone and without the knowledge of facility staff, through the front door. This deficient practice placed R1 in immediate jeopardy for potential accidents and/or life threating injury. The deficient practice was abated on 12/15/21 at 05:00 PM when the facility implemented the following corrective actions: R1 was placed on 15-minute checks. Facility staff had to verify and ensure R1 was safe. This practice would continue for an undetermined amount of time. All residents were evaluated to ensure potential elopement risks were identified. Elopement books at each nurse's station and front desk were updated with all current information regarding residents at risk for elopement in the facility. The OWL Program was initiated. This ensured that all residents at risk for elopement were monitored for safety and wellbeing. An owl picture was placed on the back of the wheelchair, front of walkers and outside of resident's rooms who were identified as elopement risks so all staff would be constantly aware of residents at risk for elopement. All staff were in serviced on 12/15/21 on elopement risk, and processes in place to ensure resident safety. The deficient practice remained at a scope and severity of a D

The facility reported a census of 53 residents. The sample included three residents with three residents reviewed for accidents. Based on record review, observation, and interview, the facility failed to ensure Resident (R)1 received adequate care and supervision to prevent an accident with injury during a staff assisted transfer. On 10/10/21 in the late morning or early afternoon, Certified Nurse Aid inappropriately transferred R1, who required two staff members for transfers per his plan of care. During this transfer, R1 felt a pop in his chest, significant pain, and a subsequent x-ray revealed a right sided non-displaced fracture of rib number eight. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab, listed diagnoses of [CONDITION(S)] ([CONDITION(S)]-a group of lung diseases that block airflow and make it difficult to breathe of which [CONDITION(S)] and chronic [CONDITION(S)] are most common), diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine) and muscle weakness. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented R1 had a Brief Interview for Mental Status score of 10 which indicated R1 had moderately impaired cognition. The MDS documented R1 required extensive assistance of two staff members with most activities of daily living (ADL's) such as bed mobility, transfers, locomotion on and off the unit, dressing, toileting, and personal hygiene. The assessment recorded R1 had functional limitations in range of motion to one side of R1's body and required staff assistance with stabilization during transfers. The resident ambulated by use of a wheelchair. The 05/07/21 ADL Care Area Assessment (CAA) recorded R1 needed extensive assistance from staff for most tasks and received therapy services for strengthening and endurance in order to return home safely. The Functional Performance Evaluation dated 04/29/21 documented: R1 required substantial maximal assistance for transfer to and from a bed to a chair (or wheelchair). R1's ADL's Care Plan dated 5/28/21 documented R1 had an ADL self-care performance deficit related to history of a stroke and required two staff members' participation with transfers. Review of the Facility Report revealed an incident occurred on 10/10/21 in the late morning or early afternoon. The report documented staff transferred R1 from a wheelchair to his bed by one staff member using a stand and pivot transfer technique. R1 reported feeling a pop in his chest. Certified Nursing Assistant (CNA) N reported hearing this pop and reported to the Licensed Nurse (LN) H. On the morning of 10/11/21, R1 complained of pain and an x-ray was obtained and revealed R1 sustained a non-displaced rib fracture . In a Witness Statement on 10/10/21 CNA N documented she transferred R1 from the bed to a wheelchair. CNA N proceeded to lift R1, turned, and placed R1 gently in the wheelchair. CNA N heard and R1 felt a pop in R1's chest. CNA N asked R1 if he was ok. R1 stated he was fine but had a little pain in his chest. CNA N recorded that after the transfer, she reported the occurrence to LN H. In a Witness Statement LN H recorded on [10/10/21] in the late morning or early afternoon, CNA N transferred R1 to a wheelchair from the bed using a one person stand and pivot transfer. Following the transfer, R1 reported to CNA N that R1 felt a pop to R1's right chest and had pain. LN H assessed R1, who had no obvious injuries at that time. Staff treated R1 with scheduled pain medication and a muscle relaxer. On [10/11/21] R1 continued to complain of pain and staff notified Consultant GG who ordered a chest x ray. The chest x-ray was completed that afternoon showed R1 had a non-displaced right rib fracture. The Physical Therapy Outpatient PT Eval and Plan of Treatment signed 10/13/21 recorded staff transferred R1 using a bear hug technique, then the resident complained of rib pain. Radiograph (x-ray) was positive for a rib fracture. R1 also had severe left lower extremity contractures (abnormal permanent fixation of a joint) due to [CONDITION(S)] (muscle weakness or paralysis on one side of the body). On 10/18/2021 at 11:28 A.M. R1 laid in bed, with the head of the bed elevated. R1 had right and left-hand contractures. He stated he remembered a staff member attempted to transfer him by holding his left side, but R1 did not remember the staff person used a gait belt or if he was getting out the right or left side of the bed. R1 stated his ribs hurt from time to time and reported significantly increased pain when he coughed . On 10/18/21 at 11:44 A.M. Administrative Nurse D stated there was no reason why the staff member did not use assistance of two staff members for the transfer. Administrative Nurse D stated R1 would tell staff how to transfer him, and staff did it the way he told them, instead of following the resident's care plan. Administrative Nurse D stated staff were expected to follow the resident's care plan and stated education was done with all staff after the occurrence. On 10/18/21 at 10:00 A.M. Administrative Staff A acknowledged CNA N did not follow the resident's care plan for transfers. Review of the facility's Accident Prevention Policy/procedure revised September 2013 documented: It is the policy of this facility that the resident's environment remained as free of accident hazards as possible and that each resident received adequate supervision and safety devices to prevent accident occurrences. The policy further recorded accident prevention and safety would be achieved (in part) by the lifting and/or transfer of residents using proper body mechanics. The facility's Safe Lifting and Movement of Residents revised December 2013 documented: in order to protect the safety and wellbeing of staff and residents and to promote quality of care, the facility uses appropriate techniques and devices to lift and move residents. The policy included: manual lifting of residents shall be eliminated when feasible. The facility failed to provide adequate level of assistance as directed in R1's plan of care when only one staff assisted R1 with a transfer during which R1 sustained a fractured right rib. The facility completed the following corrective actions on 10/13/21. R1's Care Plan was revised to reflect the use of a mechanical lift with transfers, R1 was evaluated by therapy and therapy provided one on one to nursing staff regarding safe transfer practices. Relevant staff were educated regarding following the residents' plan of care. The deficient practice was cited at past noncompliance.

The facility identified a census of 43 residents. The sample included 14 residents with two sampled for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observations, interviews, and record reviews the facility failed to provide pressure ulcer treatments as ordered by the wound care physician consultant for Resident (R)92 when the facility failed to ensure a low air loss mattress was ordered for R92 until a week after his admission to the facility. The facility failed to ensure wound care orders were obtained and treatments implemented for a stage three pressure area. The facility also failed to implement interventions to prevent and ensure wound care orders were obtained to treat a right heel wound noted. The facility failed to ensure wound care orders were followed for a back wound found by the Wound Care Consultants. The facility delayed preventative measures and subsequently the resident developed wounds on his heel and back, and the coccyx wound worsened after a delay in treatment measures of physician ordered treatments. Findings included: - The Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set, dated dated dated [DATE] documented a Brief Interview for Mental Status score of six, which indicated significantly impaired cognition. He required extensive staff assistance with his transfers, positioning, toileting, and bed mobility. He was frequently incontinent of urine and had an ostomy for bowel elimination. R92 was at risk for pressure ulcers and had one stage three pressure ulcer present on admission. He had no pressure reducing device for his chair or bed and was not on a turning/repositioning program. The Pressure Ulcer/Injury Care Area assessment dated [DATE] documented R92 admitted with a stage three pressure ulcer (an ulcer which has broken completely through the top two layers of skin into the fatty tissue below) on his coccyx (small triangular bone at the base of the spine). A referral was made to the wound care consultant nurse. Staff provided wound treatments as ordered. The Comprehensive Care Plan revised on 04/27/21 documented the facility staff administered treatments as ordered and monitored for effectiveness. Daily body checks were made. A low air loss mattress was provided. The nurse was immediately notified of any new areas of skin breakdown and weekly head to toe skin At Risk Assessments were made. The Braden Scale for Predicting Pressure Score Risk assessment dated [DATE] documented R92 was at low risk for pressure ulcer development. The Initial Admission Record/Skin Integrity assessment dated [DATE] documented R92 had open areas with intact dressings to the upper mid-vertebral (spine) area and to the sacrum. The Licensed Nurse Daily Skilled assessment dated [DATE] documented R92 had skin injury to his coccyx and moisture barrier was used as needed. The areas for pressure reducing devices for chair/bed, turning/repositioning program were not marked as provided to R92. The Licensed Nurse Daily Skilled assessment dated [DATE] documented R92's overall skin description was warm, dry, and intact with no changes observed. The areas for skin injury/ulcer, pressure reducing devices for chair/bed, turning/repositioning program were not marked as provided to R92. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Low air loss mattress (pressure reducing mattress) for skin integrity dated 04/02/21 Wound care consult for sacral wound dated 04/02/21 The Licensed Nurse Daily Skilled assessment dated [DATE] documented R92 had discoloration to both arms due to thin skin integrity. The overall skin description documented his skin was clean, dry, and intact. The areas for skin injury/ulcer, pressure reducing devices for chair/bed, turning/repositioning program were not marked as provided to R92. The Licensed Nurse Skin Evaluation PRN (as necessary)/Weekly assessment dated [DATE] documented a previously mentioned area on coccyx was observed, otherwise no skin issues were noted. No measurements were documented. The Licensed Nurse Skin Evaluation PRN/Weekly assessment dated [DATE] documented a full thickness coccyx wound with no drainage measured 2 centimeters (cms.) in length 1 cm. in width and 0.1 cm. in depth. The wound was cleansed with wound cleanser, applied Xeroform (a gauze dressing used to treat dry wounds) and covered with bordered gauze daily. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Wound care consultants to evaluate and treat revision dated 04/14/21 A Wound Care Consultant Progress Note dated 04/14/21 documented a coccyx wound was 2 cm in length, 1 cm in width, and 0.1 cm in depth. No orders were documented on the progress note. A sacral wound measured 2 cm in length, 1 cm in width, and 0.1 cm in depth. An order was documented to cleanse the sacral (large triangular bone between the two hip bones) wound with wound cleanser of facility choice to scrub the wound bed. Protect the peri-wound (tissue surrounding a wound) with Skin Prep, apply Xeroform gauze cut to fit inside wound edges, cover with bordered gauze, to be changed daily and as needed for soiling, saturation, or unscheduled removal. Follow the current treatment orders until able to obtain supplies/medications for updated orders. Offload wound as often as resident tolerated, and low air loss mattress. The Plan of Care was discussed with the facility staff and resident. Upon review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The review revealed no wound care orders for the coccyx wound until 04/25/21. The Licensed Nurse Skin Evaluation PRN/Weekly assessment dated [DATE] documented no changes noted. The Licensed Nurse Skin Evaluation PRN/Weekly assessment dated [DATE] documented a full thickness coccyx wound measured 2 cm in length, 1 cm in width and 0.1 cm in depth. The wound was cleansed with wound cleanser, applied Xeroform, and covered with bordered gauze daily. A Wound Care Consultant Progress Note dated 04/21/21 documented a coccyx wound measured 2 cm in length, 1.7 cm in width, and 0.1 cm in depth. Orders for the coccyx wound were to cleanse the wound with hypochlorous acid, no need to rinse, and apply skin prep to protect the peri-wound. A right heel wound was covered in eschar (dark scab or falling away of dead skin) and measured 6.2 cm in length, six cm in width and 0.1 cm in depth. The right heel wound order was documented to cleanse the wound with wound cleanser, paint skin with Skin Prep over area of stable eschar. Ensure edges and surrounding skin were painted as well, twice daily. Offloading boots were worn at all times. Plan of Care was discussed with R92 and the facility staff. Upon review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Licensed Nurse Skin Evaluation PRN/Weekly assessment dated [DATE] documented R92 had right heel discoloration and a coccyx wound. No measurements were documented. