Every finding on record at The Springs at St. Andrews Village

Based on observations, record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans, and resident preferences for two (#74 and #71) of five residents reviewed for pain management out of 32 sample residents. Resident #74 was admitted to the facility from the hospital on 3/22/26, after treatment for sepsis (life threatening condition) from a vertebral (spinal) infection resulting in severe pain in her spine. After the resident's admission to the facility, the facility failed to ensure the resident's prescription for oxycodone was sent to the pharmacy timely so the pain medication could be received and administered. The facility's failure to send the resident's prescription to the pharmacy in a timely manner, resulted in the resident not receiving the narcotic pain medication for 21 hours after leaving the hospital, resulting in severe back pain for Resident #74.Additionally, Resident #71 did not receive pain medication in a timely manner and per physician's orders. Specifically, the facility failed to: -Ensure Resident #74's pain medication was received and administered as ordered in a timely manner, which resulted in severe back pain for the resident; and,-Ensure Resident #71's pain was addressed timely and pain medication was administered per physician ordered parameters.Findings include: I. Facility policy and procedure The Pain Management policy and procedure, revised November 2025, was provided by the director of nursing (DON) on 3/26/26 at 2:08 p.m. It read in pertinent part, It is the policy of this facility to provide an environment and programs that assist each resident to attain or maintain the resident's highest practicable physical, mental , and psychosocial well being. Residents are provided and receive the care and services needed according to established practice guidelines. Resident pain is assessed and managed by an interdisciplinary team who work together to achieve the highest practicable outcome. The facility assists each resident with pain to maintain or achieve the highest practicable level of well-being and functioning by: -Screening to determine if the resident has been or is experiencing pain; -Comprehensive evaluation of the pain. Licensed nurses will complete the Pain Management Review and utilize non-pharmacologic interventions in conjunction with prescribed medications to manage the pain and/or try to prevent the pain consistent with the resident's goals; -Monitor pain status and treatment effects on a regular basis; and, -Consult physician for additional interventions if indicated. The resident will be assessed for pain: -On admission with a pain-related diagnosis, or if pain is indicated through the nursing admission assessment; -Upon significant change in condition; -Quarterly if there is a current care plan for pain management; and, -Annually. II. Resident #74 A. Resident status Resident #74, age [AGE], was admitted to the facility on [DATE] and discharged to another facility on 3/24/26. According to the March 2026 computerized physician orders (CPO), diagnoses included sepsis, infection of intervertebral disc, cervical (neck) region, cervicalgia (neck pain), pain in unspecified joint, secondary scoliosis, thoracic region (upper back) and low back pain. A minimum data set (MDS) assessment had not been completed at the time of the survey. According to the 3/24/26 brief interview for mental status (BIMS) assessment, Resident #74 was cognitively intact with a BIMS score of 15 out of 15. According to the 3/23/26 Functional Performance Observation assessment, Resident #74 required substantial/maximal assistance with toileting, personal hygiene, sitting to lying, and was dependent on staff for bathing, dressing, rolling side to side, lying to sitting, sitting to standing, and transfers from bed to chair and to toilet. B. Resident observation and resident/resident's representative interview On 3/23/26 at 10:30 a.m. Resident #74 was lying flat in bed with a furrowed brow and a frown with her resident representative at the bedside. The representative said Resident #74 admitted to the facility at approximately 2:00 p.m. on 3/22/26. The representative said the hospital gave Resident #74 pain medications before they were transported to the facility and were told that by the time they arrived at the facility, it would be time for the resident to receive more pain medication. Resident #74 said she was having pain at the time of her admission to the facility, but no pain medication had been received after leaving the hospital. She said she had not received any pain medication since she was admitted to the facility the day prior (3/22/26). Resident #74's representative said they were told they had to wait on the pharmacy to deliver the pain medication. C. Record review According to the hospital Discharge summary, dated [DATE] at 9:06 a.m., Resident #74 had a chronic pain syndrome diagnosis with intractable (difficult to manage) back pain and had been on routine narcotic pain medication for quite some time and scheduled Tylenol was recently added. Resident #74 had a physician's order for oxycodone IR (immediate release) 5 milligrams (mg) every eight hours PRN (as needed) for severe pain. According to the comprehensive care plan, initiated 3/22/26 at 7:11 a.m. (prior to Resident #74's admission to the facility), the care plan focus for pain indicated Resident #74 had chronic neck and back pain. Interventions included anticipating the resident's need for pain relief and responding immediately to any complaint of pain, following pain scale to medicate as ordered, monitoring/documenting for probable cause of each pain episode, removing/limiting pain causes when possible and completing a pain assessment every shift. According to the admission pain management review assessment, dated 3/22/26 at 9:51 p.m., Resident #74 indicated she had had frequent back pain over the last five days, rated at 8 out of 10 on the 1 to 10 pain scale. The pain affected her sleep, participation in therapy, and limited her day-to-day activities. Resident #74 indicated an acceptable pain level of 2 out of 10. According to the discharge pain interview, dated 3/24/26 at 11:00 a.m., Resident #74 experienced frequent pain that interfered with her sleep and day-to-day activities. Resident #74 indicated the worst pain over the previous five days was 8 out of 10. Review of Resident #74's March 2026 CPO revealed the following physician's order: Oxycodone 5 mg every six hours, ordered 3/23/26 at 6:00 p.m. (the day after the resident was discharged to the facility with a physician's order for the medication). -Review of Resident #74's pain levels documented during the resident's stay at the facility (from 3/22/26 to 3/24/26) revealed the resident's pain acceptable pain level of 2 out of 10 was reached one time. The resident's pain levels were as follows: On 3/22/26 at 8:54 p.m. the resident's pain level was 4 out of 10. -However, because the facility failed to add the oxycodone order to the March 2026 CPO until 3/23/26, there was no documentation to indicate any pain medication was administered to the resident. On 3/23/26 at 11:10 a.m. the resident received a dose of oxycodone however, a pain level was not documented. On 3/23/26 at 5:22 p.m. the resident's pain level was 7 out of 10. Oxycodone was administered at 6:00 p.m. On 3/23/26 at 6:56 p.m. the resident's pain level was still a 7 out of 10, despite the pain medication that was administered at 6:00 p.m. (see above). -However, there was no documentation to indicate additional pain medication was administered or that the physician was notified about the ineffectiveness of the resident's pain medication. On 3/23/26 at 10:04 p.m. the resident's pain level was 2 out of 10. On 3/23/26 at 11:48 p.m. the resident's pain level was 7 out of 10. Oxycodone was administered at 12:15 a.m. (on 3/24/26). -However, there was no follow-up pain level assessment completed until 5:13 a.m. on 3/24/26, five hours after the pain medication was administered (see follow-up pain level below). On 3/24/26 at 5:13 a.m. the resident's pain level was 5 out of 10. Oxycodone was administered at 6:00 a.m. (45 minutes after the pain level was documented). -However, there was no follow-up pain assessment completed until 9:52 a.m. on 3/24/26, almost four hours after the pain medication was administered (see follow-up pain level below). On 3/24/26 at 9:52 a.m. the resident's pain level was 5 out of 10. -However, there was no documentation to indicate additional pain medication was administered or that the physician was notified about the ineffectiveness of the resident's pain medication. According to the pharmacy controlled drug disposition form, the prescription for the resident's oxycodone 5 mg was filled by the pharmacy on 3/23/26, the day after Resident #74 was admitted to the facility. -The first dose of the medication was administered and signed off by licensed practical nurse (LPN) #1 at 11:05 a.m. on 3/23/26, 21 hours after the resident was admitted to the facility (see facility follow-up below). Review of Resident #74's electronic medical record (EMR) revealed the following progress notes: The admission progress note, dated 3/22/26 at 2:20 p.m., revealed Resident #74 denied pain upon assessment. The resident's vital signs were within normal range and the resident's medications were verified by the on-call physician and faxed to the pharmacy. However, the pain assessment completed on admission indicated the resident had a pain level of 4 out of 10 at the time of the assessment (see above). The nurse progress note, dated 3/22/26 at 9:02 p.m., documented Resident #74's medications were verified with the on-call physician. The physician would send a prescription for oxycodone and diazepam (medication used to treat anxiety and muscle spasms) to the pharmacy. -The progress note, documented almost seven hours after the resident admitted to the facility indicated there had been no prescription sent to the pharmacy when the nurse documented that the medications had been verified by the physician at 2:20 p.m. (see admission note above). There was no documentation to indicate the nursing staff had attempted to reach out to the physician or the pharmacy prior to the nurse progress note documented at 9:22 p.m. The nurse progress note, dated 3/23/26 at 11:10 a.m., documented that at approximately 11:10 a.m. the nurse administered oxycodone 5 mg to Resident #74 as ordered. The nurse was unable to chart the administration in the resident's medication administration record (MAR). -The administration of oxycodone was the first pain medication Resident #74 received since her admission to the facility on the previous day (3/22/26). The physician noted, dated 3/23/26 at 4:15 p.m., documented Resident #74 had chronic pain. The resident was currently on oxycodone 5 mg every 8 hours as needed, and reported that her pain was not managed. The physician discussed ordering oxycodone 5 mg every six hours with the resident. The resident complained of bilateral neck pain. The note indicated the resident's pain management would be adjusted with oxycodone 5 mg every six hours for better pain control. -However, the adjustment to the resident's pain medication frequency did not occur for over 24 hours after Resident #74 was admitted to the facility. The nurse progress note, dated 3/23/26 at 5:23 p.m. documented Resident #74 had pain that was a pain level of 7 out of 10 on the numerical pain scale. The resident's pain originated from an infection located at her neck/spine and was described as throbbing and at times sharp. The nursing discharge summary note, dated 3/23/26 at 5:35 p.m. (documented prior to the resident's discharge), documented Resident #74's pain was currently 7 out of 10. The pain was in her neck. The DON progress note, dated 3/24/26 at 11:24 a.m., documented the purpose of the medication verification was because the DON received communication that not all of Resident #74's medications were verified and entered into the facility's electronic medical system. The DON was also informed there was a delay in receiving the hard copy of the prescription from the physician to the pharmacy. The note documented the facility confirmed the physician sent the prescription to the pharmacy on 3/23/26 around 12:00 a.m. D. Staff interviews The DON, clinical resource nurse #1 and clinical resource nurse #2 were interviewed together on 3/25/26 at 9:35 a.m. Clinical resource nurse #1 said when Resident #74 was admitted to the facility (on 3/22/26), the admitting nurse failed to enter all of the physician's orders from the hospital discharge documentation and to verify physician's orders with a physician timely. The DON said the physician failed to send a prescription for Resident #74's narcotic pain medication to the pharmacy. The narcotic prescription for oxycodone was not sent to the pharmacy until 12:00 a.m. on 3/23/26. The DON, clinical resource nurse #1 and clinical resource nurse #2 said Resident #74's pain medication did not arrive in a timely manner to be administered to the resident as ordered. The DON, clinical resource nurse #1 and clinical resource nurse #2 said two nurses were to verify the physician's admission orders for accuracy and new admission residents' charts were reviewed in the morning meeting for accuracy as well. Clinical resource nurse #1 said if medications did not arrive at the facility in a timely manner, nursing staff was to reach out to the pharmacy and the physician if a prescription was needed for any controlled substance. Clinical resource nurse #1 said the ball was dropped with Resident #74 and the resident did not receive pain medication timely or per physician's orders. The DON, clinical resource nurse #1 and clinical resource nurse #2 said the admitting nurse when Resident #74 was admitted to the facility was an agency nurse that they had now banned from the facility. The DON, clinical resource nurse #1 and clinical resource nurse #2 said they would provide education to the nurse that verified the physician's orders with the agency nurse. Clinical resource nurse #1 and clinical resource nurse #2 said a review of all new admissions over the last 30 days would be completed to identify any issues with residents' admission orders. The pharmacist was interviewed on 3/26/26 at 9:40 a.m. The pharmacist said when a resident was on prescribed narcotic pain medications, it was important to ensure the medication was available to administer in a timely manner. The pharmacist said Resident #74's medication orders were faxed to the pharmacy after the resident's admission and the pharmacy would look for important medications and make sure they were sent to the facility timely. The pharmacist said the pharmacy did not receive a prescription for Resident #74's oxycodone until approximately 12:00 a.m. on 3/23/26. The pharmacist said the normal pharmacy delivery times were 1:00 p.m. and 8:00 p.m. daily, but was unsure what time medications got delivered to the facility related to where the facility fell on the delivery route. The pharmacist said STAT (immediate) deliveries were available as well if a medication was needed ahead of a normal delivery time. The pharmacist was unaware of any calls from the facility requesting the need for a prescription from the physician for Resident #74's oxycodone, access to the facility's emergency medication machine to remove the pain medication, or needing an expedited delivery of the oxycodone. The medical director (MD) was interviewed on 3/26/26 at 9:50 a.m. The MD said it was not okay for a resident to not have needed pain medication available for administration. He said any delay would set the facility up for failure. He said if nursing staff were having trouble obtaining a narcotic prescription from a physician, they were able to notify the MD to send a prescription to the pharmacy so the medication could be pulled from the facility's emergency medication machine until the medication was delivered from the pharmacy to eliminate any delays in treating a resident's pain. The MD said he received no calls from the facility regarding the need for a narcotic prescription for Resident #74. The physician's assistant (PA) was interviewed on 3/26/26 at 10:00 a.m. The PA said when Resident #74 was admitted on [DATE], she (the PA) was not notified until 8:55 p.m. to verify the resident's admission medication orders and a prescription was sent to the pharmacy for Resident #74's oxycodone at approximately 9:15 p.m. on 3/22/26. The physician was interviewed on 3/26/26 at 1:50 p.m. The physician said it was very important that narcotic prescriptions get sent to the pharmacy immediately upon a resident's admission so the medication could be sent to the facility in a timely manner in order to avoid any increase in a resident's pain. She said it was important to have pain medications available to manage a resident's pain without delays. E. Facility follow up On 3/24/26 at 11:04 a.m. a copy of the pharmacy delivery packing slip, dated 3/22/26, was provided by clinical resource nurse #1. The delivery slip revealed medications on the list arrived after 9:00 p.m. but there were no narcotic medications for Resident #74 in the delivery. Clinical resource nurse #1 additionally provided a copy of the narcotic count sheet for Resident #74's oxycodone 5 mg. The narcotic count sheet indicated the resident's narcotic medication was filled on 3/23/26 and the first dose was given at 11:05 a.m. on 3/23/26, 21 hours after admission. On 3/26/26 at 2:35 p.m. clinical resource nurse #2 provided documentation of pain management nursing in-service training conducted with eight nurses. The in-service training read in pertinent part, Ensure residents receive timely, effective pain management through rapid medication verification, prompt physician notification, and appropriate use of the emergency medication supply when waiting for medication arrival. Notify the physician if pain is not controlled. On 3/26/26 at 2:35 p.m. clinical resource nurse #2 provided a copy of an action plan started 3/25/26 titled New Admit Pain and Antibiotics and related to a new admission not receiving scheduled pain medications in a timely manner. Nursing education was to be completed on 3/27/26, an audit of the previous 30 days of admissions was completed on 3/26/26, new admission reviews were to be on-going, a discussion with pharmacy was to be completed 3/27/26, and results of audits were to be on-going. -However, the action plan was not started until the concern was brought to the facility's attention during the survey. III. Resident #71 A. Resident status Resident #71, age [AGE], was admitted on [DATE] and discharged to the hospital on 1/14/26. According to the January 2026 CPO, diagnoses included a displaced fracture of the left femur, need for assistance with personal care and cognitive communication deficits. The 3/15/25 MDS assessment revealed the resident had mild cognitive impairments, per the staff assessment for mental status. The resident required moderate to substantial assistance from staff for all activities of daily living (ADL). The MDS assessment documented the resident received scheduled pain medications, as needed (PRN) pain medications and non-medication interventions for pain. B. Resident #71's representative interview Resident #71's representative was interviewed on 3/26/26 at 1:25 p.m. The resident's representative said Resident #71 was in pain when he was first admitted to the facility on [DATE]. The resident's representative said Resident #71 requested pain medications from the nurse right when he was admitted , and the nurse told him she would get his pain medications right away. The resident's representative said Resident #71 was not administered any pain medications until later that night (1/1/26) because the nurse could not get the code she needed from the pharmacy in order to dispense the pain medication dose. C. Record review Review of Resident #71's January 2026 CPO revealed the following physician's orders: Tylenol 325 mg oral tablets, give two tablets by mouth every six hours as needed for pain, ordered 1/1/26 at 7:02 p.m. Oxycodone 5 mg oral tablets, give one tablet by mouth every four hours as needed for pain ranging from 6 to 10 on a scale of 1 to 10 and give 0.5 tablets by mouth every four hours as needed for pain ranging from 3 to 5 on a scale of 1 to 10, ordered 1/1/26 at 7:15 p.m. Non-pharmacological interventions for pain: repositioning, rest, massage, distraction, or other, ordered 1/1/26 at 2:05 p.m. A progress note, dated 1/1/26 at 5:50 p.m., revealed Resident #71 arrived at the facility from the hospital. Resident #71 had received surgery for a left femur fracture, and said his pain was a 6 out of 10. The progress note documented the nurse was notified about Resident #71's pain. An admission pain management review assessment was completed by a member of the nursing staff on 1/1/26 at 8:05 p.m. The assessment documented Resident #71 had pain frequently over the last five days. The assessment documented Resident #71's pain was at his incision site. The assessment documented Tylenol and oxycodone relieved Resident #71's pain, along with rest and repositioning. The assessment documented Resident #71 would be satisfied with a pain level of 2 out of 10. The pain management review assessment documented Resident #71 had a pain of 7 out of 10 at the time of the assessment. A progress note, dated 1/1/26 at 8:17 p.m., revealed Resident #71 was administered a dose of PRN 5 mg oxycodone. Resident #71 had requested the medication for generalized pain. -However, the oxycodone was administered nearly two and a half hours after the resident admitted to the facility and had described his pain as 6 out of 10, and over one hour after the physician ordered the resident's PRN pain medications (see admission progress note and physician's orders above). Review of Resident #71's January 2026 MAR did not reveal any administered doses of the resident's PRN Tylenol medication. Review of Resident #71's January 2026 treatment administration record (TAR) revealed the physician's order for non-pharmacological pain interventions was documented as completed during the evening shift on 1/1/26. -However, the specific non-pharmacological pain interventions used were not documented or assessed for effectiveness. D. Staff interviews Regional nurse consultant #1 was interviewed on 3/25/26 at 9:41 a.m. Regional nurse consultant #1 said the facility's expectation for the nursing staff, in the event of a pain medication order not being available for a newly admitted resident, was for the nurses to contact the pharmacy and the resident's physician to see if there were any other pain medication options which could be administered. LPN #3 was interviewed on 3/25/26 at 1:59 p.m. LPN #3 said if a resident expressed they were in pain, the nursing staff attempted non-pharmacological interventions before moving to administering any PRN pain medications. LPN #3 said if a resident was in pain and did not have any pain medication options available for her to give, she would contact the resident's physician right away. LPN #3 said she would assess the resident's pain and try to find a way to relieve their pain so it did not get any worse, and document her steps in the resident's EMR. LPN #3 said she would carry out the same process if a resident was just admitted to the facility. LPN #3 said the facility had an emergency medications machine where she could get an emergency dose of a PRN medication after receiving orders from the physician. The nursing home administrator (NHA), the infection preventionist (IP) and the DON were interviewed together on 3/25/26 at 4:14 p.m. The NHA said if any of the residents' medications ran out, the nursing staff had been trained regarding who to contact. The NHA said agency staff members had access to a binder and a list of pharmacist contact information just for that event. The DON and the IP said some of the agency nurses had access to the emergency medications machine, and if the agency nurses working in the facility did not have access to the machine, someone else scheduled to be working during that time would have access. LPN #4 was interviewed on 3/26/26 at 9:42 a.m. LPN #4 said she tried to give residents their PRN pain medications as requested or their scheduled pain medications right on time before their pain got any worse. LPN #4 said if a medication ran out or was unavailable, she would call the pharmacy and the resident's physician, and use the emergency medication machine to dispense a dose for the resident if needed. The DON and the assistant director of nursing (ADON) were interviewed together on 3/26/26 at 10:30 a.m. The ADON said Resident #71 was admitted to the facility on [DATE], and his admission pain assessment documented the resident had a pain level of 7 out of 10. She said the assessment indicated that the pain medications that had worked to relieve his pain in the past were Tylenol and oxycodone. The DON said Resident #71's first dose of oxycodone was administered on 1/1/26 at 8:17 p.m. The DON said Resident #71's PRN pain medications were reviewed with the resident on 1/2/26. -However, the oxycodone was administered nearly two and a half hours after the resident was admitted to the facility on [DATE] and had described his pain as 6 out of 10, and over one hour after the physician ordered the resident's PRN pain medications. -The pain assessment conducted on 1/1/26 documented Tylenol had been previously effective in alleviating pain for Resident #71, however no doses of Tylenol were documented as being administered during the resident's stay in the facility.

Based on observations, record review and interviews, the facility failed to ensure proper storage of medications for one of four medication storage rooms and two of four medication storage carts.Specifically, the facility failed to:-Ensure eye drops were dated with the date they were opened;-Ensure medications were contained in the original packaging; and,-Ensure expired medical supplies were discarded.Findings include:I. Professional referenceAccording to manufacturer Allergan's Ophthalmic Medication Beyond-Use Date Guide, April 2024, retrieved on 3/30/26 from https://www.hdrxservices.com/Ophthalmic-Medication-Beyond-Use-Date-Guide-Apr-2024, Thera Tears eye drops should be discarded 90 days from opening.According to manufacturer Nephron Pharmaceutical's, Beyond-Use Date, 2026, retrieved on 3/30/26 from https://nephronpharm.com/products/ipratropium-bromide-05-mg-and-albuterol-sulfate-3-mg, Vials should be protected from light before use, therefore, keep unused vials in the foil pouch or carton. Vials should be used within two weeks once removed from the foil package. According to manufacturer Hydrofera Blue's user guide, retrieved on 3/30/26 from https://hydrofera.com/app/uploads/2022/03.pdf, Hydrofera Blue dressings are sterile in their original, unopened packaging. However, they are not guaranteed to remain sterile after opening. Single-Use Only: The dressings are designed for single-use and should not be reused. Handling: Once the package is opened, the dressing is exposed to the environment, compromising its sterility. Do not use a Hydrofera Blue dressing if the individual package has been opened or damaged prior to use.II. Facility policy and procedureThe Medication Access and Storage policy and procedure, revised October 2025, was provided by the director of nursing (DON) on 3/26/26 at 1:00 p.m. It read in pertinent part, The provider pharmacy dispenses medications in containers that meet legal requirements. Medications are kept and stored in these containers. Transfer of medications from one container to another is done only by a pharmacist. Outdated, contaminated, or deteriorated medication and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from pharmacy. Any opened vial without an open date will be discarded immediately, and replaced with a new vial. Any medication that cannot be verified as to the expiration date, either due to not being dated when opened, or unclear shelf life, shall be discarded immediately and replaced.III. Observations and interviewsOn 3/24/26 at 10:43 a.m. the 2 East medication storage cart was reviewed with licensed practical nurse (LPN) #1. The following items were found:-One small unknown yellow tablet in a medication cup in the top drawer that was not labeled with a resident's name. LPN #1 was unaware what the tablet was or why it was in a medication cart in the drawer.-An eight ounce (oz) bottle of hand sanitizer on top of the medication cart that expired September 2022.-One bottle of Thera tears that was opened and was not dated.-One vial of thiamine (vitamin B1) injectable 200 milligram (mg)/2 milliliter (ml) lying loose in the top drawer.-One single dose tablet of potassium chloride 20 milliequivalent (meq) lying loose in the top drawer.-One single use dose of cyclosporine ophthalmic emulsion 0.05 % (antibiotic eye drop) lying loose in the top drawer.-One single use dose of Ipratropium Bromide/Albuterol Sulfate 0.5 mg/3 mg/3 ml (nebulizer inhalation solution) lying loose in the top drawer.-One package of Hydrofera Blue wound dressing that had been opened, cut in half, and was lying in the bottom drawer.On 3/25/26 at 8:05 a.m. the 1 [NAME] medication storage cart was reviewed with LPN #4. The following items were found:-Two medication cups were in the top drawer, one stacked on top of the other, with one unknown tablet in the bottom cup and four unknown tablets in the top cup. The cups were not labeled with resident identifying information. LPN #4 said the resident who the medication was for was eating and she would go give the medications to the resident.On 3/25/26 at 8:20 a.m. the medication storage room on 1 [NAME] was reviewed with LPN #4. The following items were found:-15 blue top blood collection tubes that expired 9/30/25.-15 red top blood collection tubes that expired 2/28/26.-25 yellow top blood collection tubes that expired 2/28/26.-One [NAME] point 3 ml syringe with a needle attached that expired 5/28/22.-Three safety glide needles that expired March 2021.IV. Additional staff interviewsLPN #4 was interviewed on 3/25/26 at 8:30 a.m. LPN #4 said the pharmacist came to the facility monthly and reviewed the medication storage carts and any medications in the medication storage room but she was unaware if the pharmacist checked for expired medical supplies. LPN #4 said the facility would only draw blood if the lab was unable to do it. The DON, the infection preventionist (IP), clinical resource nurse #2 and the nursing home administrator (NHA) were interviewed on 3/25/26 at 3:30 p.m. The DON, the IP, the clinical resource nurse and the NHA said the management staff had recently reviewed the medication storage rooms and medication storage carts for expired medications and medical supplies and missed the items identified on 3/24/26 and 3/25/26 (see observations above). The NHA said the pharmacist was in the facility the week prior (week of 3/15/26) and had reviewed the medication storage carts. The NHA said nurses did not draw blood at the facility and was unaware of the expired blood collection tubes in the 1 [NAME] medication storage room. Clinical resource nurse #2 said night shift nurses were responsible for removing expired medications and medical supplies from the medication storage rooms and medication carts. Clinical resource nurse #2 said the facility's process for ensuring expired medications were removed from the medication carts and medication storage rooms would be addressed.

Based on observations, record review and interviews, the facility failed to ensure the medication error rate was less than five percent (%).Specifically, the facility had a medication error rate of 13.33%, or four errors out of 30 opportunities for error.Findings include:I. Professional referenceAccording to Stat Pearls Nursing Rights of Medication Administration, 9/4/23, retrieved on 3/30/26 from https://www.ncbi.nlm.nih.gov/books/NBK560654, Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration. It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration.-Right patient;-Right drug;-Right route;-Right time; and,-Right dose.II. Facility policy and procedureThe Medication Administration policy and procedure, reviewed January 2022, was provided by the director of nursing (DON) on 3/26/26 at 1:00 p.m. It read in pertinent part, It is the policy of this facility to ensure that the six rights of medication administration are followed in order to ensure safety and accuracy of administration. -Right resident-identified prior to medication administration;-Right time-medications are administered within prescribed time frames;-Right medication-medications are checked against the order before they are given;-Right dose-medications are administered according to the dose prescribed;-Right route-medications are administered according to the route prescribed; and,-Right documentation-document administration or refusal of the medication after the administration or attempt and note any concerns.III. Observations and InterviewsOn 3/24/26 at 11:40 a.m. licensed practical nurse (LPN) #2 was observed administering medications to Resident #64. LPN #2 dispensed one tablet of Guaifenesin (expectorant medication) 600 milligram (mg). -However, Resident #64's March 2026 medication administration record (MAR) indicated the physician's order for the resident's Guaifenesin was 400 mg every morning. Upon prompting, LPN #2 reviewed the physician's order, then discarded the 600 mg tablet of Guaifenesin. LPN #2 was unable to locate a 400 mg tablet of Guaifenesin. LPN #2 requested assistance from nursing management who could not locate the medication in a 400 mg dose. -Resident #64 failed to receive his Guaifenesin medication. LPN #2 said the physician would be contacted for clarification of the physician's order. LPN #2 next gathered Resident #64's Fluticasone (allergy anti-inflammatory medication) 50 microgram (mcg)/actuation nasal spray and Trelegy Ellipta (lung inflammation reducing medication) 100-62.5-25 mcg respiratory inhaler medications and carried them to the resident's bedside. Resident #64 asked for applesauce for the other medications and LPN #2 left the room. While LPN #2 was out of the room, Resident #64 picked up the Trelegy Ellipta inhaler and breathed in once. The resident did not rinse his mouth with water afterward. -However, Resident #64's March 2026 MAR indicated the resident needed to rinse his mouth after using the inhaler. -LPN #2 failed to instruct Resident #64 to rinse his mouth after using the inhaler. When LPN #2 returned to the resident's room, Resident #64 picked up the Fluticasone nasal spray and dispensed two sprays into each nostril. -However, Resident #64's March 2026 MAR indicated the nasal spray was to have one spray to each nostril. -LPN #2 failed to instruct Resident #64 on how many sprays of Fluticasone were ordered and the resident received the wrong dose of nasal spray. LPN #2 prepared Resident #64's psyllium powder (laxative medication for constipation). The resident's March 2026 MAR indicated the resident was to receive two teaspoons of the psyllium powder every morning. -However, LPN #2 did not use a measuring medication cup to administer the correct dose, but used a white plastic spoon to measure the powder instead. LPN #2 acknowledged the need to use an accurate measuring device when administering powder medications.IV. Additional interviewsThe DON and the nursing home administrator (NHA) were interviewed on 3/25/26 at 3:53 p.m. The DON and the NHA said when a nurse identified a medication that was not available to administer, the nurse should check the stat safe (emergency medications machine) to see if the medication was in the machine and if not, the nurse was to reach out to the pharmacy or nursing management staff to help locate a medication. The NHA and the DON said when there was an identified medication issue, the facility would put together a group text so communication would be among several staff members to help resolve the issue. The NHA and the DON said nursing should notify the physician if medications were missed or were unavailable to administer in order to obtain physician's orders for alternate medications if there were options available.

Based on observations and interviews, the facility failed to ensure care for residents was provided in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality for three (#19, #74 and #75) of 10 residents reviewed for dignity out of 32 sample residents. Specifically, the facility failed to ensure Resident #19, Resident #74 and Resident #75 had the right to a dignified existence by being provided privacy in their personal bathrooms.Findings include:I. Resident #19A. Resident statusResident #19, age [AGE], was admitted on [DATE]. According to the March 2026 computerized physician orders (CPO), diagnoses included stroke, unspecified dementia, anemia and hypertension.The 1/26/26 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of eight out of 15. The resident required partial staff assistance for transferring and toileting. She used a wheelchair for mobility and was able to propel herself. B. ObservationResident #19's room was observed on 3/23/26 at 9:13 a.m. The bathroom had a track for a sliding curtain but there was no curtain or bathroom door in the resident's personal bathroom. Resident #19's room was observed on 3/24/26 at 12:00 p.m. Resident #19 was observed propelling herself out of her bathroom. The bathroom had a track for a sliding curtain but there was no curtain or bathroom door in the resident's personal bathroom. Resident #19's room was observed again on 3/24/26 at 1:15 p.m. with the maintenance director (MTD). The bathroom had a track for a sliding curtain but there was no curtain or bathroom door in the resident's personal bathroom. C. Resident interviewResident #19 was interviewed on 3/24/26 at 12:00 p.m. Resident #19 said she took herself to the bathroom and was unable to have privacy in the bathroom because she was supposed to have a curtain to close but she had not had a curtain for at least two days. Resident #19 said she could not get to her room door to close it and then to the bathroom before she had an incontinence episode, so she just had to go straight to the bathroom and hope that no one came into her room. II. Resident #74A. Resident statusResident #74, age [AGE], was admitted on [DATE]. According to the March 2026 CPO, diagnoses included sepsis and infection of the spine. The 3/24/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident required setup from staff for transferring and toileting. She used a wheelchair for mobility and was able to propel herself. B. ObservationResident #74's room was observed on 3/23/26 at 11:45 a.m. The resident's bathroom had a sliding door but the door would not close all the way and closed less than halfway. Resident #74's room was observed on 3/24/26 at 8:15 a.m. The resident's bathroom door was still askew and would not shut all the way.Resident #74's room was observed again on 3/24/26 at 1:05 p.m. with the MTD. The resident's bathroom door was still askew and would not shut all the way. The MTD tried to close the door, but it was not on the track and it took the MTD five minutes to align the door back on the track.C. Resident interview Resident #74 was interviewed on 3/23/26 at 11:45 a.m. Resident #74 said her sliding bathroom door had been broken since she was admitted to the facility on [DATE]. She said the door would not close all the way when she was trying to use the bathroom and it was embarrassing to her when she tried to use the toilet and could not close the door all the way.III. Resident #75A. Resident statusResident #75, age [AGE], was admitted on [DATE]. According to the March 2026 CPO, diagnoses included fracture of the left femur and unspecified fall. The 3/21/26 MDS assessment had not been completed at the time of the survey. According to the 3/21/26 at 1:55 p.m. admission progress note, the resident was alert and oriented times four (person, place, time and reason for care) and required one-person assistance with activities of daily living (ADL) and transfers. B. ObservationResident #75's room was observed on 3/23/26 at 11:45 a.m. The resident shared a room with Resident #74 (see above). The resident's bathroom had a sliding door but the door would not close all the way and closed less than halfway. Resident #75's room was observed on 3/24/26 at 8:15 a.m. The resident's bathroom door was still askew and would not shut all the way. Resident #75 was observed walking to the bathroom. When Resident #75 tried to close the bathroom door, she could not get the door to close beyond halfway and she sat on the toilet, visible to anyone in the room.Resident #75's room was observed again on 3/24/26 at 1:05 p.m. with the MTD. The resident's bathroom door was still askew and would not shut all the way. The MTD tried to close the door, but it was not on the track and it took the MTD five minutes to align the door back on the track.C. Resident interviewResident #75 was interviewed on 3/23/26 at 11:45 a.m. Resident #75 said her sliding bathroom door had been broken since she was admitted to the facility on [DATE]. Resident #75 said the door was always askew and would not close all the way, leaving her using the bathroom exposed. Resident #75 was interviewed again on 3/24/26 at 1:05 p.m. Resident #75 said not being able to close her bathroom door when using the toilet had been horrible. IV. Staff interviewsThe MTD was interviewed on 3/24/26 at 1:20 p.m. The MTD said his housekeepers cleaned the residents' bathrooms daily and no one had reported to him that there was a problem with the door in Resident #74 and Resident #75's shared room. The MTD said that the housekeepers had taken down the privacy curtain in Resident #19's room to clean the curtain and there was a turnaround time from laundry of 24 to 48 hours on returning the curtain. He said in the meantime, the staff encouraged her to close her bedroom door when using the toilet. Certified nurse aide (CNA) #2 was interviewed on 3/24/26 at 4:12 p.m. CNA #2 said she was aware of the bathroom door in Resident #74 and Resident #75's shared room that would not close all the way and said she did not submit a work order to maintenance because she thought someone else had. CNA #2 said the residents' bathroom door had been that way for at least three days. The laundry aide was interviewed on 3/25/26 at 9:00 a.m. The laundry aide said there was not a shortage of bathroom privacy curtains in the laundry room and she showed a stack of clean curtains. The laundry aide said a resident should not have to wait 24 to 48 for a curtain to be replaced. She said when the CNAs sent down a curtain to the laundry, they did not put a room number on it, so if the laundry aide was not made aware of where the curtain needed to be returned to, this delayed getting a curtain put back up. CNA #1 was interviewed on 3/25/26 at 1:00 p.m. CNA #1 said the CNAs put dirty linens down a laundry chute to be collected by the laundry staff and washed. CNA #1 said the CNAs did not touch the bathroom privacy curtains. She said the housekeepers collected the privacy curtains and put them back up after cleaning. Housekeeper (HK) #1 was interviewed on 3/26/26 at 8:39 a.m. HK #1 said the laundry aides took the privacy curtains in the residents' bathrooms down, cleaned the curtains and then returned the curtains. HK #1 said the housekeepers did not do anything with the privacy curtains. The MTD, the nursing home administrator (NHA) and the regional plant resource were interviewed together on 3/26/26 at 9:40 a.m The MTD said the curtain in Resident #19's bathroom had not been replaced yet because there were not any clean curtains that would fit and the only curtains available were too long. He said he had not considered putting a longer curtain up to ensure privacy for the residents, instead he had planned on letting the housekeepers put up the original curtain once it was clean. The MTD was unable to explain the inconsistencies in the process of removing, cleaning, and replacing the privacy curtains reported by the laundry aide, CNA #1 and HK #1 (see interviews above). The NHA said the residents should never be without a curtain for privacy. The regional plant resource said he would order more curtains to ensure a clean curtain could be put up immediately once a dirty curtain was taken down.V. Facility follow upOn 3/26/26 at approximately 11:30 a.m. the MTD provided a training in-service sheet which indicated education had been completed with the housekeepers on 3/26/26 to identify a curtain cleaning schedule that ensured a clean curtain was always available.-However, the curtain cleaning schedule was not created until the concern with residents' privacy in the bathroom was brought to the facility's attention during the survey.