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Wound team to evaluate and treat the right heel discoloration dated 04/25/21. Apply Skin Prep (liquid film-forming dressing which forms a protective film to help reduce friction) to right posterior heel twice daily for wound care and prn (as necessary) dated 04/25/21. Kerlix bandage roll (a brand of gauze used to wick away moisture from wounds), applied to right heel in the evening to protect site, cushion and to reduce pressure dated 04/25/21. Cleanse coccyx wound with hypochlorous acid (a cleaning agent used to disinfect wounds), apply [MEDICATION(S)] (antibiotic), apply calcium alginate (type of dressing that can absorb moisture from wounds), covered with bordered gauze (an absorbent gauze with an adhesive tape attached) twice daily for wound care and prn for soiling and saturation dated 04/25/21. A Wound Care Consultant Progress Note dated 04/28/21 documented the coccyx wound measured 2.2 cm long, 1.7cm wide, and 0.1 cm in depth. Orders documented as cleanse wound with hypochlorous acid, no need to rinse, protect peri-wound with Skin Prep, apply [MEDICATION(S)] to affected area, apply calcium alginate to wound base, cover with bordered gauze twice daily. The right heel wound measured six cm in length, seven cm in width and 0.1 cm in depth. Wound orders documented as cleanse wound with wound cleanser of facility choice, paint Skin Prep over area of stable eschar, staff were to ensure edges and surrounding tissue were also painted. Apply a super absorbent pad for moderated to heavy drainage. Secure with a roll gauze. Change dressing daily and as needed for soiling, saturation, or unscheduled removal. A back wound was measured at 4.2 cm in length, 0.7 cm in width, and 0.1 cm in depth. An order was written instructing staff to cleanse wound with hypochlorous acid, no need to rinse, apply calcium alginate to wound base, cover with silicone bordered gauze change every other day and as needed for soiling, saturation, or unscheduled removal. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Licensed Nurse Skin Evaluation PRN/Weekly assessment dated [DATE] documented R2 had no new skin impairment noted. On 06/16/21 at 11:40 AM Licensed Nurse (LN) G stated if a new wound was found, on a resident, during a skin assessment, a measurement of the wound was done, and the physician was notified for a new treatment order. On 06/16/21 at 12:02 PM LN I stated wounds found on a new admission were assessed by the admitting nurse who in turn notified the facility's wound nurse. The wound care nurse then did a full assessment with the nurse practitioner. After the wound assessments wound care orders were initiated. The nurses could call for new wound care orders when they felt they were needed due to the condition of the wound. R92 had refused the low air loss mattress when he first arrived. LN I verified the lack of wound care orders in R92's EMR. On 06/16/21 at 03:13 PM Administrative Nurse D stated the facility contracted with a wound care consulting company for wound care. The company assessed resident's wound(s) weekly and provided wound care orders to the facility staff to initiate. On 06/17/21 at 11:40 AM Medical Consultant (MC) II stated she assessed wounds upon the residents' admission and if complications developed. MC II gave orders for wound care to the facility staff and reviewed the orders if a resident told her the wounds were not treated or if she noted a discrepancy in the care provided. MC II stated a resident's skin condition could be negatively impacted if interventions were followed for four to seven days after the orders were written. She had not been involved in R92's care. The facility's Wound Care policy dated September 2020 documented the facility provided excellent wound care to promote healing. A weekly assessment was done on all wounds requiring treatment which included measurements ad descriptions. The facility failed to ensure a low air loss mattress was ordered for R92 until a week after his admission to the facility. The facility failed to ensure wound care orders were obtained and treatments implemented for a stage three pressure area, until 04/25/21. The facility also failed to implement interventions to prevent and ensure wound care orders were obtained to treat a right heel wound noted on 04/21/21. The facility failed to ensure wound care orders were followed for a back wound found by the Wound Care Consultants on 04/28/21. The facility delayed preventative measures and subsequently the resident developed wounds on his heel and back, and the coccyx wound worsened after a delay in treatment measures of physician ordered treatments.

The facility identified a census of 50 residents. The sample included 26 residents, with 2 residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to develop and implement timely and effective interventions to prevent the development of 4 facility-acquired, unable to determine (UTD) pressure ulcers for 1 resident (#22). Findings included: - Resident #22's electronic medical record (EMR) physician's orders [REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 00 which indicated severely impaired cognition. The resident required extensive assistance for ADLs (activities of daily living) from 2 staff members for bed mobility, transfer, dressing, and toilet use. This same assessment documented the resident had indwelling Foley catheter (tube inserted into the bladder to drain urine into a collection bag). The MDS further documented the resident had no pressure ulcers but was at risk for pressure ulcers and received no protective equipment for the prevention of pressure ulcers. The MDS also noted the resident baseline weight was 195.0 pounds. The Care Area Assessment (CAA) dated 3/25/18 for pressure ulcers identified the resident was at risk for development of pressure ulcers and directed staff to reposition him/her as needed. The CAA dated 3/25/18 for nutrition documented no nutritional concerns related to body mass index. The Quarterly MDS dated [DATE] documented the resident had no cognitive or functional changes. However, now presented with a stage 3 (a sore that extends into the tissue beneath the skin, forming a small crater. Fat may show in the sore) pressure ulcer and received pressure relieving devices on the bed. His/her recorded weight was 152.0 pounds and recorded the resident had more than 5% in 1 month or 10% in 6 months weight loss that was not planned. Review of the EMR lacked evidence of documentation of a formal skin assessment or Braden assessment (numerical score used to determine the potential for pressure ulcers). Review of the physician's orders [REDACTED]. For pressure ulcer: 6/12/18 Barrier cream to buttocks as needed for skin integrity every two hours as needed. 6/12/18 monitor for signs and symptoms of infection relate to open areas, report to medical doctor if indicated every shift for wound monitoring (Nurses Progress notes first identified the residents stage 3 pressure ulcer on 5/31/18). 8/30/18 Right buttock: clean wound with wound cleanser, apply A&D ointment two times a day for wounds. Physician orders [REDACTED].>7/25/18 Multivitamin adult give one tablet by mouth daily for wound healing. 8/20/18 Regular diet, regular texture, thin liquids consistency and ice cream with dinner every night. 9/5/18 Boost (dietary supplement drink) twice daily for wound healing. The care plan revised on 4/6/18 documented staff implemented the use of pressure reducing wheelchair cushion, a pressure reducing mattress for the resident's bed. On 8/7/18 the intervention directing staff to provide Boost (liquid that provides protein, vitamins, minerals, and calories) 1 time a day (this order was subsequently updated on 9/5/18 to give Boost twice a day and not added to the care plan). This same care plan also documented the resident should receive Prostat (liquid protein supplement) every day (this was not a valid order recorded on the physician order [REDACTED]. The care plan lacked evidence of new interventions after the development of a stage 3 pressure ulcer on the right buttocks on 5/31/18 that was noted in the nurses' notes. The care plan dated 3/20/18 documented that staff were to honor residents' rights to make personal dietary choices and provide dietary education as needed, to offer a meal replacement if resident ate less than 50%, provide a calm quiet setting at meal times with adequate eating time and to encourage socialization and interaction with table mates during meals. It further directed staff to report to medical director any signs and symptoms of decreased appetite, nausea and vomiting, unexpected weight loss and complaint of stomach pain. The care plan lacked evidence of new interventions after the development of a pressure area related to a medical device on 5/31/18. The care plan further lacked a new intervention after the development of a second wound on 6/21/18. The care plan lacked documentation of the low air loss mattress. Review of the EMR nursing note dated 5/31/18 at 4:54 PM, documented that the resident had a new stage 3 pressure ulcer to his/her right buttocks. The EMR lacked an assessment that detailed measurement and description of the wound or new intervention related to the identification of the new stage 3 pressure ulcer to the resident's right buttocks The Tissue Analytics report dated 6/21/18 documented a new wound to the resident's right buttock which measured 1.5 centimeters (cm) in length (L) by 0.5 cm in width (W) by 0.1 cm in depth (D). The report ordered staff to clean wound with wound cleanser, apply moisture barrier in thin layer to the wound and to change dressing every shift and as needed for soiling. The Tissue Analytic report dated 6/26/18 documented the right buttocks wound measured 0.5 cm L by 0.5 cm W by 0.1 cm D with small eschar (dead tissue) still present, continued current treatment. The Tissue Analytic report dated 7/5/18 documented the right buttock wound measured 2.5 cm L by 0.5 cm W by 0.1 cm D and documented the wound looked more open, no change in treatment noted. The Tissue Analytic report dated 7/12/18 documented the right buttock wound measured 4.0 cm L by 1.0 cm W by 0.1 cm D and documented the wound looked abraded (scrape or wear away by friction or erosion). Noted to monitor and continue current treatment. The Tissue Analytic report dated 7/26/18 documented the right buttock wound measured 1.0 cm L by 1.0 cm W by 0.1 cm D and documented the wound had one small scab present, no change in treatment noted. The Tissue Analytic report dated 8/2/18 documented the right buttock wound measured 0.5 cm L by 1.2 cm W by 0.1 cm D and documented the wound was covered in eschar, no change in treatment noted, and was seen by the wound physician. The Tissue Analytic report dated 8/9/18 documented the right buttock wound measured 0.5 cm L by 1.5 cm W by 0.1 cm D and documented eschar continued to be present, no change in treatment noted, and was seen by the Medical Director. The Tissue Analytic report dated 8/16/18 documented the right buttock wound measured 0.5 cm L by 0.5 cm W by 0.1 cm D and documented granulation (new vascular tissue in granular form on an ulcer or healing surface of a wound), no change in treatment noted, and was seen by wound physician. The Tissue Analytic report dated 8/30/18 documented the right buttock wound measured 7.0 cm L by 4.0 cm W by 0.1 cm D and documented the area now covered the sacrum and left buttocks. Noted growth of 5.5 cm L by 3.5 cm W when initially identified. Treatment changed on 8/30/18 to cleanse wound with wound cleaner and apply A&D ointment two times a day. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The clinical record lacked documentation of baseline labs for [MEDICATION NAME] (blood test used to determine nutritional status), protein (measure the amount of protein in the blood), and [MEDICATION NAME] (blood test used to measure the amount of protein in the blood, used in part to determine a person's nutritional status). A nursing note, dated 8/22/18, documented the resident had an area noted to coccyx and would be followed weekly and to continue his/her current treatment. The nursing note, dated 9/9/18, documented 3 new pressure ulcers on the right side of resident's right foot. The nursing notes lacked description of the newly identified areas. The nursing notes lacked documentation of when the wound was noted to be worse, furthermore the clinical recorded lacked treatment changes when the wounds were noted to be worse. On 9/10/18 at 7:50 AM, the resident laid on his/her low air loss bed on his/her back. On 9/10/18 at 12:06 PM, resident sat in his/her wheelchair in the dining room, with pillows noted under his/her feet and a pressure relieving cushion in the wheelchair. On 9/10/18 at 3:37 PM, nursing staff reported to the charge nurse that resident was repositioned in his/her chair and was noted to prop his/her leg up on the side. On 9/11/18 at 12:30 PM, licensed nursing staff G stated that the area to the resident's right buttocks was getting worse. He/she stated that staff attempted to reposition the resident but he/she always rolled back to his/her back side. On 9/11/18 at 2:18 PM, administrative nursing staff D stated the resident was non-compliant and would expect to see that documented in the chart. He/she further stated that the resident needed to have Prostat added to the orders, protective boots added as an intervention and therapy was getting the resident a different wheelchair. The facility's policy Pressure Ulcer Management, revised 9/2018 documented that interventions included vitamin C 500 milligrams (mg) twice a day or three times a day, folic acid 1 mg daily, zinc 220 mg every day and iron sulfate 250 mg twice a day. The policy also recommended baseline labs for [MEDICATION NAME], protein, and [MEDICATION NAME]. The facility failed to develop and implement interventions to prevent the development of this resident's UTD pressure ulcer to the right buttocks and three areas to the right leg, failed to implement timely and effective interventions to promote healing and prevent deterioration of the wound. The facility's failure resulted in the worsening of the resident's pressure ulcer and the development of 3 new areas in this dependent resident. The facility also failed to adequately assess and document progression of wounds.

The facility identified a census of 50 residents. The sample included 26 residents, with 1 resident reviewed for significant weight. Based on observation, record review, and interview, the facility failed to develop and implement timely and effective interventions to prevent significant weight loss of 48 pounds weight loss or 24.37% from 2/10/18 to 7/27/18 furthermore 43.3 pounds weight loss or 22.26% from 3/25/18 to 9/10/18 in 6 months to prevent 1 resident (#22). Findings included: - Resident #22's electronic medical record (EMR) physician's orders [REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 00 which indicated severely impaired cognition. The resident required extensive assistance for ADLs (Activities of daily living) from 2 staff members for bed mobility, transfer, dressing, and toilet use. The MDS documented the resident required setup assistance for eating, identified the resident was at risk for pressure ulcers but did not have any pressure ulcers and required no protective equipment for the prevention of pressure ulcers. The MDS noted the resident had no weight loss. The CAA dated 3/25/18 for nutrition documented no nutritional concerns related to body mass index. The Quarterly MDS dated [DATE] documented the resident had no cognitive or functional changes, however required setup and assistance of 1 staff for eating. The resident now presented with a stage 3 (a sore that extends into the tissue beneath the skin, forming a small crater. Fat may show in the sore) pressure ulcer and received pressure relieving devices to the bed and nutritional interventions. The MDS recorded the resident had more than 5% in 1 month or 10% in 6 months weight loss that was not planned. Review of the Nutrition/Hydration Risk Evaluation dated 6/20/18 documented at risk. Review of the physicians orders recorded the following related to the residents nutritional status. 7/25/18 multivitamin adult give one tablet by mouth one time a day for wound healing 8/20/18 regular diet, regular texture, thin liquids consistency and ice cream with dinner every night. 9/5/18 Boost (nutritional supplement drink) twice daily for wound healing. The care plan dated 3/20/18 documented that staff were to honor residents' rights to make personal dietary choices and provide dietary education as needed, to offer a meal replacement if resident ate less than 50%, provide a calm quiet setting at meal times with adequate eating time and to encourage socialization and interaction with table mates during meals. It further directed staff to report to medical director signs and symptoms of decreased appetite, nausea and vomiting, unexpected weight loss and complaint of stomach pain. The care plan lacked evidence of new interventions for documented weight loss on 6/1/18 (39.1 pounds), 7/27/18 (17 pounds), and 8/27/18 (3 pounds). The physician's orders [REDACTED]. The Dietary Quarterly Evaluation dated 3/20/18 documented resident had weight loss related to inadequate oral intake. This evaluation further documented a 10 pound weight loss from (MONTH) (YEAR) and recommended staff to offer meal replacement if the resident consumed less than 50% of the meal. The Dietary Quarterly Evaluation dated 5/21/18 documented gradual weight gain over the past 6 months, however failed to record a weight for (MONTH) (YEAR). There were no recommendations made. (The clinical record lacked evidence to support the resident gained weight). The Dietary Quarterly Evaluation dated 8/22/18 documented resident triggered for a 5% weight loss in 1 month and a 22.8% weight loss in 6 months with no new labs noted. Dietitian recommended to add ice cream at dinner. Review of residents intake from 8/13/18 to 9/11/18 documented that resident consumed 76 to 100% of the meal 57 times, 51-75% of the meal 9 times, 26 to 50% of the meal 9 times and 0 to 25% of the meal 5 times. It further revealed the resident did not have 3 meals 4 days during this time and 1 day only had 1 meal documented. Review of residents weight noted that there was a 2 pound loss from (MONTH) to (MONTH) and the Dietitian made recommendation to offer meal replacement if the resident consumed less than 50% of the meal. Review of residents weight recorded revealed on 2/10/18 - 197.0 pounds and then 7/27/18 - 149.0 pounds which indicated a significant weight loss of 24.73%. The clinical record lacked evidence of interventions implemented for the residents weight loss. Further review of weights reveled on 3/25/18 the resident weighed 195.0 pounds and on 9/10/18 weighted 151.6 pounds, which indicated a significant weight loss of 22.26%. On 7/4/18 the clinical record documented the resident weighed 166.0 pounds, a 16 pound weight loss in 2 weeks. The clinical record lacked any intervention to prevent further weight loss. An Interdisciplinary Team note dated 8/22/18 at 10:50 AM, documented that resident had significant weight loss (5% in 30 days or 10% in 180 days) at that time. The Registered Dietitian placed resident on Boost and ice cream and recommend an appetite stimulant. An Interdisciplinary Team note dated 9/5/18 at 12:59 PM, documented that residents weight continued to decrease and that the Registered Dietitian continued to follow. An Interdisciplinary Team note dated 9/7/18 at 12:46 PM, documented that resident received a new order for [MEDICATION NAME] 7.5 milligrams (mg) by mouth at bed time to increase appetite and treat for depression. The clinical record lacked evidence of further documentation related to monitoring significant weight loss and interventions put into place. On 9/10/18 at 7:50 AM, the resident laid on his/her low air loss bed on his/her back, no breakfast tray was noted in residents room. On 9/10/18 at 12:06 PM, the resident sat in his/her wheelchair for lunch in the dining room. Staff removed the resident from the dining room prior to being served and propelled him/her to his/her room. Staff asked the resident what he/she would like to eat for lunch. On 9/11/18 at 12:30 PM, direct care staff Q stated that the residents nutritional intake depended on how he/she felts but he/she does eat good. On 9/11/18 at 2:18 PM, administrative nursing staff D stated he/she knew the resident experienced weight loss and that the Registered Dietitian was following that resident. The resident does not like stimulation and likes to eat in his/her room and will signal to staff that he/she wants to be removed. The facility's policy Resident Weight Monitoring, revised 3/2017 lacked guidance to staff on what to do for residents that have 5% and 10% weight loss. The facility failed to develop and implement interventions to prevent a significant weight loss of 48 pounds weight loss or 24.37% from 2/10/18 to 7/27/18, 43.3 pounds weight loss or 22.26% from 3/25/18 to 9/10/18 in 6 months for this cognitively impaired resident dependent resident.