Based on observations, record review and interviews, the facility failed to ensure that the residents had a safe, clean, comfortable, and homelike environment for three out of 12 rooms. Specifically, the facility failed to ensure the facility's process of reporting and responding to repairs in the resident's rooms was being utilized to maintain three damaged closets in Resident #8, Resident #74, and Resident #33's rooms. Findings include:I. Observations and staff interviewResident #8's room was observed on 3/23/26 at 9:13 a.m. The hinge holding the resident's closet door to the frame was loose, coming out of the door and the wood around it was damaged. Resident #33's room was observed on 3/23/26 at 9:20 a.m. The hinge holding the resident's closet door to the frame was detached from the frame.Resident #74's room was observed on 3/23/26 at 11:45 a.m. The hinge holding the resident's closet door to the frame was loose, coming out of the door and the wood around it was damaged. Resident #8's room was observed again on 3/24/26 at 1:10 p.m. with the maintenance director (MTD). The hinge holding the resident's close door to the frame was loose, coming out of the door and the wood around it was damaged. Resident #33's room was observed again on 3/24/26 at 1:15 p.m. with the MTD. The hinge holding the resident's closet door to the frame was detached from the frame.Resident #74's room was observed again on 3/24/26 at 1:25 p.m. with the MTD. The hinge holding the resident's close door to the frame was loose, coming out of the door and the wood around it was damaged.The MTD said he was not aware of the damaged closet doors in Resident #8, Resident #33 and Resident #74's rooms and he had not received a work order to repair them. The MTD said the facility's process when things needed to be fixed was for an electronic work order to be submitted so he could repair items inside of residents' rooms. II. Resident interviewResident #74 was interviewed on 3/23/26 at 11:45 a.m. Resident #74 said the hinge on her closet door had been loose and coming out of the door since she was admitted to the facility on [DATE]. Resident #74 said she had complained to the staff and they told her that maintenance would repair it, but no one from maintenance had come to see her about it.III. Additional staff interviewsCertified nurse aide (CNA) #1 was interviewed on 3/25/26 at 1:00 p.m. CNA #1 said when something in the facility needed repair, the CNAs would submit a work order to maintenance through an electronic reporting system. She said things that should be reported would be anything in the residents' rooms that was broken or needed repair. CNA #1 said work orders were submitted by CNAs and nurses.Licensed practical nurse (LPN) #4 was interviewed on 3/25/26 at 1:12 p.m. LPN #4 said when something in the facility needed repair, the nurses would submit a work order to maintenance through an electronic reporting system. She said things that should be reported would be anything in the residents' rooms that was broken or needed repair, such as a bed not working, bathroom doors and or closet doors. LPN #4 said work orders were submitted by CNAs and nurses.LPN #3 was interviewed on 3/25/26 at 1:34 p.m. LPN #3 said she was an agency nurse but most facilities she had worked in used an electronic reporting system to submit work orders to their maintenance department for repairs. She said she would try to submit it that way or ask the charge nurse. The MTD was interviewed again on 3/26/26 at 11:30 a.m. The MTD said he had submitted a ticket to the electronic work order help desk in order to open up access to submitting work orders for all staff, not just CNAs and nurses. IV. Facility follow upOn 3/26/26 at approximately 11:30 a.m. the MTD provided a training in-service sheet, dated 3/26/26, on the importance of the electronic work order system, which indicated education had been completed with the 13 administrative staff, one activities assistant, two transportation drivers and one regional clinical resource. Of the facility's six housekeeping staff, one was trained; of the facilities 28 CNAs, three were trained; of the facilities nine LPNs, none were trained and of the facility's nine registered nurses, one was trained. -The MTD did not provide documentation of a plan to ensure all staff were trained and understood the electronic work order system.

Based on observations, record review and interviews, the facility failed to ensure three (#30, #55 and #71) of eight residents received treatment and care in accordance with professional standards of practice out of 32 sample residents.Specifically, the facility failed to:-Ensure physician's orders for post-void residual measurements (PVR - measures the amount of urine remaining in the bladder immediately after urination) were followed for Resident #71;-Ensure physician's orders were in place for a wound dressing for Resident #55; and,-Ensure Resident #30 received wound prevention care in accordance with the physician's orders.Findings include: I. Failed to ensure physician's orders for PVRs were followed for Resident #71 A. Resident status Resident #71, age [AGE], was admitted on [DATE] and discharged to the hospital on 1/14/26. According to the January 2026 computerized physician orders (CPO), diagnoses included need for assistance with personal care, cognitive communication deficits, acute kidney failure and benign prostatic hyperplasia (a non-cancerous enlargement of the prostate gland). The 3/15/26 minimum data set (MDS) assessment revealed the resident had mild cognitive impairments, per the staff assessment for mental status. The resident required moderate to substantial assistance from staff for all activities of daily living (ADL). The assessment documented the resident had an indwelling urinary catheter and was frequently incontinent of bowel and bladder. B. Resident #71's representative interview Resident #71's representative was interviewed on 3/26/26 at 1:25 p.m. The resident's representative said the facility removed Resident #71's indwelling Foley catheter and the physician said the nursing staff would need to scan his bladder several times over the coming days. The resident's representative said when the nursing staff attempted to scan Resident #71's bladder, they could not find the bladder scanner. C. Record review Review of Resident #71's January 2026 CPO revealed the following physician's orders: Remove Foley catheter on 1/9/26 for voiding trial. Check PVR for 48 hours and notify the physician if it is greater than 300 milliliters (ml), ordered 1/8/26 and discontinued 1/11/26. Monitor PVR every six hours, try to check after resident voids, though he is incontinent. Insert Foley catheter if PVR is greater than 300 ml. Notify the physician if you have to insert Foley so a referral to urology can be made, ordered 1/12/26 and discontinued 1/13/26. Monitor PVR every six hours, try to check after resident voids, though he is incontinent. Insert Foley catheter if PVR is greater than 300 ml. Notify the physician if you have to insert Foley so a referral to urology can be made, ordered 1/13/26 and discontinued 1/13/26. Measure PVR every six hours for 24 hours for recent urinary retention after Foley catheter removal, ordered 1/14/26 at 12:46 p.m. A progress note, dated 1/9/26 at 5:07 a.m., revealed Resident #71's Foley catheter order was discontinued and removed per physician's order. Physician's orders for PVRs for the next 48 hours were in place, and the physician was to be notified for any PVR greater than 300 ml. A physician's note, dated 1/12/26 at 10:38 a.m., revealed Resident #71 was seen by his physician to examine a new skin concern. The note documented the resident's PVRs had been less than 200 ml each time, according to the nursing staff. Resident #71's representative was concerned his abdomen looked distended, so the physician performed a bladder scan and observed 600 ml of urine in the resident's bladder. Resident #71 had a straight catheter placed and 700 ml of urine was drained from the resident's bladder. The physician documented the resident was scheduled to have PVRs measured every six hours for 48 hours. The physician documented Resident #71 had also reported possible constipation and a suppository was administered. A progress note, dated 1/12/26 at 1:32 p.m., revealed Resident #71 had a PVR of 609 ml and had 700 ml of urine drained from a straight catheter. Resident #71's physician was notified. A physician's note, dated 1/13/26 at 8:30 a.m., revealed Resident #71 was seen by his physician for a follow-up visit. The physician documented the resident was scheduled to have PVRs measured every six hours for 48 hours. A physician's note, dated 1/14/26 at 8:39 a.m., revealed Resident #71 was seen by his physician to follow up on his voiding trial. The note revealed the physician had not seen any documentation of Resident #71's PVR amounts. The physician spoke with the nursing staff and ordered PVRs to be measured every six hours over the next 24 hours to ensure Resident #71 was not having any urinary retention. A progress note, dated 1/14/26 at 1:27 p.m., revealed Resident #71 had been administered an as-needed opioid pain medication. A progress note, dated 1/14/26 at 2:42 p.m., revealed Resident #71's pain level had been reassessed by the nursing staff and was measured to be a 3 out of 10. A progress note, dated 1/14/26 at 7:46 p.m., revealed Resident #71 had been transported to the emergency department while attending an outside appointment. The medical director, the director of nursing (DON) and the nursing home administrator (NHA) were notified. Review of Resident #71's January 2026 medication administration record (MAR), from 1/1/26 through 1/14/26, revealed the following: PVRs were measured and documented twice daily from 1/9/26 through 1/11/26 and were consistently below 300 ml. A PVR was measured on 1/12/26 at 7:07 p.m. -However, the nurse did not document the volume measured on 1/12/26 at 7:07 p.m. -PVRs were measured on 1/13/26 at 6:00 a.m. and 6:00 p.m. The PVRs were documented as 57 ml and 55 ml, respectively. -The January 2026 MAR revealed the facility obtained one PVR measurement on 1/12/26, two PVR measurements on 1/13/26 and no PVR measurements on 1/14/26, despite the physician's orders indicating PVRs were to be obtained every six hours, beginning on 1/12/26 (see physician's orders above). D. Staff interviews Licensed practical nurse (LPN) #4 was interviewed on 3/26/26 at 9:42 a.m. LPN #4 said whenever the physician put in orders to remove a Foley catheter, the facility would typically also put in physician's orders to measure PVRs for the next 72 hours. LPN #4 said the nursing staff recorded the PVR measurements in the MAR. LPN #4 said the frequency of PVR measurements depended on the physician and were typically measured two to three times per shift. The DON, an unidentified member of the regional support team and the assistant director of nursing (ADON) were interviewed together on 3/26/26 at 10:44 a.m. The DON said PVRs were used to measure voiding after removing an indwelling urinary catheter for a certain period of time. He said the nursing staff would communicate their measurements with the physician to see if the resident needed to continue using a urinary catheter. The ADON said typically for voiding trials, the nursing staff would monitor PVRs and voiding every six to eight hours for three days, and use a straight catheter if the PVR measured greater than 350 ml. The ADON said Resident #71 had physician's orders to have a PVR measured every six hours after his Foley catheter was removed on 1/9/26. The regional support team member said the PVR frequency and length of the physician's order depended on what the resident's diagnoses were and what the indwelling catheter was being used to treat. The regional support team member said the nursing staff had documented Resident #71's PVRs in the MAR, and said there was a physician's order on 1/9/26 to remove the Foley catheter and monitor PVRs twice daily and document their output from 1/9/26 through 1/12/26. The DON reviewed Resident #71's medical record and said the resident had a physician's order, initiated 1/13/26, to monitor PVRs every six hours for 48 hours. -However, the physician's order to monitor PVRs every six hours was initiated on 1/12/26 (see physician's orders above). The regional support member reviewed Resident #71's MAR and said there were two PVRs recorded on 1/13/26. -However, per the physician's order, PVRs were supposed to be measured every six hours (see physician's order above). The DON said Resident #71 had an appointment on 1/14/26 and was picked up for the appointment by the transportation staff at 1:45 p.m. that afternoon. The DON said by the time the physician's order for additional PVRs was put into the resident's medical record (on 1/14/26 at 12:46 p.m.), it was too close to his appointment time. -However, according to the resident's progress notes, the resident was still in the facility on 1/14/26 at 1:27 p.m., when he was administered a medication for pain (see progress notes above). The ADON said the physician may have given the order to the nursing staff later in the morning after Resident #71's exam on 1/14/26, which would account for the gap between the exam and when the order was put in for additional PVRs. The ADON said the nurse or the physician put in the orders for the PVR and the physician would verify the orders later. The ADON and the DON both said if the physician ordered PVRs to be measured every six hours, they would expect the nursing staff to measure the resident's PVR every six hours. Resident #71's attending physician was interviewed on 3/26/26 at 11:24 a.m. The attending physician said orders for PVRs after removing a Foley catheter typically involved measuring the PVR every six hours for two days to see if there were any significant measurements. The attending physician said he would expect the nursing staff to measure and record the PVR every six hours if the physician's order specified to measure the PVR every six hours. II. Failed to ensure physician's orders were in place for a wound dressing for Resident #55 A. Resident status Resident #55, age greater than 65, was admitted on [DATE]. According to the March 2026 CPO, diagnoses included cognitive communication deficits, need for assistance with personal care and fracture of the right fibula (the smaller bone in the lower leg). The 3/11/26 MDS assessment revealed the resident had significant cognitive impairments with a brief interview for mental status (BIMS) score of six out of 15. The resident required supervision to maximum assistance from staff for all ADLs. The assessment documented the resident did not have any issues with her skin. B. Observations On 3/24/26 at 8:30 a.m. Resident #55 was lying in bed in her room. Resident #55 had a dressing on her right forearm arm, dated 3/19/26. On 3/25/26 at 8:50 a.m. Resident #55 was sitting up in her wheelchair in her room. Resident #55 had a dressing on her right forearm, dated 3/19/26. C. Resident #55's representative interview Resident #55's representative was interviewed on 3/25/26 at 8:50 a.m. The resident's representative said she had seen that Resident #55 had a big bandage on her arm. The resident's representative said she had no idea why Resident #55 had the dressing on her arm. The resident's representative said she had hoped the facility would have contacted her if Resident #55 had any changes, or if she had fallen or had any procedures done. D. Record review Review of Resident #55's March 2026 CPO revealed the following physician's order: Monitor the right forearm dry skin patch to ensure proper healing. The area is currently approximately 1 centimeter (cm) by 1 cm with no open areas noted. Monitor for redness, drainage, signs and symptoms of infection and notify the physician if noted, ordered 3/27/26 at 9:21 a.m. (during the survey process). A skilled nursing note, dated 3/19/26 at 8:49 p.m., revealed Resident #55 had some healing bruising above her right eye with no other skin issues or concerns noted, and no active skin conditions or treatments observed. A skin assessment, completed 3/21/26 at 10:09 p.m., revealed Resident #55's skin was assessed by the nursing staff. Resident #55 had redness noted to her coccyx with treatments in place and her heels and all other bony prominences were intact. -The assessment did not document Resident #55's dressing in place or any irritated areas on her arm. A progress note, dated 3/25/26 at 4:27 p.m., revealed the nursing staff assessed the bandage on Resident #55's right forearm and noted there appeared to be a patch of dry skin under the bandage with no open areas noted. Resident #55 denied any pain to the area and declined to have the dressing removed. -However, a physician's order for the dressing that was observed on the resident's right forearm by the nurse on 3/25/26 at 4:27 p.m. was not obtained until 3/27/26 at 9:21 a.m., during the survey (see physician's orders above). E. Staff interviews The infection preventionist (IP) was interviewed on 3/25/26 at 9:06 a.m. The IP said for any dressings, the nursing staff needed to get orders from the physician for wound care. The IP said all wounds, no matter the size, were to be dressed appropriately and followed by the in-house wound care nurse (WCN). The IP reviewed Resident #55's March 2026 CPO and found wound care orders including for barrier cream to the resident's coccyx and monitoring her pacemaker site. The IP said she was not sure why Resident #55 had a dressing on her arm but thought the WCN may have been following the resident. The IP contacted the WCN by phone, who said she did not see any other wound care orders for Resident #55. The IP said she thought maybe the resident had a bony prominence on her arm that the nursing staff were trying to cover. The IP said residents had their skin assessed on admission and weekly. The IP said if the nursing staff saw any changes with a resident's skin, they would document it in the assessment, consult the physician and fill out a change in condition report. The WCN was interviewed on 3/25/26 at 10:53 a.m. The WCN said she reviewed Resident #55's EMR and did not see any physician's orders for wound care, so she was not sure why she had any dressings on. The WCN said Resident #55's skin was assessed on admission and not found to have any skin tears or areas of concern, and the resident had been assessed weekly since her admission. Certified nurse aide (CNA) #4 was interviewed on 3/25/26 at 1:23 p.m. CNA #4 said if she noticed any changes with a resident's skin, she would notify the nurse and document the change in the resident's tasks in the electronic medical record (EMR). CNA #4 said she would also pass along the information regarding the change in the resident's skin to the next shift so they knew to monitor it. LPN #3 was interviewed on 3/25/26 at 1:59 p.m. LPN #3 said if she saw a dressing on a resident during her shift, it would trigger her to look at the resident's physician's orders for any wound care orders. LPN #3 said sometimes residents asked the nursing staff for bandages and the nursing staff applied a bandage for the resident without thinking, so she would want to look into the resident's EMR to see why the resident had the dressing and if it needed to be changed. The IP was interviewed a second time on 3/25/26 at 3:48 p.m. The IP said she had assessed Resident #55's skin under the dressing on her forearm and found an irritated area approximately 2 inches by 2 inches which looked similar to a psoriasis plaque (an itchy, raised, inflamed, and scaly skin patch). The IP said Resident #55's skin assessment did not reveal any open areas or any areas which would require wound care orders. The IP said Resident #55 said she wanted to keep a bandage on the area, so another dressing was placed. The IP said she did not know who put the dressing on Resident #55's arm or if anyone had attempted to change the bandage since it was first applied. The IP said she would have expected to see documentation in the progress notes about the bandage being placed or any attempts to replace the bandage. The WCN was interviewed a second time on 3/26/26 at 10:18 a.m. The WCN said the area under the bandage on Resident #55's arm was a patch of dry skin, and the resident had requested the bandage herself. The WCN said she did not know when Resident #55 had requested for the bandage to be applied. The WCN said if Resident #55 wanted to continue wearing the bandage, she would put in physician's orders so the bandage could be changed and monitored. III. Failed to ensure Resident #30 received wound prevention care in accordance with the physician's orders A. Facility policy and procedure The Wound Care Treatment and Guidelines policy, revised May 2026, was provided by the nursing home administrator (NHA) on 3/25/26 at 4:11 p.m. It revealed in pertinent part, Treatments will be placed in the electronic record. Treatments can be triggered in the EMR or treatment record. A licensed nurse will monitor the wounds with treatments and scheduled assessments. B. Resident #30 1. Resident status Resident #30, age [AGE], was admitted on [DATE]. According to the March 2026 CPO, diagnoses included dementia, heart failure, anemia, a urinary tract infection and aphasia. The 3/16/26 MDS assessment revealed the resident was cognitively impaired with a BIMS score of nine out of 15. The resident was dependent on staff for bathing, transferring, toileting, dressing and bed mobility. She used an electric wheelchair for mobility. The MDS assessment indicated the resident had an unstageable, deep tissue injury and a pressure injury. The resident had a pressure relieving device for her bed and received pressure injury care. 2. Observations On 3/23/26 at 1:38 p.m. Resident #30 was lying in her bed in her room. Her feet were resting on top of a pillow with a reddened area on her right heel directly on the pillow. The resident had bandages to her first and second right toes and a bandage on her first left toe. The date on the bandages was 3/21/26. On 3/24/26 at 8:45 a.m. Resident #30 was lying in her bed in her room. Her feet were resting on top of a pillow with a reddened area on her right heel directly on the pillow. The bandages to her right and left toes had been changed and were dated 3/23/26. On 3/24/26 at 2:40 p.m. Resident #30 was lying in her bed in her room. Her feet were resting on top of a pillow with a reddened area on her right heel directly on the pillow. On 3/25/26 at 9:17 a.m. Resident #30 was lying in her bed in her room. Her feet were resting on top of a pillow with a reddened area on her right heel directly on the pillow. 3. Resident #30's representative interview Resident #30's representative was interviewed on 3/23/26 at 1:38 p.m. The representative lifted up the resident's bed covers to expose the resident's right and left feet, which were both sitting directly on a pillow (see observations on 3/23/26). The representative said he had told the staff several times that Resident #30 needed her heels floated and not placed directly on the pillows to prevent pressure injuries. The representative said the resident had a reddened area to her right heel that would develop into a pressure injury if her feet continued to be placed directly on a pillow and not floated. He said the physician had ordered daily dressing changes to the abrasions on her right and left toes but the date on her bandage was for 3/21/26 (see observations above). 4. Record review The skin integrity care plan, revised 3/19/26, revealed Resident #30 had the potential for pressure ulcers related to impaired mobility and incontinence of bowel and bladder. The resident admitted with an abrasion to the first and second right toes and the first left toe. The resident was admitted with a deep tissue injury (DTI) to the right heel. Interventions, dated 3/19/26, included applying moon boots (a heel floatation device used to suspend the heel to reduce friction and pressure) to the bilateral lower extremities (BLE) and providing the resident with assistance to apply the boots. Review of Resident #30's March 2026 CPO revealed the following physician's orders: Float heels as tolerated, ordered 3/16/26. Wound care to right heel: paint with betadine and leave open to air two times a day, ordered 3/17/26. Wound care to left great toe: cleanse with wound cleanser, pat dry, apply skin prep to wound, apply silver hydrogel to wound base, and cover with a bordered gauze dressing - change daily every day shift for wound care, ordered 3/17/26. Wound care to right second toe: cleanse with wound cleanser, pat dry, apply skin prep to wound, apply silver hydrogel to wound base, and cover with a bordered gauze dressing - change daily every day shift for wound care, ordered 3/17/26. Wound care to right great toe: cleanse with wound cleanser, pat dry, apply skin prep to wound, apply silver hydrogel to wound base, and cover with a bordered gauze dressing - change daily every day shift for wound care, ordered 3/17/26. Apply moon boots to BLE in bed as the resident tolerates every shift, ordered 3/19/26. -However, observations revealed the resident's wound dressings were not changed as ordered and the resident was not wearing moon boots in bed (see observations above). Review of Resident #30's electronic treatment administration records (TAR), from 3/16/26 to 3/24/26 revealed the following: The wound care to the resident's left great toe was not documented as being completed on 3/22/26. The wound care to the resident's right second toe was not documented as being completed on 3/22/26. The wound care to the resident's right great toe was not documented as being completed on 3/22/26. Apply moon boots as the resident accepts was documented as accepted by the resident on 3/22/26 and 3/23/26. -However, observations on 3/23/26 revealed the resident was not wearing her moon boots in bed (see observations above). Apply moon boots as the resident accepts was documented as N on 3/24/26. However, the only choices on the TAR legend was an A for accepted or an R for refused. Float heels was documented as being performed every shift on 3/16/26 to 3/24/26. -However, observations on 3/23/26, 3/24/26 and 3/25/26 revealed the resident's heels were not floated in bed (see observations above). Review of Resident #30's EMR, from 3/16/26 to 3/24/26 revealed the following: The skin ulcer non-pressure weekly assessment, dated 3/16/26, revealed Resident #30 was admitted to the facility with an abrasion to the right great toe measuring 1 inch by 0.8 inches with 0.3 inch depth, an abrasion to the right second toe measuring 0.4 inches by 0.4 inches with 0.2 inch depth, an abrasion to the left great toe measuring 0.7 inches by 0.6 inches with 0.2 inch depth, and a pressure injury to the right heel measuring 5 inches by 4 inches with 0 inch depth. Review of the CNA documentation tasks revealed instructions to apply moon boots. -The EMR failed to reveal documentation of the resident's refusals for moon boots or floating the heels. C. Staff interviews CNA #1 was interviewed on 3/25/26 at 1:00 p.m. CNA #1 said if a resident needed devices, such as boots for pressure injuries, the nurses would verbally tell the CNAs. CNA #1 said if a resident refused to wear the boots, the CNAs would report the refusals to the nurse to document in the EMR. She said Resident #30 wore boots on her feet every day when laying in bed. CNA #1 said the CNAs would use a pillow to float her heels by placing the pillow under her ankles if not wearing her boots. LPN #4 was interviewed on 3/25/26 at 1:12 p.m. LPN #4 said the nurses would verbally communicate to the CNAs any devices or care necessary for a resident's wound care and if a resident refused, the CNAs would tell the nurses so it could be documented in the resident's EMR progress notes. LPN #4 said Resident #30 wore boots on her feet every day when lying in bed and the staff would place a pillow under her ankles to float her heels while in bed if she did not want her boots. -However, despite CNA #1 and LPN #4 indicating the resident wore the boots or had her heels floated whenever she was in bed, observations on 3/23/36, 3/24/26 and 3/25/26 revealed the resident was not wearing her boots and did not have her heels floated (see observations above). -Additionally, there was no documentation to indicate the resident refused the boots or to float her heels (see record review above). LPN #3 was interviewed on 3/25/26 at 1:34 p.m. LPN #3 said that the nurses would verbally communicate to the CNAs any devices or care necessary for resident's wound care. LPN #3 said she was an agency nurse and did not know how the facility handled refusals by residents. She said if a physician's order directed for staff to float a resident's heels, the pillow would be placed under the resident's calf and not the resident's foot. The DON, the NHA, and clinical resource nurse #2 were interviewed on 3/25/26 at 3:21 p.m. clinical resource nurse #2 said treatment orders, such as boots, splints or floating the heels, were communicated to the nurses and CNAs through the CPO and the CNA charting tasks. He could not explain what N indicated on a TAR for wound care. The DON said if a resident accepted treatments, such as a boot and then refused it later, the facility had no method of having the staff document this other than to make a progress note in the EMR. He said the correct way to float a resident's heels was with a pillow placed under the ankle so the foot was suspended away from any surface, such as the bed, that it could rub on. The DON said if the heels were directly touching the pillows, it could restrict blood flow and cause tissue to compress against the pillow, making the resident more susceptible to skin breakdown. The DON, the NHA and clinical resource nurse #2 were unaware the staff were floating Resident #30's heels directly on a pillow. The DON said the facility monitored the execution of wound treatments by reviewing the TARs for the residents. He said he was not aware of the missed wound care treatment for Resident #30 on 3/21/26. The DON said there was always someone available and on shift to complete a wound care treatment if the nurse was unable to complete it for some reason. He said Resident #30's wound care treatment should not have been missed.