The facility identified a census of 43 residents. The sample included 3 residents sampled for medications. Based on observation, interview, and record review, the facility failed to ensure 1 (#1) of 3 residents sampled for medications was free from significant medication errors when licensed nursing staff H administered 2 milliliters (mL), equal to 200 units of [MEDICATION NAME]-R insulin (a fast-acting form of the hormone insulin that works by lowering the amount of glucose in the blood, which helps to treat diabetes), instead of the physician ordered amount of 2 units. This deficient practice placed resident #1 in immediate jeopardy. Findings included: - The clinical record documented resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Initial Admission Record dated 7/13/17 documented the resident was alert and oriented, had diabetes, and was admitted for therapy. The record lacked documentation the resident had a [MEDICAL CONDITION] disorder. The care plan dated 7/14/17 documented the resident had diabetes mellitus and directed staff to administer diabetes medication as ordered by the physician and to monitor, document, and report to the physician any signs or symptoms of [DIAGNOSES REDACTED] (low blood sugar). A physician order [REDACTED]. A physician order [REDACTED]. A physician order [REDACTED]. for a blood sugar of 351 to 400 mg/dL SQ before meals for diabetes. The facility's investigation dated 7/14/17, documented on 7/14/17 at 6:35 P.M., licensed nursing staff H reported to administrative nursing staff D that he/she had administered 2 milliliters (mL), equal to 200 units of [MEDICATION NAME]-R insulin into the abdomen of resident #1, using an intramuscular (IM) syringe, instead of the physician ordered 2 units in a subcutaneous (SQ) syringe. Administrative nursing staff D instructed licensed nursing staff H to report the incident to the physician while he/she checked on the resident and notified the family in person that the resident was given more insulin than was ordered. Licensed nursing staff H reported to administrative nursing staff D that the physician had ordered an intravenous infusion of [MEDICATION NAME] 50% (D50), a medication used in emergency care to treat [DIAGNOSES REDACTED]. Administrative nursing staff D was not able to establish intravenous (IV) access for the resident and he/she instructed licensed nursing staff H to continue to check the resident's blood sugar every 15 minutes and ensure [MEDICATION NAME] (a medication used to quickly increase blood sugar levels in diabetics with low blood sugar) was available. At 11:45 P.M., licensed nursing staff I administered [MEDICATION NAME] to the resident for a blood sugar level of 76 milligrams per deciliter (mg/dL). On 7/15/17 at 8:30 A.M., licensed nursing staff I notified administrative nursing staff D the resident's IV access was never established and licensed nursing staff H had not reported that to the physician. Licensed nursing staff I reported that at 6:20 A.M., the resident's blood sugar was 52 mg/dL and he/she administered [MEDICATION NAME] per physician orders, a consultant IV nurse had established IV access for the resident, and IV D50 was infusing. On 7/15/17 at 10:35 A.M., licensed nursing staff H reported to administrative nursing staff D that the physician had ordered for the resident to be sent to the hospital for evaluation because he/she had two [MEDICAL CONDITION]. The resident's family reported the resident had a history of [REDACTED].M., the facility was notified the resident was admitted to the hospital for observation due to the medication error. According to www.cdc.gov, the target blood sugar level before a meal for people with diabetes was 80 to 130 mg/dL. A physician order [REDACTED]. The clinical record lacked documentation of a physician order [REDACTED]. The July 2017 Medication Administration Record (MAR) documented, on 7/14/17 at 8:42 A.M., licensed nursing staff H administered [MEDICATION NAME] 10 units SQ in the resident's right arm for a blood sugar level of 145 mg/dL. On 7/14/17 at 11:45 P.M., licensed nursing staff I administered [MEDICATION NAME] Kit 1 mg SQ in the resident's right arm for a blood sugar level of 76 mg/dL. On 7/15/17 at 6:57 A.M., licensed nursing staff I administered [MEDICATION NAME] Kit 1 mg SQ in the resident's right arm for an undocumented blood sugar level. The July 2017 MAR lacked documentation staff checked the resident's blood sugar on 7/13/17. On 7/14/17, documentation revealed the resident's blood sugar was 145 mg/dL at 7:00 A.M., 149 mg/dL at 11:00 A.M., and 76 mg/dL at 8:00 P.M. The MAR lacked evidence facility staff checked the resident's blood sugar before dinner and prior to the incorrect dose of the [MEDICATION NAME]-R insulin. On 7/15/17, documentation revealed the resident's blood sugar was 130 mg/dL at 7:00 A.M. The July 2017 MAR lacked further documentation staff monitored the resident's blood sugar level after medication error, lacked documentation of the 4:00 P.M. dose of [MEDICATION NAME]-R insulin (the reported medication error), and lacked documentation of the IV fluid that staff administered on 7/15/17. Review of the Blood Sugar Summary in the electronic medical record (EMR) documented the following blood sugars: 7/14/17 at 7:56 A.M. - 145 mg/dL, 7/14/17 at 11:23 A.M. - 149 mg/dL, 7/14/17 at 9:14 P.M. - 76 mg/dL, 7/15/17 at 7:06 A.M. - 130 mg/dL, 7/15/17 at 7:07 A.M. - 130 mg/dL, and 7/15/17 at 8:42 A.M. - 204 mg/dL. Review of progress notes from 7/13/17 through 7/14/17 lacked documentation regarding the resident's blood sugar, insulin administration, or the medication error. A progress note dated 7/15/17 at 12:08 A.M. by licensed nursing staff I documented the staff continued to check the resident's blood sugar every 30 minutes per the physician's orders [REDACTED]. The nurse notified the nurse practitioner and obtained an order to administer [MEDICATION NAME] and to check the resident's blood sugar every hour. After staff administered the [MEDICATION NAME], the resident's blood sugar was 107 mg/dL. A progress note dated 7/15/17 at 6:52 A.M., by licensed nursing staff I documented staff continued to check the resident's blood sugar hourly. At 6:00 A.M., the resident's blood sugar level was 67 mg/dL staff contacted the physician and obtained an order to administer a second dose of [MEDICATION NAME]. Staff contacted the consultant IV nurse to obtain IV access for the resident. A progress note, dated 7/15/17 at 12:16 P.M., by licensed nursing staff H documented at 6:00 A.M., he/she was told in nursing shift report that the consultant IV nurse would arrive to place an IV and administer an [MEDICATION NAME] of [MEDICATION NAME] 45 (this contradicts the physician ordered [MEDICATION NAME] of [MEDICATION NAME] 50%) because the resident had unstable blood sugar levels throughout the night. At the start of licensed nursing staff H's shift, the resident's blood sugar level was 67 mg/dL. He/she called the nurse practitioner and obtained an order to administer [MEDICATION NAME] until the consultant IV nurse arrived. Licensed nursing staff I administered the ordered [MEDICATION NAME]. At 7:00 A.M., the patient experienced convulsing for 45 seconds and his/her eyes rolled back in his/her head. The resident's blood sugar at that time was 200 mg/dL. Licensed nursing staff H called the nurse practitioner to report the [MEDICAL CONDITION] and received an order to check the resident's vital signs and blood sugars every 2 hours, obtain stat (immediate) laboratory studies for a basic metabolic panel (BMP, a test used to check the status of a person's kidneys, electrolyte and acid/base balance, and blood glucose level all which are related to the metabolism) and complete blood count (CBC, a test used to evaluate the overall health and detect a wide range of disorders), and for the IV glucose rate to infuse at 50 milliliters per hour (mL/hr). At 7:30 A.M., the consultant IV nurse arrived to the facility and started the IV glucose infusion (this contradicts the physician ordered [MEDICATION NAME] of [MEDICATION NAME] 50%). At 10:30 A.M., the resident's family informed licensed nursing staff H that the resident experienced another [MEDICAL CONDITION], but he/she was responsive. Licensed nursing staff H notified the nurse practitioner of the second [MEDICAL CONDITION] and obtained an order to send the resident to the hospital for evaluation. The resident left the facility at 10:50 A.M. A progress note dated 7/15/17 at 2:45 P.M. by licensed nursing staff H documented the family reported the resident often had [MEDICAL CONDITION] when stressed and the resident's vital signs and blood sugar was stable prior to discharge. Review of the hospital record dated 7/15/17 documented the resident presented to the emergency room with [DIAGNOSES REDACTED] after facility staff administered 2 mL (200 units) of insulin rather than 2 units. In the 12 hours after administration, the resident was hypoglycemic, received two doses of [MEDICATION NAME], and staff initiated an IV of D5 (this contradicts the physician ordered [MEDICATION NAME] of [MEDICATION NAME] 50%). The resident experienced two witnessed [MEDICAL CONDITION] of unknown duration, but the family refused the ordered radiology tests, stating his/her [MEDICAL CONDITION] were chronic and well controlled. The resident was admitted to the hospital for further glucose monitoring. The facility notarized witness statement, dated 7/18/17, by licensed nursing staff H documented on 7/14/17 at approximately 4:30 P.M., he/she checked the resident's blood sugar before the evening meal. Licensed nursing staff H looked through the medication carts, thought he/she found an insulin syringe, pulled up 2 mL of [MEDICATION NAME]-R insulin instead of 2 units, and administered the insulin at approximately 4:45 P.M. After he/she administered the medication, he/she realized he/she used the wrong syringe and immediately notified administrative nursing staff D of the medication error. He/she notified consultant physician KK of the error and received an order to place an IV, run an amp D50, and to check the resident's blood sugar every 30 minutes. Administrative nursing staff D attempted, but was not able, to place the IV. Licensed nursing staff H documented administrative nursing staff D instructed him/her to sit with the resident to observe him/her for [DIAGNOSES REDACTED], check the resident's blood sugars every 10-15 minutes, to notify the director of nursing of every blood sugar level, to continue to give the resident orange juice with added sugar, and to administer [MEDICATION NAME] if the resident's blood sugar fell below 100 mg/dL. After two hours of monitoring, the resident's blood sugars stopped decreasing and administrative nursing staff D instructed licensed nursing staff H to continue to check the resident's blood sugar every 30 minutes for 4 hours. On 7/15/17 at 6:00 A.M., licensed nursing staff I reported to licensed nursing staff H that the resident's blood sugars had been in the 60s during the night and the consultant IV nurse was on his/her way to the facility to obtain IV access. At that time, the resident's blood sugar level was 67 mg/dL. Licensed nursing staff H called the nurse practitioner and asked if he/she could administer [MEDICATION NAME] SQ while staff waited for the consultant IV nurse to arrive to the facility to place the IV. Licensed nursing staff I administered the ordered [MEDICATION NAME]. At 7:30 A.M., the consultant IV nurse arrived and placed an IV. Licensed nursing staff H called the nurse practitioner back for a rate for the amp of [MEDICATION NAME] and the consultant IV nurse hung the bag. Before the consultant IV nurse arrived, licensed nursing staff H witnessed the resident have a [MEDICAL CONDITION]. The resident's family reported to him/her that the resident had [MEDICAL CONDITION] when he/she was stressed. Licensed nursing staff H notified the nurse practitioner and received an order to monitor the resident's vital signs and blood sugars every 30 minutes or every hour. At 10:20 A.M., the resident's family reported to licensed nursing staff H that the resident had another [MEDICAL CONDITION]. Licensed nursing staff H notified the nurse practitioner of the second [MEDICAL CONDITION] and received instructions to send the resident to the hospital. The resident left the facility at approximately 10:50 A.M., on 7/15/17. The facility notarized witness statement, dated 7/18/17, by licensed nursing staff J documented on 7/14/17 at approximately 4:00 P.M., licensed nursing staff H reported he/she administered 2 mL of insulin in an IM syringe instead of the ordered dose of 2 units per his/her sliding scale order. Licensed nursing staff J obtained the [MEDICATION NAME] kit and notified the director of nursing (DON). Licensed nursing staff J and the DON monitored the resident while licensed nursing staff H notified the physician of the error. The physician gave an order to start an IV and administer [MEDICATION NAME] 10% (D10, a medication used to treat [DIAGNOSES REDACTED]) (this contradicts the physician ordered [MEDICATION NAME] of [MEDICATION NAME] 50%). The DON was not able to obtain IV access for the resident. Licensed nursing staff H followed the physician's orders [REDACTED]. The resident's blood sugar did not drop below 158 mg/dL during that time. The facility notarized witness statement, dated 7/18/17, by licensed nursing staff I documented on 7/14/17 during nursing shift report, he/she was informed by licensed nursing staff H that the resident received more insulin than ordered and staff was to check the resident's blood sugar every 30 minutes. Licensed nursing staff I continued to monitor the resident and gave him/her orange juice when the blood sugar was low. At one point during the shift, the resident's blood sugar was in the 50s, so he/she notified consultant staff JJ, who gave an order to give a [MEDICATION NAME] injection. After administration of the [MEDICATION NAME], the resident's blood sugar was 107 mg/dL. Licensed nursing staff I notified consultant staff JJ the resident's blood sugar had dropped again and consultant staff JJ suggested that staff place the IV in the resident. Licensed nursing staff I informed consultant staff JJ that staff had attempted the IV, but were unable to place it, and staff obtained an order for [REDACTED]. The facility notarized witness statement, dated 7/14/17, by licensed nursing staff K documented on 7/15/17 while waiting for the consultant IV nurse to arrive, the resident experienced a [MEDICAL CONDITION]. The family reported the [MEDICAL CONDITION] were chronic and were stress induced. The consultant IV nurse placed the IV, and licensed nursing staff H hung the IV fluid. The resident then had a second [MEDICAL CONDITION], and licensed nursing staff H notified consultant staff II, who gave an order to send the resident to the hospital. A typed notarized statement, dated 7/18/17, from administrative nursing staff D and witnessed by administrative staff C documented on 7/14/17 around dinner time, licensed nursing staff H reported to him/her that he/she gave the resident the incorrect amount of insulin and believed he/she gave 2 mL of [MEDICATION NAME]-R when the order