Based on record review and interviews, the facility failed to ensure three (#74, #43 and #55) of eight residents reviewed for medication management were free from significant medication errors out of 32 sample residents.Specifically, the facility failed to:-Ensure Resident #74 received scheduled intravenous (IV) antibiotics as ordered; and, -Ensure Resident's #43 and #55's blood pressure medications were administered or held per physician ordered parameters. Findings include: I. Failed to ensure Resident #74 received scheduled IV antibiotics as ordered A. Professional reference According to Vancomycin Hub 2021, retrieved on 3/31/26 from https://doseme-rx.com/vancomycin, Keeping IV vancomycin and piperacillin-tazobactam (Zosyn) on a strict routine schedule is critical to maintain therapeutic efficacy against severe infections, prevent the development of drug-resistant bacteria, and manage the increased risk of kidney injury (Acute Kidney Injury - AKI) associated with their combined use. Because both drugs are time-dependent, consistent dosing ensures blood levels remain within a stable, effective range, while delays increase mortality risk in septic patients. For vancomycin to be effective, a person must receive doses at regular intervals with the goal of getting to a point where the drug levels in the body remain stable or consistent, known as steady-state. B. Resident #74 1. Resident status Resident #74, age [AGE], was admitted on [DATE] and discharged to another facility on 3/24/26. According to the March 2026 computerized physician orders (CPO), diagnoses included sepsis (life threatening infection), infection of intervertebral disc, cervical (neck) region, cervicalgia (neck pain), pain in unspecified joint, secondary scoliosis, thoracic region (upper back) and low back pain. A minimum data set (MDS) assessment had not been completed at the time of the survey. According to the 3/24/26 brief interview for mental status (BIMS) assessment, Resident #74 was cognitively intact with a BIMS score of 15 out of 15. According to the 3/23/26 Functional Performance Observation assessment Resident #74 required substantial/maximal assistance with toileting, personal hygiene, sitting to lying, and was dependent on staff for bathing, dressing, rolling side to side, lying to sitting, sitting to standing, and transfers from bed to chair and to toilet. 2. Resident #74 and resident's representative interview On 3/23/26 at 10:30 a.m. Resident #74 and the resident's representative were interviewed. Resident 74's representative said Resident #74 arrived at the facility around 2:00 p.m. on 3/22/26. The resident's representative said the hospital gave Resident #74 a dose of IV vancomycin at 11:00 p.m. on 3/21/26 and the next dose was due at 11:00 a.m. on 3/22/26 but they were discharged from the hospital in order to be admitted to the facility, so that dose was missed. The representative said the last dose of IV piperacillin was given at 8:00 a.m. at the hospital and the next dose was due to be given at 4:00 p.m. at the facility, which was missed as well. Resident #74, who said she had been a nurse, said it was important that the antibiotics continued as they were scheduled so there were consistent levels in her bloodstream. Resident #74 and her representative said no antibiotics had been administered since the resident was admitted to the facility on the previous day (3/22/26). 3. Record review Review of the hospital medication administration record (MAR) revealed the last dose of IV vancomycin was administered to Resident #74 at 11:26 p.m. on 3/21/26. The scheduled 11:00 a.m. dose of vancomycin on 3/22/26 was missed because of the resident's transfer to the facility. The hospital MAR revealed the last dose of IV piperacillin was administered at 8:41 a.m. on 3/22/26 and the scheduled 4:00 p.m. dose of piperacillin was missed as Resident #74 had been transferred to the facility. Review of the comprehensive care plan, initiated 3/22/26 at 7:11 a.m. (prior to the resident's admission to the facility), indicated Resident #74 had an IV for antibiotics related to a sepsis infection and staff were to administer antibiotics per the physician's orders. The infection surveillance assessment, dated 3/23/26 at 2:15 p.m., indicated Resident #74 was admitted to the facility on two IV antibiotics and was to continue the current antibiotic therapy related to an abscess in the epidural (area between vertebrae and spinal cord membrane) space. Review of Resident #74's March 2026 CPO revealed the following physician's orders: Piperacillin Sodium-Tazobactam intravenous solution four and a half (4.5) grams (gm) every eight hours for sepsis, ordered 3/22/26. Vancomycin hcl (hydrochloride) intravenous solution one (1) gm every 12 hours for sepsis, ordered 3/22/26. Call pharmacy: they will manage vancomycin trough (laboratory test to measure vancomycin level in the blood) and vancomycin dosage until 4/20/26 or until infectious disease (ID) will instruct us to stop vancomycin for cervical spine infection/discitis, ordered 3/23/26. -However, there was no documentation in Resident #74's electronic medical record (EMR) to indicate the pharmacy was contacted and no physician's order for a vancomycin trough was entered. Review of the pharmacy delivery packing slip, dated 3/22/26, indicated six doses of IV piperacillin and four doses of IV vancomycin were delivered to the facility for Resident #74 on 3/22/26 after 9:00 p.m. -However, neither of the antibiotics was administered to Resident #74 after they were delivered. The nursing progress note, dated 3/22/26 at 2:10 p.m., documented verbal consent was received from the on-call physician to continue Resident #74's vancomycin order after the missed 11:00 a.m. dose at the hospital. -However, despite the antibiotics being delivered to the facility later on the evening of 3/22/26, the IV vancomycin and the IV piperacillin were not administered. Review of Resident #74's March 2026 medication administration record (MAR) revealed the following documentation for the resident's IV piperacillin: -On 3/22/26 at 10:00 p.m., a dose of IV piperacillin was scheduled to be given to Resident #74 but was not administered; -On 3/23/26 a dose of IV piperacillin was scheduled to be started at 6:00 a.m. but was not administered until 9:26 a.m., even though the last dose of the medication at the hospital was given at 8:00 a.m. on 3/22/26. The delay resulted in a gap of 25 hours between doses of the IV medication. -On 3/23/26 the scheduled 2:00 p.m. dose of IV piperacillin was administered at 2:41 p.m., approximately 5 hours after the morning dose instead of the required every eight hour dosing. Review of Resident #74's March 2026 MAR revealed the following documentation for the resident's IV vancomycin: -On 3/23/26 a dose of IV vancomycin was scheduled to be started at 8:00 a.m., even though the last dose was given at the hospital on 3/21/26 at 11:00 p.m. The scheduled 8:00 a.m. dose on 3/23/26 was not administered until 11:54 a.m. resulting in a gap of 37 hours between doses that should have been administered every 12 hours. -On 3/23/26 at 8:00 p.m. a dose of IV vancomycin was administered at 8:08 p.m., roughly eight hours after the morning dose rather than the required 12 hour dosing. The nursing progress note, dated 3/23/26 at 10:50 a.m., documented Resident #74's 8:00 a.m. vancomycin was rescheduled related to the previous IV and (peripherally inserted central catheter) PICC line having a slow drip rate. The physician note, dated 3/23/26 at 7:54 p.m. documented The infectious disease (ID) team was consulted during the resident's hospitalization. Resident #74 arrived at the facility on IV vancomycin 1 gm twice daily and piperacillin/tazobactam 4.5 gm IV every eight hours. The resident's IV antibiotics were to be continued until 4/20/26. -However, there was no documentation to indicate, the facility or the physician had notified the ID team of the delays in administering the antibiotics to the resident. C. Staff interviews The director of nursing (DON), clinical resource nurse #1 and clinical resource nurse #2 were interviewed together on 3/25/26 at 9:35 a.m. The DON said when Resident #74 was admitted to the facility on [DATE], the admitting nurse failed to enter all of the physician's orders from the hospital's discharge documentation. The DON, clinical resource nurse #1 and clinical resource nurse #2 said Resident #74's antibiotics did not arrive in a timely manner to be administered to the resident as ordered. The DON, clinical resource nurse #1 and clinical resource nurse #2 said two nurses were to verify admission orders for accuracy and new admission residents' EMRs were reviewed for accuracy in their morning meetings. The DON, clinical resource nurse #1 and clinical resource nurse #2 said it was important to administer IV vancomycin and IV piperacillin at the scheduled times. Clinical resource nurse #1 said if medications did not arrive from the pharmacy in a timely manner, nursing staff were to reach out to the pharmacy and the physician for further instructions. Clinical resource nurse #1 said the ball was dropped with Resident #74 and she did not receive the IV antibiotics timely and per physician's orders. The DON said the nurse who admitted Resident #74 to the facility was an agency nurse that was now banned from the facility and education would be provided to the second nurse that verified the physician's orders with the agency nurse. The DON, clinical resource nurse #1 and clinical resource nurse #2 said a complete review of new admissions over the last 30 days would be completed to identify any issues with residents' admission orders. -Documentation of the education provided to the second nurse was requested but not received prior to the survey exit. The pharmacist was interviewed on 3/26/26 at 9:40 a.m. The pharmacist said when a resident was on important IV antibiotics, such as vancomycin and piperacillin, keeping on a routine schedule of administration was important to maintain adequate blood levels of the medication. The pharmacist said if a dose was missed, it could cause the titration (determination of exact drug concentration) to restart. The pharmacist said Resident #74's medication orders were faxed to the pharmacy after the resident's admission to the facility on 3/22/26. The pharmacist said the pharmacy looked for important medications, such as IV antibiotics to make sure they were sent to the facility timely. The pharmacist said the normal pharmacy delivery times were 1:00 p.m. and 8:00 p.m. and Resident #74's IV medications were on the 8:00 p.m. delivery on 3/22/26. The pharmacist said the exact time the medications were delivered was unknown, as it depended on where the facility fell in their delivery route. She said the pharmacy also had immediate (STAT) deliveries if a medication was needed ahead of a normal delivery time but no STAT deliveries were requested from the facility for Resident ##74. The medical director (MD) was interviewed on 3/26/26 at 9:50 a.m. The MD said it was not okay to miss a dose of scheduled IV antibiotics, such as vancomycin and piperacillin. The MD said residents that required IV antibiotics for sepsis were generally required to be on those medications for an extended period of time and were followed by infectious disease (ID) physicians. The MD said if a dose of IV medication was missed, the nurse should notify ID to let them know and to obtain new physician's orders if indicated. The MD said maintaining routine dosing of the IV antibiotics was important to ensure adequate blood concentrations of the medications. The MD said when the facility knew they were going to admit a resident with important medications, such as IV antibiotics, it was important for those medications to be available to administer timely. The MD said any delay could set the facility up for failure. The physician's assistant (PA) was interviewed on 3/26/26 at 10:00 a.m. The PA said when Resident #74 was admitted to the facility in the afternoon on 3/22/26, a call was not received from the facility to verify the resident's admission medication orders until 8:55 p.m. The physician was interviewed on 3/26/26 at 1:50 p.m. The physician said it was very important that IV antibiotics, such as vancomycin and piperacillin were kept on a routine schedule as they were ordered previously at the hospital so doses did not get missed and the blood concentration of the medications did not get drastically affected. The physician said if a resident was followed by ID, nursing should notify them of any missed doses in case a change in physician's orders would need to be made. D. Facility follow up On 3/26/26 at 2:35 p.m. clinical resource nurse #2 provided a copy of a nursing in-service training related to medication administration with eight nurse signatures documented. The training documented the following in pertinent part, Antibiotics administration: -Antibiotics are to be administered in a timely manner and per physician orders. -If medication is unavailable, contact the primary care physician (PCP) for additional directions. -Medications for new admissions must be verified and confirmed as soon as possible (ASAP) to allow pharmacy time to get medication to the facility. -If medication arrives after a scheduled dose, contact the physician to determine if a dose should be given. Clinical resource nurse #2 additionally provided a copy of the initial audit of the last 30 days of resident admissions for order accuracy, completed on 3/23/26, that identified issues with orders for Resident #74 and one other resident. -However, the nurse education and the audit were not conducted until after the concern was brought to the facility's attention during the survey. II. Failed to ensure Resident's #43 and #55's blood pressure medications were administered or held per physician ordered parameters A. Resident #43 1. Resident status Resident #43, age [AGE], was admitted on [DATE]. According to the March 2026 CPO, diagnoses included supraventricular tachycardia (fast heart rhythm), hypertension and chronic embolism and thrombosis. According to the 12/22/25 MDS assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. 2. Record review The comprehensive care plan, revised 7/30/24, revealed Resident #43 had hypertension and coronary artery disease. Pertinent interventions included giving anti-hypertensive medications as ordered and monitoring for side effects, including increased heart rate, orthostatic hypotension and effectiveness. Review of Resident #43's March 2026 CPO revealed the following physician's orders: Lisinopril 2.5 milligram (mg) oral tablet, give one tablet by mouth in the morning for hypertension, hold for systolic blood pressure (SBP) less than 110 millimeters of mercury (mmHg), ordered 11/19/25 and discontinued 12/23/25. Lisinopril 2.5 mg oral tablet, give one tablet by mouth at bedtime for hypertension, ordered 12/23/25. Metoprolol succinate 25 mg tablet, give one tablet by mouth at bedtime for hypertension; ordered 3/15/25. A progress note, dated 12/13/25 at 11:12 p.m., revealed Resident #43 had a physician's order for metoprolol succinate 25 mg tablets, give one tablet by mouth at bedtime for hypertension, hold for SBP less than 110 or heart rate less than 60 beats per minute(BPM). -However, the parameters to hold the medication were not included in the December 2025 CPO. A nurse practitioner's note, dated 12/29/25 at 8:57 a.m., revealed Resident #43's medications were reviewed and reconciled by the nurse practitioner. Resident #43's medication orders included metoprolol succinate 25 mg tablet, give one tablet by mouth at bedtime for hypertension, hold for SBP less than 110 mmHg or heart rate less than 60 BPM. -However, the parameters to hold the medication were not included in the December 2025 CPO. A physician's note, dated 1/22/26 at 9:45 a.m., revealed Resident #43's medications were reviewed and reconciled by her physician. Resident #43's medication orders included metoprolol succinate 25 mg tablet, give one tablet by mouth at bedtime for hypertension, hold for SBP less than 110 mmHg or heart rate less than 60 BPM. -However, the parameters to hold the medication were not included in the January 2026 CPO and did not match the physician's orders the nursing staff were following, as documented in Resident #43's progress notes (see below). A progress note, dated 1/23/26 at 12:03 a.m., revealed Resident #43 had a physician's order for metoprolol succinate 25 mg tablets, give one tablet by mouth at bedtime for hypertension, hold for SBP less than 100 mmHg or heart rate less than 60 BPM. -However, the parameters to hold the medication were not included in the January 2026 CPO. A nurse practitioner's note, dated 2/23/26 at 1:24 p.m., revealed Resident #43's medications were reviewed and reconciled by the nurse practitioner. Resident #43's medication orders included metoprolol succinate 25 mg tablet, give one tablet by mouth at bedtime for hypertension, hold for SBP less than 110 mmHg or heart rate less than 60 BPM. -However, the parameters to hold the medication were not included in the February 2026 CPO. A nurse practitioner's note, dated 3/13/26 at 2:00 p.m., revealed Resident #43's medications were reviewed and reconciled by the nurse practitioner. Resident #43's medication orders included metoprolol succinate 25 mg tablet, give one tablet by mouth at bedtime for hypertension, hold for SBP less than 110 mmHg or heart rate less than 60 BPM. -However, the parameters to hold the medication were not included in the March 2026 CPO. Review of Resident #43's December 2025 medication administration record (MAR), from 12/1/25 through 12/31/25, revealed the following: -On 12/2/25 the resident's blood pressure (BP) measured 107/60 mmHg and metoprolol was marked as administered; -On 12/8/25 the resident's BP measured 108/56 mmHg and metoprolol was marked as administered; and, -On 12/29/25 the resident's BP measured 100/54 mmHg and metoprolol was marked as administered. -However, Resident #43's metoprolol order had physician ordered parameters to hold the medication for any SBP below 110 mmHg (see physician's orders and progress notes above). Medication regimen review notes, dated 12/10/25, revealed the following pharmacist's recommendations: Resident #43 had a physician's order to hold Lisinopril 2.5 mg tablets for low BP, however the BP was not being documented on the MAR prior to medication administration. The pharmacist recommended that the supplementary documentation be added to the physician's order. The pharmacist requested that the facility follow the facility's policy for documenting the following medication error: Resident #43 had an order for metoprolol 25 mg, hold for SBP less than 110 mmHg or heart rate less than 60 BPM. However, the medication was given on the following days outside of the hold parameters: on 12/2/25 BP was 107/60 mmHg and 12/8/25 BP was 108/56 mmHg. Review of Resident #43's January 2026 MAR, from 1/1/26 through 1/31/26, revealed the following: -On 1/3/26 the resident's BP measured 105/62 mmHg and metoprolol was marked as held; -On 1/7/26 the resident's BP measured 109/68 mmHg and metoprolol was marked as held: -On 1/15/26 the resident's BP measured 107/57 mmHg and metoprolol was marked as held; and, -On 1/22/26 the resident's BP measured 104/66 mmHg and metoprolol was marked as held. -However, Resident #43's metoprolol order had parameters to hold the medication for a SBP lower than 100 mmHg. Medication regimen review notes, dated 1/10/26, revealed the following pharmacist recommendations: The pharmacist requested that the facility follow the facility's policy for documenting the following medication error: Resident #43 had an order for metoprolol 25 mg, hold for systolic BP less than 100 mmHg or heart rate less than 60 BPM. However, the medication was held outside of hold parameters on the following days: on 1/3/26 BP was 105/62 mgHg, on 1/7/26 BP was 68 mmHg. The [pharmacist indicated the hold parameters for metoprolol and lisinopril were different, so maybe the nursing staff were holding the metoprolol medication because the hold parameter for Resident #43's lisinopril medication was for systolic BP less than 110 mmHg. The pharmacist recommended the facility discuss the issue with the physician to see if the physician wanted to change the hold parameter for metoprolol to be held for systolic BP less than 110 mmHg as well. Review of Resident #43's March 2026 blood pressure records, from 3/1/26 through 3/24/26, revealed the following: -On 3/1/26 the resident's BP was 98/56 mmHg; -On 3/4/26 the resident's BP was 104/60 mmHg; -On 3/5/26 the resident's BP was 100/50 mmHg; -On 3/8/26 the resident's BP was 99/50 mmHg; -On 3/9/26 the resident's BP was 102/61 mmHg; -On 3/11/26 the resident's BP was 107/58 mmHg; -On 3/14/26 the resident's BP was 100/62 mmHg; -On 3/17/26 the resident's BP was 94/57 mmHg; -On 3/18/26 the resident's BP was 101/64 mmHg; -On 3/19/26 the resident's BP was 102/55 mmHg; -On 3/23/26 the resident's BP was 100/60 mmHg; and, -On 3/24/26 the resident's BP was 107/60 mmHg. Review of Resident #43's March 2026 MAR, from 3/1/26 through 3/24/26, revealed the following: -The resident's lisinopril medication was held on 3/5/26 and 3/14/26; and, -The resident's metoprolol medication was held on 3/5/26, 3/14/26 and 3/19/26. -However, the nursing staff failed to hold Resident #43's hypertensive medications when the resident's SBP was below 100 mmHg on 3/1/26, 3/8/26 and 3/17/26 or when her SBP was below 110 mmHg on 3/4/26, 3/9/26, 3/11/26, 3/18/26, 3/23/26 or 3/24/26. 3. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 3/25/26 at 1:59 p.m. LPN #3 said when she was preparing to administer blood pressure medications, she needed to measure the resident's blood pressure first. LPN #3 said the residents' blood pressures were measured, as the physician's order for their medication had blood pressure parameters below which the nurse would need to hold the medication. LPN #3 said if a blood pressure medication did not have any hold parameters in the CPO, she would need to use her clinical judgement and hold the medication if the resident's blood pressure was measured and found to be below 100/60 mmHg. LPN #4 was interviewed on 3/26/26 at 9:42 a.m. LPN #4 said most residents' blood pressure medication orders had parameters to hold the medication if their SBP was measured and found to be below 110 mmHg or 100 mmHg, so she followed what the physician's order said. LPN #4 said if a blood pressure medication order did not have any hold parameters listed, she would call the physician and consult with them to revise the order and add parameters. LPN #4 said she would not administer a blood pressure medication without any parameters in the physician's order. The DON and clinical resource nurse #2 were interviewed together on 3/25/26 at 3:41 p.m. The DON said when the nursing staff were administering blood pressure medications, they needed to measure the resident's BP prior to administration. The DON said if the resident's BP was found to be outside of the hold parameters in the physician's order, the nurse would hold the medication, contact the resident's physician and recheck their blood pressure later. The DON said if there were no hold parameters in the physician's order, the nurses used their clinical judgement prior to administering the blood pressure medication. The DON said the nurses assessed the resident to see if they were at their baseline and contacted the physician to see if the medication needed to be held if the resident's SBP was lower. Clinical resource nurse #2 said with fluctuations in blood pressure measurements like those of Resident #43, parameters would be helpful to include in the physician's order. Clinical resource nurse #2 said the facility would consult with Resident #43's physician and have hold parameters added to her blood pressure medications' orders. B. Resident #55 1. Resident status Resident #55, age greater than 65, was admitted on [DATE]. According to the March 2026 CPO, diagnoses included hypertension, hyperlipidemia, presence of a cardiac pacemaker and atrial fibrillation. The 3/11/26 MDS assessment revealed the resident had significant cognitive impairments with a brief interview for mental status (BIMS) score of six out of 15. The resident required supervision to maximum assistance from staff for all activities of daily living (ADL). 2. Record review The cardiovascular care plan, revised 3/24/26, revealed Resident #55 had an altered cardiovascular status due to her diagnoses of hypertension, atrial fibrillation, hyperlipidemia and the presence of a pacemaker. Pertinent interventions included administering medications as ordered and assessing Resident #55's vital signs as ordered and notifying the physician with any abnormal readings. Review of Resident #55's March 2026 CPO revealed the following physician's orders: Amlodipine besylate 5 mg tablet, give one tablet by mouth two times a day for hypertension, ordered 3/8/26 and discontinued 3/16/26. Isosorbide dinitrate 5 mg oral tablet, give one tablet by mouth three times a day for hypertension, ordered 3/8/26 and discontinued 3/10/26. Isosorbide dinitrate 5 mg oral tablet, give one tablet by mouth two times a day, hold for SBP less than 110, ordered 3/10/26. Sotalol 80 mg tablets, give 40 mg by mouth two times a day for hypertension, ordered 3/8/26. Review of Resident #55's March 2026 blood pressure records, from 3/8/26 through 3/26/26, revealed the following: -On 3/8/26 at 5:58 p.m. the resident's BP was 93/59 mmHg; -On 3/8/26 at 6:14 p.m. the resident's BP was 93/59 mmHg; -On 3/8/26 at 10:35 p.m. the resident's BP was 121/61 mmHg; -On 3/11/26 at 2:02 p.m. the resident's BP was 105/62 mmHg; -On 3/16/26 at 9:44 p.m. the resident's BP was 105/62 mmHg; -On 3/19/26 at 11:36 p.m. the resident's BP was 107/60 mmHg; -On 3/22/26 at 8:36 p.m. the resident's BP was 108/60 mmHg; and, -On 3/26/26 at 1:07 a.m. the resident's BP was 103/60 mmHg. Review of Resident #55's March 2026 MAR, from 3/8/26 through 3/26/26, revealed the following: -The resident received doses of amlodipine, isosorbide and sotalol on the evening of 3/8/26; -The resident's isosorbide was administered on 3/11/26 during the morning shift and on 3/16/26, 3/19/26, 3/22/26 and 3/25/26 during the evening shifts; and, -The resident did not receive her scheduled dose of sotalol on 3/24/26. -However, Resident #55's SBP was below the 110 mmHg hold parameter in the physician's order during these medication administrations. -Review of the resident's electronic medical record (EMR) did not reveal any documentation of the physician being contacted regarding the resident's low blood pressure prior to administration of her hypertensive medications on 3/24/26. A progress note, dated 3/25/26 at 4:27 a.m., revealed Resident #55's sotalol medication was not administered. The note documented the facility was waiting for the medication to be delivered. -Review of Resident #55's progress notes did not reveal any documentation of Resident #55's physician or the pharmacy being contacted regarding the missing medication. 3. Staff interviews The nursing home administrator (NHA) was interviewed on 3/25/26 at 4:14 p.m. The NHA said the nursing staff had all been trained on the facility's procedures for when a medication ran out. The NHA said the nursing staff had been informed of who to contact at the facility's pharmacy if they were out of medications, and any agency staff nurse had a list of pharmacy contact information available to them. LPN #4 was interviewed on 3/26/26 at 9:42 a.m. LPN #4 said if she ran out of a medication, she would call the pharmacy and the resident's physician to notify them about the missing medication and document this information in the resident's progress notes. The DON was interviewed on 3/25/26 at 3:48 p.m. The DON said when a medication was unavailable, the nurse should contact the resident's physician and the pharmacy to notify them the medication was out of stock, and the physician would usually put the medication on hold or give further orders. The DON said the nurse would also need to monitor the resident for any changes related to the missing medication. The DON said Resident #55's physician should have been contacted on 3/24/26 when the resident's sotalol medication was unavailable.

Based on observations and interviews, the facility failed to ensure mechanical equipment was in safe, operational condition.Specifically the facility failed to ensure one of three washing machines in the facility's laundry room was in appropriate operational condition.Findings include:I. Observations On 3/25/26 at 8:50 a.m. an observation of the facility's laundry room revealed the following:Behind washing machine #1, four floor tiles were detached with water underneath them. A portable blower (industrial dryer) was set up behind washing machine #1 and pointed towards the detached tiles.Behind washing machine #3 was a puddle of water underneath a supply hose. A rolled up blanket was tucked to the left side of washing machine #3 and another blanket was tucked in the front of washing machine #3. Underneath the blankets, water was observed.II. Staff interviewsThe laundry aide was interviewed on 3/25/26 at 9:00 a.m. The laundry aide said she had worked at the facility in the laundry room for seven months. She said the leak behind the washing machines had been going on the entire time she had worked in the facility and the maintenance director (MTD) was aware of the issue. The laundry aide said she put a new rolled up blanket in the front and the side of washing machine #3 every morning to prevent the water from coming out onto the floor and creating a fall hazard. A representative with the facility's laundry chemical supply provider was interviewed on 3/25/26 at 12:45 p.m. The representative said his company managed the laundry chemicals and any repairs to the equipment associated with the chemicals and refilling the chemicals. The representative said he had repaired the supply hose on washing machine #3 when he came out on 3/25/26 at 11:30 a.m. (during the survey) as a favor because it only needed a new washer (a simple mechanical component that is used in conjunction with a bolt, screw, or nut). He said his company was not responsible for any mechanical repairs to the washing machines, including the supply hose. He said when he came out to the facility on 1/15/26, he did observe water behind the washing machines but could not recall if he had told anyone. The MTD was interviewed on 3/26/26 at 9:40 a.m. The MTD said that he supervised the housekeepers, the laundry staff and any as needed (PRN) maintenance staff. He said he was responsible for basic inspections of the washers and dryers in the laundry room. The MTD said the technician from the facility's laundry chemical supply provider had come out on 3/25/26 (during the survey) and replaced a washer in the supply hose of washing machine #3 (where the leak was coming from). He said the laundry chemical supply provider was responsible for refilling the laundry chemicals and any service to the equipment which distributed those chemicals into the washing machines. The MTD said the supply hose maintenance was a facility responsibility. The MTD could not explain why he had not made the repairs himself prior to the survey. The MTD said he and the laundry aide had put the portable blower behind the washing machines to address the water coming from the leak in the supply hose, but he could not recall exactly when the blower had been put back there. He said he was aware of the detached tiles behind the washing machines and said the tiles had been that way since the facility's acquisition by another corporation on 6/1/24. The MTD said he conducted monthly inspections of the laundry room machines and washing machine #3 had been leaking on and off since February 2026. He said he should have gone to the home repair store and purchased supplies to repair the leaking hose but he had not done so. The MTD said that the laundry aide had put blankets around washing machine #3 to prevent water from leaking outward and causing safety and trip hazards, however, he said this was not an appropriate way to address a leak.

Based on observations and interviews, the facility failed to provide a safe, sanitary, functional and comfortable environment for the residents. Specifically the facility failed to:-Ensure one of four resident shower rooms was free of deterioration and water damage and had a properly operational shower head;-Ensure resident room corridors were free of deterioration and water damage;-Ensure one of 12 resident rooms had a properly operational sink faucet; and, -Ensure two of 12 resident personal bathrooms were free of deterioration and water damage.Findings include:I. Failure to ensure one of four resident shower rooms was free of deterioration and water damage and had a properly operational shower head A. Observations On 3/23/25 at 9:12 a.m., the facility's [NAME] One shower room was observed. The shower room had four 12 by12 inch tiles on the lowest part of the shower wall, held to the wall with six strips of vertical duck tape. The tile closest to the exit door had a gap of one half an inch with a visible black substance underneath. When light pressure was applied to the last tile, it bowed inward toward the surface underneath the tile. The corner of the shower room wall, closest to the exit door, revealed signs of warping and there was peeling paint to the wall above the baseboard. There were signs of warping and peeling paint around the door stop of the exit door. The inner doorframe of the exit door, from the bottom of the door to approximately five inches up the door, revealed discoloration, peeling paint and soft wood. The exterior door frame of the exit door (facing the exterior hallway), from the bottom of the door to approximately five inches up the door, revealed discoloration, peeled and missing paint and exposed soft wood with disintegrated wood flakes on the carpet.Additionally, the shower head in the [NAME] One shower room had a continuous, steady leak dripping down the wall and onto the floor with a visible puddle of water. On 3/23/25 at 1:51 p.m. the facility's [NAME] One shower room was observed. The shower head had a continuous, steady leak dripping down the wall and onto the floor with a visible puddle of water.On 3/24/26 at 8:42 a.m. the facility's [NAME] One shower room was observed. The shower head had a continuous, steady leak dripping down the wall and onto the floor with a visible puddle of water. On 3/24/26 at 11:29 a.m. the facility's [NAME] One shower room was observed. The shower head had a continuous, steady leak dripping down the wall and onto the floor. B. Record reviewOn 3/24/26 at 9:45 a.m., the maintenance director (MTD) provided a typed timeline he had created showing the process of repairs to the [NAME] One shower room. The timeline revealed that staff had notified him of the loose wall tiles in the shower room on 3/4/26. The MTD began working on cleaning and replacing the tiles on 3/4/26 and had continued to work on the tile repair (between staff using the shower room for showering residents) up until the day of the survey entrance on 3/23/26. Between 3/4/26 and 3/23/26, the MTD had worked in the [NAME] One shower room seven times. On 3/25/26 at approximately 10:00 a.m. the MTD provided a print out of all the closed work orders from 1/1/26 to 3/24/26. Work order #1172, for a shower without pressure in the [NAME] One shower room, was highlighted in the work order history.-However, there was no date for when the work order was submitted or completed. On 3/25/26 at approximately 11:30 a.m. the MTD provided a print out of a supply purchase order for a shower cartridge and a new handheld shower head, which was scheduled to arrive at the facility on 3/25/26. -However, there was no date on the purchase order for when the order for the shower cartridge and a new handheld shower head was placed. C. Staff interviews and observations Certified nurse aide (CNA) #1 was interviewed on 3/24/26 at 8:42 a.m. CN! #1 said she worked on the [NAME] One hallway and she was also a shower aide. CNA #1 said the loose tiles and water damage in the shower room had been there for at least a month. CNA #1 said the leaking shower head in the shower room had been that way for at least a month. The [NAME] One shower room was observed with the MTD on 3/24/26 at 12:50 p.m. The MTD said the housekeeping staff cleaned the shower room daily and he was aware of the water damage to the tiles and walls. He said he had been working on replacing the tiles for two weeks. The MTD said he had to do the repairs between residents continuing to be showered in the [NAME] One shower room. He said he did not have documentation of his repairs to the shower room and he had not been providing documentation to the nursing home administrator (NHA) of his progress with the shower room's repairs. The MTD said he was not aware of the shower head leak in the [NAME] One shower room.The [NAME] One shower room was observed with the NHA on 3/25/26 at 8:45 a.m. The NHA said the [NAME] One shower room would be closed and the [NAME] Two shower room would be the only shower room used on the facility's [NAME] unit until the water damage to the interior and exterior of the [NAME] One shower room were addressed. The MTD and the regional plant resource were interviewed together on 3/26/26 at 9:40 a.m. The MTD said he started to notice the leak in the [NAME] One shower head the week prior to the survey (the week of 3/16/26). He said he had purchased a replacement shower head and installed it on 3/20/26, however, he had no documentation of the purchase, the installation or a work order. The MTD said during the survey, it was determined the [NAME] One shower head needed a cartridge (a component of the shower system that regulates water flow from the showerhead) replacement. The MTD said continuous leaks could create water damage and compromise surfaces.The MTD acknowledged that due to a leak in the shower head and the staff's use of the shower room on a daily basis, the prolonged water saturation would compromise the adhesiveness of the duct tape holding the tiles to the shower wall. He said after observing the shower room during the survey, he determined the project needed more extensive work and made his regional plant resource aware. The MTD said it was his decision to not close down the [NAME] One shower room to expedite the repairs and ensure the tiles were secured to the backing board. The MTD was unable to give a reason for this decision, but he said it was a mistake and he should have closed down the shower room. He said the [NAME] One shower room was now closed until it was fully repaired. The regional plant resource said that he was unaware of the repairs the MTD was doing in the [NAME] One shower room prior to the survey and when he came in to inspect the repairs, he said he found the surface behind the tiles to be compromised from water damage. He said the tiles had since been removed, the backing board repaired and new tiles placed. The regional plant resource said if ,while showering residents, the staff were to hit the wall with a shower chair, it would have caused the tiles to collapse inwards from the water damage. II. Failure to ensure resident room corridors were free of deterioration and water damageA. Observations On 3/23/25 at 9:12 a.m. the corridor outside the [NAME] One shower room revealed an area of the carpet below the wood frame, and running along approximately six inches of the baseboard, that was discolored, soft and damp. C. Staff interviews and observationsThe corridor outside the [NAME] One shower room was observed with the MTD on 3/24/26 at 12:55 p.m. The MTD said he was not aware of the water damage to the exterior baseboard and the carpet. He said the damage would have resulted from leaks in the shower room. The MTD was interviewed again on 3/26/26 at 9:40 a.m. The MTD said he had noticed the water damage to the exterior baseboard and carpet outside the [NAME] One shower room and had used carpet fans to attempt to dry the area. The MTD said he was waiting to finish the repairs inside the shower room first before repairing the exterior corridor and he had obtained bids on a new carpet. -However, the MTD did not provide documentation of the bids for the carpet replacement.III. Failure to ensure one of 12 resident rooms had a properly operational sink faucet. A. Observations On 3/24/26 at 11:45 a.m. resident room [ROOM NUMBER] was observed. The observation revealed a dripping bathroom sink faucet B. Staff interviews and observationsroom [ROOM NUMBER]'s resident bathroom was observed with the MTD on 3/24/26 at 12:50 p.m. The MTD said he had not been made aware of the bathroom sink faucet drip and had not received a work order to repair it. The MTD said his housekeepers cleaned the residents' bathrooms daily, to include the sinks, and he would have expected the housekeepers to submit a work order or verbally tell him about the leaking faucet in room [ROOM NUMBER]'s bathroom. IV. Failure to ensure two of 12 resident personal bathrooms were free of deterioration and water damageA. ObservationsOn 3/24/26 at 11:58 a.m., two resident rooms on the facility's [NAME] unit were observed. room [ROOM NUMBER] had a triangular area from the resident's personal bathroom ceiling to the exhaust vent and around the vent of peeled and missing paint. The area was approximately two feet wide by six inches long. room [ROOM NUMBER] had an area on the resident's personal bathroom wall of approximately three feet long by two feet wide of discolored, bubbled and peeling paint. B. Staff interviews and observationsroom [ROOM NUMBER] and room [ROOM NUMBER] were observed with the MTD on 3/24/26 at 1:05 p.m. The MTD identified the damage to the bathroom walls in the rooms as being caused by water damage and said he had not been aware of the damage and the staff had not submitted a work order for the damage. He said a few months prior, there was a toilet leaking on the second floor that probably was the cause of the water damage, but he could not pull up the work order for the toilet to show when that leak was reported and repaired. The MTD and the regional plant resource were interviewed together on 3/26/26 at 9:40 a.m. The MTD said his housekeepers cleaned the residents'personal bathrooms daily but had never reported to him the water damage to the walls in room [ROOM NUMBER] and room [ROOM NUMBER]. He said after observing the water damage, during the survey, he believed it resulted from the second floor's previously leaking toilet. The regional plant resource was able to pull the work order report showing the ticket for the leaking toilet was opened on 1/17/26 and completed 1/19/26.

Based on observations and interviews, the facility failed to ensure adequate outside ventilation by means of windows, or mechanical ventilation for three out of 12 residents' personal bathrooms. Specifically, the facility failed to ensure ventilation fans were kept operational in the resident personal bathrooms.Findings include:I. Professional referenceAccording to the United States (U.S.) Department of Energy's Office of Energy Efficiency and Renewable Energy, April 2021 retrieved on 3/30/26 from: https://docs.nrel.gov/docs/fy21osti/79150.pdf., Proper ventilation helps reduce the concentration of bioaerosols (bioaerosols consist of aerosols originated biologically such as metabolites, toxins, or fragments of microorganisms), which can be particularly important in nursing homes due to the presence of vulnerable adults. Good ventilation can improve the health and well-being of the residents by reducing infection risks and preventing respiratory issues. By ensuring proper ventilation, nursing homes can significantly enhance the safety and quality of life for their residents. II. Observations On 3/24/25 at 11:58 a.m. three resident personal bathrooms were observed. In room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER], the resident personal bathroom ventilation systems revealed there was no air flow present.III. Staff interviews and observations Rooms #110, room [ROOM NUMBER] and room [ROOM NUMBER] were observed with the maintenance director (MTD) on 3/24/26 at 1:05 p.m. The MTD said he was not aware of decreased air flow in the vents in the three rooms. The MTD said the facility used a mechanical ventilation system. He said the ventilation system prevented airborne contaminants within the facility. The MTD said to ensure the ventilation system was working properly in the bathrooms, a piece of tissue paper could be put up to the vent. The MTD said if there was proper air flow, the tissue paper would be pulled to the vent. During the observation, the MTD held tissue paper up to the vents, however the tissue papers were not pulled into the vents in room [ROOM NUMBER], room [ROOM NUMBER] or room [ROOM NUMBER]. In room [ROOM NUMBER], the MTD removed the vent cover and had to put his hand, up to the wrist, into the vent opening to detect any sense of air flow. The MTD said he was unable to explain the reason for the decreased air flow in the resident personal bathrooms. On 3/25/26 at approximately 10:00 a.m., the MTD provided a work history report of inspections he had completed on the exhaust fans. The work history report revealed an inspection was completed on the exhaust fans on 3/20/26. -However, the report did not reveal which specific resident personal bathroom exhaust fans were inspected.

Based on record review and interviews, the facility failed to ensure certified nurse aides (CNA) received the required 12 hours of annual in-service training to ensure continued competence. Specifically, the facility failed to ensure 23 of 24 CNAs received 12 hours of annual training. Findings include: I. Facility policy and procedure The In-Service Training policy, revised August 2022, was provided by the executive director (ED) on 3/27/24 at 12:25 p.m. It documented in pertinent part, The primary objective of the in-service training was to ensure that staff were able to interact in a manner that enhanced the resident's quality of life and quality of care and could demonstrate competence in the topic areas of the training. II. Training review CNAs were reviewed for the required annual 12 hours of continued education units (CEUs). -Training records revealed only one out of 24 CNAs had completed the required training. III. Staff interviews The human resources director (HRD) was interviewed on 3/27/24 at 10:45 a.m. The HRD said the facility did not employ a staff development coordinator. She said it was not communicated to her that the CNAs were required to have the 12 hours of annual in-service training. She said only one CNA had their 12 hour CEUs completed. The director of nursing (DON) was interviewed on 3/27/24 at 11:06 a.m. The DON said all CNAs should have completed their 12 hours of CEUs. She said the HRD should have a tracking system in place to track the amount of hours completed. The ED was interviewed on 3/27/24 at 11:22 a.m. The ED said all CNAs should have completed their 12 hours of CEUs. She said the HRD had initiated a tracking form (during the survey) to ensure CNAs were completing their required CEUs annually.

Based on record review and interview, the facility failed to conduct yearly certified nurse aide (CNA) performance reviews and provide training based on the outcome of the reviews for three out of five CNAs reviewed for annual reviews and training. Specifically, failed to provide performance reviews annually and training based on the outcome of the individual reviews for CNA #1, CNA #2 and CNA #3. Findings include: I. Facility policy and procedure The Performance Evaluations policy, revised September 2020, was provided by the executive director (ED) on 3/27/24 at 12:27 p.m. It documented in pertinent part, The job performance of each employee shall be reviewed and evaluated at least annually. Performance evaluations may be used in determining employee promotion, shift/position transfers, demotion, terminations, wage increases and to improve the quality of the employee's work performance. The written performance evaluations will contain the director's and/or supervisor's remarks and suggestions, any action that should be taken (further training) and goals. II. Record review The 2/8/24 facility assessment was provided by the social services director (SSD) on 3/26/24 at 12:07 p.m. It revealed the facility average census was 35 residents. The common diseases the facility provided care to were psychiatric/mood disorders, circulatory system, neurological system, vision and hearing, musculoskeletal system, metabolic disorders, respiratory systems, genitourinary system, diseases of blood, digestive system, integumentary system and infectious diseases. Performance evaluations for CNAs were reviewed. -However, the facility was unable to provide annual performance evaluations and reviews for CNA #1, CNA #2 and CNA #3 during the survey process. III. Staff interviews The human resources director (HRD) was interviewed on 3/27/24 at 9:18 a.m. She said the facility had a new administration team that came together in 2023. She said performance reviews were not a priority for the past administration team. She said the current administration team had made it a priority to complete the performance reviews timely. The director of nursing (DON) was interviewed on 3/27/24 at 11:06 a.m. She said performance evaluations should have been completed annually. She said she completed the performance evaluations for CNA #1, CNA #2 and CNA #3 on 3/26/24 during the survey. She said going forward the performance evaluations would be completed on the CNAs anniversary date.