read for 2 units. Administrative nursing staff D instructed licensed nursing staff H to call the doctor while he/she went to assess the patient. The patient was stable, he/she notified the family that the nurse had given too much insulin, and that staff would monitor him/her closely. The nurse reported that the doctor gave an order for [REDACTED]. Administrative nursing staff D told the nurse on the floor caring for the resident to continue to check his/her blood sugar every 15 minutes and to text him/her the results. [MEDICATION NAME] was available if needed. Licensed nursing staff H asked him/her if he/she should notify the doctor, and he/she told the nurse to notify doctor the IV was not started, to continue the 15-minute checks, and if needed, [MEDICATION NAME] was available. Administrative nursing staff D informed licensed nursing staff H if the resident's blood sugar dropped below 120 mg/dL to call him/her immediately and to text him/her every 15 minutes with the blood sugar checks. Every blood sugar was above 200 until approximately 2045. On 7/15/17 at 8:30 A.M., administrative nursing staff D received a text from licensed nursing staff I that the IV was never started and that licensed nursing staff H had not notified the doctor. Licensed nursing staff I reported that the resident's blood sugar was down to 52 at 6:20 A.M., he/she administered [MEDICATION NAME], the IV had been placed and D50 was infusing. Review of the Peripheral Intravenous Catheter/Care & Maintenance Documentation dated 7/15/17 at 7:30 A.M. documented consultant IV staff HH inserted a 22-gauge peripheral IV into the left forearm and intravenous fluids were initiated. On 7/19/17 at 3:15 P.M., observation revealed the medication cart contained a drawer of syringes that were separated according to type of syringe. The insulin syringe had an orange cap and the manufacturer's packaging clearly labeled it as an insulin syringe. The intramuscular syringe had a larger barrel, a 25-gauge needle, and the packaging was labeled for intramuscular use. An observation of the resident was not available, as the resident no longer resided in the facility. On 7/17/17 at 11:50 A.M., the family reported to the state agency that facility staff administered 200 units of fast acting insulin instead of the physician ordered 2 units because the nurse used the wrong type of syringe. He/she stated the consultant IV nurse started an IV and gave the resident IV glucose. On 7/19/17 at 3:15 P.M., licensed nursing staff L stated the insulin syringes were clearly labeled on their packaging, all blood sugars should be documented on the MAR, and all administered medications should be documented on the MAR. On 7/20/17 at 6:50 A.M., licensed nursing staff M stated he/she did not complete a skills checklist or competency regarding insulin administration during orientation. He/she stated the package of the syringe was clearly labeled as an insulin syringe. On 7/20/17 at 7:43 A.M., licensed nursing staff N stated the insulin syringes were clearly identified, all blood sugars and insulin administration should be documented on the MAR, and all administered medications should be documented on the MAR. On 7/20/17 at 1:50 P.M., administrative staff A and administrative nursing staff E stated administrative nursing staff D was no longer employed by the facility and was not available for interview. Administrative nursing staff E confirmed the clinical record lacked documentation of the telephone orders that were given by consultant staff KK, JJ, and II. He/she acknowledged the clinical record lacked documentation on the MAR of the medication error, lacked documentation of all the blood sugar monitoring, and lacked documentation of the IV being administered even though it was noted in the facility witness statements. On 7/20/17 at 2:10 P.M., administrative nursing staff B stated on 7/15/17 at approximately 3:00 P.M., the DON notified him/her that a significant medication error had occurred on 7/14/17. Administrative nursing staff B stated the DON reported he/she was aware staff were unable to start the resident's IV on 7/14/17, but the resident was stable. Administrative nursing staff B stated he/she immediately reported the incident to the state agency on 7/15/17 and started the facility investigation. He/she stated he/she was told by the nursing staff that consultant staff did start the IV, but he/she could not confirm who administered the IV fluids. Administrative nursing staff B confirmed the clinical record lacked documentation of the order for IV fluids, lacked documentation of the administration of the IV fluid, and confirmed there were no additional blood sugars documented by the staff. Administrative nursing staff B stated the organization had a competency checklist that staff were to complete during orientation, but stated this facility did not utilize the checklist. On 7/20/17 at 2:30 P.M., administrative nursing staff E acknowledged the clinical record was missing documentation of the physician orders, documentation of the actual incident, and documentation of the completion of the scheduled blood sugar at 4:00 P.M. on 7/14/17. Administrative nursing staff E stated staff when staff checked a resident's blood sugar during an unscheduled time, they could manually chart it in the clinical record in the Blood Sugar Summary. On 7/20/17 at 2:40 P.M., licensed nursing staff H stated on at approximately 4:30 P.M., he/she looked for an insulin syringe in all of the medication carts and thought he/she selected the correct syringe. Licensed nursing staff H stated right after he/she administered the insulin, he/she realized that he/she had administered 2 mLs of regular insulin instead of 2 units and he/she immediately reported the incident to the DON. Licensed nursing staff H stated he/she talked to the physician on the phone and informed him/her of the incident, but did not document the physician notification in the clinical record. Licensed nursing staff H further acknowledged he/she did not enter the physician's telephone orders into the clinical record and stated he/she did not receive a lot of training and needed assistance to put the orders in the computer. He/she stated he/she did not complete a skills checklist or competency regarding insulin administration during orientation. Licensed nursing staff H stated he/she documented all of the resident's blood sugars on the risk management form but was not aware that it was not part of the resident's clinical record. Licensed nursing staff H stated after the consultant IV nurse started the IV, he/she called the nurse practitioner to clarify the rate the IV should infuse. Licensed nursing staff H stated he/she was not IV certified, so the consultant IV nurse administered the IV fluid, but licensed nursing staff H could not remember what type of fluid the physician ordered. On 7/20/17 at 3:00 P.M., administrative nursing staff E stated staff administered [MEDICATION NAME] 5% in 0.45% saline (D5 ½ NS, an intravenous solution used for daily maintenance of body fluids and rehydration) to the resident (this contradicts the physician ordered [MEDICATION NAME] of [MEDICATION NAME] 50%). He/she stated staff did not document which medications they had removed from the emergency kit on 7/15/17, but that it was the only fluid missing. Administrative nursing staff E stated the facility did not have D50 in the emergency kit and would have had to obtain it from the pharmacy. On 7/20/17 at 7:13 P.M., consultant physician KK stated on 7/14/17 around dinnertime, he/she was notified by the nurse that there had been a medication error. The nurse informed him/her that 200 units of [MEDICATION NAME]-R had been administered instead of the ordered 2 units. Consultant physician KK stated he/she gave the nurse an order to start an IV, to administer 50% [MEDICATION NAME] injection 25 grams (0.5 g/mL), which was known as D50, to check the resident's glucose hourly, and to report each blood sugar to him/her until further notice. Consultant physician KK stated staff failed to notify him/her that staff were unable to start the IV. Consultant physician KK stated the nurse practitioner reported to him/her that staff told the nurse practitioner they had administered D50 as an intramuscular injection (IM), which confused him/her because D50 was always given IV and would not be given IM. Consultant physician KK stated the lowest blood sugar he/she was aware of was 57 mg/dL and that [MEDICATION NAME] had been administered twice. He/she was not aware the nurse had not written down any of the orders given by him/her or the nurse practitioner, and stated he/she did not order D5 ½ NS, because it was not typically ordered for the correction of [DIAGNOSES REDACTED]. Consultant physician KK stated he/she was very concerned about the seriousness of the medication error. On 7/24/17 at 11:27 A.M., consultant staff II stated on 7/15/17, he/she was informed by nursing staff H the resident had two [MEDICAL CONDITION] and his/her blood sugar had dropped below 60 twice during the shift. Consultant staff II stated he/she did not give an order for [REDACTED].½ NS or any IV fluids. Consultant staff II stated the nurse asked what rate the IV fluids that consultant physician KK ordered were to infuse at, and he/she clarified the rate of the IV was 60 mL/hr. Consultant staff II stated he/she felt alarmed that the staff did not obtain IV access and administer [MEDICATION NAME] 50% when ordered by the physician on 7/14/17. On 7/24/17 at 12:16 P.M., consultant pharmacy staff GG stated he/she was not aware that a medication error occurred at the facility. He/she stated the pharmacy was not contacted for the D50 or any other medications for the resident. Consultant pharmacy staff GG stated had staff contacted them, they would have had to send the medication out via courier because they do not keep it in the facility, but stated they would have advised the staff to call 911 and transfer the resident to the hospital since it was across the street from the facility. He/she stated [MEDICATION NAME]-R is an older medication that had not been converted into the [MEDICATION NAME] yet, so the only way to administer [MEDICATION NAME]-R was to draw it up with an insulin syringe. He/she stated the insulin syringes were clearly labeled on the packaging and were obviously much smaller than an intramuscular syringe. Consultant pharmacy staff GG stated the IV emergency kit contained a bag of normal saline and a bag of D5 ½ NS, so if any fluid was hung, that would be the only choice available that has [MEDICATION NAME] in it. He/she stated the emergency kit had glucose tabs and [MEDICATION NAME] in it, but there was not any D50. Consultant pharmacy staff GG stated staff should administer the D50 through the IV, not IM. On 7/20/17 at 3:54 P.M., consultant IV nurse HH stated he/she was notified on 7/15/17 the resident needed a peripheral IV due to low blood sugar and he/she inserted a 22-gauge IV into the resident's left forearm. Consultant IV nurse HH confirmed that he/she administered D5 ½ NS at 50 mL/hr because licensed nursing staff H was not IV certified. He/she stated the consultant IV nurses were expected to visually review the physician's orders [REDACTED]. Consultant IV nurse HH stated he/she heard licensed nursing staff H read back the order for D5 ½ NS at 50 mL/hr (this contradicts the physician ordered [MEDICATION NAME] of [MEDICATION NAME] 50%) via telephone to the nurse practitioner and he/she felt the IV needed to be hung since the resident's blood sugar had been low through the night. He/she stated the consultant IV nurses occasionally hung IV fluids for the facility staff but it was dependent on the circumstances. The facility's Administering Insulin policy dated March 2009 documented the facility would administer all insulin injections in an organized and safe manner. The policy directed staff to check the physician order, determine the correct amount of insulin to be withdrawn, read the MAR and compare with the label on the insulin, prepare the needle and syringe, withdraw the ordered dosage of insulin, to check the medication label with the MAR a third time, and to document the administration on the MAR. The facility's Medication Orders policy dated July 2017 documented that medications were administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. Each medication order was documented in the resident's medical record with the date, time, and signature of the person receiving the order. The order was recorded on the physician order [REDACTED]. The following steps were initiated to complete documentation: clarify the order, enter the orders on the medication order and receipt record, call or fax the medication order to the provider pharmacy, transcribe newly prescribed medications on the MAR, and after completion, document each medication order noted on the physician's orders [REDACTED]. The facility's Transcribing Physician order [REDACTED]. All orders for medications must include a diagnosis. An order should be considered to be in writing if dictated to a Licensed Practical Nurse (LPN) and/or Registered Nurse (RN) and signed by the attending physician. All medication orders were to be called or faxed to the pharmacy before the end of every shift. The date, time noted, and legal signature would be signed at the end of all orders. All medication orders were to be transcribed to the MAR. All orders for new medications were to be added to the 24-hour report for 24 hours. Each shift must acknowledge the receipt and effect of this medicine in nursing notes and on the 24-hour sheet. All new orders were to be documented in nursing notes. Families were to be notified of all new orders and documented. The facility failed to ensure this resident was free of a significant medication error. Licensed nursing staff H administered 2 mL (200 units) of [MEDICATION NAME]-R insulin instead of the physician ordered 2 units, which placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on 7/23/17 at 5:55 P.M. by implementing the following: resident #1 no longer resided in the facility, all licensed staff were educated on the revised insulin administration policy and on the two-nurse verification procedure prior to insulin administration, and all licensed nursing staff completed a skills checkoff. Any licensed staff not in-serviced were removed from the schedule until education was provided. Additional in-service education and competency/skills checks would be performed by the Director of Nursing and/or designee on all new licensed nursing staff in orientation and all licensed staff quarterly, annually, and as needed. As part of the facility's Quality Assurance and Performance Improvement (QAPI) program, there would be ongoing, random weekly verification that licensed nursing staff had reviewed the revised insulin administration policy related to the two-nurse verification process and the proper administration of insulin until substantial compliance was achieved and maintained. Issues identified would be addressed with staff involved and findings would be forwarded to the monthly QAPI Committee for further review and recommendations. The deficient practice remained at a scope and severity of G.

The facility identified a census of 43 residents. The sample included 3 residents sampled for medications. Based on observation, interview, and record review, the facility failed to ensure 1 (#1) of 3 residents sampled for medications was free from significant medication errors when licensed nursing staff H administered 2 milliliters (mL), equal to 200 units of [MEDICATION NAME]-R insulin (a fast-acting form of the hormone insulin that works by lowering the amount of glucose in the blood, which helps to treat diabetes), instead of the physician ordered amount of 2 units. This deficient practice placed resident #1 in immediate jeopardy. Findings included: - The clinical record documented resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Initial Admission Record dated 7/13/17 documented the resident was alert and oriented, had diabetes, and was admitted for therapy. The record lacked documentation the resident had a [MEDICAL CONDITION] disorder. The care plan dated 7/14/17 documented the resident had diabetes mellitus and directed staff to administer diabetes medication as ordered by the physician and to monitor, document, and report to the physician any signs or symptoms of [DIAGNOSES REDACTED] (low blood sugar). A physician order [REDACTED]. A physician order [REDACTED]. A physician order [REDACTED]. for a blood sugar of 351 to 400 mg/dL SQ before meals for diabetes. The facility's investigation dated 7/14/17, documented on 7/14/17 at 6:35 P.M., licensed nursing staff H reported to administrative nursing staff D that he/she had administered 2 milliliters (mL), equal to 200 units of [MEDICATION NAME]-R insulin into the abdomen of resident #1, using an intramuscular (IM) syringe, instead of the physician ordered 2 units in a subcutaneous (SQ) syringe. Administrative nursing staff D instructed licensed nursing staff H to report the incident to the physician while he/she checked on the resident and notified the family in person that the resident was given more insulin than was ordered. Licensed nursing staff H reported to administrative nursing staff D that the physician had ordered an intravenous infusion of [MEDICATION NAME] 50% (D50), a medication used in emergency care to treat [DIAGNOSES REDACTED]. Administrative nursing staff D was not able to establish intravenous (IV) access for the resident and he/she instructed licensed nursing staff H to continue to check the resident's blood sugar every 15 minutes and ensure [MEDICATION NAME] (a medication used to quickly increase blood sugar levels in diabetics with low blood sugar) was available. At 11:45 P.M., licensed nursing staff I administered [MEDICATION NAME] to the resident for a blood sugar level of 76 milligrams per deciliter (mg/dL). On 7/15/17 at 8:30 A.M., licensed nursing staff I notified administrative nursing staff D the resident's IV access was never established and licensed nursing staff H had not reported that to the physician. Licensed nursing staff I reported that at 6:20 A.M., the resident's blood sugar was 52 mg/dL and he/she administered [MEDICATION NAME] per physician orders, a consultant IV nurse had established IV access for the resident, and IV D50 was infusing. On 7/15/17 at 10:35 A.M., licensed nursing staff H reported to administrative nursing staff D that the physician had ordered for the resident to be sent to the hospital for evaluation because he/she had two [MEDICAL CONDITION]. The resident's family reported the resident had a history of [REDACTED].M., the facility was notified the resident was admitted to the hospital for observation due to the medication error. According to www.cdc.gov, the target blood sugar level before a meal for people with diabetes was 80 to 130 mg/dL. A physician order [REDACTED]. The clinical record lacked documentation of a physician order [REDACTED]. The July 2017 Medication Administration Record (MAR) documented, on 7/14/17 at 8:42 A.M., licensed nursing staff H administered [MEDICATION NAME] 10 units SQ in the resident's right arm for a blood sugar level of 145 mg/dL. On 7/14/17 at 11:45 P.M., licensed nursing staff I administered [MEDICATION NAME] Kit 1 mg SQ in the resident's right arm for a blood sugar level of 76 mg/dL. On 7/15/17 at 6:57 A.M., licensed nursing staff I administered [MEDICATION NAME] Kit 1 mg SQ in the resident's right arm for an undocumented blood sugar level. The July 2017 MAR lacked documentation staff checked the resident's blood sugar on 7/13/17. On 7/14/17, documentation revealed the resident's blood sugar was 145 mg/dL at 7:00 A.M., 149 mg/dL at 11:00 A.M., and 76 mg/dL at 8:00 P.M. The MAR lacked evidence facility staff checked the resident's blood sugar before dinner and prior to the incorrect dose of the [MEDICATION NAME]-R insulin. On 7/15/17, documentation revealed the resident's blood sugar was 130 mg/dL at 7:00 A.M. The July 2017 MAR lacked further documentation staff monitored the resident's blood sugar level after medication error, lacked documentation of the 4:00 P.M. dose of [MEDICATION NAME]-R insulin (the reported medication error), and lacked documentation of the IV fluid that staff administered on 7/15/17. Review of the Blood Sugar Summary in the electronic medical record (EMR) documented the following blood sugars: 7/14/17 at 7:56 A.M. - 145 mg/dL, 7/14/17 at 11:23 A.M. - 149 mg/dL, 7/14/17 at 9:14 P.M. - 76 mg/dL, 7/15/17 at 7:06 A.M. - 130 mg/dL, 7/15/17 at 7:07 A.M. - 130 mg/dL, and 7/15/17 at 8:42 A.M. - 204 mg/dL. Review of progress notes from 7/13/17 through 7/14/17 lacked documentation regarding the resident's blood sugar, insulin administration, or the medication error. A progress note dated 7/15/17 at 12:08 A.M. by licensed nursing staff I documented the staff continued to check the resident's blood sugar every 30 minutes per the physician's orders [REDACTED]. The nurse notified the nurse practitioner and obtained an order to administer [MEDICATION NAME] and to check the resident's blood sugar every hour. After staff administered the [MEDICATION NAME], the resident's blood sugar was 107 mg/dL. A progress note dated 7/15/17 at 6:52 A.M., by licensed nursing staff I documented staff continued to check the resident's blood sugar hourly. At 6:00 A.M., the resident's blood sugar level was 67 mg/dL staff contacted the physician and obtained an order to administer a second dose of [MEDICATION NAME]. Staff contacted the consultant IV nurse to obtain IV access for the resident. A progress note, dated 7/15/17 at 12:16 P.M., by licensed nursing staff H documented at 6:00 A.M., he/she was told in nursing shift report that the consultant IV nurse would arrive to place an IV and administer an [MEDICATION NAME] of [MEDICATION NAME] 45 (this contradicts the physician ordered [MEDICATION NAME] of [MEDICATION NAME] 50%) because the resident had unstable blood sugar levels throughout the night. At the start of licensed nursing staff H's shift, the resident's blood sugar level was 67 mg/dL. He/she called the nurse practitioner and obtained an order to administer [MEDICATION NAME] until the consultant IV nurse arrived. Licensed nursing staff I administered the ordered [MEDICATION NAME]. At 7:00 A.M., the patient experienced convulsing for 45 seconds and his/her eyes rolled back in his/her head. The resident's blood sugar at that time was 200 mg/dL. Licensed nursing staff H called the nurse practitioner to report the [MEDICAL CONDITION] and received an order to check the resident's vital signs and blood sugars every 2 hours, obtain stat (immediate) laboratory studies for a basic metabolic panel (BMP, a test used to check the status of a person's kidneys, electrolyte and acid/base balance, and blood glucose level all which are related to the metabolism) and complete blood count (CBC, a test used to evaluate the overall health and detect a wide range of disorders), and for the IV glucose rate to infuse at 50 milliliters per hour (mL/hr). At 7:30 A.M., the consultant IV nurse arrived to the facility and started the IV glucose infusion (this contradicts the physician ordered [MEDICATION NAME] of [MEDICATION NAME] 50%). At 10:30 A.M., the resident's family informed licensed nursing staff H that the resident experienced another [MEDICAL CONDITION], but he/she was responsive. Licensed nursing staff H notified the nurse practitioner of the second [MEDICAL CONDITION] and obtained an order to send the resident to the hospital for evaluation. The resident left the facility at 10:50 A.M. A progress note dated 7/15/17 at 2:45 P.M. by licensed nursing staff H documented the family reported the resident often had [MEDICAL CONDITION] when stressed and the resident's vital signs and blood sugar was stable prior to discharge. Review of the hospital record dated 7/15/17 documented the resident presented to the emergency room with [DIAGNOSES REDACTED] after facility staff administered 2 mL (200 units) of insulin rather than 2 units. In the 12 hours after administration, the resident was hypoglycemic, received two doses of [MEDICATION NAME], and staff initiated an IV of D5 (this contradicts the physician ordered [MEDICATION NAME] of [MEDICATION NAME] 50%). The resident experienced two witnessed [MEDICAL CONDITION] of unknown duration, but the family refused the ordered radiology tests, stating his/her [MEDICAL CONDITION] were chronic and well controlled. The resident was admitted to the hospital for further glucose monitoring. The facility notarized witness statement, dated 7/18/17, by licensed nursing staff H documented on 7/14/17 at approximately 4:30 P.M., he/she checked the resident's blood sugar before the evening meal. Licensed nursing staff H looked through the medication carts, thought he/she found an insulin syringe, pulled up 2 mL of [MEDICATION NAME]-R insulin instead of 2 units, and administered the insulin at approximately 4:45 P.M. After he/she administered the medication, he/she realized he/she used the wrong syringe and immediately notified administrative nursing staff D of the medication error. He/she notified consultant physician KK of the error and received an order to place an IV, run an amp D50, and to check the resident's blood sugar every 30 minutes. Administrative nursing staff D attempted, but was not able, to place the IV. Licensed nursing staff H documented administrative nursing staff D instructed him/her to sit with the resident to observe him/her for [DIAGNOSES REDACTED], check the resident's blood sugars every 10-15 minutes, to notify the director of nursing of every blood sugar level, to continue to give the resident orange juice with added sugar, and to administer [MEDICATION NAME] if the resident's blood sugar fell below 100 mg/dL. After two hours of monitoring, the resident's blood sugars stopped decreasing and administrative nursing staff D instructed licensed nursing staff H to continue to check the resident's blood sugar every 30 minutes for 4 hours. On 7/15/17 at 6:00 A.M., licensed nursing staff I reported to licensed nursing staff H that the resident's blood sugars had been in the 60s during the night and the consultant IV nurse was on his/her way to the facility to obtain IV access. At that time, the resident's blood sugar level was 67 mg/dL. Licensed nursing staff H called the nurse practitioner and asked if he/she could administer [MEDICATION NAME] SQ while staff waited for the consultant IV nurse to arrive to the facility to place the IV. Licensed nursing staff I administered the ordered [MEDICATION NAME]. At 7:30 A.M., the consultant IV nurse arrived and placed an IV. Licensed nursing staff H called the nurse practitioner back for a rate for the amp of [MEDICATION NAME] and the consultant IV nurse hung the bag. Before the consultant IV nurse arrived, licensed nursing staff H witnessed the resident have a [MEDICAL CONDITION]. The resident's family reported to him/her that the resident had [MEDICAL CONDITION] when he/she was stressed. Licensed nursing staff H notified the nurse practitioner and received an order to monitor the resident's vital signs and blood sugars every 30 minutes or every hour. At 10:20 A.M., the resident's family reported to licensed nursing staff H that the resident had another [MEDICAL CONDITION]. Licensed nursing staff