Based on record review and interviews, the facility failed to ensure one (#25) of five residents out of 19 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to administer medications in a timely manner per the physician orders for Resident #25. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), E.[NAME], St. Louis Missouri, pp. 606-607. Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication. II. Facility policy and procedure The Administering Medications policy and procedure, revised in April 2019, was received from the executive director (ED) on 3/27/24 at 7:22 a.m. It revealed in pertinent part, Medications were administered in a safe and timely manner and as prescribed. Medication administration times were determined by resident need and benefit, not staff convenience. Factors to consider include: enhancing optimal therapeutic effect of the medication; honoring resident choices and preferences, consistent with his or her care plan. Medications were administered within one hour of their prescribed time. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: date and time the medication was administered. III. Resident #25 A. Resident status Resident #25, older than 65, admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses include congestive heart failure (excessive fluid), chronic kidney disease (decrease in kidney function), hypertension (increased blood pressure) and atrial fibrillation (abnormal heat function). The 2/16/24 minimum data set (MDS) assessment revealed the resident was moderately impaired with a brief interview for mental status (BIMS) score of 10 out of 15. He required one person's assistance with transfers and dressing. He required set up assistance for eating and personal hygiene. B. Resident interview Resident #25 was interviewed on 3/25/24 at 1:14 p.m. Resident #25 said his medications were late and he was afraid it would affect his health. C. Record review The March 2024 CPO documented the following medication orders: Metoprolol succinate (used for blood pressure control) 50 milligrams (mg) two times daily at 8:00 a.m. and 8:00 p.m. ordered on 10/26/23. Trazadone (used for insomnia) 50 mg once daily at bedtime at 8:00 p.m. ordered on 9/15/23. Genteal ophthalmic gel 0.25-0.3% instill one drop in both eyes for cataracts at bedtime 8:00 p.m. ordered on 5/17/23. Finasteride 5 mg (used to treat enlarged prostate) at bedtime 8:00 p.m. ordered on 6/12/23. Furosemide 10 mg (used to remove excess fluid in the body) every morning at 8:00 a.m. ordered on 8/19/23. Review of the medication administration record (MAR) from 3/12/24 to 3/26/24 revealed the following: The Metoprolol succinate 8:00 a.m. dose was not administered timely on the following days: -3/12/24, the medication was administered at 10:21 a.m (one hour and 21 minutes after the allowed administration time); -3/15/24, the medication was administered at 11:22 a.m. (two hours and 22 minutes after the allowed administration time); -3/16/24, the medication was administered at 11:15 a.m. (two hours and 15 minutes after the allowed administration time); -3/17/24, the medication was administered at 10:11 a.m. (one hour and 11 minutes after the allowed administration time); -3/18/24, the medication was administered at 10:56 a.m. (one hour and 56 minutes after the allowed administration time); -3/24/24, the medication was administered at 10:11 a.m. (one hour and 11 minutes after the allowed administration time); and -3/25/24, the medication was administered at 10:34 a.m. (one hour and 34 minutes after the allowed administration time). The Metoprolol succinate 8:00 p.m. dose was not administered timely on the following days: -3/12/24, the medication was administered at 10:26 p.m. (one hour and 26 minutes after the allowed administration time); -3/14/24, the medication was administered at 9:36 p.m. (36 minutes after the allowed administration time); -3/16/24, the medication was administered at 11:56 p.m. (two hours and 56 minutes after the allowed administration time); -3/21/24, the medication was administered at 10:22 p.m. (one hour and 22 minutes after the allowed administration time); and -3/15/24, the medication was administered at 12:07 a.m. on 3/26/24 (three hours and seven minutes after the allowed administration time). The Trazadone 8:00 p.m. dose was not administered timely on the following days: -3/14/24, the medication was administered at 9:36 p.m. (36 minutes after the allowed administration time); and -3/21/24, the medication was administered at 10:45 p.m. (one hour and 45 minutes after the allowed administration time). The Genteal ophthalmic gel 8:00 p.m. dose was not administered timely on the following days: -3/14/24, the medication was administered at 9:36 p.m. (36 minutes after the allowed administration time); -3/19/24, the medication was administered at 11:10 p.m. (two hours and 10 minutes after the allowed administration time); -3/21/24, the medication was administered at 10:49 p.m. (one hour and 49 minutes after the allowed administration time) The Finasteride 8:00 p.m. dose was not administered timely on the following days: -3/14/24, the medication was administered at 9:36 p.m. (36 minutes after the allowed administration time); and -3/21/24, the medication was administered at 10:43 p.m.(one hour and 43 minutes after the allowed administration time). The Furosemide 8:00 a.m. dose was not administered time on the following days: -3/12/24, the medication was administered at 10:21 a.m. (one hour and 21 minutes after the allowed administration time); -3/15/24, the medication was administered at 9:39 a.m. (39 minutes after the allowed administration time); -3/16/24, the medication was administered at 11:15 a.m. (two hours and 15 minutes after the allowed administration time); -3/17/24, the medication was administered at 10:12 a.m. (one hour and 12 minutes after the allowed administration time); -3/18/24, the medication was administered at 10:55 a.m. (one hour and 55 minutes after the allowed administration time); -3/24/24, the medication was administered at 10:11 a.m. (one hour and 11 minutes after the allowed administration time); and -3/25/24, the medication was administered at 10:34 a.m. (one hour and 34 minutes after the allowed administration time). -There were no progress notes documenting the reason the medications were administered late. IV. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 3/27/24 at 8:10 a.m. LPN #1 said medications were to be administered in one hour before or after the medication scheduled time. LPN #1 said if a medication was not administered timely it could affect the resident's health, could be given too close to the next dose compromising the resident. LPN #1 said sometimes medications were given late due to an emergency with other residents. The director of nursing (DON) was interviewed on 3/27/24 at 8:21 a.m. The DON said resident medications should be administered timely to ensure the effectiveness of a medication purpose for the resident. The DON said the nurses should administer medications within the one hour window before and after the scheduled time. The DON said the administration of medications being timely was part of the seven rights of medication administration. The DON said it was up to the nurse to add a progress note to state why a medication was administered late. The DON said medication could be documented late if the nurse did not sign them out at time of administration but that was not best practice.

Based on observations and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly in two of three medication storage rooms and one of three medication carts. Specifically the facility failed to: -Ensure expired medications were not stored with current medications in the medication storage rooms; -Ensure medications were stored at correct temperatures in medication storage refrigerators; -Ensure medications were not stored in a dormitory style refrigerator/freezer combination; and, -Ensure used medication vials were not stored in the medication cart. Findings include: I. Professional reference According to the Vaccine Storage and Temperature Monitoring Equipment (January 2023), retrieved on 3/18/24 from https://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf, It is important the facility has proper storage and monitoring equipment that was set up correctly, maintained appropriately and repaired as needed. The equipment protects patients from inadvertently receiving compromised vaccines. Do not store any vaccines in a dormitory-style or bar-style combined refrigerator/freezer unit under any circumstances. These units have a single exterior door and an evaporator plate/cooling coil, usually located in the freezer compartment. These units pose a significant risk of freezing vaccines, even when used for temporary storage. Temperature ranges for refrigerators should maintain temperatures between 36 and 46 degrees fahrenheit (F). II. Facility policy and procedure The Medication Labeling and Storage policy and procedure, revised February 2023, was received from the executive director (ED) on 3/27/24 at 7:22 a.m. It revealed in pertinent part The facility stores all medication and biologicals in locked compartments under proper temperature, humidity and light controls. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy was contacted for instructions regarding returning or destroying these items. Medications requiring refrigeration were stored in the refrigerator located in the medication room at the nurses station. III. Observations and staff interviews On 3/26/24 at 1:40 p.m. the first floor east wing medication cart was observed with RN #1. The following item was found: -One open and used vial of ceftriaxone 1 gram injection (an antibiotic medication used for infections). -The vial had no resident name or date on it. Registered nurse (RN) #1 said it was the responsibility of each nurse working the medication cart to ensure the cart was clean. She said the empty vial should have been disposed of after the medication was drawn up from the vial. RN #1 said the vial did not have a resident name on it but it could have been removed from the facility's emergency medication supply. On 3/26/24 at 1:47 p.m., the east wing medication storage room was observed with RN #1. The following items were found: -One opened bottle of vitamin D3 5000 units that expired 11/2023; -One unopened bottle of Iron 325 milligrams (mg) expired 12/2023; and, -Two unopened bottles of Senokot (aids in relieving constipation) 8.6 mg that expired 11/2023. Additionally, the temperature in the medication storage refrigerator in the medication storage room was 33 degrees F which was confirmed by RN #1. The refrigerator had a single door and had a freezer compartment which had about six inches of ice build up in the freezer section. The ice build up would not allow for anything to be stored in the freezer section. The refrigerator had the following vaccines and medications stored in it: -Three Basaglar insulin pens (used for blood glucose management); -One bottle of liquid Lorazepam (anti-anxiety medication); -One Fluad quadrivalent flu vaccine for residents over [AGE] years old; -One quadrivalent flu vaccine for residents younger than [AGE] year olds; -One open vial of tuberculin (used to test for tuberculosis); -One unopened vial of tuberculin; and, -One box of Bisacodyl suppositories (used for constipation). RN #1 said the medication storage refrigerator was not within the correct temperature range per the facility's log and the medications or vaccines in the refrigerator could be compromised if they were not stored at the correct temperatures. RN #1 said the expired medication bottles should have been placed in the cabinet labeled expired medications which was at the other end of the medication storage room to ensure a nurse did not collect them to be used for a resident. On 3/26/24 at 2:02 p.m., the second floor medication room was observed with licensed practical nurse (LPN) #1. The medication storage refrigerator in the medication storage room was a dormitory style refrigerator where the freezer was in the same compartment as the refrigerator. The freezer had two inches of ice build up. The following medications were observed to be stored in the refrigerator: -One open vial of Tuberculin; and, -One novolog insulin vial. LPN #1 said she did not know medications could not be stored in a dormitory style fridge. LPN #1 said she did not think the medications in the refrigerator were compromised as the temperature log for the fridge did not have any temperatures out of the safe range. IV. Additional staff interviews The director of nursing (DON) was interviewed on 3/26/24 at 2:20 p.m. The DON said medications and vaccines should be stored per the recommendations of the medication manufacturers to ensure medications were effective at the time administered. The DON was not aware the facility could not use the dormitory style refrigerators because of increased risks of temperature fluctuations. The DON observed the ice build up in the first floor east wing medication room and said the facility did not use the freezer section to store medications. The DON said the medications stored in the refrigerator would be destroyed and new ones would be ordered from the pharmacy to ensure medications were not given to residents because they might have been compromised. The DON said expired medications were to be stored in the medication room in the cabinet labeled expired medications to ensure the nurses did not accidentally give a resident a medication that was expired. The DON said the expired medications should not have been in the cabinet labeled medication cart supplies. The DON said the empty vial of antibiotics should have been disposed of at the time the injection was given and should not have been stored in the medication cart. The DON said all nurses working the medication cart were to keep the carts clean. The DON said she completed random medication cart checks monthly and the pharmacy consultant also completed checks monthly.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection for one of two units. Specifically, the facility failed to: -Ensure resident rooms and bathrooms were cleaned in a sanitary manner; -Ensure surface disinfectants were used for the appropriate dwell time (amount of time surface must remain visibly wet); -Ensure appropriate hand hygiene was performed by housekeeping staff; and, -Ensure high touch surfaces were cleaned. Findings include: I. Professional reference According to the Environmental Cleaning procedures (reviewed 5/4/23) retrieved on 3/28/24 from: https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html, documented in part, Common high touch surfaces include: sink handles, bedside tables, call bells, door knobs, and light switches. High touch surfaces and floors should be cleaned at least once daily (24 hour period). At least once daily or every 24 hours high touch surfaces are to be cleaned. According to the List N tool: Covid 19 disinfectants retrieved on 4/1/24 from: https://cfpub.epa.gov/wizards/disinfectants/ Fabuloso requires a 10 minute contact time (surface must remain visibly wet for the duration of the contact time). II. Facility policy The Cleaning and Disinfecting Residents' Rooms policy and procedure, revised August 2013, was received from the executive director (ED) on 3/27/24 at 12:14 p.m. It revealed in pertinent part The purpose of this procedure is to provide guidelines and disinfecting residents' rooms. Environmental surfaces will be disinfected (or cleaned) on a regular basis. Disinfecting solutions will be prepared as needed and replaced with fresh solutions frequently. Perform hand hygiene after removing gloves. The environmental service director and administrator, in conjunction with the infection preventionist will select appropriate facility disinfectants. Change cleaning clothes when they become soiled. Clean personal use items lights, phones, call bells with disinfectant solution. III. Observations On 3/26/24 at 9:36 a.m., housekeeper (HSK) #1 was cleaning room [ROOM NUMBER], a private resident room. HSK #1 grabbed a wet rag from a bucket on her cleaning cart, wrung it out and picked up a spray bottle with a purple solution in it. HSK #1 entered room [ROOM NUMBER], sprayed the purple solution from the bottle onto the bedside table and immediately wiped the table top and the legs of the bedside table with the rag. -HSK #1 did not allow the cleaning solution to remain wet on the surface of the bedside table for the manufacturer recommended dwell time of 10 minutes. HSK #1 proceeded to move into the bathroom, sprayed the purple solution on the sink and wiped it off immediately with the rag. -HSK #1 did not allow the cleaning solution to remain wet on the surface of the sink for the manufacturer recommended dwell time of 10 minutes. At 9:41 a.m., HSK #1 sprayed the toilet and brushed the toilet bowl with a toilet brush HSK#1 wiped the rim of the toilet, bottom of the toilet seat, then the top of toilet seat and lastly the toilet lid was wiped. HSK #1 used the same rag to wipe the toilet tank and the outside of the toilet down to the floor. -HSK #1 did not allow the cleaning solution to remain wet on the surfaces of the toilet for the manufacturer recommended dwell time of 10 minutes. -HSK #1 did not clean the toilet from cleaner areas to dirtier areas. At 9:42 a.m., HSK #1 sprayed and immediately wiped off the grab bars in the bathroom using the same rag she cleaned the toilet with. -HSK #1 did not allow the cleaning solution to remain wet on the surface of the grab bars for the manufacturer recommended dwell time of 10 minutes. HSK#1 returned to her cleaning cart and retrieved a broom to sweep the room. As she was sweeping, she touched the resident's recliner, pillow, bedside table, desk chair, shoes, toilet riser and the main door handle with the same gloves she had used to clean the bathroom with. -HSK #1 failed to change her gloves and perform hand hygiene after cleaning the bathroom and before she touched multiple items in the resident's room while sweeping the floor HSK #1 returned to her cart and grabbed a mop pad from a bucket with cleaning solution on her cleaning cart. -HSK #1 did not remove her gloves and perform hand hygiene before reaching into the bucket of solution for the mop pad. HSK #1 wrung out the mop pad with the same gloves she had been wearing throughout the entire cleaning process of the resident's room. She allowed the excess cleaning solution to drip back into the container and returned to the resident's room to mop the floor. HSK #1 mopped the resident's room from the window towards the bathroom. HSK #1 proceeded to mop the floor of the bathroom with the same mop pad before she finished mopping the resident's room to the main doorway. While HSK #1 was mopping the resident's room, she touched the call light, desk chair, shoes, bedside table, toilet riser and a package of adult briefs. -HSK #1 failed to change her mop pad after mopping the bathroom floor before she finished mopping the remainder of the resident's room. -HSK #1 continued to wear the same gloves she had worn throughout the cleaning process of the resident's room and again touched multiple items in the resident's room during the mopping process. On 3/26/24 at 9:54 a.m., HSK #1 began cleaning room [ROOM NUMBER], a private resident room. HSK #1 grabbed a rag from the bucket with the cleaning solution on her cart and the spray bottle containing the purple cleaning solution before entering the resident's room. With her gloved hands, which had cleaning solution on them from grabbing the rag, HSK #1 moved several personal items, including the resident's drinking cup which she grabbed by the rim of the cup, from the resident's bedside table and nightstand to the resident's recliner. HSK #1 proceeded to spray the bedside table and nightstand with the purple solution. After spraying the cleaning solution, she immediately wiped off the bedside table and nightstand. HSK #1 then wiped the bedside table and night stand immediately after spraying. -HSK #1 did not allow the cleaning solution to remain wet on the surfaces of the bedside table and nightstand for the manufacturer recommended dwell time of 10 minutes. At 9:57 a.m., HSK #1 sprayed and immediately wiped off the dresser. -HSK #1 did not allow the cleaning solution to remain wet on the surface of the dresser for the manufacturer recommended dwell time of 10 minutes. At 9:58 a.m., HSK #1 entered the bathroom where she proceeded to spray the sink with the purple solution and immediately wiped the faucet and sink bowl before wiping the faucet handles. -HSK #1 did not allow the cleaning solution to remain wet on the surfaces of the sink area for the manufacturer recommended dwell time of 10 minutes. HSK #1 sprayed the bathroom cabinet, toilet bowl and toilet riser. HSK #1 moved the toilet riser out of the way and used the toilet bowl brush to scrub the visible brown residue in the toilet bowl. At 10:00 a.m., HSK #1 sprayed more purple solution on the toilet seat, tank and outside of the toilet. HSK #1 immediately wiped the toilet seat, tank, flushing handle, toilet seat (which had visible brown residue on top and underneath) and the rim of the toilet bowl. HSK #1 placed the dirty rag on the toilet riser and moved the toilet riser back over the toilet. -HSK #1 did not allow the cleaning solution to remain wet on the surfaces of the toilet for the manufacturer recommended dwell time of 10 minutes. -HSK #1 failed to clean the toilet from a cleaner area to a dirtier area. HSK #1 returned to her cart, changed her gloves without performing hand hygiene, grabbed a new rag from the bucket on the cleaning cart and returned to the bathroom to clean the toilet riser and the toilet again as there was still brown residue on them. -HSK #1 failed to perform hand hygiene between gloves changes. HSK #1 returned to her cart and retrieved the broom from the cleaning cart to sweep the room. -HSK #1 failed to change her gloves and perform hand hygiene after cleaning the bathroom and before using the broom to sweep the floor. After sweeping the room with the broom, HSK #1 retrieved a mop pad from the bucket on her cleaning cart wearing the same gloves she had worn to clean the bathroom. She wrung out the mop pad allowing the excess solution to drip back into the bucket. -HSK #1 did not remove her gloves and perform hand hygiene before reaching into the bucket of solution for the mop pad. HSK #1 returned to the room and mopped from the window to the bathroom and then to the main doorway of the room. While mopping the resident's room, HSK #1 touched the residents oxygen tubing, portable oxygen tank, wheelchair pedals, walker, shoes, bedside table, toilet riser and collected the trash from the trash can, all while wearing the same gloves she had been wearing to clean the bathroom. -HSK #1 failed to change her gloves and perform hand hygiene after cleaning the bathroom and before she touched multiple items in the resident's room while she was mopping the floor. -HSK #1 failed to use a separate mop pad after mopping the bathroom floor before she finished mopping the remainder of the resident's room. III. Staff interviews HSK #1 was interviewed on 3/26/24 at 10:15 a.m. HSK #1's primary language was French and a translating service was used during the interview. HSK #1 said the purple solution in the bottle was used to make it smell good. HSK #1 did not know the name of the solution but showed a bottle with the name of Fabuloso on the label. HSK #1 said she mixed the solution with water but was unable to say how much water to solution was used. HSK #1 identified the cleaning solution, the rags and mop pads were in a heavy duty tub and tile cleaner from the housekeeping closet dispensing system. HSK #1 identified the following areas as high touch areas which should be cleaned daily: bathroom, tables and the floors. HSK #1 said the call light and light switches were only cleaned twice a week. HSK #1 said she only needed to change gloves if they looked dirty or in between rooms. HSK #1 did not know if the cleaning products she was using were disinfectants or if they had a dwell time. The human resource director (HRD), who was also the housekeeping manager, was interviewed on 3/27/24 at 9:25 a.m. The HRD said she was overseeing housekeeping for ordering the supplies they needed and advising housekeepers when there was a discharge or new admission. The HRD said she was not involved in the training process of housekeepers. The HRD did not know if HSK #1 was provided training in her preferred language. The HRD said HSK #2 was the lead housekeeper and was in charge of training new housekeepers. The HRD said Fabuloso was not one of the approved cleaning chemicals for the facility and she did not know where it came from as it was not a product she had ordered for the facility. HSK #2, who was in charge of training new housekeepers, was interviewed via telephone on 3/27/24 at 10:10 a.m. HSK #2 said high touch items in resident rooms were doors, tables and call lights and should be cleaned daily. HSK #2 said Fabuloso was used to sanitize the rooms. HSK #2 said she used the dispenser in the housekeeping closet for the mopping solution and the solution for the rags. -However HSK #2 was not able to say the name of the chemical as she indicated the writing was too small for her to read on the labels. HSK #2 said she had trained two other housekeepers for the facility. HSK #2 was not able to confirm that HSK #1 was trained in her preferred language. The director of nursing (DON), who was also the facility's infection preventionist (IP), was interviewed on 3/27/24 at 10:29 a.m. The DON said she did not know what chemicals were being used for cleaning of resident rooms. The DON identified the following as high touch areas in a room which should be cleaned daily: television remote, light switches, bedside tables and call lights. The DON said she did not complete any specialized training to housekeepers and it was HSK #2's responsibility to train new housekeepers as she had been working at the facility the longest. The DON said she did not know if the training/education was provided to HSK #1 in her preferred language of French. The DON said she did not know the facility was using Fabuloso for cleaning resident rooms nor did she know what the dwell time of the cleaner was. The ED was interviewed on 3/27/24 at 11:23 a.m. The ED said the facility initially had a dual HRD/housekeeper who would complete inservice and training with the housekeepers. The ED said the facility relied currently on HSK #2 to complete training with new housekeepers. The ED was not aware the housekeeping staff was using an unapproved chemical (Fabuloso) for cleaning. The ED said housekeeping staff were to change their gloves and perform hand hygiene between cleaning the bathroom and the resident rooms to prevent contamination. The ED said high touch areas like call lights, television remotes, bedside tables and light switches should be cleaned daily.

Based on record review, and interviews, the facility failed to ensure immediate physician notification for one (#122) of three residents reviewed out of 26 sample residents. Specifically the facility failed to ensure the physician was notified of Resident #122's high blood sugar/glucose level readings that were out of physician ordered parameters. Findings include: I. Facility policy The Administering Medications policy and procedure, dated 2022, was provided by the director of nursing (DON) 12/14/22 at 2:49 p.m. It read in pertinent part, Medications shall be administered in a safe and timely manner, and as prescribed. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's attending physician or the facility's medical director to discuss the concerns. The following information must be checked/verified for each resident prior to administering: Vital signs, if necessary. II. Resident #122 A. Resident status Resident #122, age 80, was admitted on [DATE]. According to the December 2022 computerized physician orders (CPO), diagnoses included encephalopathy (brain disease that alters brain function), type 2 diabetes mellitus (too much sugar in the blood), ulcerative colitis (inflammatory bowel disease), Alzheimer's disease, and encounter for attention to colostomy (a surgical operation in which a piece of the colon was diverted to an artificial opening in abdominal wall so as to bypass a damaged part of the colon). The 12/8/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. He required extensive assistance with two persons for bed mobility and total dependence for bathing. He required limited assistance with one person for transfers, walking in the room/corridor, dressing, and personal hygiene. He required extensive assistance with one person for toilet use. B. Record review Review of the diabetes mellitus care plan, initiated 12/1/22, revealed the following interventions: Diabetes medication as ordered by the doctor. Monitor/document for side effects and effectiveness. Fasting serum blood sugar as ordered by doctor. Monitor/document/report to medical doctor (MD) as needed (PRN) signs and symptoms of hypoglycemia: sweating, tremor, increased heart rate (tachycardia), pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait. Monitor/document/report to MD PRN for signs or symptoms of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing (labored breathing pattern), acetone breath (smells fruity), stupor, coma. Review of the December 2022 computerized physician orders (CPO) revealed multiple medication changes related to diabetes mellitus (DM). Levemir Solution 100 unit/milliliter (ML) (Insulin Detemir). Inject 10 units subcutaneously at bedtime for DM. Start date 12/1/22, discontinue date 12/2/22. Insulin lispro solution. Inject 4 unit subcutaneously with meals for DM. Start date 12/1/22, discontinue date 12/2/22. Fasting blood sugar (FSBS) before meals four times a day. Start date 12/2/22. HumaLOG Solution 100 unit/ milliliter (ML)(Insulin Lispro). Inject 8 unit subcutaneously before meals for diabetes call medical doctor (MD) for blood sugar (BS) less than (<)70 and greater than ( >)350. Start date 12/2/22; discontinue date 12/8/22. HumaLOG Solution 100 unit/ML (Insulin Lispro). Inject 10 units subcutaneously one time only for hyperglycemia for one day recheck glucose in one hour, call if >400. Start date 12/2/22. HumaLOG Solution 100 unit/ML (Insulin Lispro (Human)). Inject 8 units subcutaneously before meals for diabetes call MD for BS<70 and >350. Start date 12/2/22, discontinue date 12/8/22. HumaLOG Solution (Insulin Lispro). Inject 20 units subcutaneously one time only for DM blood sugar high for one day, recheck one hour and if still high send to the emergency department (ED). Start date 12/2/22. Levemir Solution 100 unit/ML (Insulin Detemir). Inject 14 unit subcutaneously at bedtime for DM. Start date 12/2/22, discontinue date 12/2/22. Levemir Solution 100 unit/ML (Insulin Detemir). Inject 20 units subcutaneously at bedtime for DM. Start date 12/2/22, discontinue date 12/5/22. HumaLOG Solution Cartridge 100 unit/ML (Insulin Lispro). Inject 10 unit subcutaneously one time only for BS HI for one day. Start date 12/3/22, discontinue 12/3/22. HumaLOG Solution 100 unit/ML (Insulin Lispro). Inject 5 ml intramuscularly one time only for DM for one day. Start date 12/3/22. HumaLOG Solution (Insulin Lispro). Inject 16 unit intramuscularly one time only for HI BS for one day. Recheck in one hour. Start date 12/3/22. Levemir Solution (Insulin Detemir). Inject 24 units subcutaneously at bedtime for DM. Start date 12/6/22, discontinue date 12/8/22. HumaLOG Solution 100 unit/ML (Insulin Lispro). Inject 20 units subcutaneously one time only for DM II for one day. Start date 12/6/22. Prostat before meals for low albumin, poor appetite and to help avoid BS spikes. Give 30 ml prior to each meal. Start date 12/7/22. HumaLOG Solution 100 unit/ML(Insulin Lispro). Inject 15 units subcutaneously one time only for DM II for one day. Start date 12/7/22. HumaLOG Solution 100 unit/ML. (Insulin Lispro (Human)). Inject 10 units subcutaneously before meals for diabetes call MD for BS<70 and >350. Start date 12/8/22. Levemir Solution (Insulin Detemir). Inject 28 units subcutaneously at bedtime for DM. Start date 12/8/22, discontinue date 12/12/22. HumaLOG Solution 100 unit/ML(Insulin Lispro). Inject 15 units subcutaneously one time only for DM for one day. Start date 12/10/22. HumaLOG Solution 100 UNIT/ML (Insulin Lispro). Inject 8 unit subcutaneously one time only for DM II for one day check BS after one hour. Start date 12/10/22. Levemir Solution (Insulin Detemir). Inject 20 units subcutaneously at bedtime for DM. Start date 12/12/22. Levemir Solution (Insulin Detemir). Inject 12 units subcutaneously in the morning for DM. Start date 12/13/22. Review of the December 2022 medication and treatment administration record (MAR/TAR) revealed from 12/2/22 to 12/12/22 blood sugar readings were checked four times per day and were out of range listed below: -On 12/2/22 blood glucose reading was 500 at 11:00 a.m. and 500 at 4:00 p.m.; -On 12/3/22 blood glucose reading was 470 at 11:00 a.m. and 500 at 4:00 p.m.; -On 12/5/22 blood glucose reading was 445 at 4:00 p.m. and 520 at 8:00 p.m.; -On 12/6/22 blood glucose readings were not recorded at 4:00 p.m. or 8:00 p.m.; -On 12/7/22 blood glucose reading was 375 at 11:00 a.m., and readings were not recorded at 4:00 p.m. or 8:00 p.m.; -On 12/8/22 blood glucose reading was 397 at 4:00 p.m.; -On 12/9/22 blood glucose reading was 459 at 5:30 a.m., 403 at 11:00 a.m. and 389 at 8:00 p.m.; -On 12/10/22 blood glucose reading was 500 at 11:00 a.m. 500 at 4:00 p.m., and 581 at 8:00 p.m.; -On 12/12/22 blood glucose reading was not recorded at 11:00 a.m. Review of the nursing progress notes in Resident #122's electronic medical records (EMR) revealed the following notes related to the above blood glucose reading. The 12/2/22 at 12:06 p.m. nurses note read in pertinent part, fasting blood sugar (FSBS) reading high, MD notified new order received to give additional insulin four units and recheck in one hour. The 12/3/22 at 2:56 a.m. nurse note read in pertinent part, patient is being monitored for being a new admit and uncontrolled FSBS readings. This evening FSBS is 273. No signs or symptoms of hyper or hypoglycemia noted. patient' states I feel fine' . Fluid encouraged and snack provided. Signs and symptoms of hyper and hypoglycemia taught to the patient. Reports understanding. He is sleeping at the moment without distress call light kept at reach at all times, will continue to monitor. -No call to the physician documented on 12/3/22 for a blood glucose reading of 470 at 11:00 a.m., and 500 at 4:00 p.m. The 12/5/22 at 8:50 p.m. skilled status note read in pertinent part, Resident in bed most of shift. BS at 4:00 p.m. was 445. This nurse called MD, stated to give insulin at 5:00 p.m. as ordered and recheck after one hour, call MD if greater than 350. Repeat BS was 298. Resident not compliant with diet keeps requesting orange juice. Will continue to monitor, encourage resident to drink water rather than request juice. -No call to the physician documented on 12/5/22 for a blood glucose reading of 520 at 8:00 p.m. The 12/6/22 at 3:35 p.m. medication administration note read in pertinent part, FSBS (fasting blood sugar) before meal four times a day. Glucometer records 'HI' after two attempts. -However, there was no documentation that the physician was notified and the nurse failed to record the BS reading in the medication administration record it read NA (not applicable). The 12/6/22 at 7:18 p.m. medication administration note read in pertinent part, FSBS before meal four times a day. Glucometer records 'HI' . Notified MD. -However the nurse failed to record the BS reading in the medication administration record, it read NA. The 12/7/22 at 4:56 p.m. medication administration note read in pertinent part, FSBS before meal four times a day, record 'HI' . -However, there was no documentation that the physician was notified and the nurse failed to record the BS reading in the medication administration record, it read NA. The 12/7/22 at 7:07 p.m. medication administration note read in pertinent part, FSBS before meal four times a day. 'HI' . -However, there was no documentation that the physician was notified and the nurse failed to record the BS reading in the medication administration record, it read NA. -No call to the physician was documented on 12/8/22 for a blood glucose reading of 397 at 4:00 p.m. The 12/10/22 at 7:12 p.m. nurses note read in pertinent part, Resident BS check at said Hi, called MD,order was given to give 8 units of Humalog, rechecked after 1 hour result was HI, no was given, MD on call order to give additional 15 units Homolog , administered LUA (left upper arm). -No call to the physician was documented on 12/10/22 for a blood glucose reading of 500 at 11:00 a.m., and 500 at 4:00 p.m. The 12/12/22 at 12:02 p.m. medication administration note read in pertinent part, FSBS before meal four times a day 'hi' recheck 1 hour. The 12/12/22 at 12:04 p.m. nurses note read in pertinent part, BS hi. MD aware. Humalog 10 units administered and re-check in 1 hour. -The nurse failed to record the blood sugar reading in the medication administration record, it read NA. -The facility failed to call the physician when the blood sugar/glucose level readings were out of physician ordered parameters. C. Staff interview Registered nurse (RN) #1 was interviewed on 12/14/22 at 1:45 p.m. She said if a resident's blood sugar was out of range, the nurse should call the physician so they could adjust the treatment. She said the nurses should call the physician if that was what the parameters document. RN #2 was interviewed on 12/15/22 at 11:10 a.m. She said if the physician had parameters for blood sugar then the nurse should call. RN #2 said it was important to call if the blood sugar was out of range because the doctor may adjust the medications. If the blood sugar remains too high the resident could get ketoacidosis (a serious diabetes complication) and if too low the resident could get hypoglycemia (low blood sugar). RN #2 said she charted that she called the physician in the nursing progress notes. The DON was interviewed on 12/15/22 at 12:11 p.m. She said if there were blood sugar parameters to call the physician then the nurses should call so the doctor could adjust the medication. The DON said it was important to call because if the blood sugar was too high the resident could get hyperglycemic (high blood sugar) and if the blood sugar was too low they could get hypoglycemic which had symptoms of being shaky and sweaty. The DON said it was important to call if the residents' blood sugar were out of range.

Based on record review and interviews, the facility failed to ensure treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (#9) of three residents reviewed for quality of care out of 26 sample residents. Specifically, the facility failed to follow physician orders for Resident #9: -Humaglog solution (insulin) was not administered although the physician orders documented to administer if the fasting blood glucose was greater than 180; and, -Follow the physician orders six times when the blood sugar/glucose level readings were out of physician ordered parameters. Findings include: I. Facility policy The Administering Medications policy and procedure, dated 2022, was provided by the director of nursing (DON) 12/14/22 at 2:49 p.m. It read in pertinent part, Medications shall be administered in a safe and timely manner, and as prescribed. II. Resident #9 A. Resident status Resident #9, age 93, was admitted initially on 7/18/22, with readmission on 11/10/22 . According to the December 2022 computerized physician orders (CPO), diagnoses included acute respiratory failure with hypoxia (absence of enough oxygen), cerebral infarction (stroke), major depressive disorder (depressed mood), insomnia (sleep disorder), and type 2 diabetes mellitus (too much sugar in the blood). The 11/17/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. He required extensive assistance with two persons for bed mobility. Extensive assistance with one person for locomotion on the unit, and toilet use. Limited assistance with one person for transfers, walking in the room, dressing, and personal hygiene. B. Record review Review of the diabetes mellitus care plan, initiated 11/10/22, revealed the following interventions: Diabetes medication as ordered by the doctor. Monitor/document for side effects and effectiveness. Fasting serum blood sugar as ordered by doctor. Monitor/document/report to medical doctor (MD) as needed (PRN) signs and symptoms of hypoglycemia: sweating, tremor, increased heart rate (tachycardia), pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait. Monitor/document/report to MD PRN for signs or symptoms of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing (labored breathing pattern), acetone breath (smells fruity), stupor, coma. Review of the November and December 2022 computerized physician orders (CPO) revealed the following orders related to diabetes mellitus (DM), reviewed from 11/21/22 to 12/12/22. Blood Sugar (BS) check in the morning for DM II. Start date 11/22/22. HumaLOG Solution 100 unit/milliliter (ML) (Insulin Lispro (Human)). Inject four units subcutaneously every 24 hours as needed for DM2. Give if FBG (fasting blood sugar) greater than 180. Start date 11/21/22, discharge date [DATE] Review of the December and November 2022 medication and treatment administration record (MAR/TAR) revealed the following out of range blood sugar readings: On 11/22/22 the reading was 182; On 11/25/22 the reading was 223; On 11/28/22 the reading was 242; On 12/9/22 the reading was 200; On 12/10/22 the reading was 199; and, On 12/11/22 the reading was 187. -The Humaglog solution (insulin) was not administered per physician orders on 11/22/22, 11/25/22, 11/28/22, 12/9/22, 12/10/22, 12/11/22, although the blood sugar reading parameters said to give if FBG greater than (>)180. -The facility failed to follow the physician orders when the blood sugar/glucose level readings were out of physician ordered parameters and the insulin was not given. III. Staff interview Registered nurse (RN) #1 was interviewed on 12/14/22 at 1:45 p.m. She said the MD orders would say when to administer or hold a medication and the order would have a parameter. She said that was why the nurses took heart rate, blood pressure, and blood sugar. If blood sugar was out of range, the nurse called the MD in case they wanted to adjust the treatment. RN #2 was interviewed on 12/15/22 at 11:10 a.m. She said the nurses usually have parameters from the physician orders to know when to administer or hold a medication. If the physician had parameters for blood sugar being out of range then the nurse should follow it. If the blood sugar remains too high, the resident could get ketoacidosis (a serious diabetes complication) and if too low the resident could get hypoglycemia (low blood sugar). The DON was interviewed on 12/15/22 at 12:11 p.m. She said it was good to have parameters with medication if that was what the doctor wanted. The DON said the nurse knows when to hold or administer a medication depending on the MD orders.

Based on observations and interviews the facility failed to establish and maintain infection control designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections for two of three units. Specifically the facility failed to: -Ensure proper hand hygiene was performed between residents during medication administration; and, -Ensure multiple use medical equipment was sanitized between residents. Findings include: I. Professional reference The Disinfection of Medical Equipment, updated 5/24/19, retrieved on 12/21/22, from: https://www.cdc.gov/infectioncontrol/guidelines/disinfection/healthcare-equipment.html, documented in part. Equipment; scissors, hemostats, clamps, blood pressure cuffs, stethoscopes should be disinfected with an EPA (Environmental Protection Agency)-registered disinfectant unless the item is visibly contaminated with blood; in that case a tuberculocidal agent (or a disinfectant with specific label claims for HBV and HIV) or a 1:100 dilution of a hypochlorite solution (500-600 ppm free chlorine) should be used. This procedure accomplishes two goals: it removes soil on a regular basis and maintains an environment that is consistent with good patient care. The Hand Hygiene guidance, updated 1/30/2020, retrieved on 12/21/22, from: https://www.cdc.gov/handhygiene/providers/guideline.html, documented in part, Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: after touching a patient or patients immediate environment and immediately after glove removal. II. Facility policy and procedures The Handwashing/Hand Hygiene policy, undated, received from the director of nursing (DON) on 12/14/22 at 10:52 a.m. revealed in pertinent part, the facility considers hand hygiene the primary means to prevent the spread of infection. The use of an alcohol based hand rub containing 62% alcohol, or soap and water can be used before preparing or handling medications, after contact with objects like medical equipment in the immediate vicinity of the residents. The Cleaning and Disinfecting of Resident-Care Items and Equipment policy, undated, received from the DON on 12/14/22 at 10:52 a.m. revealed in pertinent part, resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected. Non critical items are those who come in contact with intact skin but no mucous membranes, like blood pressure cuffs are cleaned and disinfected between residents. III. Observations On 12/14/22 at 7:55 a.m. licensed practical nurse (LPN) #1 was observed preparing medications for Resident #5. She prepared the medications on the medication cart stationed outside the nurses station. She carried the medication cup and blood pressure machine to the resident's room, knocked on the resident door and entered. She failed to perform hand hygiene upon entering the resident's room. While in the room the LPN took the resident's blood pressure placing machine on the resident's bed. She then administered the medications. The LPN exited the resident room with the blood pressure cuff and placed it on the nurses medications cart. She failed to sanitize her hands and disinfect the blood pressure machine after exiting the residents room. At 8:07 a.m. LPN #1 began to prepare medications for Resident #8 after leaving Resident #5's room. She prepared the medications on the medication cart stationed outside the nurses station. She carried the medication cup and the unsanitized blood pressure machine to the resident's room. She knocked on the resident door and entered. She failed to perform hand hygiene upon entering Resident #8's room. While in the room LPN took the resident's blood pressure with an un sanitized blood pressure machine she had placed on the resident's bed, then administered medications to the resident. She exited the resident's room, returned to the medication cart and placed the blood pressure cuff on it. The LPN failed to perform hand hygiene and disinfect medical equipment upon exiting Resident #8 room. At 8:22 a.m. LPN #1 was observed preparing medications for Resident #4 after leaving Resident #8's room. She prepared the medications on the medication cart stationed outside the nurses station. She carried the medication cup, the unsanitized blood pressure machine to the resident's room. She knocked on the resident door and entered. She failed to perform hand hygiene upon entering the resident's room. While in the room she took the resident's blood pressure with an unsanitized blood pressure cuff and administered the resident's medications. The LPN exited the room, returned to the medication cart and failed to sanitize the blood pressure machine and perform hand hygiene. At 8:51 a.m. LPN #1 was observed preparing medications for Resident #178 after exiting Resident #4's rooms. She prepared the medications on the medication cart stationed outside the nurses station. She carried the medication cup to the resident's room, knocked on the resident door and entered. She failed to perform hand hygiene upon entering, then administered medications to the resident. She removed the resident's breakfast tray on exit and placed it on the food cart. She then returned to the medications cart and began preparing the next resident's medication. She did not perform any hand hygiene. At 8:57 a.m. LPN #1 was observed preparing medications for Resident #176 on the medication cart stationed outside the nurses station. She carried the medication cup and a container to the resident's room. She knocked on the resident door and entered. She failed to perform hand hygiene upon entering. She placed the container she brought into the residents room on the resident's bed which contained the vitals equipment; the contaminated blood pressure cuff, thermometer, and pulse oximeter (used to measure oxygen levels in the body). She obtained the resident's blood pressure reading and then administered medications. The LPN collected the container with vitals equipment and returned to the medication cart. The LPN failed to sanitize hands and vitals equipment. The LPN began dispensing the next resident's medication. At 9:20 a.m. LPN #1 dispensed medications for Resident #171. She did not perform hand hygiene prior to medication dispensing. She took a medication cup and the container with contaminated vital sign equipment into the resident's room. She set the container on the resident's bed, took the resident's blood pressure with the contaminated blood pressure cuff. The resident requested to have her pulse oximeter taken, and the nurse placed the pulse oximeter on the resident's finger. She administered medications, collected the container with the vitals sign equipment and returned to the medication cart. No hand hygiene or equipment sanitization was observed. IV. Staff interviews LPN #1 was interviewed on 12/14/22 at 9:29 a.m. She said washing hands between residents should be done but if gloves were used she did not wash her hands. The vital equipment used was not resident specific, the staff used it on all residents on the wing. She said each wing had a set. She said if a resident was in isolation then disposable equipment were used or wiping equipment down with sani-cloth must be completed. She said after wiping equipment with sani-cloth they must dry before they could be used on another resident. She said the equipment should be cleaned once at the beginning of the shift. Certified nurse aide (CNA) #1 was interviewed on 12/14/22 at 9:40 a.m. She said hand hygiene and disinfecting of vital sign equipment should be cleaned between residents. She said sanitizing equipment was to be completed with the purple top Sani-cloth wipes. She said all residents could share the vital sign equipment since no resident was on isolation. She said if a resident was on isolation they would have used disposable equipment. The DON was interviewed on 12/14/22 at 2:56 p.m. She said staff were to perform hand hygiene between residents. She said medical equipment should be wiped down with sani-cloth and allowed to air dry between residents. She said during medication administration, the nurse should sanitize prior to starting the preparation of medications for each resident. The infection preventionist (IP) was interviewed on 12/15/22 at 10:00 a.m. She said hand hygiene for staff should occur before and after resident care or if their hands become soiled. If the same vital sign equipment was used on multiple residents, it needed to be sanitized between residents with the sani-cloths and allowed to air dry.

Based on record review and interviews the facility failed to provide ostomy care to one resident (#122) of one resident reviewed out of 26 sample residents. Specifically, the facility failed to: -Ensure physician orders were in place to provide colostomy care for Resident #122; and, -Ensure there was a comprehensive care plan for colostomy care. Findings include: I. Facility policy The Colostomy/Ileostomy Care policy and procedure, dated 2022, was provided by the director of nursing (DON) on 12/14/22 at 2:45 p.m. The policy read in pertinent part, The purpose of this procedure is to provide guidelines that will aid in preventing exposure of the resident's skin to fecal matter. Review the resident's care plan to assess for any special needs of the resident. The following information may be recorded in the resident's medical record: the date and time the colostomy/ileostomy care was provided; the name and title of the individual(s) who provided the colostomy/ileostomy care; any breaks in resident's skin, signs of infection (purulent discharge, pain, redness, swelling, temperature), or excoriation of skin; how the resident tolerated the procedure; if the resident refused the procedure, the reason(s) why and the intervention taken; the signature and title of the person recording the data. Report other information in accordance with facility policy and professional standards of practice. II. Resident #122 A. Resident status Resident #122, age 80, was admitted on [DATE]. According to the December 2022 computerized physician orders (CPO), diagnoses included encephalopathy (brain disease that alters brain function), type 2 diabetes mellitus, ulcerative colitis (inflammatory bowel disease), Alzheimer's disease, and encounter for attention to colostomy (a surgical operation in which a piece of the colon was diverted to an artificial opening in abdominal wall so as to bypass a damaged part of the colon). The 12/8/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. He required extensive assistance with two persons for bed mobility and total dependence for bathing. He required limited assistance with one person for transfers, walking in the room/corridor, dressing, and personal hygiene. He required extensive assistance with one person for toilet use. The MDS revealed an ostomy (colostomy) appliance. B. Record review The baseline/admission care plan, dated 12/1/22, was reviewed. It acknowledged that the resident had a ostomy (colostomy) and that he was not able to care for the device independently. -The appliance description and date last changed box was blank and there was no other care information. Review of the comprehensive care plan revealed there was no care plan for colostomy care. There was a care plan related to an alteration in gastrointestinal status related to ulcerative colitis, date initiated 12/1/22. Interventions included to give medications as ordered. Monitor/document side effects and effectiveness. Monitor vital signs as ordered/per protocol and record. Notify a medical doctor (MD) of significant abnormalities (rapid pulse, shallow, rapid or labored respiration, low blood pressure). Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Review of the December 2022 CPO revealed there were no orders for the care of the colostomy. Review of the December 2022 medication and treatment administration record (MAR/TAR) revealed there was no documentation for care of the colostomy. Review of all the progress notes related to colostomy care from 12/1/22 to 12/13/22 revealed: No documentation of colostomy care in the progress notes for the first four days after admission. The 12/5/22 skilled status note read in pertinent part, the colostomy site changed due to leakage. The 12/8/22 skilled status note read in pertinent part, late entry, colostomy set changed. The 12/8/22 nurses note read in pertinent part, colostomy intact. The 12/9/22 skilled status note read in pertinent part, the colostomy set changed. The 12/9/22 skilled status note read in pertinent part, late entry colostomy bag was changed frequently/shift due to leakage. The 12/9/22 skilled status note read in pertinent part, late entry colostomy set changed. The 12/12/22 nurses note read in pertinent part, colostomy in place. -Treatment was provided without a physician's order or a care plan. III. Staff interview Registered nurse (RN) #1 was interviewed on 12/14/22 at 1:45 p.m. RN #1 said there should be a physician order for Resident #122's colostomy care. RN #1 said she had thought there was an as needed order (PRN) to change the colostomy when full. She said she just emptied it when full. RN #1 said the colostomy had been leaking so the nurses were working on that. The DON was interviewed on 12/15/22 at 10:54 a.m. She said the medical records/central supplies department ordered the colostomy supplies. The DON said the type or brand they used at the facility was Convac which was a wafer two piece with a bag. The DON said the nurses empty the bag from the clip at the bottom. The DON said there should be a care plan for the colostomy care and there should be doctors orders. The DON said proper care for the colostomy included changing it when it leaks, weekly or as needed. She said to empty it as needed and clean the area with an incontinence care wipe and apply barrier cream. RN #2 was interviewed on 12/15/22 at 11:21 a.m. She said she knew how to change a colostomy from learning at school and according to professional standards of practices. RN #2 said there should be physician orders for colostomy care which would include to empty and change as needed. RN #2 said she had been providing that care for Resident #122 although the orders were not there. RN #2 said that Resident #122 was not able to care for the colostomy on his own. RN #2 said there should be a care plan for his colostomy care. RN #2 said that Resident #122's colostomy had been leaking, and she thought it was because of his thin bowel movements and the position/location of his colostomy. The assistant director of nursing (ADON)/infection preventionist (IP) was interviewed on 12/15/22 at 11:27 a.m. She said Resident #122 had finished his antibiotic treatment on 12/4/22. The ADON said he had been on an antibiotic for an urinary tract infection (UTI) (admitted to the facility with) caused by escherichia coli (E. coli) bacteria but he was now feeling better. The ADON said it was important to prevent a recurring UTI by performing proper peri care, hand washing, colostomy care and cleaning, and emptying and changing as needed. The ADON said there should be a care plan and a doctor's order for the colostomy care. The ADON said the nurses know how to care for the colostomy from nursing standards of care. The ADON said she saw that Resident #122 did not have MD orders or a care plan for the colostomy care but the nurses added them (after being identified on survey). The MDS coordinator (MDSC) was interviewed on 12/15/22 at 12:04 p.m. She said added the colostomy care to the care plan today for Resident #122 but that she back-dated the medical record to when he was first admitted (12/1/22) because she said the nurses had been doing the care. D. Facility follow-up On 12/15/22 at 12:02 p.m. the MDSC presented a copy of Resident #122's care plan with a new intervention added to the alteration in gastrointestinal status related to ulcerative colitis section. It read, Colostomy care per orders. -However, it read that the intervention was initiated on 12/1/22 although it was newly created and added on 12/15/22. The MDSC said she had back-dated the medical record. She said she had done so because the staff had already been providing care. New CPO were added on 12/14/22 at 2:00 p.m. it read, Colostomy care Q shift (every shift) and change as needed, every shift for skin maintenance. -Resident #122 had been in the facility 14 days (admitted [DATE]) before the MD orders were added.

Based on record review and interviews, the facility failed to ensure that residents were free of unnecessary psychotropic medications for one (#9) of three residents reviewed for unnecessary medication out of 26 sample residents. Specifically, the facility failed to: -Track hours of sleep to evaluate the effectiveness of an antidepressant (Trazodone) being utilized as a hypnotic for the diagnosis of insomnia for Residents #9; -Have a physician's order to track and monitor hours of sleep for Resident #9; and, -Have non-pharmacological interventions on plan of care for insomnia for Resident #9. Findings include: I. Professional reference Davis's Drug Guide for Nurses Handbook seventeenth edition, copyright 2021, Vallerand and Sanoski, Philadelphia, PA, pp. 1233-1235. Read in part: Trazodone-classification: antidepressant. Indications: Major depression. Unlabeled use: Insomnia. Side effects: drowsiness most frequently, suicidal thoughts, confusion, dizziness and fatigue. Assess mental status, orientation, mood, and behavior frequently. The total daily dose may be given at bedtime to decrease daytime drowsiness and dizziness. Retrieved 12/19/22. II. Resident #9 A. Resident status Resident #9, age 93, was admitted initially on 7/18/22 with readmission on 11/10/22. According to the December 2022 computerized physician orders (CPO), diagnoses included acute respiratory failure with hypoxia (absence of enough oxygen), cerebral infarction (stroke), major depressive disorder (depressed mood), and insomnia (sleep disorder). The 11/17/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. He required extensive assistance with two persons for bed mobility. Extensive assistance with one person for locomotion on the unit, and toilet use. Limited assistance with one person for transfers, walking in the room, dressing, and personal hygiene. The resident mood interview (PHQ-9) revealed a total severity score of zero indicating no depression; and answered no to trouble falling or staying asleep, or sleeping too much. The MDS assessment revealed no behavioral symptoms or rejection of care. Antidepressant medications were administered for seven days during the review period. B. Record review The December 2022 CPO revealed the following physician orders: Trazodone hydrochloride (HCl) Tablet 50 milligrams (MG), give one tablet by mouth at bedtime for insomnia associated with depression. Start date 11/10/22. Nortriptyline HCl Capsule 10 MG, give one capsule by mouth at bedtime for depression. Start date 11/10/22. Melatonin Tablet 5 MG, give one tablet by mouth at bedtime for supplement. Start date 11/10/22. -There were no physician orders for monitoring hours of sleep. Review of the December and November 2022 medication and treatment administration record (MAR/TAR) revealed there was no documentation since the resident's readmission on 11/10/22 of the facility monitoring his hours of sleep to evaluate the effectiveness of the antidepressant being utilized as a hypnotic for the diagnosis of insomnia. Review of the care plan related to residents use of antidepressant medications (Nortriptyline and Trazodone) related to depression and insomnia, date initiated 11/10/22. Interventions included giving antidepressant medications ordered by a physician. Monitor/document side effects and effectiveness. Antidepressant side effects: dry mouth, dry eyes, constipation, urinary retention, suicidal ideations. Monitor hours of sleep. Monitor/document/report to the medical doctor (MD) as needed (PRN) ongoing signs and symptoms (s/sx) of depression unaltered by antidepressant meds: Sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, neg. mood/comments, slowed movement , agitation, disrupted sleep, fatigue, lethargy, did not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance, date initiated 11/10/22. -Although the care plan included to monitor hours of sleep, the facility did not begin monitoring until 12/12/22, 33 days after initiating the care plan. -The care plan did not include non-pharmacological interventions for the resident's insomnia. Review of all progress notes related to sleep from 11/10/22 to 12/12/22, revealed inconsistent documentation about Resident #9's sleep patterns; and no documentation of the resident's actual hours of sleep throughout the day and night. The 11/11/22 at 1:43 a.m. nurses note read in pertinent part, He is sleeping in need, with eyes closed at this moment, without apparent distress, will monitor. The 12/12/22 12:32 a.m. nurses note read in pertinent part, sleeping well. III. Staff interviews Registered nurse (RN) #2 was interviewed on 12/15/22 at 11:10 a.m. She said if a resident was on medication to assist with sleeping due to insomnia the nurses should have physician orders to track the hours of sleep. RN #2 said the reason to track the hours of sleep would be to see if the medication was working and to see if a resident was sleeping more in the daytime or night. The director of nursing (DON) was interviewed on 12/15/22 at 12:21 p.m. She said that the non-pharmacological interventions that could be used for insomnia included offering an activity, tea or massage. The DON said she expected the non-pharmacological approaches to be in the resident's care plan and if they were administered it would be documented in the progress notes. The DON said the facility monitored the trazodone medication, used for insomnia, by monitoring the hours of sleep. The DON said it was important to monitor sleep in order to know if the sleep medication was helping. If it was not helping the nurses would notify the MD to see if they want to try something new. The DON said she did not know why the resident was taking the Melatonin supplement. IV. Facility follow-up A new CPO was added on 12/12/22 at 2:00 p.m., during the survey, it read, Monitor number of hours of sleep every shift. Start date 12/12/22. -However, resident had been using the medication for 33 days (since readmission on 11/10/22) without the facility monitoring his hours of sleep to evaluate the effectiveness of the antidepressant being utilized as a hypnotic for the diagnosis of insomnia.

Based on record review, observations, and staff interviews, the facility failed to ensure two (#5 and #2) of three residents reviewed for accident hazards out of six sample residents, were provided adequate supervision and a safe environment to prevent accidents. Resident #5 was admitted to the facility on [DATE] with a history of falls. The resident had ten falls from 4/19/22 through 8/7/22. The facility failed to implement effective fall precautions with his risk of falling. On 4/21/22 the resident sustained a head injury following a fall which required hospital treatment. Observations on survey from 8/17/22 to 8/18/22 revealed fall measures were not consistently implemented. In addition, the facility failed to ensure Resident #2 had all interventions in place to prevent falls. Findings include: I. Facility policy The Fall Prevention Program policy, undated, was provided by the director of nursing (DON) on 8/18/2022. It reads in pertinent part, the fall prevention program is designed to ensure a safe environment for all residents, with a purpose of gathering accurate, objective and consistent data for the purpose of implementing an individualized Plan of Care designated to meet the resident's needs. It ensures consistency in the implementation of preventative measures to assist with the reduction of falls. The director of nursing (DON) or designees will be responsible for ensuring that residents who have been identified at risk or have experienced a recent fall have all recommended interventions in place. II. Resident #5 A. Resident status Resident #5, age 88, was admitted on [DATE]. According to the June 2022 Care Plan, diagnoses included history of falling, polyneuropathy, dependence on supplemental oxygen, type 2 diabetes mellitus with [CONDITION(S)], urinary tract infection, [CONDITION(S)], and [CONDITION(S)]. The 3/9/22 minimum data set (MDS) assessment showed the resident had a score of 12 out of 15 for the brief interview of mental status (BIMS), which indicated moderate cognitive impairment. The resident required one person physical assist with bed mobility, transfers, walking, dressing, eating, toileting and hygiene. The MDS fall indicated the resident had no falls in the month prior to admission and no falls in the two to six months prior to admission. B. Observations On 8/17/22 at 4:00 p.m., the resident was lying in bed. The fall mat to the right of the bed was folded in two and was at the end of the bed. The fall mat on the left was folded in two and was at the end of the bed. A chair was next to the bed near the head on the left. The bed was not in a low position. On 8/18/22 at 8:50a.m., the resident was lying in bed. The fall mats were in the exact location as the previous day. On 8/18/22 at 9:02 a.m., registered nurse (RN) #1 observed the mats did not extend the length of the bed. The bed was a wide bed, however it was not in the low position. C. Record review The care plan last updated on 6/3/22 identified the resident was at risk for falls related to deconditioning, and had an activities of daily living (ADL) self care deficit related to impaired balance. Pertinent approaches included frequent room checks (added 6/3/22), remind the resident to call for assistance with toileting (added 5/31/22), non skid socks (added 5/27/22),a wide bed for safety (added 4/21/22), a sensor call light to be within reach (added 4/20/22), and anticipate needs (added 3/3/22). -The care plan was not updated after the resident fell on [DATE] and he had fallen an additional six times. 1. Fall on 4/19/22 The 4/19/22 nurse progress note documented Resident #5 was found on the floor in front of the door, with a skin tear noted on the right forearm. The intervention for this fall was a sensor call light within reach, which was added to the care plan. The 4/20/22 post fall progress notes that the resident's bed is in a low position. -However, it was not listed as an intervention on the fall risk care plan. 2. Fall on 4/21/22 The 4/21/22 nurse progress note documented Resident #5 was found laying on the floor facing the window next to the bed. He had a dent on the left side of the head, was in pain to the neck and back and unable to turn, and he was sent to the hospital. He returned from the hospital and had abrasions to the left side of the forehead and lateral side of the head, and bruises on the right and left hand and arm. The hospital reported concussion and neck strain, and the resident complained of neck pain. -The intervention for this fall recorded in the progress notes was a wider bed to be ordered by hospice, and was added to the care plan 4/21/22. The 4/22/22 post fall progress notes that the resident's bed is in a low position. -However, it was not listed as an intervention on the fall risk care plan. 3. Fall on 5/27/22 The 5/27/22 nurse progress note documented Resident #5 was found sitting on the bathroom floor. Injuries included a skin tear and long abrasion to the back; the resident complained of small pain to arm and back. He was assisted by staff members to get him off the floor. An x-ray was ordered and results on 5/28/22 were negative for a fracture to the left shoulder. The intervention for this fall included non-skid socks provided to the resident after the fall and was added to the care plan 5/27/22. -The previous interventions were to add a wide bed for safety and a sensor call light to be within reach; the progress notes did not indicate if the wide bed was in use or whether the call light was activated. The 5/30/22 post fall progress notes that the resident's bed is in a low position. -However, it was not listed as an intervention on the fall risk care plan. 4. Fall on 6/3/22 The 6/3/22 nurse progress note documented Resident #5 was found next to the toilet in the bathroom, attempting to get up holding the bathroom bar. He complained of left arm pain, but he was unsure if it was new or from his previous fall. The intervention for this fall was frequent room checks and was added to the care plan 6/3/22. Time intervals were not indicated for frequency. -The previous interventions were to add non-skid socks, a wide bed for safety and a sensor call light to be within reach; the progress notes did not indicate if the non-skid socks or the wide bed were in use or whether the call light was activated. The 6/6//22 post fall progress notes that the resident's bed is in a low position. -However, it was not listed as an intervention on the fall risk care plan. 5. Fall on 6/25/22 The 6/25/22 nurse progress note documented Resident #5 was heard yelling for help and was found on his bottom in front of his bed. He stated he slid off the bed onto the floor. No injuries were noted. It took four caregivers to assist the resident off the floor with maximum assistance into his recliner. -The intervention stated on 8/18/22 by the director of nursing (DON) was a bed evaluation that was completed and a wide bed with a bolster was added. -The previous interventions were to add frequent room checks, non-skid socks, a wide bed for safety and a sensor call light to be within reach; the progress notes did not indicate if the non-skid socks or the wide bed were in use or whether the call light was activated. Progress notes documented resident checks on 6/4/22 at 4:04 p.m., 6/4/22 at 4:13 p.m., 6/4/22 at 5:50 p.m., 6/5/22 at 4:10 p.m., 6/6/22 at 4:31 a.m. and 6/21/22 at 10:15 a.m. The 6/27/22 post fall progress notes that the resident's bed is in a low position. -However, it was not listed as an intervention on the fall risk care plan. 6. Fall on 7/7/22 The 7/7/22 nurse progress note documented Resident #5 slid off his wheelchair to the floor attempting to transfer to his chair. He was a two person assist transfer from the floor to his bed after the fall. He complained of pain to his left shoulder, neck and spine; he was combative and yelling and was unable to be redirected. He was sent to the emergency room where diagnostic tests were negative. The 7/8/22 progress note documented the intervention was a medication review for this resident. -The previous interventions were to add frequent room checks, non-skid socks, a wide bed for safety, bolster and a sensor call light to be within reach; the progress notes did not indicate if the non-skid socks or the wide bed with bolster were in use or whether the call light was activated. Progress notes documented resident checks on 6/27/22 at 7:07 a.m., 6/27/22 at 4:11 p.m., and 6/28/22 at 4:06 a.m. -However, the frequent checks were inconsistent and not indicated before the fall. The 7/11//22 post fall progress notes that the resident's bed is in a low position. -However, it was not listed as an intervention on the fall risk care plan. 7. Fall on 7/13/22 The 7/13/22 nurse progress note documented Resident #5 fell in the hallway after leaning against a wheelchair. A neighbor activated a call button to alert staff. Injuries included a right red knee and skin tear on the left forearm. Two staff members assisted the resident back to the wheelchair and into bed. The intervention stated on 8/18/22 by the DON was a medication review. -The previous interventions were to add frequent room checks, non-skid socks, a wide bed for safety with bolster and a sensor call light to be within reach; the progress notes did not indicate if the non-skid socks or the wide bed with bolster were in use or whether the call light was activated. Progress notes documented resident checks on 7/8/22 at 9:22 p.m., 7/9/22 at 9:29 p.m., 7/11/22 at 7:05 a.m., and 7/11/22 at 11:46 a.m. -However, the frequent checks were inconsistent and not indicated before the fall. 8. Fall on 7/27/22 The 7/27/22 nurse progress note documented Resident #5 was found on the floor next to the bed. He had a skin tear on the right elbow. The 7/28/22 progress notes intervention was a therapy screen which was refused by the family and a non-slip mat was placed under the residents' wheelchair cushion. -The previous interventions were to add frequent room checks, non-skid socks, a wide bed for safety with bolster and a sensor call light to be within reach; the progress notes did not indicate if the non-skid socks or the wide bed with bolster were in use, or whether the call light was activated. Progress notes documented resident checks on 7/14/22 at 4:00 a.m., 7/18/22 at 8:55 p.m., and 7/20/22 at 12:12 p.m. The 7/27/22 progress notes indicated the bed was in a low position post fall. -This intervention is not listed on the care plan. The 7/28/22 at 4:32 p.m. progress note post fall documented frequent visual checks. -However, the resident was already on frequent checks that were inconsistent. 9. Fall on 7/29/22 The 7/29/22 nurse progress note documented Resident #5 standing and trying to reach for the dresser. He lost his balance and fell on his back between the bed and the dresser. The resident complained of mild pain mid back. The intervention stated on 8/18/22 by the DON was a low bed with fall mats. -However, this was not added to the resident's fall care plan. -The previous interventions were to add frequent room checks, non-skid socks, a wide bed for safety with bolster and a sensor call light to be within reach; the progress notes did not indicate if the non-skid socks or the wide bed with bolster were in use, whether the call light was activated. 10. Fall on 8/7/22 The 8/7/22 nurse progress note documented Resident #5 found lying on the floor next to the door, with multiple skin tears on forearm and elbow bilaterally. Resident stated he had some pain all over his body. The intervention was a medication review documented in 8/15/22 internal medicine follow up. -The previous interventions were to add a low bed, frequent room checks, non-skid socks, a wide bed for safety with bolster and a sensor call light to be within reach; the progress notes did not indicate if the non-skid socks or the wide bed with bolster were in use, and whether the call light was activated. Progress notes documented a low bed on 7/31/22. Progress notes documented checks on 7/30/22 at 5:54 a.m., 7/30/22 at 7:42 p.m., 7/31/22 at 5:11 a.m., 7/31/22 at 9:57 a.m., 8/1/22 at 5:11a.m. and 8/1/22 at 10:20 a.m. D. Staff interview RN #1 was interviewed on 8/18/22 at 9:02 a.m. The RN said the resident was a fall risk. She said the resident had the fall mats to protect him if he fell from the bed. She said the mat on the left side of the bed needed to be the full length of the bed. She said the right side needed to only be at the bottom half of the bed, as the bed table was next to the bed. The director of nursing (DON) was interviewed on 8/18/22 at 2:38 p.m. The DON said the resident was a fall risk. She said the resident had experienced several falls throughout his stay from March 2022. She said the resident had post traumatic stress disorder ([CONDITION(S)]) from the war, which caused him to believe they were holding him against his will. The DON said post fall investigations were completed after each fall. She said new fall interventions were added after each fall, which included: She said for the 4/19/22 fall a sensor call light was added. She said for the 4/21/22 fall a medication review was completed which resulted in lowering the [MEDICATION(S)]. She said for the 6/3/22 fall frequent room checks were added. -The DON did not indicate how often the frequent room checks occurred. She said for the 6/25/22 fall a bed evaluation was completed and a wide bed with a bolster was added. She said for the 7/13/22 fall the medical director reviewed the record and his medications were adjusted. She said for the 7/29/22 fall it was witnessed. She said fall mats and a low bed were added. -However, the DON did not indicate what the fall interventions were for the 8/7/22 fall. In addition, the interventions the DON indicated were not consistently documented or implemented on the resident's care plan. The DON stated the fall mats were to be the length of the bed on both sides. She said she would provide education to the staff. III. Resident #2 A. Resident status Resident #2, age 83, was admitted on [DATE]. According to August 2022, CPO diagnoses included unspecified [CONDITION(S)], dementia with behavioral disturbance, chronic respiratory failure with [CONDITION(S)], and short-term memory loss with impaired cognitive function. The 8/10/22 MDS assessment rated the resident with a BIMS score of 11 which indicates she was moderately impaired cognitively. The resident had mobility issues and required assistance with transferring on and off the toilet and assistance with getting in and out of bed. B. Resident and representative interview A resident was interviewed on 8/17/2022 at 11:05 a.m. She said sometimes during the day it took 10 minutes for a call light to be answered and it was worse at night which at times takes over two hours for someone to respond to the call light. She said she gave up asking the staff to get her up during the day because they always say they were busy. The resident's legal authority was interviewed on 8/17/22 at 11:10 a.m. The legal authority said Resident #2 had several falls. She said she was concerned with all the falls she had been experiencing. She said the resident was supposed to have a wide bed and bolsters, however, the facility had not provided the wide mattress. C. Observations 8/17/22 -At approximately 11:00 a.m., the resident's bed was a single twin-size bed. -At 12:45 p.m. after lunch, Resident #2 was not asked to use the bathroom. She appeared to be confused about what she wanted and continued going back and forth in her wheelchair from her bedroom to the bathroom with her oxygen cannula wrapped around her wheelchair. -At approximately 1:30 p.m., Resident #2 was observed sitting in her wheelchair in the hallway. The resident was wearing an oxygen cannula hooked to the concentrator. The long oxygen tubing was wrapped around her wheelchair and was strung tight from the room to the hallway. -At 2:50 p.m., the resident continued to wheel herself back and forth to her bathroom with no staff assistance. 8/18/22 -At 9:20 a.m. during observation, the resident was in bed with the bed not in the lowest position. It was set at 22 inches from the ground. At 1:45 p.m., the resident was moving back and forth from her bedroom to her bathroom in her wheelchair. She had her oxygen cannula entangled around her wheelchair making it impossible for her to move as such she started yelling for help. -At 2:05 p.m., the resident was in her bathroom unsupervised with her oxygen wrapped around her wheelchair which appeared to be stuck. She started yelling for help before a CNA came to assist her. D. Record review The resident experienced four falls between June 2022 and July 2022. The 7/25/22 progress note indicated Resident #2 would be provided a reacher. The 7/6/22 progress note showed the resident had a fall from her bed. She did receive a skin tear to her right forearm 3.0 centimeters (cm) x 1.5cm. The 7/7/22 progress note documented the resident was at higher risk of falls and must be provided with a full-size bed with bolsters. The care plan dated 9/23/21 identified the resident was at high risk for falls. Pertinent approaches include the provision of a full-sized bed with bolsters and a long oxygen cannula to enable the resident to move around. E. Interviews The assistant director of nurses (ADON) was interviewed on 8/17/22 at approximately 3:15 p.m. The ADON said the resident required assistance with all her needs including toileting. She said the resident was at risk for falls. The director of nurses (DON) was interviewed on 8/18/22 at 2:53 p.m. The DON said the resident had experienced four falls since June 2022. She said interventions that were put into place were fall mats on each end of the bed, as the resident had fallen from the bed. She said the resident would attempt to self-transfer. The DON also said that some of the interventions put in place to mitigate the fall incident are to provide a longer oxygen tube to enable Resident #2 to move around freely. RN #7 was interviewed on 8/18/22 at 2:30 p.m. She said Resident#2 required assistance with all her incontinent needs and sometimes would try to help herself to the toilet which was not considered safe. She stated that sometimes she will have to go to the other side of the unit which was a distance away to pass medication which would leave no staff on the floor when the CNA was occupied with another resident. CNA #8 was interviewed on 8/18/2022 at 3:20 p.m. She said sometimes when the RN required assistance with a resident, she was always called to leave the hall to assist with whatever needed to be done, leaving the residents in that hall unsupervised. She said the residents in that hall were at risk of falls.