H notified the nurse practitioner of the second [MEDICAL CONDITION] and received instructions to send the resident to the hospital. The resident left the facility at approximately 10:50 A.M., on 7/15/17. The facility notarized witness statement, dated 7/18/17, by licensed nursing staff J documented on 7/14/17 at approximately 4:00 P.M., licensed nursing staff H reported he/she administered 2 mL of insulin in an IM syringe instead of the ordered dose of 2 units per his/her sliding scale order. Licensed nursing staff J obtained the [MEDICATION NAME] kit and notified the director of nursing (DON). Licensed nursing staff J and the DON monitored the resident while licensed nursing staff H notified the physician of the error. The physician gave an order to start an IV and administer [MEDICATION NAME] 10% (D10, a medication used to treat [DIAGNOSES REDACTED]) (this contradicts the physician ordered [MEDICATION NAME] of [MEDICATION NAME] 50%). The DON was not able to obtain IV access for the resident. Licensed nursing staff H followed the physician's orders [REDACTED]. The resident's blood sugar did not drop below 158 mg/dL during that time. The facility notarized witness statement, dated 7/18/17, by licensed nursing staff I documented on 7/14/17 during nursing shift report, he/she was informed by licensed nursing staff H that the resident received more insulin than ordered and staff was to check the resident's blood sugar every 30 minutes. Licensed nursing staff I continued to monitor the resident and gave him/her orange juice when the blood sugar was low. At one point during the shift, the resident's blood sugar was in the 50s, so he/she notified consultant staff JJ, who gave an order to give a [MEDICATION NAME] injection. After administration of the [MEDICATION NAME], the resident's blood sugar was 107 mg/dL. Licensed nursing staff I notified consultant staff JJ the resident's blood sugar had dropped again and consultant staff JJ suggested that staff place the IV in the resident. Licensed nursing staff I informed consultant staff JJ that staff had attempted the IV, but were unable to place it, and staff obtained an order for [REDACTED]. The facility notarized witness statement, dated 7/14/17, by licensed nursing staff K documented on 7/15/17 while waiting for the consultant IV nurse to arrive, the resident experienced a [MEDICAL CONDITION]. The family reported the [MEDICAL CONDITION] were chronic and were stress induced. The consultant IV nurse placed the IV, and licensed nursing staff H hung the IV fluid. The resident then had a second [MEDICAL CONDITION], and licensed nursing staff H notified consultant staff II, who gave an order to send the resident to the hospital. A typed notarized statement, dated 7/18/17, from administrative nursing staff D and witnessed by administrative staff C documented on 7/14/17 around dinner time, licensed nursing staff H reported to him/her that he/she gave the resident the incorrect amount of insulin and believed he/she gave 2 mL of [MEDICATION NAME]-R when the order read for 2 units. Administrative nursing staff D instructed licensed nursing staff H to call the doctor while he/she went to assess the patient. The patient was stable, he/she notified the family that the nurse had given too much insulin, and that staff would monitor him/her closely. The nurse reported that the doctor gave an order for [REDACTED]. Administrative nursing staff D told the nurse on the floor caring for the resident to continue to check his/her blood sugar every 15 minutes and to text him/her the results. [MEDICATION NAME] was available if needed. Licensed nursing staff H asked him/her if he/she should notify the doctor, and he/she told the nurse to notify doctor the IV was not started, to continue the 15-minute checks, and if needed, [MEDICATION NAME] was available. Administrative nursing staff D informed licensed nursing staff H if the resident's blood sugar dropped below 120 mg/dL to call him/her immediately and to text him/her every 15 minutes with the blood sugar checks. Every blood sugar was above 200 until approximately 2045. On 7/15/17 at 8:30 A.M., administrative nursing staff D received a text from licensed nursing staff I that the IV was never started and that licensed nursing staff H had not notified the doctor. Licensed nursing staff I reported that the resident's blood sugar was down to 52 at 6:20 A.M., he/she administered [MEDICATION NAME], the IV had been placed and D50 was infusing. Review of the Peripheral Intravenous Catheter/Care & Maintenance Documentation dated 7/15/17 at 7:30 A.M. documented consultant IV staff HH inserted a 22-gauge peripheral IV into the left forearm and intravenous fluids were initiated. On 7/19/17 at 3:15 P.M., observation revealed the medication cart contained a drawer of syringes that were separated according to type of syringe. The insulin syringe had an orange cap and the manufacturer's packaging clearly labeled it as an insulin syringe. The intramuscular syringe had a larger barrel, a 25-gauge needle, and the packaging was labeled for intramuscular use. An observation of the resident was not available, as the resident no longer resided in the facility. On 7/17/17 at 11:50 A.M., the family reported to the state agency that facility staff administered 200 units of fast acting insulin instead of the physician ordered 2 units because the nurse used the wrong type of syringe. He/she stated the consultant IV nurse started an IV and gave the resident IV glucose. On 7/19/17 at 3:15 P.M., licensed nursing staff L stated the insulin syringes were clearly labeled on their packaging, all blood sugars should be documented on the MAR, and all administered medications should be documented on the MAR. On 7/20/17 at 6:50 A.M., licensed nursing staff M stated he/she did not complete a skills checklist or competency regarding insulin administration during orientation. He/she stated the package of the syringe was clearly labeled as an insulin syringe. On 7/20/17 at 7:43 A.M., licensed nursing staff N stated the insulin syringes were clearly identified, all blood sugars and insulin administration should be documented on the MAR, and all administered medications should be documented on the MAR. On 7/20/17 at 1:50 P.M., administrative staff A and administrative nursing staff E stated administrative nursing staff D was no longer employed by the facility and was not available for interview. Administrative nursing staff E confirmed the clinical record lacked documentation of the telephone orders that were given by consultant staff KK, JJ, and II. He/she acknowledged the clinical record lacked documentation on the MAR of the medication error, lacked documentation of all the blood sugar monitoring, and lacked documentation of the IV being administered even though it was noted in the facility witness statements. On 7/20/17 at 2:10 P.M., administrative nursing staff B stated on 7/15/17 at approximately 3:00 P.M., the DON notified him/her that a significant medication error had occurred on 7/14/17. Administrative nursing staff B stated the DON reported he/she was aware staff were unable to start the resident's IV on 7/14/17, but the resident was stable. Administrative nursing staff B stated he/she immediately reported the incident to the state agency on 7/15/17 and started the facility investigation. He/she stated he/she was told by the nursing staff that consultant staff did start the IV, but he/she could not confirm who administered the IV fluids. Administrative nursing staff B confirmed the clinical record lacked documentation of the order for IV fluids, lacked documentation of the administration of the IV fluid, and confirmed there were no additional blood sugars documented by the staff. Administrative nursing staff B stated the organization had a competency checklist that staff were to complete during orientation, but stated this facility did not utilize the checklist. On 7/20/17 at 2:30 P.M., administrative nursing staff E acknowledged the clinical record was missing documentation of the physician orders, documentation of the actual incident, and documentation of the completion of the scheduled blood sugar at 4:00 P.M. on 7/14/17. Administrative nursing staff E stated staff when staff checked a resident's blood sugar during an unscheduled time, they could manually chart it in the clinical record in the Blood Sugar Summary. On 7/20/17 at 2:40 P.M., licensed nursing staff H stated on at approximately 4:30 P.M., he/she looked for an insulin syringe in all of the medication carts and thought he/she selected the correct syringe. Licensed nursing staff H stated right after he/she administered the insulin, he/she realized that he/she had administered 2 mLs of regular insulin instead of 2 units and he/she immediately reported the incident to the DON. Licensed nursing staff H stated he/she talked to the physician on the phone and informed him/her of the incident, but did not document the physician notification in the clinical record. Licensed nursing staff H further acknowledged he/she did not enter the physician's telephone orders into the clinical record and stated he/she did not receive a lot of training and needed assistance to put the orders in the computer. He/she stated he/she did not complete a skills checklist or competency regarding insulin administration during orientation. Licensed nursing staff H stated he/she documented all of the resident's blood sugars on the risk management form but was not aware that it was not part of the resident's clinical record. Licensed nursing staff H stated after the consultant IV nurse started the IV, he/she called the nurse practitioner to clarify the rate the IV should infuse. Licensed nursing staff H stated he/she was not IV certified, so the consultant IV nurse administered the IV fluid, but licensed nursing staff H could not remember what type of fluid the physician ordered. On 7/20/17 at 3:00 P.M., administrative nursing staff E stated staff administered [MEDICATION NAME] 5% in 0.45% saline (D5 ½ NS, an intravenous solution used for daily maintenance of body fluids and rehydration) to the resident (this contradicts the physician ordered [MEDICATION NAME] of [MEDICATION NAME] 50%). He/she stated staff did not document which medications they had removed from the emergency kit on 7/15/17, but that it was the only fluid missing. Administrative nursing staff E stated the facility did not have D50 in the emergency kit and would have had to obtain it from the pharmacy. On 7/20/17 at 7:13 P.M., consultant physician KK stated on 7/14/17 around dinnertime, he/she was notified by the nurse that there had been a medication error. The nurse informed him/her that 200 units of [MEDICATION NAME]-R had been administered instead of the ordered 2 units. Consultant physician KK stated he/she gave the nurse an order to start an IV, to administer 50% [MEDICATION NAME] injection 25 grams (0.5 g/mL), which was known as D50, to check the resident's glucose hourly, and to report each blood sugar to him/her until further notice. Consultant physician KK stated staff failed to notify him/her that staff were unable to start the IV. Consultant physician KK stated the nurse practitioner reported to him/her that staff told the nurse practitioner they had administered D50 as an intramuscular injection (IM), which confused him/her because D50 was always given IV and would not be given IM. Consultant physician KK stated the lowest blood sugar he/she was aware of was 57 mg/dL and that [MEDICATION NAME] had been administered twice. He/she was not aware the nurse had not written down any of the orders given by him/her or the nurse practitioner, and stated he/she did not order D5 ½ NS, because it was not typically ordered for the correction of [DIAGNOSES REDACTED]. Consultant physician KK stated he/she was very concerned about the seriousness of the medication error. On 7/24/17 at 11:27 A.M., consultant staff II stated on 7/15/17, he/she was informed by nursing staff H the resident had two [MEDICAL CONDITION] and his/her blood sugar had dropped below 60 twice during the shift. Consultant staff II stated he/she did not give an order for [REDACTED].