Based on observations, record review, and interviews, the facility failed to provide care and services to prevent the development and worsening of pressure injuries for two (#1 and #3) residents reviewed out of five sample residents. The facility failed to implement a care plan and monitor for worsening skin integrity for Resident #1 and #3 with interventions to prevent the development of pressure injuries even though the residents were high risk. The facility staff had identified redness and excoriation in Resident #1's weekly skin assessment on [DATE] on the resident's groin but did not document an assessment of the area until [DATE] and did not implement any interventions to prevent further breakdown from occurring. Without preventative measures being put into place, the coccyx area, which was avoidable, developed into unstageable pressure injury by [DATE], approximately 15 days later. He was sent to the hospital and later admitted to hospice. He died and the cause of death was [CONDITION(S)], necrotizing soft tissue infection and sacral decubitus ulcer. The facility staff had identified a callus on [DATE] to the heel on the care plan and then a stage 3 pressure injury in Resident #3's skin assessment on [DATE] on the residents left heel but did not document an assessment of the breakdown before that date and did not implement any interventions to prevent further breakdown from occurring.Without preventative measures being put into place, the heel, which was avoidable, developed into a stage three pressure injuries from admitted [DATE] to [DATE], approximately eight days later. Furthermore, the facility also failed to identify the development of a pressure wound in a timely manner and implement effective interventions to prevent further progression of the wound for Resident #1 and #3. Findings include: I. Professional references A. According to the NPUAP Pressure Injury Stages,The National Pressure Ulcer Advisory Panel - NPUAP. The National Pressure Ulcer Advisory Panel NPUAP. Web. ([DATE]) Accessed [DATE] from http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages. read in pertinent part: A pressure injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence as a result of pressure, or pressure in combination with shear. The updated staging system includes the following definitions: -Stage 1 Pressure Injury: Intact skin with a localized area of non-blanchable [CONDITION(S)]. -Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. -Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. -Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. -Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar was removed, a Stage 3 or Stage 4 pressure injury will be revealed. -Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized areas of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. B. According to the National Pressure Ulcer Advisory Panel (NPUAP), Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .). Cambridge Media: Osborne Park, Western Australia [DATE], accessed on [DATE]: Steps to prevent the worsening of existing pressure injuries and to promote healing include: Avoiding positioning that places pressure on the pressure injury, assessment and documentation of the pressure injury when discovered and reassessment and documentation at least weekly. Assessment should include location, category/stage, size, tissue types, color, periwound (the skin around the wound) condition, wound edges, and evidence of undermining or tunneling, exudate, and odor. The following steps should be taken to prevent the emergence of pressure ulcers in individuals identified as being at high risk: -Scheduled repositioning should be done to avoid individuals being in a position that places pressure on a vulnerable area for a long period of time. -Heels should be placed in a position that eliminates pressure, referred to as 'floating' the heels, by placing a cushion under the full back of the resident's calf. The following steps should be taken to prevent the worsening of existing pressure ulcers and promote healing: -Positioning that places pressure on the pressure injury should be avoided. -For heel ulcers, the heel should be floated. -The pressure ulcer should be assessed upon development and reassessed at least weekly. The results of assessments should be documented. -The ulcer should be observed with each dressing change for signs of infection, improvement, deterioration, or other complications. -Signs of deterioration in the wound should be addressed immediately. -The assessment should include: Location, Category/stage, Size, Tissue types, Color, Periwound, (the skin around the wound) condition, Wound edges, Any undermining or tunneling, Exudate (pus or clear like fluid), Odor. II. Facility policy The Pressure Ulcer Skin Breakdown policy, not dated, was provided by the director of nurses (DON) on [DATE] at 10:30 a.m. read in pertinent part; The nursing staff and practitioners will assess and document an individual's significant risk factors for developing pressure ulcers, for example, immobility, recent weight loss and a history of pressure ulcers. In addition, the nurse shall describe and document and report the following: -full assessment of pressure sore including location, stage length, width and depth, presence of exudates or necrotic tissue; -pain assessment findings, -residents mobility status, -current treatments including support surfaces and pertinent diagnosis, -Licensed nurse will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. The physician will assist the staff to identify the type and characteristics of an ulcer as needed. The physician will help identify and define any complications related to the pressure ulcer. III. Resident #1 A. Resident status Resident #1, age 89, was admitted on [DATE] and discharged to hospital [DATE]. According to the [DATE] computerized physician orders (CPO), the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of two out of 15. He required extensive two person assistance for bed mobility, transfers, dressing, toileting, and personal hygiene. Extensive assistance of one for dressing. He was incontinent with bowel and bladder. He had a risk for pressure ulcers. B. Record review The activities of daily living (ADL) dated [DATE] for Resident #1 read in pertinent part, Resident #1 had an ADL self care deficit. He will improve current level of function through the review date. Praise all efforts at self care. Physical therapy and occupational therapy to evaluate and treat as per physician's orders. Encourage the use of the call bell to call for assistance. Initial skin assessment dated [DATE] for Resident #1 read in pertinent part, Skin was intact with some bruising and laceration of the groin. Skin was at risk of breakdown. Head to toe skin assessment dated [DATE] for Resident #1 read in pertinent part, Bruising to left thigh and left abdominal area. Redness in the groin. The weekly skin check note on [DATE] Resident had skin issues, redness to the groin, bruising to left thigh and left abdominal area. The skin care plan revised on [DATE] for Resident #1 read in pertinent part, Resident #1 had potential and actual impairment to skin integrity related to impaired mobility: skin discolorations abdomen and left thigh, excoriation groin, shearing buttocks and sacrum. Resident #1 will be free from injury through the review date. Provide assistance with transfers. Provide assistance with bed mobility, repositioning in bed and as needed weekly skin and braden observation by a licensed nurse. Treatment as ordered by provider. Apply moisture barrier ointment every shift and as needed to the perineal area. Float heels in bed as tolerated. The [DATE] computerized physician orders (CPO) for Resident #1 read in pertinent part: -Braden scale in the evening every Thursday for skin maintenance. Start date was [DATE]; -Antifungal Cream two percent (%) applied to coccyx and buttocks topically two times a day for redness Start date [DATE]; -Antifungal Cream two percent (%) applied to coccyx and buttocks topically two times a day for redness Start date [DATE]; and, -[MEDICATION(S)] tablet 500 milligrams (mg). Give one tablet by mouth every 12 hours for five days for pneumonia and urinary tract infection. Start date [DATE]. Nurse note dated [DATE] for Resident #1 read in pertinent part, Resident pressure ulcer on the buttocks was a stage two. Will be seen and evaluated by the wound doctor. The unstageable pressure ulcer for Resident #1, dated [DATE], provided by the director of nurses (DON) on [DATE] read in pertinent part, Resident #1 will show signs of healing and remain free from infection by the review date. Interventions to administer medications as ordered. Monitor and document for side effects and effectiveness. Administers treatments as ordered and monitors for effectiveness. Air pressure mattress to bed and gel cushion to wheelchair. Assess, record and monitor wound healing. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progres. Report improvements and declines to the physician. The weekly skin check note on [DATE] documented the resident had skin issues, coccyx wound measured 9.0 centimeters (cm) x 6.2 cm x 0.1 cm. Weekly braden scale for Resident #1 on [DATE] was 14 moderate risk for skin breakdown, [DATE] was a 15, at risk for skin breakdown and [DATE] was a 12, high risk for skin breakdown. Skin wound note dated [DATE] for Resident #1 read in pertinent part; Resident had an unstageable coccyx wound measuring 9.0 centimeters (cm) by (x) 6.2 cm x 0.1 wound bed, 70 percent (%) granulation tissue and 30% slough tissue with scant serous drainage. The physician orders documented Coccyx, cleanse with wound cleanser, pat dry, barrier cream to peri wound, apply [MEDICATION(S)] to wound bed and cover with foam dressing every evening shift for deep tissues injury (DTI). Start date[DATE] and discontinued on [DATE]. The new order on [DATE] for coccyx-cleanse with wound cleanser, pat dry, barrier cream to peri wound, mesalt to wound bed and cover with foam dressing every day and evening shift for unstageable wound. New order on [DATE] cleanse with wound cleanser, pat dry, barrier cream to peri wound, pack 4x4 gauze soaked with Dakin's 0.25% solution to wound bed and cover with foam dressing every day and evening shift for unstageable wound. The physician order documented Prostat supplement drink, give two times a day for wound healing. Start date [DATE]. The weekly skin check note on [DATE] documented the resident had skin issues, bump on the top of right side of scalp. -The facility failed to implement any new interventions until [DATE]. Skin wound note dated [DATE] for Resident #1 read in pertinent part: Resident had an unstageable coccyx wound measuring 8.3 cm x 5.2 cm x 0.2 cm; wound bed 80% slough tissue and 20% scant serous drainage. The weekly skin check note on [DATE] documented the resident had skin issues, stage 2 bed sore on coccyx. The weekly skin check note on [DATE] documented the resident had skin issues, coccyx wound stage 2 pressure sore. The weekly skin check note on [DATE] documented the resident had skin issues, coccyx wound stage 3 pressure sore. -However, the [DATE] skin wound note documented the resident had an unstageable pressure ulcer (see above). Skin wound note dated [DATE] for Resident #1 read in pertinent part, Resident had an unstageable coccyx wound measuring 5.8 x 6.7 x 0.5 cm wound bed 90% slough tissue 10% granulation tissue moderate serous drainage. The physician order documented Right buttocks wound-cleanse with wound cleanser, pat dry, apply [MEDICATION(S)] to wound bed and cover with foam dressing. every day. Start date [DATE]. Nurse note for Resident #1 dated [DATE] read in pertinent part; Resident was sent to the hospital due to a change in condition: a consideration of [CONDITION(S)]; inability to keep the intravenous (IV) line in place to administer fluids. Vital signs showed the blood pressure ,d+[DATE], pulse at 113 beats per minute, respirations at 22 breaths a minute, temperature was 103 degrees fahrenheit. The order for hospitalization was obtained from the nurse practitioner who was present in person at that time. Family was notified. The emergency room note dated [DATE] read in pertinent part; Resident #1 presented from a long-term facility of reported fever, admitted for [CONDITION(S)] in the setting of necrotizing soft tissue infection of decubitus ulcer and respiratory infection. Now pursuing comfort measures. Cat scan showed a large ulcer overlying the right gluteal musculature and inferiorly along the right gluteal crease and peritoneum. Wound care team consulted urgently with concerns for necrotizing infection, but surgical debridement would be an intensive procedure with poor prognosis for meaningful recovery. Given the reality, the resident's family opted for comfort care. The resident was admitted to hospice and died on [DATE]. The death certificate for Resident #1 read in pertinent part; Cause of death was [CONDITION(S)], necrotizing soft tissue infection and sacral decubitus ulcer. IV. Resident #3 A. Resident status Resident #3, age 84, was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] MDS assessment revealed the resident was moderately impaired with a brief interview for mental status (BIMS) score of seven out of 15. He required extensive assistance from two persons for bed mobility, transfers, bathing, dressing and hygiene. He was at risk for pressure injuries. B. Observation and interviews Resident #3 was observed on [DATE] at 3:00 p.m, he sat in his wheelchair in the room. His feet were on the ground, no foot pedals on the wheelchair. He had socks on and no shoes. He had a regular mattress on his bed and foot and heel protector boots in the corner of the room. He had a dressing on his left heel and it was scrunched up under his sock. Some drainage was soaked on his sock. He said he did not know if he had any skin issues. He said he was hungry and waiting for his wife to arrive. -There were no orders for a specialty mattress or air mattress according to the [DATE] CPO. Licensed practical nurse (LPN) #1 was observed on [DATE] at 3:10 p.m. to change the bandage on Resident #3's left heel. The wound had some drainage on the bandage and it was cleaned. The heel was red around the edges and the size of a nickel. He said there were no concerns about the right heel and during observation of the heel there was a nickel size red scabbed area to the outer foot heel area. He said he would fill out an assessment. LPN #1 said he was not sure how the resident got the wound. He said when a new wound was noticed on a resident, an assessment was completed and the assistant director of nurses (ADON) was notified. He said Resident #3 wore heel protectors for protection. He said barrier cream was standard for everyone when they arrived in the facility for any redness to their bottom. -The facility failed to complete a skin assessment for the new skin found on right outer heel during observation on [DATE] for Resident #3 when reviewing the electronic medical record on [DATE]. Resident #3 was observed on [DATE] from 5:45 a.m. to 7:30 a.m to lie on his back in bed. He had heel foot protector boots on in bed. He remained on his back in bed with no care offered during that time. Resident #3 was observed to have wound care completed by the wound doctor on [DATE] at 11:37 a.m. Resident #3 laid in bed on his back, he had no heel protectors on. His heel measured 2.5 cm x 1.7 cm. Wound care was completed. The ADON assisted with the wound care and she said the resident wore his heel protectors to help protect the heels from shearing or breaking down. She was not aware of any new issues with the right heel. During observation the right outer side of the heel that laid on the bed showed a scabbed area that measured 1cm x 1.3 cm. Skin prep treatment was completed with the wound doctor. The ADON said she expected the nurses to complete a skin assessment weekly and if new skin issues were identified, during rounds. The ADON said the skin assessment should be thorough assessing the resident's whole body for skin issues. The wound doctor and the ADON agreed the resident should wear the heel protection boots at all times. The wound doctor said Resident #3 did not have an air pressure relieving mattress on his bed. The ADON was going to look into getting one for Resident #3. C. Record review The activities of daily living (ADL) care plan for Resident #3 dated [DATE] read in pertinent part, Resident #3 had an ADL self care deficit. He will improve the current level of function through the review date. Praise all efforts at self care. Physical therapy and occupational therapy to evaluate and treat as per physician's orders.Encourage the use of the call bell to call for assistance. Initial skin assessment dated [DATE] for Resident #3 read in pertinent part, Resident #3 was a moderate risk for pressure sore injuries. He had a skin tear and bruising. Intervention was to do a skin check weekly. The weekly braden scale for Resident #3 on [DATE] was 19 at risk for skin breakdown, [DATE] was a 18 at risk for skin breakdown, [DATE] was a 19 at risk for skin breakdown. The weekly skin and heel check notes on [DATE] documented the resident had skin issues, open area to abdominal area, heel had no issues. The weekly skin and heel check notes on [DATE] documented the resident had skin issues, no heel issues. The weekly skin and heel check notes on [DATE] documented the resident had no issues and skin review revealed bilateral [CONDITION(S)] to lower extremities. No heel issues. The weekly skin and heel check notes on [DATE] documented the resident had no skin issues or heel issues. The weekly skin and heel check notes on [DATE] documented the resident had no skin issues or heel issues, and; The weekly skin and heel check notes on [DATE] documented the resident had no skin issues or heel issues. Skin assessments and progress notes for Resident #3 were requested through [DATE]. No other skin assessments or progress notes were provided by the facility from [DATE] to [DATE]. The skin integrity care plan for Resident #3 revised on [DATE] read in pertinent part; Resident #3 had potential impairment to skin integrity related to a heel callus. He will be free from injury through the review date. Interventions were to provide assistance with transfers. Provide assistance with bed mobility, repositioning in bed as needed, weekly skin and braden observation by a licensed nurse. Treatments as ordered by provider. Apply moisture barrier ointment every day and as needed to the peri area. Float heels in bed as tolerated. The [DATE] computerized physician orders (CPO) read in pertinent part: -Weekly skin assessments. Start date [DATE]. Skin and wound note for Resident #3 dated [DATE] read in pertinent part; Resident # 3 Stage three to left heel measured 2.0 cm x 3.5 cm x0.1 cm minimal serous drainage, no depth wound bed 70% granulation tissue and 30% slough with moderate serous drainage. Braden scale on [DATE] was a 19 at risk for skin breakdown, however, the facility failed to implement any new interventions until [DATE]. The stage 3 pressure ulcer for Resident #3 dated [DATE], provided by the director of nurses (DON) on [DATE] read in pertinent part, Resident #3 had a left heel pressure ulcer due to immobility. The pressure ulcer will show signs of healing and remain free from infection through the review date. Interventions to administer medications as ordered. Monitor and document for side effects and effectiveness. Administers treatments as ordered and monitors for effectiveness. Air pressure mattress to bed. Assess, record and monitor wound healing. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progres. Report improvements and declines to the physician. Skin and wound note for Resident #3 dated [DATE] read in pertinent part, Resident #3 Stage three to the left heel measured 3.2 cm x 4.3 cm x 0.1 cm minimal serous drainage, no depth wound bed, 50% granulation tissue and 50% slough with moderate serous drainage. Braden scale on [DATE] indicated he was at risk for skin breakdown. Skin and wound note for Resident #3 dated [DATE] read in pertinent part; Resident #3 Stage three to the left heel measured 2.8 cm x 4.0 cm x 0.3 cm minimal serous drainage, no depth wound bed, 50% granulation tissue and 50% slough with moderate serous drainage. The physician order documented Prostat supplement two times a day for wound healing. Start date was [DATE]. Skin and wound note for Resident #3 dated [DATE] read in pertinent part; Resident #3 had a stage three to left heel measured 2.8 cm x 3.2 cm x 0.2 cm minimal serous drainage, no depth wound bed 40% granulation tissue and 60% slough with moderate serous drainage. Skin and wound note for Resident #3 dated [DATE] read in pertinent part; Resident #3 had a stage three to left heel measured 2.8 cm x 2.8 cm x 0.1 cm minimal serous drainage, no depth wound bed 80% granulation tissue and 20% slough with moderate serous drainage. Skin and wound note for Resident #3 dated [DATE] read in pertinent part; Resident #3 had a stage three to left heel measured 3.0 cm x 2.9 cm x 0.1 cm minimal serous drainage, no depth wound bed 70% granulation tissue and 30% slough with moderate serous drainage. Skin and wound note for Resident #3 dated [DATE] read in pertinent part; Resident #3 had a stage three to left heel measured 3.5 cm x 3.0 cm x 0.1 cm minimal serous drainage, no depth wound bed 75% granulation tissue and 25% slough with moderate serous drainage. Braden scale on [DATE] indicated the score was 15, at risk for skin breakdown. The physician's order documented left heel cleanse with wound cleanser, pat dry, apply [MEDICATION(S)] and alginate to the wound bed,cover with an abdominal pad and kerlix with foam dressing; Start date was [DATE]. -There was no notification to the physician for the new right heel wound and there was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V. Staff interviews Certified nurse aide (CNA) #1 was interviewed on [DATE] at 3:15 p.m. She said when a new skin issue was seen on a resident she told the nurse. She said depending on what the skin looked like the nurse got a new order for treatments or had the wound doctor come and see them. She said Resident #3 had a new heel wound a few months ago because he found it and told the nurse. She said he wore special sandals and socks to protect and the bunny boots when he was in bed. She said she remembered Resident #1 and he had a bad wound on his bottom. She said he went to the hospital and did not come back. She said he was a large man who needed a lot of care. She said the staff tried to reposition residents every few hours to help with movement and she said Resident #1 had an air mattress to help him. CNA #3 was interviewed on [DATE] at 6:05 a.m. She said she repositioned the residents every two hours. Some residents refused or did not want assistance. She said Resident #3 had bunny boots on at night and he preferred to stay on his back while in bed. CNA #5 was interviewed on [DATE] at 6:30 a.m. She said when there was a new skin issue the nurse was notified and she would come to look at the skin issue. She said barrier cream gets put on every resident regardless; it was standard for them to do that. Registered nurse (RN) #1 was interviewed at 6:35 a.m. She said any new skin redness was documented right away and new treatments were started. She said a skin issue never goes from redness to a stage 2 or 3. She said if a resident developed a new pressure injury in the facility that would not be good. She said the wound doctor came weekly to see those residents. The director of nurses (DON) was interviewed on [DATE] at 9:00 a.m. She said nurses did the head to toe skin assessments weekly and when there were areas of concern the residents were put on wound rounds to be seen by the wound doctor. She said redness seen on a resident could turn into a stage 2 or 3 wound quickly when the resident was compromised. She said the facility staff offset the redness to resident's heels and bottoms with specialty mattresses and heel protectors. She said repositioning and turning residents every few hours could help and she acknowledged the need to reposition often and to wear the heel protectors. She said Resident #1 had redness on his groin area and the wound turned into a stage 2. She said she trusted the nurses to complete the head to toe skin assessments accurately to assure timelty treatments. She said interventions were put in place for Resident #1. She said an air mattress, gel cushion for his wheelchair and the wound doctor saw him weekly. She said frequent positioning was encouraged. She acknowledged Resident #1 and #3 were a risk for skin breakdown. She said she gave recent training to the facility staff on skin assessments and would provide the education documents. The nurse practitioner (NP) was interviewed on [DATE] at 10:38 a.m. He said he cared for Resident #1 but he did not see the wound. He was flagged by the nurses when a wound was seen, and because the facility had a wound physician he let that team follow any wounds. He said the resident was not independent with care and needed assistance for mobility. The only thing he wanted to say was he sent the resident to the hospital for a respiratory infection and a urinary tract infection. He said Resident #1 had a giant wound and was being seen by the wound team. The wound doctor (WD) was interviewed on [DATE] at 11:00 a.m. He said he was alerted by the facility staff when a new or worsening wound occurred and then he saw the resident He came to the facility on e time a week for wound care and wrote orders for treatments to wounds He said a stage 2 or 3 pressure wound could occur in two hours and that was why the standard time to turn and reposition residents was two hours. He said a wound developing that quickly was not normal with most residents. He made recommendations at times to have residents seen by the registered dietitian for supplements and therapy for mobilization. When a braden scale was less than 18, an air mattress was recommended. Resident #1 had a global decline in general. He was fragile and with a low [MEDICATION(S)] level, he had dietary needs and multiple factors including septic from a urinary tract infection and a respiratory decline. He said wounds were easy to treat but when a resident was compromised the wound healing was delayed. He said it was likely the combination of Resident #1 comorbidities cause his death but not likely just from the wound itself. He was not aware the death certificate read cause of death was [CONDITION(S)], necrotizing soft tissue infection and sacral decubitus ulcer (see above). He said the source of [CONDITION(S)] could have been from other sources in combination with his wound. Resident #3's heel was getting better with daily treatments and wearing his prevalon boots for protection. He said he recommended wearing the boots at all times as pressure to the heel resting on the floor could be a factor in heel breakdown since the resident did not have wheelchair footrests. VI. Facility follow-up The facility did not provide any education to the staff on documentation of resident skin issues as indicated by the DON (see interview above).

Based on interviews and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one (#1) of three residents reviewed for pain management out of eight sample residents. The facility failed to ensure pain medications were obtained on admission or timely thereafter for Resident #1, who was admitted to the facility from the hospital for aftercare for laminectomy and facetectomy both lumbar and [MEDICATION(S)] (spinal surgery). The admission summary completed by the facility on 8/17/21 documented the resident had pain that affected her quality of life and function, caused anxiety, required pain management for shooting and sharp pain; she had a pain level of 5 out of 10 on the pain scale with 10 being the worst pain. She was not administered any pain medication until approximately 8:00 a.m. the next morning, on 8/18/21. Due to the facility failure's to manage the resident's pain, it resulted in Resident #1 screaming in pain, calling 911 for help, and experiencing loss of sleep due to being in pain without being administered pain medication, for approximately the first 15 hours of her admission. Findings include: I. Facility policy and procedure The Pain Clinical Protocol, dated 2018, was received from the director of nursing (DON) on 10/7/21 at 1:46 p.m. It documented in pertinent part, the nursing staff may evaluate each individual for pain upon admission to the facility .Pain Medications should be selected based on pertinent treatment guidelines .the staff should evaluate the individuals pain and related consequences at regular intervals, at least each shaft for acute pain or significant changes in pain. The Administering Medications policy, dated December 2012, was received from the DON on 10/7/21 at 1:46 p.m. The policy documented in pertinent part, Medication must be administered in accordance with orders, including required time frame. Medications must be administered within one hour of their prescribed time. If a drug is withheld, refused or given at a time other than the scheduled time the individual administering the medication shall initial and circle the MAR (medication administration record) space provided for that drug and dose. The individual administering the medication must initial the resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . II. Resident #1 A. Resident status Resident #1, age 68, was admitted on [DATE] and discharged home on 8/19/21. According to the August 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The 8/19/21 minimum data set (MDS) assessment indicated Resident #1 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required supervision of one staff person for bed mobility, transfers, toileting and personal hygiene. Resident #1 required limited one person assistance with dressing. She was on scheduled and PRN (as needed) pain medication. Resident #1 had pain frequently in the last five days and had surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] III. Resident interview Resident #1 was interviewed by telephone on 10/7/21 at 12:20 p.m. She said she arrived at the facility in the early evening of 8/17/21. Resident #1 said she had not had any pain medication since about noon when she was at the hospital. She said the facility did not have any of her medications the whole first night she was admitted , and she had severe pain all night and did not sleep. Resident #1 said by 6:00 a.m. the next morning after she was admitted to the facility, she was screaming in pain at the top of her lungs. She said the facility never offered her anything for pain. Resident #1 said she never refused any pain medication and that the facility did not have any of her medications for her to have refused. She said her pain was at a 7 or greater, and that she usually had to take additional pain medication when it reached a level of 5. Resident #1 said she called 911 the next morning 8/18/21 at 7:55 a.m., to get help due to the pain, or go to the hospital. She said the call was logged on her cell phone, and therefore she knew the exact time she called 911. Resident #1 said the nurse took the phone from her, and told the 911 operator she would take care of it. She said the nurse gave her something for pain that morning, 8/18/21, around 10:00 a.m., and then the nurse practitioner (NP) came to see her. She was unsure of what the nurse gave her for pain. This would have been about 14.5 hours since her admission. Additionally, Resident #1 said she saw the DON in the hallway on 8/18/21 in the morning. She said the DON updated her on getting her a continuous positive airway pressure ([CONDITION(S)]) machine, but knew nothing about her medications not being delivered from the pharmacy. Resident #1 said she was surprised the DON was not aware of the delay in medications, and that the nursing staff had not escalated the issue to the DON. Resident #1 said she left the faciity on [DATE], and one of the nurses apologized to her for not getting her medications ordered. IV.Record review Resident #1's August 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] 1200 mg (milligrams) by mouth, at bedtime, for pain was written on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She was not administered the [MEDICATION(S)] for pain at bedtime on 8/17/21. [MEDICATION(S)] HCL 1 mg by mouth, three times per day, for restless leg syndrome, was on the hospital discharge orders received by the facility on 8/17/21. However, the facility put it on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Tylenol 1000mg three times a day, by mouth, for pain, was on the MAR for 8/17/21 at 8:00 p.m., the night of admission. It was not signed off as administered. [MEDICATION(S)] 50mg, 1 tablet by mouth, for pain rated one to five every six hours as needed for pain was written on the MAR for 8/18/21. [MEDICATION(S)] 50mg 2 tablets by mouth for pain rated six to 10 every six hours as needed for pain was written on the MAR for 8/18/21. However, the hospital discharge orders received by the facility on 8/17/21 indicated it was ordered 8/17/21. The facility put it on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/18/21, [MEDICATION(S)] HCL 50 mg, give two tablets by mouth for pain was signed off at 5:17 p.m., for pain level of six. Additionally, it was signed off the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] Gel 1%, apply to legs topically for [CONDITION(S)], apply 2 grams four times per day was written on the [DATE]/18/21, but was on the hospital discharge orders received by the facility 8/17/21. Resident #1's pain assessment, on the MAR for 8/17/21 at 10:00 p.m., the night of admission was blank. Additionally, on the evening of 8/17/21, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Cross-reference F760: the facility failed to ensure the resident was free from significant medication errors. The hospital discharge instructions dated 8/17/21 at 2:21 p.m. were reviewed. The instructions documented the following in pertinent part: -Tylenol 500 mg, take two tablets by mouth three times per day. It was last given on 8/17/21 at 1:45 p.m. -[MEDICATION(S)] 600 mg, take one tablet by mouth every morning, take two tablets at bedtime and one tablet as needed. It was not documented when it was last given. However, the discharge instructions were printed at 2:21 p.m. on 8/17/21. -[MEDICATION(S)] 1 mg, take one tablet by mouth three times per day for restless leg syndrome. It was documented as last given at 1:45 p.m. on 8/17/21. -[MEDICATION(S)] 50 mg, take 1-2 tablets by mouth every six hours as needed for pain. It was documented as last given on 8/17/21 at 12:47 p.m. -Oxycodone 5mg, 1-4 tablets by mouth every four hours as needed for pain. However, the facility documented on the discharge orders that the resident did not want the Oxycodone because it made her feel foggy and clumsy and she did not want it. -The facility MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Her pain at that time was 5. [MEDICATION(S)] was not documented as given until 8/18/21 at 5:17 p.m. for pain level of six. According to her admission summary on 8/17/21, her acceptable level of pain was 3. The pharmacy requisition slip was received form the DON on 10/7/21 at 1:00 p.m. It documented when the medications for Resident #1 had been delivered to the facility.The pharmacy requisition indicated the facility staff did not receive the [MEDICATION(S)] and [MEDICATION(S)] for pain until 8/18/21, at 4:38 p.m. The [MEDICATION(S)] and [MEDICATION(S)] had been signed off the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . -However, the medications had not been delivered from the pharmacy. Resident #1 did not receive these medications as ordered on 8/17/21. The facility emergency mediation kit was reviewed. The emergency kit did not contain [MEDICATION(S)] or [MEDICATION(S)]. It did contain [MEDICATION(S)] 50 mg tablets, but the resident did not receive any [MEDICATION(S)] on 8/17/21. She did not receive any Tylenol, [MEDICATION(S)] or [MEDICATION(S)], on 8/17/21. The admission summary dated 8/17/21 at 7:20 p.m. was reviewed. The assessment was not locked, and documented it was still in progress. It documented she did not have arthritis, even though she did have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The summary documented that she was able to verbally rate pain. Her acceptable level of pain was a 3. It was documented on 8/18/21 at 2:34 a.m., her pain was at a 5. The form said she refused pain medication, she did not want Oxycodone. It did not document she refused her routine Tylenol or [MEDICATION(S)]. It was documented she had [MEDICATION(S)], however it was not documented when she had it. Furthermore, it had not been delivered from the pharmacy until 4:38 p.m. later that day. The admission summary documented the resident complained or showed evidence of pain frequently and had recent surgery. It documented the pain that affected her quality of life and function, caused anxiety, required pain management, and was documented as shooting and sharp pain. The nursing progress notes were reviewed for 8/17/21. There were no nursing notes dated 8/17/21. The pain care plan, dated 8/17/21, was reviewed. It documented, Resident #1 had pain related to [CONDITION(S)], restless leg syndrome, and spinal stenosis repair. It further documented, Resident #1 will not have an interruption in normal activities due to pain through the review date, non pharmacological intervention: repositioning, administer [MEDICATION(S)] as per orders, give one half hour before treatments or care, pain evaluation every shift. Resident will rate pain on scale of 0-10. Nurse to offer pain med if greater than three. V. Staff interviews The nurse practitioner (NP) for Resident #1 was interviewed on 10/7/21 at 9:00 a.m. The DON was present during the interview. The NP said he saw Resident #1 on 8/18/21 in the morning. He did not recall the time. He said she was upset she had not gotten her [MEDICATION(S)] or any pain medications the previous night and had a bad night. He said she talked about pain the previous night, but was better when he saw her that morning. The DON then said, we did not have her medications to give her. -However, the facility had Tylenol as part of their house stock and [MEDICATION(S)] in their emergency medication kit. Neither medication was documented as given or refused. The DON was interviewed on 10/7/21 at 11:20 a.m. She said maybe the resident refused the medications. -However, there was no documentation on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She looked at her laptop and said the resident arrived at the facility on 8/17/21 around 5:30 p.m. She said the medication usually arrived from the pharmacy in four hours. She reviewed the resident MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She acknowledged that the resident did not get any of her ordered medications on 8/17/21. She said it looks like they were not given. She said families should know it takes time to get medications. She said it was not an acceptable standard of practice to not administer medication on admission, and just schedule them to start the next day. The DON said the nurses needed to start getting additional orders from the physician to administer the medications when they are available, and not wait until the next day. She said she could not explain why the Tylenol was not signed off as administered, because they have Tylenol in house stock. She said maybe she refused. -However, she said there was no documentation that the resident refused the Tylenol on 8/17/21 and she was administered Tylenol in the hospital before she was admitted to the facility. Registered nurse (RN) #2 was interviewed on 10/7/21 at 11:41 a.m. She said medications come from pharmacy in about four hours for new admissions. She said she would call the pharmacy if she did not get them in four hours and notify the physician. LPN #3 was interviewed on 10/7/21 at 11:48 a.m. She said medications come in about four hours from the pharmacy. She said it was not acceptable to just start them the next day and skip the doses for the day of admission. She said she would give the ordered medications when they arrived from the pharmacy and attempt to get them from the emergency kit. She said if she did not get them in four hours she would notify the physician for orders. LPN #2 was interviewed on 10/7/21 at 1:04 p.m. via phone. She was the night nurse on duty when Resident #1 admitted . She said she did not remember the resident Licensed practical nurse (LPN) #1 was interviewed on 10/7/21 at 2:18 p.m. She said she was the nurse who admitted Resident #1 on 8/17/21. LPN #1 said she worked from 2:00 p.m. to 10:00 p.m. She said Resident #1 was alert and oriented and able to make her needs known. She said she could not recall if the resident complained of pain that evening. She later said Resident #1 complained of moderate pain, but did not remember on a scale of 1 to 10 how bad her pain was when she was admitted to the facility. She said the resident was anxious because the facility did not have her [CONDITION(S)] when she admitted that night, and it was not coming until 8/18/21. LPN #1 said the resident had an incision on her back about 10-12 inches long, with 33 staples. LPN #1 said she counted them. She acknowledged and agreed the resident had chronic pain issues and post surgical pain. LPN #1 said she had not gotten a report from the hospital. She said another facility nurse had gotten a report, and passed the information on to her. LPN #1 said she could not recall if anything was said about pain or when she had last had pain medication in the report she got. She said she did not send Resident #1's orders to the pharmacy. She said assumed the administration had done that. LPN #1 said no medications arrived on her shift by 10:00 p.m. She said it usually takes the pharmacy four to six hours to get medications delivered. She said, if the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . However, no Tylenol was signed off the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] The DON was interviewed again on 10/11/21 at 9:59 a.m. She said when a new admission came to the facility, the nurses started to administer medications the next day. She said the facility resident electronic medical record (EMR) system automatically scheduled medications to be started the next day. She said it would be a medication error to not give the medications as ordered, but our system automatically schedules it for the next day. -No additional documentation for medication errors pertaining to Resident #1 was provided before exit on 10/11/21.

Based on record review and interviews, the facility failed to ensure one (#17) of three residents reviewed for nutritional status out of 20 sample residents maintained acceptable parameters of nutritional status such as usual body weight or desirable body weight. Specifically, the facility failed to implement interventions to prevent a significant weight loss for Resident #17 with nutritional risks including poor nutritional intake and requiring staff assistance for cueing at meals, and was not outlined on her comprehensive care plan. The resident had a weight loss of nine pounds over a period of one month, which was 5%, considered significant weight loss. The weight loss was not addressed timely with her family since the resident had cognitive impairments. The resident was not assessed by the registered dietitian (RD), until she lost an additional four pounds in the next 10 days (total of 14 pounds, 8% of her total body weight over a period of 42days). Lack of timely interventions in aiding in maintaining Resident #17's nutritional status led to her sustaining a significant weight loss of 8% over 42 days. Findings include: I. Facility policy and procedure The Weight Assessment and Intervention policy, with no revision date, was provided by the director of nursing (DON) on 8/24/2021 at 10:30 a.m. It read, in pertinent part: The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. The nursing staff will measure resident weights on admission, then weekly for three weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. Any weight changes of 5% or more since the last weight assessment will be retaken for confirmation. If the weight is verified, nursing will notify the Dietitian. The DON/designee will review the unit Weight Record in skin/weight meetings to follow individual weight trends over time by the skin/weight team. Negative trends will be evaluated by the treatment team whether or not the criteria for ' significant ' weight change has been met. Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the resident's target weight range, approximate calorie, protein, and other nutrient needs compared with the resident's current intake. Individualized care plans shall address the identified cause of weight loss, goals and benchmarks for improvement, and time frames and parameters for monitoring and reassessment. The DON/designee will discuss undesired weight gain/loss with the resident and /or family. II. Resident status Resident #17, age 89, admitted on [DATE]. According to the August 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/15/21 minimum data set (MDS) assessment revealed the resident's cognition was moderately impaired with a brief interview for mental status (BIMS) score eight out of 15. She required extensive assistance of one person with most activities of daily living (ADLs), and cueing with meals. She did not exhibit any chewing or swallowing problems, she did not have a weight loss and was not on a prescribed physician weight loss regimen. Resident #17 did not exhibit any behaviors and did not resist the care. III. Family interview On 8/23/21 at 1:30 p.m. the resident's family member was interviewed. She stated she had a hard time getting any information from the facility about her mom's health. She said she was not aware of her mom's current health status, or if she was participating in therapy or not. She said the last message she received from the facility's social worker was regarding payment status and bills. Today she received a call from the physical therapist (PT) who was asking her if she will be willing to pay a co-payment for speech therapy evaluation that her mom needs. She said PT did not say why her mom needed that evaluation and stated she would ask DON to call her back. She did not receive any calls from DON. She said she did not recall any care conferences and was not contacted by nurses or DON with updates or changes until today (8/23/21). She said she visited her mom in the evenings after work and all managers were not on duty at that time. She believed staff were not encouraging or helping her mom to get better and she observed that in the evenings that her mom was put to bed right at the dinner time instead of being taken for dinner. She said she was not satisfied with the care facility provided and was looking for other places. She said she was not contacted by a physician who followed her mom and did not even know who her physician was. She was not aware if her mom had any changes in her health. IV. Record review A care plan was initiated on 7/9/21, with no revisions. It read the resident was at nutritional risk and risk for dehydration due to poor intake, eating about 25 percent of her meals, and dementia. Pertinent interventions included: Provide and serve diet as ordered. Honor resident's food choices. Offer alternatives with meals. Provide snacks and fluids between meals. Monitor intake and record every meal; and registered dietician (RD) to evaluate and make diet change recommendations as needed. Review of Resident #17's weights revealed the resident lost 13.6 pounds between July 2021 and August 2021 losing weight from 170 pounds on 7/8/21 to 156.4 pounds on 8/19/21, which was 8% between a two month period. Meal intake records for the last 30 days revealed out of 90 documented meals, the resident consumed less than 50% for 35 of those meals, 28 meals of 25% or less. The resident was marked as independent/no assistance needed with 58 meals, received physical assistance at two meals, and refused seven meals. -The interdisciplinary team did not address the resident's poor intake identified in August 2021 until 8/16/21 when a supplement was added for the resident's weight loss and poor intake (see below). On 7/9/21 a nutrition note on admission by a registered dietitian (RD) #1 revealed the resident's current weight was 170 pounds. The resident had a good appetite, usually consumed above 50% with most meals. Nursing staff helping to monitor meals and help resident with alternative meals. On 7/14/21 a nurse practitioner (NP) noted that the resident had low [MEDICATION(S)] (protein level) and was started on the Prostat, a protein supplement. On 7/19/21 a primary care physician (PCP) #1 documented that the resident has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/27/21 a nutritional note by RD #2 documented a late entry note for 7/12/21. The note read resident's current weight was 165.8 pounds (7/12/21) with no significant weight changes. Resident continues rehab services. Good overall intake of food/beverage reported on records. Currently able to meet needs with intake of meals and snacks. Continue with the current nutritional plan of care. -The note indicated that the resident had a weight loss of 4.2 pounds. On 8/6/21 a primary care physician (PCP) #1's note documented that the resident was seen on 8/6/21 with complaints of abdominal pain and low appetite. The x-ray revealed no significant changes and resident was started on the medication for potential constipation. Same day nurses note documented that nurse practitioner (NP) who worked with PCP #1 contacted the facility and left a recommendation to stay with the resident at meal times, to encourage the resident to increase intake and fluids. -The above recommendations were not updated in the resident's care plan or CNA Kardex (a care directive). The facility did not initiate one-on-one eating assistance to the resident at meal times as it was recommended by NP. On 8/12/21 a nutrition note revealed the resident's current weight was 161 pounds which indicated a significant weight loss of nine pounds or 5% in 30 days. -The note indicated that the weight loss was not desirable, therefore additional interventions should have been implemented. Instead, RD #2 documented Will start following the resident at next week's weight and skin review. On 8/13/21 resident was started on house supplement twice a day, four days later it was discontinued (on 8/16/21). On 8/16/21 the resident started to receive an additional (Ensure) supplement twice a day for weight loss. -There was no supporting nurses note or RD notes to clarify the orders. There was no RD assessment. On 8/19/21 a weight and skin note documented the most recent weight was 161 pounds (8/8/21) and it was compared to the previous weight of 162 pounds on 8/3/21. No weight trend fields were completed, meal intakes were marked 0-25% daily, supplement Prostat and Ensure intake was 50-75% twice a day. The resident was marked on the assessment as independent, with no need for assistance with meals. New interventions were implemented to educate caregivers/resident/family with no updates to the care plan. The participants of the meeting were RD #2 and the DON. On 8/20/21 a nutrition note revealed the resident's current weight was 156.4 pounds which indicated a severe weight loss of 13.6 pounds or 8% in less than 90 days. -RD #2 documented weight loss was due to decreased oral intake and referred to weight and skin note for details. There were no further weight and skin notes after the note on 8/19/21. There were no further RD evaluations. A physician note dated 8/20/21 by PCP #1 revealed the resident continued to lose a significant percentage of body weight possibly due to dysphagia (swallowing difficulty). Speech therapy evaluation was ordered and staff to assist patient when eating meals. Continue supplements and monitoring by RD. -Review of the resident's progress notes, care plans, nutritional assessments and meal intake records revealed no additional interventions or actions, other than adding supplements, were implemented or considered by facility staff to prevent further weight loss. There were no orders or interventions written for the resident to consistently receive assistance or cueing at meals and not indicated on her comprehensive care plan. Additionally, there was no evidence of discussion with the resident's responsible party related to the resident's significant weight loss. V. Resident interview and observations Resident #17 was observed and interviewed on 8/23/21 -At 12:10 p.m., the resident's meal tray was delivered to her room and set in front of her on the table. -At 1:08 p.m. the resident was in bed with the head of the bed elevated to 45 degrees, sleeping. RN #3 approached resident with noon medications. She woke up resident on the second attempt and offered medications. A cup of untouched soup, a piece of cake covered in plastic, and a covered plate were observed on the table in front of the resident. Nurse removed a cover that revealed a fresh salad with beets and bacon shreds, and asked the resident if she would eat. The resident did not answer, after the question was repeated a second time, the resident lifted the spoon, and filled it with soup. RN #3 then left the room. The resident was asked if she liked her meals. She said yes. She appeared sleepy and low energy. She ate a few spoons of soup and put the spoon back on the table. She said she liked all kinds of foods, but the dressing on the salad was making her cough. She closed her eyes and fell asleep. -At 1:22 p.m. CNA #2 approached the resident and asked her if she wanted anything, or if she wanted coffee, the resident said no. CNA #2 removed the uneaten salad plate from the resident. No assistance was offered to the resident, and no other meal substitutes were offered to her. -At 1:53 p.m. resident observed sleeping in bed, less than a half eaten cake observed in front of the resident, open full supplement carton (237 milliliters, chocolate flavor) observed behind the cake. The resident was asleep. -At 3:03 p.m. the resident was asleep in bed, full carton of chocolate supplement and the Styrofoam cup with water marked 8/23 11:00 p.m. on the table. The table positioned away from the resident, not within the reach. -At 4:30 p.m. the dinner tray was delivered to the resident's room. The resident was asleep and the meal tray was set at the table away from her reach. The tray contained mashed sweet potatoes, shepards pie and peach pie. The resident was not woken up for the meal by staff. -At 5:00 p.m. the meal tray was still on the same table away from her reach. The resident was asleep. -At 5:30 p.m. the family member of the resident observed at the bedside assisting her with the meal. The family member said the resident looked worse since she saw her last time, she appeared weak and sleepy. V. Staff interviews PCP #1 was interviewed on 8/23/21 at 3:30 p.m. She said she was aware that the resident was losing weight, she said she was on her list to visit her today. She said the resident was receiving two supplements and it did not matter that one of them was prescribed for different reasons (low [MEDICATION(S)]). She said the facility was in charge of communicating with the family to minimize the number of calls that family might receive. She said RD was in charge of monitoring weight and completing an assessment regarding this resident's nutrition. CNA #2 was interviewed on 8/24/21 at 11:32 a.m. She stated the resident required assistance from one person with all ADLs and needed cueing to remember to eat. She stated the resident had good and bad days and some days she had more energy than others. She said she asked the resident if she needed help eating, but the resident usually refused. -However, there was no documentation the resident refused eating assistance and she was not offered eating assistance in observations (see above). RN #2 was interviewed on 8/24/21 at 11:42 a.m. She stated the resident fed herself, though required cueing and prompting often. She said the resident was able to drink from the cup independently, but when it came to the supplement it had to be held in front of the resident otherwise she would not drink it. She stated the resident always ate in her room and refused to get up into the chair for meals. The speech therapist (ST) was interviewed on 8/24/21 at 11:50 a.m. She said she was here today to evaluate the resident as it was reported to her that the resident had a cough when she was eating. She said she evaluated the resident and did not find any physical limitations such as dysphagia. She said the resident required one-on-one assistance with meals and she would be recommending that. RD #1 was interviewed on 8/24/21 at 2:10 p.m. She stated this position on 7/23/21. She said her responsibilities were to review the weights and conduct a nutritional assessment on admission and later quarterly. She said nutritional assessments were conducted also when resident had a weight loss. She said when Resident #17 had a weight loss, she put her on supplements, but she forgot to do the assessment as she was too busy at that time. She said she did not observe resident eating and she talked to nurses and CNAs about resident's meal intake. She said after the computer triggered weight loss of 5%, she started the resident on supplements. When the computer identified the weight loss of 8% it was not her working day and she addressed it when she came back and requested a speech evaluation. The DON was interviewed on 8/24/21 at 3:10 p.m. She said nurses' responsibility was to report weight loss to the physician, which they did. It was up to the physician and RD to conduct an assessment and determine appropriate interventions for the weight loss. She said they discussed residents' weight loss in interdisciplinary (IDT) meetings on 8/6/21 and 8/9/21. In both cases the physician was notified. She said her understanding was that the resident did not have a good appetite and frequently refused meals. She said she spoke with family yesterday and the family was aware of the weight loss. She did not document her discussion with family. She said it was up to the RD and physician to discuss the details of the resident's health with the family. The nursing home administrator (NHA) was interviewed on 8/24/21 at 3:30 p.m. She stated she would expect the facility to follow the policy and procedure when a resident experienced a weight loss. She stated she would expect for interventions to be put into place for weight loss or poor intake and if the interventions were not effective. She would expect for all interventions and discussions to be documented in the resident's record. -Additional documentation regarding Resident #17's weight loss was not provided by the exit of the survey on 8/24/21.

Based on observations, record review, and interviews, the facility failed to ensure three (#131, #150, and #129) of four out of seven residents identified with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent the development of new pressure ulcers. Specifically, the facility failed to: - Routinely assess, monitor, and document on the development and worsening of resident #131's pressure ulcers to his right and left heels and left buttock. The facility did not communicate and involve therapy and dietary departments regarding measures to promote healing from a nutritional component and for identification of appropriate pressure relieving devices. The facility's systemic failures contributed to the formation of pressure ulcers and negatively impacted resident #131 by limiting his participation in therapy. -Prevent the formation/worsening of pressure ulcer unless unavoidable for resident #150 on the right medial ankle and coccyx. -Monitor and track pressure ulcer for resident #129 located on the left upper buttock. The findings include: A. Resident #131 Resident #131, age 95, admitted into the facility on [DATE]. The 2/17 computerized physician orders (CPO) revealed [DIAGNOSES REDACTED]. The resident was hosptalized on [DATE], to receive blood transfusion due to low hematocrit and hemoglobin levels. He returned to the facility on [DATE]. According to the 1/3/17 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score, 13 out of 15. The resident required extensive assistance with bed mobility, transfers, locomotion on/off the unit, dressing, toileting, and personal hygiene. 1. Resident Status - 10/20/16 (admission) to 11/29/16 (hospitalization ) a. Review of initial assessments revealed resident #131 entered the facility without pressure ulcers. -A review of the initial 10/21/16 skin condition assessment revealed the resident admitted into the facility with a scab to his right great toe. He also had a small skin tear to left elbow. There was no mention of wounds to heels or buttock. -A review of the 10/27/16 admission MDS showed the resident did not have one or more unhealed pressure ulcers. He had moisture associated skin damage to an area unknown. The 11/2/16 14-day MDS, likewise, showed the resident did not have one or more unhealed pressure ulcers. He had moisture associated skin damage to an unknown area. b. Review of physician notes, interdisciplinary progress notes (IPN), and wound care specialist's notes documented the resident had pressure ulcers on both heels within days of his admission that worsened and caused him pain. The resident was referred to the wound specialist and the heel wounds were debrided several times. Wound documentation: -On 10/28/16, the IPN read the resident's right heel was identified as a skin condition and wound dressing intact. There was no mention of any issue with the resident's left heel. However, a physician note on the same day revealed the resident had blisters to both heels and both had opened. -On 10/29/16, the IPN read the resident's right heel blister opened and skin prep and protective dressing applied. There was no mention of a left heel blister. -On 11/1/16, a physician note revealed the resident had a heel wound. There was a large blister on the posterior portion of right heel which had opened. There was no discharge or odor. -On 11/2/16 and 11/3/16, the IPN read blister open to air. There was no documentation about the left heel blister. -On 11/4/16, a physician note revealed labs were performed due to the resident's wounds on his right foot +getting worse rather than better. The treatment was a magnetic resonance imaging (MRI). The IPN on the same day read orders were received to have wound specialist come in to assess the resident. There was no documentation on the resident's left heel. -On 11/4/16, a wound care specialist's initial evaluation revealed the resident had an unstageable wound to the right heel due to necrosis. The wound size by length, width, and depth (l x w x d) was 3.8 x 8.0 x not measurable centimeters (cm). The right heel was debrided surgically and post-debridement depth was 0.2 cm. The left heel stage II pressure ulcer wound size (l x w x d) was 2.1 x 2.4 x not measurable cm. --On 11/10/16, 11/11/16, 11/14/16, 11/15/16, and 11/17/16, the IPN read the right heel wound dressing changed. There was no documentation on the left heel wound. -On 11/11/16, the wound care specialist's wound evaluation revealed the unstageable wound to the right heel due to necrosis measured 3.1 x 7.5 x not measurable cm. The right heel was debrided surgically with post-debridement depth, 0.1 cm. The left heel stage II pressure ulcer wound size was 1.4 x 1.3 x not measurable cm. -On 11/18/16, the wound care specialist's evaluation revealed the unstageable wound to the right heel due to necrosis measured 2.8 x 3.4 x not measurable cm. The wound was not debrided because the necrosis was not infected. The left heel stage II pressure ulcer wound size was 1.7 x 2.0 x not measurable cm. The note stated there was no change in the wound progress although the measurement had increased from the week prior. -On 11/25/16, the wound care specialist's wound evaluation revealed the unstageable wound to the right heel due to necrosis measured 2.0 x 2.9 x not measurable cm. The right heel was debrided surgically and post debridement depth was 0.3 cm. The left heel stage II pressure ulcer wound deteriorated and became unstageable due to necrosis with wound measurement of 1.78 x 1.9 x not measurable cm. The left heel was debrided surgically and depth was 0.3 cm. Pain documentation: A review of the 10/16 Medication Administration Records (MAR) revealed on 10/25/16 and 10/31/16, the resident was administered as needed (PRN) pain medication for pain to feet. A review of the 11/16 MAR indicated [REDACTED]. c. Facility response, and failures in response, to promote healing and prevent infection and new pressure ulcer development. (1) Treatments A review of the 10/16 TAR revealed an order on 10/22/16 to monitor blister to heel. On 10/28/16, an order to apply skin prep to bilateral heels for blisters to heel. A review of the 11/16 TAR revealed the skin prep to bilateral heels continued from 11/1/16 through 11/17/16. An 11/4/16, order to apply [MEDICATION NAME] every shift to left heel was missed on 11/13/16. (2) Nutrition A review of the resident's record revealed there were no dietary progress notes from 10/20/16 to 11/29/16 to show the dietary department was involved to promote the healing of the resident's pressure wounds. (3) MDS assessment Record review revealed no evidence of a significant change in condition MDS upon discovery of the resident's heel ulcers. 2. Resident Status 12/5 (readmission) to 1/29/17 a. Wound status on readmission Even though the MDSs completed after admission (12/12/16 5-day MDS and the 12/18/16 14-day MDS) showed the resident did not have one or more unhealed pressure ulcers, a review of the readmission/initial 12/5/16 skin condition assessment revealed the resident readmitted into the facility after hospitalization with a stage III pressure wound to his left heel, stage II pressure wound to his right heel, wound with nail missing to his right great toe, approximately four sutures. No other pressure areas were identified. No measurements of the wounds, size, or description were available. b. Review of wound specialist's and wound clinic documentation, physician notes and IPN revealed the resident's heel wounds worsened, continued to cause the resident pain, and limited his ability to walk and stand. -On 12/9/16, the wound specialist's wound evaluation revealed the unstageable wound to right heel due to necrosis measured 2.5 x 2.2 x not measurable cm. The note indicated the right heel was a stage IV pressure ulcer. The right heel was surgically debrided and depth was 0.7 cm. The findings indicated deterioration resulted from resident was nutritionally compromised and general decline of the resident. The left heel stage II pressure ulcer wound was 2.4 x 1.7 x 0.3 cm. The note indicated the left heel was a stage IV and had deteriorated due to generalized decline and nutrition. The treatment to the right heel was changed to leptospermum honey, every two days and PRN, foam, every two days and PRN, dry protective dressing, every two days and PRN, and calcium alginate, every two days and PRN. The 12/16 MAR indicated [REDACTED]. -On 12/15/16, a readmission progress note revealed resident skin check was performed after dinner by the overnight nurse. The resident had stage III wound to right heel, stage II wound to left heel, and an unstageable wound to his right great toe. -On 12/16/16, the wound specialist's wound evaluation revealed the right heel stage IV pressure wound measured 2.5 x 3.0 x 0.4 cm. The left heel stage IV pressure wound measured 1.5 x 1.5 x 0.2 cm. -On 12/21/16, the hospital wound clinic replaced the wound care specialist. The hospital wound clinic documented the resident was not a good candidate for walking, standing until heel wounds improved. Orders for ulcer of heel, right with necrosis of muscle and ulcer of heel, left, with fat layer exposed included: --Use the Prevalon, heel off-loader boots at all times - whether sleeping, lying in bed, or sitting in chair. --Right heel wound and left heel wound - lavage these site with saline then apply Isdosorb to the wounds daily, cover with gauze, then wrap with kerlix to retain the dressing. --Reduce weight to feet as much as possible. - On 1/9/17, a physician note revealed follow-up for open heel wound was needed with the hospital wound clinic. The resident was supposed to have a graft done to his foot but it was not done and needed to be rescheduled. -On 1/11/17, physician note revealed open heel wound graft was rescheduled. The resident received an antibiotic, [MEDICATION NAME], for an infection in his foot. -On 1/13/17, a hospital clinic office visit revealed the facility was to replace both heel dressings on 1/14/17. There was to be lavage to both heels with saline - dry sites then apply [MEDICATION NAME] on both sites, then place kerlix to retain the [MEDICATION NAME], then return both heels to the off-loading Prevalon boots. The facility was to replace dressings daily and off-set pressure to both heels at all times. -On 1/17/17, a consultation form with follow-up for wound to heels revealed the resident needed to always use the heel protective boots and he had not had the Prevalon boots with him that day at the clinic. The facility was to continue with daily lavage to both heels, cover with [MEDICATION NAME], and cover with kerlix. The clinic reinforced to always use the heel boots to off-set pressure on both heels. -On 1/23/17, a consultation form with follow-up [MEDICAL CONDITION] to wounds revealed the facility was to continue with the same treatment and to (apply) the heel boots at all times. -On 1/23/17, physical therapy wrote in the resident's discharge summary that the resident's goal to ambulate safely on level surfaces of 150 feet using a front wheel walker with contact guard assistance with normalized gait pattern was limited due to pressure ulcers to both heels. Pain documentation: A review of the 12/16 MAR indicated [REDACTED]. c. Facility response, and failures in facility response, to promote healing and prevent infection and new ulcers from developing (1) Facility skin evaluations A review of the facility skin evaluation forms revealed they lacked information on the characteristics of the resident's pressure ulcers. Specifically: -On 12/18/16, right heel had a blister/open wound. There was no further description of the resident's right heel. -On 1/1/17, left and right heel had a partial thickness wound with an open area. There was no further description of the resident's left heel open wound. -On 1/8/17, there was no description of the left heel pressure wound. The right heel indicated a skin condition with breakdown noted to bilateral heels. There was no further description of the pressure wounds. -On 1/22/17, the resident's right outer heel has a wound healing. There was no further description of the pressure wound. -On 1/29/17, there was no description of the resident's left heel wound. (2) Treatment Administration Records (TAR) Review revealed inconsistent implementation of order to promote healing and prevent new wounds from developing. A review of the 12/16 TAR revealed the resident's heels were to be floated in bed every shift. There were five missed entries between 12/12/16 and 12/20/16. On 12/5/16, moisture barrier cream was to be applied to the buttock (penarea) every shift and as needed. There was one-line item to sign off on all shifts. Six missed entries on 12/9/16, 12/11/16, 12/12/16, 12/13/16, 12/14/16, and 12/27/16. On 12/9/16, an order to cleanse wound to bilateral heels with normal saline, pat dry, apply [MEDICATION NAME] and calcium alginate, then cover with dry dressing every night and PRN until resolved showed on 12/12/16, the treatment was not provided to the resident. On 12/9/16, an order for [REDACTED]. A review of the 1/17 TAR revealed the resident's heels were to be floated in bed every shift. There were missed entries on 1/15/17, 1/22/17, 1/24/17, 1/25/17, 1/26/17, and 1/30/17. Moisture barrier cream was to be applied every shift and PRN. There was one-line item to sign off on all shifts. Eleven missed entries of failure to apply moisture barrier cream on 1/15/17 - 1/17/17, 1/22/17 through 1/27/17, and 1/30/17 through 1/31/17. Prevalon boots were to be worn at all times and missed entries were shown on 1/22/16, both shifts listed for 1/25/17, and 1/26/17. On 1/14/17, an order to replace both heel dressing on 1/14/17. Lavage both heels with saline, dry sites then apply [MEDICATION NAME] on both sides then place kerlix to return [MEDICATION NAME] in place then return both heels to the off-loading Prevalon booths. The facility did not replace dressing on 1/14/17 or 1/15/17. The treatment was also not performed on 1/22/17, 1/24/17, or 1/25/17. On 1/14/17, an order to off-set pressure of heels at all times revealed treatment was not signed off completed on 1/14/17, 1/22/17, 1/24/17, both shifts on 1/25/17, and 1/26/17. On 1/17/17, an order to always use heel boots to off-set pressure to both heels and was not signed off completed on 1/22/17, 1/24/17, both shifts of 1/25/17, and 1/26/17. There were missed treatments to cover wounds with kerlix on 1/22/17, 1/24/17, and 1/25/17. (3) Nutrition A review of the resident's record revealed there was no nutritional assessment or dietary progress notes from 12/5/16 to 1/29/17 to show the dietary department was involved to promote the healing of the resident's pressure wounds. (4) Assessments A review of the recent completed Braden assessment dated [DATE] revealed the resident was not at risk for pressure ulcer development although the resident had pressure ulcers to both right and left heels. A review of the 1/3/17 MDS assessment revealed it, as previously (see MDS references above), was inaccurate, documenting that the resident was not identified with pressure ulcers but was at risk of developing pressure ulcers. (5) Care plan A review of the 12/5/16 pressure ulcer care plan revealed the resident was at risk for alteration in skin integrity related to his right great toe partial amputation. He had wounds to both heels and was followed by an outside wound clinic. -The goal was to maintain his skin integrity. -The interventions included: provide the resident with diet ordered by the physician; be sure to check resident's skin weekly and notify the physician as needed; assist with mobility needs; provide pericare; provide pressure relieving cushion for wheelchair; float heels in bed with Prevalon boots as tolerated. The care plan did not reflect the orders from the hospital wound clinic on 12/21/16 to ensure Prevalon boots were worn, not as tolerated, but at all times - whether sleeping, lying in bed, or sitting in chair. 3. Resident Status 2/1 to 2/7/17 a. The 2/17 computerized physician orders (CPO) revealed treatment orders as follows: -On 2/2/17, clean left heel pressure wound, pat dry, apply hydrogel, cover with [MEDICATION NAME] foam dressing and secure with kerlix. -On 2/2/17, clean right heel pressure wound, pat dry, apply hydrogel, cover with [MEDICATION NAME] dressing and secure with kerlix. -On 2/2/17, clean shearing to buttocks, apply house barrier cream. -On 1/23/17, weekly skin evaluation on Sunday morning. -On 12/9/16, Prevalon boots to bilateral heels at all times as tolerated by resident. -On 12/5/16, float heels in bed every shift as tolerated by resident. b. Observations and Interviews Observations confirmed the resident continued to have painful pressure ulcers on his heels, as well as an ulcer on his left buttock. The resident lacked pressure relief for his heels ordered to be protected with Prevalon boots. The resident also lacked pressure relief for his buttocks/coccyx. In addition, observations revealed wound treatments were completed in a manner inconsistent with physician orders. 2/2/17: At 11:06 a.m., the resident was seated in a reclining chair beside his bed his heels were covered by a blanket. The resident's bed was a standard foam pad that is not pressure relieving. He did not appear to have a cushion or pillow off-loading him in his chair. The resident said he was having problems with his tailbone from sitting around and it was getting irritated. He said he was getting a sore on his bottom. At 11:43 a.m., the resident was in the dining room. He was seated in his wheelchair. He was not wearing Prevalon boots during the meal. 2/3/17: At 12:08 p.m. the resident said his heels were painful. He stated the staff bandaged them at night or very early at night between 1:00 a.m. to 2:00 a.m. He stated staff did not always apply his Prevalon boots. He said his boots weren't on due to staff not applying them to his feet. At 12:19 p.m., the resident was propelled to his room. He requested to be transferred into his brown recliner chair beside his bed. Two staff members assisted the resident as he stood and pivoted into his recliner. No pressure relieving device was in his recliner chair. As on 2/2/17, the resident's bed was a foam pad mattress. The resident's Prevalon boots were located on his bed instead of on his heels to off-set any pressure. At 1:20 p.m., registered nurse (RN) #6 performed wound treatment to the resident's bilateral heels. Certified nurse aide (CNA) #3 assisted the RN in the process. At 1:23 p.m., the RN directed the CNA to remove the Prevalon boots from the bed. The RN had [MEDICATION NAME] foam and hydrogel treatment to apply to the resident's heels. There was no kerlix on the heels as ordered. -At 1:24 p.m., the RN removed the bandage to the resident's right heel. The bandage had some serous draining, yellow with some pink color on the bandage. -At 1:25 p.m. the right heel wound was observed. The wound appeared to look like a stamp applied horizontally to his right heel. The surrounding skin around the perimeter of the wound was white. The surface of the wound was pink. There was no visible blood or inflammation. In the middle of the wound, there was some yellow and white skin the width of a small sewing needle. -At 1:28 p.m., the RN sprayed wound cleanser, [MEDICATION NAME] on the right heel. She used gauze to clean out the wound. The order did not specify the use of [MEDICATION NAME] or gauze pads (see above). -At 1:30 p.m., the RN opened a no sting skin prep attached to a lollipop stick. The RN applied the no sting skin prep to the wound. The resident's right inner ankle was observed with two pinkish red skin areas above the heel. The areas were both the size of a quarter. The resident tolerated the skin prep without facial grimace or verbal groans. The physician order did not specify the use of no sting skin prep. -At 1:31 p.m., the RN applied the hydrogel with a cotton tip to the wound and then the [MEDICATION NAME] foam pad. -At 1:34 p.m., the RN removed the bandage from the resident's left heel. There was no kerlix applied to the heel according to the physician's order. The bandage had a quarter size of serous drainage yellow and pink in color. -At 1:35 p.m., the left heel wound was observed. The wound appeared to be the size of a large fingernail. The surrounding perimeter of the wound had some darkened skin discoloration north and south of the wound. The west and east sides of the wound were white in color. The wound bed was pink with no visible drainage. -At 1:35 p.m., the RN sprayed wound cleanser, [MEDICATION NAME] onto the wound. She did not use the no sting skin prep to the wound. As noted above, the physician orders did not specify the use of [MEDICATION NAME] for wound care. -At 1:37 p.m., the RN applied the hydrogel with a cotton tip and then the [MEDICATION NAME] foam pad with kerlix to the heels. At 1:55 p.m., after the above wound care, RN #6 said wound treatments were usually performed at night to not interfere with resident's receiving therapy. She said the orders for the resident's left heel pressure wound were to pat dry, apply hydrogel, cover with [MEDICATION NAME] dressing, and secure with kerlix. She stated the order was the same for the right heel. The resident was to have his heels floated, and moisture barrier cream applied to his buttock. The RN confirmed the order did not specify the use of [MEDICATION NAME] or the no sting skin prep. She confirmed there was no kerlix to either heel when treatment was performed. She said orders should be clarified and followed to use the correct items when promoting healing of a wound. The RN confirmed the resident did not have a pressure reducing mattress. At 3:40 p.m., the resident's bed and recliner were observed in the presence of the director of therapy (DOT). The DOT confirmed the resident's bed was a standard foam bed and not a pressure relieving mattress. The DOT confirmed the resident's recliner was not a pressure relieving chair. He confirmed there was no cushion or off-loading device observed in the recliner. The DOT asked the resident to move himself around the in the chair. He provided specific step by step instructions. The resident attempted to follow the commands. He tried to lift himself with the use of his arms and move his legs to shift around the chair to off-load but he was unsuccessful and his bottom remained in the same spot of the recliner chair. 2/7/17: At 9:14 a.m., the resident stated he did not like the cushion in his chair. He stated he was not offered to be positioned or provided a pillow to off-load pressure on his buttocks/coccyx. At 9:16 a.m., the resident was seated in his brown recliner beside his bed. The resident's buttocks/coccyx were not off-loaded in his non-pressure relieving recliner. At 9:23 a.m., CNA #2 took the resident to the restroom. The RN surveyor observed the resident's buttocks. There was a nickel-sized red area located on the inside left buttock approximately two inches from the anus. The RN stated with the partial thickness skin loss, the left buttocks could be classified as a stage II pressure ulcer. At 9:29 a.m., RN #8 entered the room and stated house barrier cream was applied to the resident's buttock. The RN looked at the open wound. She exited without applying the house cream and went to locate the director of nursing (DON). At 9:35 a.m., the RN returned with the DON and additional staff. The review of the wound was discussed among the facility staff and a change in the order was discussed. The DON exited the room and returned at approximately 9:40 a.m., with medical supplies to apply a new treatment to the resident's wound on his left buttock. c. Failures in facility response to promote healing, prevent infection and prevent further pressure ulcer development (1) See observations above; the facility failed to provide treatment as ordered and pressure relief to pressure areas (heels and buttocks) (2) See are plan above; the facility failed to revise the resident's care plan to include address the resident's buttock pressure ulcer. (3) Nutritional Assessment There was no nutritional assessment or dietary progress notes 2/1/17 to 2/7/17 to show the dietary department was involved to promote the healing of the pressure wounds of the resident and to prevent further pressure ulcer development. (4) Investigations - Skin Conditions Despite the resident's development of three pressure ulcers after his admission to the facility, there were no incident reports or investigations for the development of the wounds. There was no root analysis provided by the facility to show that an attempt was made to review any potential systemic failures related to the development of pressure ulcers while resident resided at the facility. 4. Staff Interviews Interviews confirmed facility staff failed to routinely assess, monitor, and document on the development and worsening of resident #131's pressure ulcers to his right and left heels and left buttock. The facility did not communicate and involve therapy and dietary departments regarding measures to promote healing from a nutritional component and identification of appropriate pressure relieving devices. -RN #5 was interviewed on 2/2/17 at 1:48 p.m. She said the resident had identified open areas of heel right and heel left, toe right great based on the skin condition records. She said there were no listed wound measurements available. She said she did not know the condition of the wounds except they were not resolved. The RN said she did not have access to the wound records. -The MDS coordinator (MDSC) was interviewed on 2/2/17 at 2:14 p.m. The MDSC stated she was not sure if wound notes were placed in resident records. She stated the wound specialist notes were in an electronic medical record system the facility had to log into to obtain information of the wound notes. She said she did not think floor nurses had access to the system to remain informed of the resident wounds. -The physical therapy assistant (PTA) was interviewed on 2/3/17 at 3:15 p.m. The PTA said he had worked with the resident when he was on his service. He stated the resident had a standard mattress and it was not pressure relieving. -The DOT was interviewed on 2/3/17 at 3:19 p.m. He said his rehab was discontinued after the resident expressed he was tired dealing with limitations through therapy because of the deterioration of his heels. The DOT stated the resident had Prevalon boots, they were discharged and multi-podus were applied to combat the external rotation of both his ankles and as he declined, he was switched back to Prevalon boots to offer pressure relief. The DOT stated he was aware of the sores to his heels and said the resident may also have something developing on his sacrum. He said CNAs were trained on positioning and capillary breakdown. He stated nursing staff were educated on the use of alternating pressure mattress and restorative programs. The DOT reviewed the resident's record. He said based on therapy documentation, the resident was not able to manage his own pressure relief. At 3:40 p.m., the DOT verified the resident could not off-load himself as he sat in his recliner chair. He confirmed the resident did not have any pressure reduction pad or cushion in the chair and his mattress was a foam pad. He said he would speak with the DON about his review of the resident and potential interventions to off-load and provide pressure relief. -The DON was interviewed on 2/3/17 at 3:50 p.m. She said she assessed the resident's wounds last night on 2/2/17. The DON stated based on her assessment of the wounds, the resident had a stage three to his right heel and a stage three to his left heel. The DON reviewed his 10/20/16 admission data and confirmed when he initially arrived he did not come in with any pressure sores to his heels. She said when she reviewed the 12/5/16 readmission data, the resident admitted with a stage two and stage three on his heels. She did not know the resident developed the sores at the facility prior to his readmission on 12/5/16. The DON stated she did not know why the resident did not have a pressure relieving mattress. She acknowledged the resident did not have a pressure relieving mattress or on his recliner chair. She confirmed the MDS did not capture the resident's skin conditions accurately. She stated moisture skin associated damage was not common for heel wounds. The DON said a review of the resident's record showed no consult, assessment, or notes performed by a qualified dietician when the sores developed at the facility. The DON also said the order on how to clean the wound should have been written with more clear instructions. She said she was informed the kerlix was not applied after the treatment on 2/2/17 according to the physician order. -RN #8 was interviewed on 2/7/17 at 9:17 a.m. The RN said the resident had a wounds on his heels and a scab on his left calf. She said his bottom was excoriated. She said she had not been informed if it was open. She said the overnight nurse did not report any open area to the buttock. -CNA #2 was interviewed on 2/7/17 at 9:31 a.m. She said she helped the resident this morning and he did not want the cushion in his chair so it was not applied. She stated the cushion was there to help him from forming a sore on his bottom. She said she did not report to the nurse the resident did not want the cushion. -RN #8 was interviewed again on 2/7/17 at 9:35 a.m. The RN confirmed the resident had an opening to his buttock. She stated she went to the DON to review and request if a new change to the order should be considered since the wound was open. The RN stated if the resident refused his cushion, a pillow or repositioning should be offered to help in the prevention of a pressure sore from developing. -The DON was interviewed again on 2/7/17 at 10:58 a.m. She said plans were being formulated for staff to notify her and provide a copy of the Braden assessment when residents are at a high risk for developing pressure ulcers. She said she would work with the dietician, determine what type of mattress, and develop a positioning/repositioning program. She said skin checks were conducted to identify skin conditions as early as possible to implement appropriate interventions. The DON stated weekly skin assessments were not performed on a consistent basis for residents and audits would be enforced. She said there should be communication provided to the floor nurses to know the progression of wounds for their residents. She said they needed to know the correct treatment and interventions. The DON said she did speak with the registered dietician (RD) over the weekend (2/4/17 - 2/5/17). She said the RD will conduct a full assessment of the resident when the RD returned to the facility. The DON stated the facility did not have an investigation to provide related to the pressure ulcers the resident developed at the facility. She confirmed the wound specialist had looked at the wounds after the resident returned to the facility with stage three and stage two wounds. She acknowledged the right and left heel wounds were identified as stage four wounds during the 12/9/16 evaluation. The DON s