½ NS or any IV fluids. Consultant staff II stated the nurse asked what rate the IV fluids that consultant physician KK ordered were to infuse at, and he/she clarified the rate of the IV was 60 mL/hr. Consultant staff II stated he/she felt alarmed that the staff did not obtain IV access and administer [MEDICATION NAME] 50% when ordered by the physician on 7/14/17. On 7/24/17 at 12:16 P.M., consultant pharmacy staff GG stated he/she was not aware that a medication error occurred at the facility. He/she stated the pharmacy was not contacted for the D50 or any other medications for the resident. Consultant pharmacy staff GG stated had staff contacted them, they would have had to send the medication out via courier because they do not keep it in the facility, but stated they would have advised the staff to call 911 and transfer the resident to the hospital since it was across the street from the facility. He/she stated [MEDICATION NAME]-R is an older medication that had not been converted into the [MEDICATION NAME] yet, so the only way to administer [MEDICATION NAME]-R was to draw it up with an insulin syringe. He/she stated the insulin syringes were clearly labeled on the packaging and were obviously much smaller than an intramuscular syringe. Consultant pharmacy staff GG stated the IV emergency kit contained a bag of normal saline and a bag of D5 ½ NS, so if any fluid was hung, that would be the only choice available that has [MEDICATION NAME] in it. He/she stated the emergency kit had glucose tabs and [MEDICATION NAME] in it, but there was not any D50. Consultant pharmacy staff GG stated staff should administer the D50 through the IV, not IM. On 7/20/17 at 3:54 P.M., consultant IV nurse HH stated he/she was notified on 7/15/17 the resident needed a peripheral IV due to low blood sugar and he/she inserted a 22-gauge IV into the resident's left forearm. Consultant IV nurse HH confirmed that he/she administered D5 ½ NS at 50 mL/hr because licensed nursing staff H was not IV certified. He/she stated the consultant IV nurses were expected to visually review the physician's orders [REDACTED]. Consultant IV nurse HH stated he/she heard licensed nursing staff H read back the order for D5 ½ NS at 50 mL/hr (this contradicts the physician ordered [MEDICATION NAME] of [MEDICATION NAME] 50%) via telephone to the nurse practitioner and he/she felt the IV needed to be hung since the resident's blood sugar had been low through the night. He/she stated the consultant IV nurses occasionally hung IV fluids for the facility staff but it was dependent on the circumstances. The facility's Administering Insulin policy dated March 2009 documented the facility would administer all insulin injections in an organized and safe manner. The policy directed staff to check the physician order, determine the correct amount of insulin to be withdrawn, read the MAR and compare with the label on the insulin, prepare the needle and syringe, withdraw the ordered dosage of insulin, to check the medication label with the MAR a third time, and to document the administration on the MAR. The facility's Medication Orders policy dated July 2017 documented that medications were administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. Each medication order was documented in the resident's medical record with the date, time, and signature of the person receiving the order. The order was recorded on the physician order [REDACTED]. The following steps were initiated to complete documentation: clarify the order, enter the orders on the medication order and receipt record, call or fax the medication order to the provider pharmacy, transcribe newly prescribed medications on the MAR, and after completion, document each medication order noted on the physician's orders [REDACTED]. The facility's Transcribing Physician order [REDACTED]. All orders for medications must include a diagnosis. An order should be considered to be in writing if dictated to a Licensed Practical Nurse (LPN) and/or Registered Nurse (RN) and signed by the attending physician. All medication orders were to be called or faxed to the pharmacy before the end of every shift. The date, time noted, and legal signature would be signed at the end of all orders. All medication orders were to be transcribed to the MAR. All orders for new medications were to be added to the 24-hour report for 24 hours. Each shift must acknowledge the receipt and effect of this medicine in nursing notes and on the 24-hour sheet. All new orders were to be documented in nursing notes. Families were to be notified of all new orders and documented. The facility failed to ensure this resident was free of a significant medication error. Licensed nursing staff H administered 2 mL (200 units) of [MEDICATION NAME]-R insulin instead of the physician ordered 2 units, which placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on 7/23/17 at 5:55 P.M. by implementing the following: resident #1 no longer resided in the facility, all licensed staff were educated on the revised insulin administration policy and on the two-nurse verification procedure prior to insulin administration, and all licensed nursing staff completed a skills checkoff. Any licensed staff not in-serviced were removed from the schedule until education was provided. Additional in-service education and competency/skills checks would be performed by the Director of Nursing and/or designee on all new licensed nursing staff in orientation and all licensed staff quarterly, annually, and as needed. As part of the facility's Quality Assurance and Performance Improvement (QAPI) program, there would be ongoing, random weekly verification that licensed nursing staff had reviewed the revised insulin administration policy related to the two-nurse verification process and the proper administration of insulin until substantial compliance was achieved and maintained. Issues identified would be addressed with staff involved and findings would be forwarded to the monthly QAPI Committee for further review and recommendations. The deficient practice remained at a scope and severity of G.

The facility identified a census of 43 residents and the sample included 3 residents. Based on observation, record review and interview the facility failed to provide interventions for the prevention of avoidable pressure ulcers for one (#1) sampled resident. Findings included: - The physician's orders [REDACTED].#1 revealed [DIAGNOSES REDACTED]. The Admission MDS (Minimum Data Set) dated 02/09/2016 documented a BIMS (Brief Interview for Mental Status) score of 15, which indicated intact cognition and the resident was able to make daily decisions. The resident required limited assist of 1 staff for activities of daily living. Review of the CAA (Care Area Assessment) dated 02/16/2016 for pressure ulcers identified the facility admitted the resident after a hospitalization due to a fall at home that resulted in a fracture (broken bone) of the right hip and placed the resident in comprehensive rehabilitation services. The resident was alert and oriented, required assistance with bed mobility, transfers, dressing, bathing, and toilet use. The resident was ambulatory with the use of a wheel chair for mobility, which he/she was able to self-propel. The resident did not currently have any pressure wounds on admission, but had a blanchable (red area which resolved with pressure relief) red area on the coccyx (tailbone). He/she was considered a low risk of pressure ulcer development based on a Braden score of 17 (system to evaluate a patient's risk of developing a pressure ulcer). The care plan dated 02/2016 identified the resident had potential for pressure ulcer development related to immobility and implemented the following interventions: call light within reach, encourage fluid intake and assist to keep the skin hydrated, follow facility policies/protocols for the prevention/treatment of [REDACTED]. Serve diet as ordered, monitor intake and record, obtain and monitor laboratory/diagnostic work as ordered and report the results to the physician and follow up as indicated. Staff were directed to complete a weekly head to toe skin at risk assessment. Review of the clinical record daily skilled note dated 02/04/2016 at 9:46 A.M. recorded the resident's skin color was normal and he/she had a surgical incision to the right hip. Daily skilled note dated 02/10/2016 at 7:08 P.M. documented the resident had blisters on the bilateral soles of his/her feet and staff notified the nurse practitioner. The physician order [REDACTED]. The physician order [REDACTED]. cover with Opti-foam. Daily skilled note dated 02/13/2016 at 10:07 A.M. documented staff applied skin prep to bilateral feet and rewrapped with Kerlix (Sterile Soft Pouch Gauze Dressing). Daily skilled note dated 02/17/2016 at 7:41 P.M. documented the resident had pressure ulcers to bilateral heels and received daily pressure ulcer care. Skin assessment note dated 02/23/2016 at 7:48 P.M. recorded the right heel blister measured 4 cm. (centimeters) long and 4.5 cm wide, positioned at the 3 and 4 o'clock area, open, oozing serosanguinous drainage (yellowish/reddish color). The left heel blister measured 6 cm. long and 5 cm. wide, located at 5 o'clock position, beefy red in color. Skin assessment note dated 03/01/2016 at 11:33 A.M. identified the right heel pressure ulcer, dry without drainage, and measured 4 cm. long and 5.5 cm. wide. The left heel pressure ulcer was open with serosanguinous drainage and measured 8 cm. long and 5 cm. wide. The daily skilled note dated 03/01/2016 at 2:21 P.M. documented that the resident had pressure ulcers to bilateral heels and staff provided daily pressure ulcer care. Pressure ulcer weekly note dated 03/08/2016 at 1:13 A.M. documented the left heel wound measured 4 cm. long by 3.5 cm. wide with a small amount of serosanguinous drainage, and granulation tissue and wound edges were attached. The right heel measured a pink wound bed 3.4 cm. long and 4 cm. wide. Review of a discharge summary nursing note dated 3/8/16 at 5:17 P.M. documented the resident discharged to home with in home care services. During an observation of wound care on 06/10/2016 at 11:19 A.M. licensed nursing staff H removed the wound vac (device applied to a wound to promote healing) and dressing, and then cleansed the wound with wound cleanser and applied skin prep around the wound. A dark area was observed beside the open wound. Licensed Staff H stated that it was a blister that broke and now had a scab. Staff H performed the treatment as physician ordered and secured the wound vac. An interview on 06/10/2016 at 9:17 A.M. the resident revealed he/she had been in and out of the facility several times for treatment. The resident reported he/she fell at home and broke his/her hip and came to the facility in February when he/she left the hospital. The resident reported while in the facility, he/she developed the pressure ulcer on his/her heel. The resident went home for a while and continued to have problems with the sore on his/her foot. In April the physician debrided (removed dead tissue) the wound on the left heel, ordered IV (intravenous) antibiotics and placed a wound vac. The resident reported he/she was going home today with the wound vac and home health services. During an interview on 06/10/2016 at 3:40 P.M. administrative nursing staff D stated that the first time the resident was here (in February) he/she developed the pressure ulcer on his/her heel, the same heel that had the wound vac. The resident was readmitted on [DATE] for continued treatment of [REDACTED]. Review of the facility provided policy dated 01/2016 documented a resident who entered the facility without pressure ulcers does not develop pressure ulcers unless the individuals clinical condition or other factors demonstrate that a developed pressure ulcer was unavoidable; and a resident having pressure ulcers receives necessary treatment and service to promote healing, prevent infection, and prevent new, unavoidable sores from developing. The facility failed to implement interventions to prevent the development of two avoidable stage 4 pressure ulcers for this resident assessed at low risk for pressure ulcer development.