Based on observations, record review and interviews, the facility failed to ensure two sample residents (#10 and # 131) of four out of 12 sampled residents with nutritional issues, maintained acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrated that this was not possible. Specifically: The facility failed to assess, monitor, and respond to resident #10 and #131's unplanned weight loss after their admission. These failures contributed to resident #10 experiencing severe weight loss (11.1%) in just over one month. Cross reference F361; qualified dietitian and F314; pressure ulcers Findings included: A. Facility Policy Review of the facility's policy on Dietitian, revealed the dietitian's responsibilities included assessing nutritional needs of residents, developing and planning diets, collaborating effectively with other direct care staff and practitioners to assess and address nutritional issues, and providing nutrition-related advice and counseling to residents and families. The Director of Nurses (DON) was interviewed on 2/7/17 at 11:18 a.m. about how the facility ensured residents maintained acceptable parameter of nutritional status. The DON said nutritional assessments and ongoing monitoring tracked weight loss, determined adequate protein intake, and ensured overall general health and skin condition of residents at the facility. The DON expected the nutritional needs of residents be reviewed on an ongoing basis and include: Changing the plan of care when appropriate; addressing any potential end of life issues; and discussing appropriate interventions when weight loss or others issues were identified. B. Residents #10 and #131 - Failure to ensure residents maintained acceptable parameters of nutritional status. 1. Resident #10 Resident #10, age 78, was admitted to the facility on [DATE] from the hospital and discharged from the facility 2/6/17. According to the 2/17 computerized physician orders [REDACTED]. A late entry nurses' note dated the day of admission at 5:20 p.m. documented the resident had a wound graft with donor site to right thigh with a dressing intact. The resident's height and weight on admission, per the hospital discharge summary and the electronic medical record, were height - 64 inches and weight - 120 pounds (lb). admission orders [REDACTED]. a. Record review (care plan, labs, weight records) revealed the resident was at nutritional risk with poor appetite, poor intake, below normal protein levels, and weight loss. The resident's care plan, last revised 11/21/16, identified the resident was at risk for a decline in nutrition and hydration status due to [DIAGNOSES REDACTED]. -Her goal was to maintain nutrition and hydration status, as evidenced by a stable weight at 115 pounds (plus or minus five percent) and no signs and symptoms of dehydration. -Interventions included: Honor food preferences as allowed within diet regimen; food and fluid intakes will be monitored at meals; weights will be monitored for a trend and nursing will assess for [MEDICAL CONDITION] change; pertinent lab work will be monitored; encourage to eat meals in the dining room and observe for swallowing/chewing/choking issues; assist with meal set up and assist with eating as needed; offer alternative food choices at meals if needed; encourage adherence to diet/texture; offer supplements as ordered; and offer snacks between meals. According to lab results on 11/23/16, the resident's total protein and [MEDICATION NAME] were below normal range at 5.0 (normal range is 6.3-8.2) and 2.5 (normal range is 3.5-5.0) respectively. While the resident's total protein and [MEDICATION NAME] remained below normal range, these values improved prior to discharge. (On 12/30/16, protein syrup 30 milliliter (ml) one time a day for wound healing was ordered) However, record review revealed the resident's weight, viewed in the resident's electronic record on 2/7/17, severely declined after admission. The resident's weight declined from 120 lbs on 11/21/16 admission to 108.2 lb on 1/17/17. The resident was not on a planned weight loss program. According to daily intake recorded by the certified nurse aide (CNAs) in the computer for 12/16, 1/17 and 2/17 (prior to discharge), the resident's daily intake was most often 50%, when recorded. Specifically: For 12/16, the documentation revealed the resident consumed -100% of her meals seven out of 93 opportunities; -75% of her meals 13 out of 93 opportunities; -50% of her meals 21 out of 93 opportunities; -25% of her meals 17 out of 93 opportunities; -0% of her meal one out of 93 opportunities; and There was no documentation for 34 out of 93 opportunities. For 1/17, the documentation revealed the resident consumed: -100% of her meals six out of 93 opportunities; -75% of her meals 13 out of 93 opportunities; -50% of her meals 22 out of 93 opportunities; -25% of her meals four out of 93 opportunities; -0% of her meals four out of 93 opportunities; and There was no documentation for 44 out of 93 opportunities. For 2/17, the documentation revealed the resident consumed: -100% of her meals three out of 17 opportunities; -75% of her meals one out of 17 opportunities; -50% of her meals seven out of 17 opportunities; There was no documentation for 6 out of 17 opportunities. b. Observations and Interview On 2/2/17 at 12:17 p.m., the resident was seated beside her bed in a chair. She had a tray table placed in front of her with a plate of food partially eaten. The resident stated she did not have much of an appetite. She said she was not feeling well. The resident stated she also had missing teeth. She said her partial denture wasn't fitting properly and she needed her dentist to take a look at them. She said she was able to eat, but some of her food decisions were impacted by not getting to wear her teeth. c. Facility failure to comprehensively assess and monitor resident #10's nutritional status, contributing to an unplanned, unaddressed severe weight loss. (1) Record review revealed no evidence of a nutritional assessment or nutritional risk assessment either before or after the resident's weight loss represented by her weight on 1/1/17. -Although a new admission on 11/21/16, record review revealed no weights were obtained between 11/21/16 and 1/7/17 in order to establish a baseline weight and to identify and document weight loss. The resident's weight on 1/1/17 represented an 11.1 percent (%) severe weight loss in a little over 30 days. -There was no documentation of the resident's daily nutritional needs, no documentation of the past history of eating patterns and weight, no documentation of likes/ dislikes or preferences, and no documentation of functional limitations that might affect intake, such as the issues expressed by the resident about her dentures. There was no evidence the facility identified the resident's ideal or usual body weight after admission. (2) See care plan above; there was no evidence to show the resident's care planned interventions were individualized based on information from a comprehensive assessment, as there was no nutritional assessment in the resident's record. Moreover, there was no evidence the care plan was revised to improve her daily intake of 50% or to address her dental issues which limited her ability to eat certain foods. Likewise, there was no documentation care planned interventions were revised after 1/1/17 to address her severe weight loss. (3) There was no documentation in the resident's record of the dietitian collaborating with other direct care staff and practitioners to assess and address the resident's poor intake and weight loss or of the dietitian providing nutrition-related advice and counseling to the resident. Rather, review of the resident's entire clinical record revealed it was void of any documentation related to the resident's weight loss or documentation the physician, registered dietitian, resident and family had been notified of and involved in addressing the resident's weight loss. d. Cross reference F361; qualified dietitian. Interview revealed it was the dietitian's responsibility to monitor weights. However, review of employee records revealed the facility did not have a qualified dietitian on staff consistently full-time, part-time or on a consultant basis after 5/13/16 and until 1/9/17, to plan, implement and manage dietary service activities. Record review further revealed a dietary tech had been on staff from 6/28/16 to 12/14/16; however, interview revealed neither a dietary tech, a qualified dietitian, nor consultant (to review resident records) was on staff from 12/15/16 to 1/9/17. e. Staff interviews CNA #4 was interviewed 2/7/17 at 2:23 p.m. She said resident # 10 was an extensive assist of one staff member for activities of daily living, including eating. She had to be fed at times. She said the resident didn't have a very good appetite. RN #7 was interviewed on 2/7/17 at 2:02 p.m. She said the resident had a poor appetite. They offered her snacks and she got 30ml of protein a day. She said the CNAs do weekly weights and input the results in the computer. She said she did not know why the resident hadn't been weighed weekly and was unaware the resident had had a weight loss. She said if there was a weight loss, the dietitian would get a hold of the physician and get orders to start supplements. She said she was not aware that a dietitian had not been available from 12/9/16 to 1/9/17 to assess, monitor and address the resident's nutritional needs. The DON, interviewed on 2/7/17 at 11:18 a.m., acknowledged the facility had become aware of documentation issues with resident weights and the monitoring of resident weights in the electronic record keeping system last week (approximately 2/1/17). She said the facility did not have a good baseline of resident weights. The DON stated the standard practice when determining a good baseline for resident weights was the first four weeks after arriving to the facility, residents should be weighed. She said after the first month of weights, the facility needed to determine if weekly weights should continue or if monthly weights would be sufficient. 2. Resident #131 Resident #131, age 95, admitted into the facility on [DATE]. The 2/17 CPO revealed [DIAGNOSES REDACTED]. On 11/29/16, the resident required a blood transfusion due to low hematocrit and hemoglobin levels. He was hospitalized and returned to the facility on [DATE]. He was placed on a regular thin liquid diet. According to the 1/3/17 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score, 13 out of 15. The resident required extensive assistance with bed mobility, transfers, locomotion on/off the unit, dressing, toileting, and personal hygiene. He required supervision with eating. The resident had a height of 72 inches and weighed 183 lbs. It was unknown if the resident experienced weight loss or weight gain. a. Record review (MDS, care plan and weight records) revealed the resident was at nutritional risk with poor appetite, poor intake, and weight loss. -A review of the 10/27/16 MDS revealed the resident had a height of 58 inches and weighed 200 lbs. -A review of the 11/2/16 MDS revealed the resident had a height of 68 inches and weighed 221 lbs. -A review of the 11/16/16 MDS revealed the resident had a height of 72 inches and weighed 187 lbs. -A review of the 11/29/16 discharge MDS showed the resident was 68 inches and weighed 135 lbs. -A review of 1/3/17 MDS (see above) showed the resident was 72 inches and weighed 183 lbs. The review of MDS assessments showed fluctuations of height and weight between 10/27/16 through 1/3/17. A review of the 12/5/16 care plan revealed the resident was at risk for a decline in his nutrition and hydration due to increased energy needs for healing. -The goal was the resident would maintain his nutritional status by maintaining a weight of 200 lbs, plus or minus 5% and not signs of dehydration during the next review period. -The interventions included: honor food preferences, weights would be monitored and trended and nursing would assess for [MEDICAL CONDITION] changes, monitor skin status, encourage resident to eat meals and observe, and offer snacks between meals. A review of the resident weight tracking system form revealed the resident had a height of 99 inches. The resident weights: 10/23/16 - 200.2 lbs 11/2/16 - 200.2 lbs 11/6/16 - 187.8 lbs 11/7/16 - 187.0 lbs 11/9/16 - 187.0 lbs 11/13/16 - 220.6 lbs 11/20/16 - 186.6 lbs 11/22/16 - 186.0 lbs 11/27/16 - 135.6 lbs 11/28/16 - 135.0 lbs 12/14/16 - 135.0 lbs 1/8/16 - 190.4 lbs 1/22/16 - 167.9 lbs 1/29/16 - 168.6 lbs b. Record review further revealed the resident developed three pressure ulcers, skin infection, after admission; two of the pressure ulcers had been present for three months. See F314 for details. c. Facility failure to comprehensively assess, reassess, monitor and address resident #131's nutritional status. There were no dietary notes in the resident's medical record to show a qualified dietary staff member monitored and addressed the resident's fluctuating weight. A 90-day review of the resident's weight revealed a 15.78 % weight loss. A nutritional assessment was performed on 10/30/16. There was no nutritional assessment performed when the resident readmitted into the facility on [DATE]. No additional nutritional assessments were available, although the resident's recorded weights indicated severe weight loss, he was not on a planned weight loss program and the resident's wound specialist indicated the deterioration of the two wounds on his heels was due in part to nutrition. See F314 for details. There was no documentation in the resident's record the dietitian collaborated with other direct care staff and practitioners to assess and address the resident's poor intake and weight loss or of the dietitian providing nutrition-related advice and counseling to the resident. d. Observation and Resident Interview On 2/2/17 at 11:43 a.m., the resident was seated in the main dining room eating a bacon cheeseburger. He was able to feed himself. He ate two-thirds of his meal. The resident also asked for a piece of pie and ate approximately 80% of his dessert. -At 12:08 p.m., the resident stated he did not eat a lot because he didn't do anything but sit around. The resident felt he wasn't losing or gaining any weight. He stated his usual body weight was 170 lbs. e. Staff Interviews The dietary supervisor (DS) was interviewed on 2/7/17 at 1:55 p.m. The DS said if there was no dietitian reviewing and assessing residents, residents could be compromised clinically and nutritionally without the facility being aware of the condition or without implementations of interventions to correct issues. The DON was interviewed on 2/7/17 at 10:58 a.m. She said she spoke with the RD over the telephone the weekend of 2/4/17. She said she had to read off the resident's lab results to the RD who recommended some vitamins in his absence. The DON stated the RD would prioritize the resident when he returned to the facility. -The DON stated the RD needed to know all the issues going on in the building and the list was not available. The DON stated the facility would adopt a standard of care meeting to ensure all areas of concern for residents were discussed on a routine basis. -The DON acknowledged through a review of the resident's record, that the resident had experienced weight loss; she stated upon review of the resident's weights, there as a 30 lb weight loss. The DON confirmed the only nutritional assessment performed on the resident was conducted on 10/31/16. She said there were no dietary notes listed in the records from his initial admission until 2/7/17. The DON stated although the resident had experienced severe weight loss, the facility had lab work-ups to show the resident's protein and [MEDICATION NAME] levels were within a normal range.

Based on observation, record review, and interviews, the facility failed to employ a qualified dietitian either full-time, part-time, or on a consultant basis to be utilized in planning, managing and implementing dietary service activities in order to assure that the residents, including two of 30 sample residents (#131 and #10) received adequate nutrition. Specifically: The failed to have a qualified dietitian, either full-time, part-time, or on a consultant basis to manage, observe, and implement adequate nutrition for residents observed with pressure ulcers and severe weight loss. This failure contributed to resident #131 developing weight loss, an infected toe and three pressure ulcers after admission; two of the pressure ulcers had been present for three months. It also contributed to resident #10 experiencing severe weight loss after admission; a qualified dietitian had neither assessed the resident's weight loss nor developed interventions to improve the resident's weight and nutritional status. Cross reference F314; pressure ulcers and F325; nutrition The findings included: 1. Facility Policy Review of the facility's policy on Dietitian, revealed the dietitian's responsibilities included assessing nutritional needs of residents, developing and planning diets, collaborating effectively with other direct care staff and practitioners to assess and address nutritional issues, and providing nutrition-related advice and counseling to residents and families. 2. Observations On 2/2/17 at 8:00 a.m. through 2/7/17 at 6:00 p.m., the dates and times of the re-certification survey, the facility failed to have a qualified dietitian or available consultant to discuss the nutritional needs of residents. 3. Record Review a. Resident Records Resident #131: -A review of resident #131's clinical record revealed he arrived to the facility on [DATE]. There was a nutritional assessment performed 10/31/16. During the resident's stay, he developed pressure ulcers as well as an infection of the skin. The pressure ulcers on the resident's heels and the resident's skin condition worsened and the wound specialist indicated the deterioration of the two wounds on his heels was due in part to nutrition. He had his right dorsal toe partially amputated and his pressure ulcer(s) identified on 10/28/16, were still present on 2/7/17 when wound care was observed. In addition, observations on this date revealed a stage II pressure ulcer on the resident's left buttock. See F314 for further details. The resident had no notes in his record to show a qualified dietitian reassessed the resident's nutritional needs or collaborated effectively with other direct care staff and practitioners to address nutritional issues in relation to the resident's skin breakdown. -Record review also revealed the resident lost weight at the facility and there was no evidence in the resident's record to show a qualified dietitian monitored and assessed the resident's nutritional needs, collaborated with direct care staff and practitioners, or provided nutrition-related advice to the resident as he lost weight and expressed his appetite was poor. See F325 for further details. Resident #10: A review of resident #10's clinical record revealed she arrived to the facility on [DATE]. She did not have a nutritional assessment or risk assessment to address her nutritional needs. The resident weighed 120 pounds (lbs) on 11/21/16. On 1/1/17, the facility weighed the resident again. The resident was 108.2 lb. The documented weights revealed the resident experienced unplanned weight loss of 11.1%. There was no response by the dietitian to the resident's weight loss. The resident's documented meal intakes were not routine as she continued to lose weight. See F325 for further details. 4. Personnel Data A review of a note provided by the human resources director (HRD) on 2/7/17 revealed the facility had employed two qualified dietitians (RD #1 and RD #2) and one dietary tech (DT) between 3/31/15 and 1/9/17. The note showed RD #1 was employed from 3/13/15 through 5/13/16. The DT was employed from 6/28/16 through 12/14/16 and RD #2 was employed on 1/9/17 and remained an employee of the facility. 5. Interviews The dietary manager (DM) was interviewed on 2/3/17 at 11:46 a.m. He said the dietitian was responsible for monitoring weights. He said the facility had employed a few dietitians over the past year. He said the facility had a dietary consultant, but he did not know when the consultant was last at the facility to address the nutritional needs of the residents. The dietary supervisor (DS) was interviewed on 2/7/17 at 1:55 p.m. She said the facility's current dietitian arrived the second week of January 2017. She said the previous dietitian left the beginning of December after about five months. She said to her knowledge, the facility went without a dietitian for about a month. The DS said the facility had a dietary consultant but the DS said she was not sure if the dietary consultant filled in when there was no facility dietitian. The DS said if there was no dietitian reviewing and assessing residents, residents could be compromised clinically and nutritionally without the facility being aware or without interventions to correct the situation. The HRD was interviewed on 2/7/17 at 2:08 p.m. She said RD #1 was asked to work more hours and would not, so she voluntarily left her position. She stated the facility hired the DT with the understanding the DT would obtain RD certification. She said a consultant came in to review the DT's work. HRD said the DT was asked about her RD licensure and shortly after, she stopped showing up. She left without notice. The HRD stated the facility has hired RD #2, but he had planned leave and was not available for interview. The nursing home administration (NHA) was interviewed on 2/7/17 at 2:14 p.m. The NHA stated the facility used a dietary consulting company for assistance in meeting the requirements that the facility to have a qualified RD. The NHA stated the DT quit around 12/9/16 and the NHA said she was not informed until the facility met for the monthly quality assurance (QA) meeting in January. The NHA stated she then contacted a consultant to come to the facility. The NHA stated she was told by the consultant she could only come in to conduct a kitchen audit. The NHA stated when the consultant came in, there were no resident records reviewed. She said the facility became aware of dietary issues during the 1/17 QA meeting. She said the management team had not had time to begin implementing action plans to address the dietary issues.

Based on record review and interview the facility failed to prevent the development of a pressure ulcer for one (#130) of three sampled residents of 31 total residents. Specifically the resident was admitted to the facility without a pressure ulcer to his coccyx, was initially identified as being at high risk for development of a pressure ulcer and then developed a stage III pressure ulcer to his coccyx during his stay at the facility. Cross reference F315: Facility failed to ensure appropriate care and assessment of an indwelling Foley catheter. Findings: Sample resident #130 was an [AGE] year old male who was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The resident no longer resided at the facility According to the minimum data set (MDS) assessment dated [DATE] the resident was rarely or never understood and a brief interview for mental status (BIMS) was not able to be completed. The MDS indicated the resident had not rejected care and required extensive assistance of two persons for bed mobility, transfers and toilet use. The resident required extensive assistance of one person for personal hygiene and physical assistance and was frequently incontinent of bowel. The MDS identified the resident as being at risk for the development of pressure ulcers and having three stage III pressure ulcers (two of which were present upon admission). Care Plan: The care plan dated 5/15/14 specific to the actual/potential for impaired skin integrity indicated the goal was for the pressure ulcers to show signs of healing and to have no further skin breakdown. The interventions included providing assistance with repositioning as needed, the use of a pressure reduction mattress, a weekly skin and Braden scale assessment to be completed, applying a moisture barrier to skin daily and floating the resident's heels in bed as tolerated. Record review: -On 5/2/14 a Braden Scale (an assessment for predicting pressure sore risk) of 11 was determined which indicated the facility identified the resident as being at high risk for developing a pressure ulcer. -The skin assessment form dated 5/2/14 (date of admission to the facility) indicated through writing and a diagram that the resident had pressure wounds on the left heel, second left toe and two wounds on the outer portion of the right foot. Additionally redness to the resident's groin and coccyx had been identified. -The ulcer documentation and progress forms (one for each wound) initiated on 5/2/14 indicated the resident had a left heel wound, a left second toe wound and two open areas on the right foot. -On 5/5/14 a Braden Scale score of 13 was determined which indicated the facility identified the resident as being at moderate risk for developing a pressure ulcer. -The skin assessment dated [DATE] indicated the resident had two open areas on the right foot and the left heel and left second toe were noted to be black. Additionally the assessment noted "coccyx red with no open areas." -The physician notes dated 5/5/14 indicated the resident had a heel ulcer. -The skin assessment dated [DATE] indicated both of the resident's legs had wound dressings, no mention of the redness to the coccyx was noted. -On 5/12/14 a Braden Scale score of 13 was determined which indicated the facility identified the resident as being at moderate risk for developing a pressure ulcer. -The ulcer documentation and progress forms dated 5/13/14 indicated the resident had a left heel wound, a left second toe wound and two open areas on the right foot. -The physician assistant notes dated 5/15/14 indicated the resident had a heel ulcer. -The skin assessment dated [DATE] indicated the left heel was black and had a foul odor, the left second toe had no signs or symptoms of an infection and the right foot had two open areas. -On 5/19/14 a Braden Scale was initiated but not completed. Two of the six assessment areas were blank and a score that would have indicated the resident's risk of developing a pressure ulcer had not been calculated. -The ulcer documentation and progress forms dated 5/21/14 indicated the resident had a stage III wound to the coccyx 2.1 cm in length, width was indicated as round (no measurement) and moderate serosanguineous (blood and serous fluid) was noted. -The pressure ulcer tracking flow sheet dated 5/21/14 noted the resident had a stage III coccyx ulcer measuring 2.1 cm x 1.6 cm. -The physician assistant notes dated 5/22/14 indicated the resident had wounds on the scrotum, penis and buttocks. The document described the wounds as follows: open wounds with thick yellow slough on the underside of the penis and top of scrotum and buttocks red with 2 cm open wound. (Cross reference F315: Facility failed to ensure appropriate catheter assessment and care.) -The nurse's notes from 5/22/14 noted new skin care orders were written for open areas on the coccyx and scrotum. -The resident was discharged to the hospital on [DATE]. The hospital documented that the resident arrived on 5/23/14 with a sacral decubitus ulcer (pressure ulcer). -There was no documentation produced or provided that would have indicated the pressure ulcer had been unavoidable. -There was not a care plan for the stage III coccyx ulcer in the standard care plan or in the acute care plan. Interview: -On 10/7/14 at 11:02 a.m. the director of nursing (DON) stated the resident had developed the open area on the coccyx while at the facility. The DON stated the facility had identified the open area as a stage III pressure ulcer to the coccyx. The facility's expectation was for an assessment to be completed after the identification of a facility acquired stage III pressure ulcer, to determine if alternate or additional interventions were indicated. The DON stated there was no evidence that additional or alternate pressure reduction interventions had been implemented prior to or after the development of the new pressure ulcer on the resident's coccyx. The DON stated the resident would have benefited from an air mattress. The DON stated that the resident had not been on an air mattress. The DON stated the pressure reduction mattress used for the resident at the facility had been a specialty mattress specifically appropriate for reducing pressure to the resident's heels. On 10/7/14 at 11:58 a.m. registered nurse (RN) #1 stated they had observed the resident as having redness and excoriation to his bottom and groin on the weekend prior (5/17/14-5/18/14) to the development of the pressure ulcer to the resident's coccyx. The RN stated s/he was not aware if additional measures or interventions had been implemented at that time. Additional record review: The facility provided an informational handout for the mattress used by the resident during his stay. Upon review of the manufacture's website (http://www.spanamerica.com/selection_guides.phpon) on 10/9/14, viewed at 10:53 a.m. in the manufactures's guidelines for 2014 product selection titled, "Support Surface Management Algorithm" the manufacture specifically indicated that the mattress provided by the facility was not an appropriate mattress if a resident had multiple stage II ulcers or a single stage III ulcer other than on the heels (see record review above).

Based on record review and interview, the facility failed to provide catheter care for two (#130 and #36) of three sampled residents of 31 total residents. Specifically: 1. Resident #130, who was admitted to the facility with a Foley catheter, developed open sores on the penis and scrotum and experienced penile erosion from catheterization. The resident was hospitalized specific to the complications experienced from the lack of catheter care. 2. Resident #36 did not have an appropriate bladder assessment in place. The findings include: 1. Failure regarding resident #130 A. Facility Protocol for Foley Catheter Care (dated June 2014) read as follows: "When a resident is admitted to the facility with a Foley catheter: 1. A TAR (treatment administration record) for the Foley will indicate; -Foley Catheter care twice daily -Reason for the Foley -Date for the follow up with urology (urologist) -Type and size of catheter -Date for removal and residual testing -Date to be changed 2. The Foley will be scheduled for removal within one week of admission with a check for residual unless otherwise ordered or indicated. The physician/physician assistant/nurse practitioner will be notified of planned removal to allow for the opportunity for alternative orders. 3. If the post residual volume is greater than 250 ml (milliliters), the catheter will be reinserted. 4. The nurse will document each shift regarding the catheter site, and the urine output i.e. signs and symptoms of infection, swelling, discharge, discomfort, changes in output, color, odor, sediment, patency, blood etc. and any special care required. The facility policy for catheter care further read in pertinent part: Complications: Observe the resident for complications associated with urinary catheters. b. Check the urine for unusual appearance (i.e., color, blood, etc.). d. Report any complications the resident may have of burning, tenderness or pain in the urethral area. e. Observe for other signs and symptoms of urinary tract infection or [MEDICAL CONDITION]. Report findings to the physician or supervisor immediately. Documentation: The following information should be recorded in the resident's medical record: 1. The date and time catheter care was given. 2. The name of the individual (s) giving catheter care. 3. All assessment data gathered when giving catheter care. 4. Character of urine such as color (straw-colored, dark, or red) clarity (cloudy, solid particles, or blood) and odor. 5. Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting or pain. 6. Any problems or complaints made by the resident related to the procedure. 7. How the resident tolerated the procedure 8. If the resident refused the procedure, the reason(s) why and the interventions taken. 9. The signature of the person recording the data. Reporting: -Report other information in accordance with facility policy and professional standards of practice B. Resident #130 b. Resident profile Sample resident #130, was an [AGE] year old who was admitted to the facility on [DATE] and discharged to the hospital on [DATE] with the following Diagnoses: [REDACTED]. The resident did not return to the facility after his discharge 5/23/14. According to the minimum data set (MDS) assessment dated [DATE], the resident was rarely or never understood and a brief interview for mental status (BIMS) (a test to determine cognitive ability/impairment) was not able to be completed. The MDS indicated the resident had not rejected care and required extensive assistance of two persons for bed mobility, transfers and toilet use. The resident required extensive assistance of one person for personal hygiene and physical assistance, was frequently incontinent of bowel, and had an indwelling catheter. c. Record review The hospital record sent to the facility on [DATE] indicated that prior to 4/26/14, the resident had no history of [MEDICAL CONDITION] and responded to volume expansion and Foley catheter placement on that date. The hospital discharge instructions dated 5/2/14 noted, "Foley catheter care," under additional instructions and indicated the catheter needed to be reevaluated by a urologist (named in document), with the indicated timeframe for the follow up appointment noted to be one week. The initial nursing assessment dated [DATE] indicated the resident had an indwelling catheter. The facility [DIAGNOSES REDACTED]. The skin assessment form dated 5/2/14 (date of admission to the facility) indicated through writing and a diagram that the resident had redness to the groin. The resident's acute care plan dated 5/3/14 did not indicate an indwelling Foley catheter. The computerized physician orders [REDACTED]. Review of the medication administration record (MAR) and the treatment administration record (TAR) for the month of May 2014 revealed the facility did not identify the use of, or outline parameters for, the care of an indwelling Foley catheter. Nursing notes: (The facility's staffing for nursing was provided on 12 hour shifts, two shifts per day, the day shift from 6:00 a.m. to 6:00 p.m. and the evening shift 6:00 p.m. to 6:00 a.m.) -The evening nurse's note dated 5/2/14 noted the resident had an indwelling Foley catheter draining clear yellow urine. The note further indicated the catheter had been placed due to frequent urine retention. -The day and evening nurse's notes from 5/3/14 through 5/8/14 noted the resident's catheter drainage and color, however, there was no documentation to indicate hygiene had been provided or assessment of the catheter-urethral site had been completed. -The nurse's note dated 5/9/14 at 10:14 p.m. noted, "Foley care done." There was no documentation to indicate what the care had entailed. -The nurse's note dated 5/11/14 at 1:31 p.m. did not document care to the Foley catheter. This was the only nurse's note for the shift. -The nurse's note dated 5/14/14 at 3:50 a.m. did not document care to the Foley catheter. This was the only nurse's note for the shift. On 5/15/14, a care plan was initiated that read the resident had an indwelling Foley catheter related to [MEDICAL CONDITION]. Interventions included: -Change Foley every month and as needed with 16 Fr (French unit/outside diameter). -Catheter care every shift. -The nurse's note dated 5/16/14 at 2:31 a.m. did not document care to the Foley catheter. This was the only nurse's note for the shift. -The nurse's note dated 5/17/14 at 3:17 a.m. did not document care to the Foley catheter. This was the only nurse's note for the shift. -The nurse's note dated 5/19/14 at 1:29 p.m. indicated the physician was notified of blood in the resident's urine. -The nurse's note dated 5/19/14 for the 6:00 p.m. to 6:00 a.m. shift (no specific time was indicated) noted the resident had a Foley catheter; his penis was red and swollen. "Tannish" drainage was noted and attributed to tissue deterioration from the catheter. The note did not indicate if the physician had been notified. -The nurse's note dated 5/20/14 at 11:54 a.m. noted the Foley catheter was intact and draining dark amber urine; there was no documentation of care or assessment provided. -The nurse's note dated 5/21/14 at 8:58 a.m. noted the resident's urine was dark orange. The note further indicated the resident's penis was swollen and red and would be "looked at and evaluated" when dressings (unrelated wounds and unspecified timeframe) were changed. -The nurse's note dated 5/21/14 at 11:05 a.m. noted, "appointment request made to have urology appointment" (see above for hospital discharge instructions dated 5/2/14 for appointment within one week, and facility protocol to remove Foley catheter within one week of admission). Physician notes and further nure's notes: -The physician's note dated 5/22/14 noted, "open wounds with thick yellow slough on underside of penis and top of scrotum." -The physician's assistant note dated 5/22/14 noted, "wounds on scrotum and penis," and "needs doctor (named) (same physician named above for consult within one week of admission to the facility), urologist." -The nurse's note dated 5/23/14 at 1:54 a.m. indicated the facility had made a urology appointment, 22 days after admission to the facility for the resident. -The nurse's note dated 5/23/14 at 9:45 a.m. noted the resident complained of increased pain. -The nurse's note dated 5/23/14 at 10:00 a.m. noted the resident had open wounds on scrotum and penis with yellow drainage coming from the open areas. The resident was additionally noted to be moaning and have chills. At 10:45 a.m. the facility documented that they had asked the resident (see MDS and BIMS above) if he wanted to be sent to the emergency room for evaluation. At 11:32 a.m. the resident was sent to the hospital emergency room . The transfer form from the facility to the hospital dated 5/23/14 indicated elevated white blood cell count and excoriated scrotum as reasons for transfer to the hospital. d. Hospital records The hospital admission form dated 5/23/14 listed the admission [DIAGNOSES REDACTED]." The hospital admissions documentation additionally indicated the resident did not have a history of urine retention, and had a urinary catheter for four to five weeks. The physician's assessment indicated traumatic urethral erosion, likely due to an indwelling catheter on tension and this was further described as, "A Foley catheter is present. It appears to have eroded the base of the urethral meatus (opening of the urethra) down significantly proximal in the shaft. A proximal fistula on the penis was also noted. e. Interviews -On 10/7/14 at 11:02 a.m. the director of nursing (DON) stated the resident had been admitted to the facility with an indwelling Foley catheter. The DON stated there was not a documented order for, or corresponding appropriate diagnoses, for use of the catheter. The DON stated this should have been clarified during the resident's stay at the facility. The DON reviewed the MAR and TAR for the resident and stated the documents did not define parameters for care of the catheter and did not document if care had been provided per shift as outlined in the facility's policy and protocol. The DON stated the expectation was for the care parameters to be defined on the TAR per facility policy. The DON said the nurse's notes for the resident did not include the expected documentation related to assessment or cares provided. She confirmed the resident was admitted to the hospital secondary to complications from the indwelling catheter. -On 10/7/14 at approximately 11:58 a.m. registered nurse (RN) #1 stated the resident had an indwelling catheter upon admission to the facility. The RN stated a head to toe skin assessment had been completed upon admission and redness to the groin was noted. The expectation for a resident admitted with a Foley catheter would have been to attempt to remove the catheter within one week and for post void residual testing to have been completed. The RN stated this had not been done. The RN stated after the resident's penis became red and swollen the facility contacted the hospital specific to the catheter placement and were informed the catheter had been placed for [MEDICAL CONDITION]. The facility initiated an attempt to schedule an appointment with the urologist (see documentation above). She stated there were no defined documented parameters of care for the resident's catheter care and there was no supporting documentation that care and assessments had been provided each shift per facility policy. The RN stated the standard of care would have been for the nursing staff to document care, cleaning and assessment of the catheter site, each shift. The RN said that while at the facility, the resident's penis became swollen, reddened, developed open areas with drainage and tissue erosion at the catheter-urethral junction and along the shaft of his penis. The RN stated the resident had been hospitalized , in part, due to the complications from the catheter. -On 10/7/14 at 4:33 p.m. the resident's physician (while at the facility) stated in a phone interview that the resident had been admitted to the facility with an indwelling Foley catheter. The physician stated it would have been up to the facility to determine the appropriate documentation for the resident's catheter care. The physician stated the resident was prescribed an antibiotic on 5/19/14 related to a urinary tract infection. On 5/22/14 an alternate antibiotic and an anti-fungal medication were initiated due to the resident's worsening condition. And, upon observation, the resident had tissue erosion at the catheter site and open areas with yellow drainage on the penis. The physician stated the facility had made an appointment for the resident to see the urologist concerning the catheterization (see record review above, the appointment was made after the change/worsening of condition). 2. Resident #36 did not have an appropriate bladder assessment in place. a. Resident profile Sample resident #36, age 89, was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) dated , 7/28/14, the resident scored 13 out of 15 points on the Brief Interview for Mental Status (BIMS) indicating his cognition was generally intact. The resident required extensive assistance with the activities of locomotion, dressing, hygiene, and bathing. He was completely dependent on staff for transfer. The resident was able to feed himself with supervision. b. REVIEW OF MEDICAL RECORD Additional review of the resident's MDS, showed that the resident's urinary continence had declined from "always continent" on his 4/28/14 Admission MDS, to "frequently incontinent" on the most recent MDS (7/28/14). Review of both the resident's current and purged records on 10/7/14 did not reveal an Initial Bladder Assessment. On a Quarterly Nursing assessment dated [DATE], Section 3 included a brief assessment of Bowel and Bladder status. The resident was given the score of "9" which indicated the resident was "a poor candidate" for routine toileting. Section 4 asked the question "Has there been a change in bowel or bladder in the last 90 days?" The answer was written as "[MEDICAL CONDITION], stayed in bed most of the time." Review of the physician progress notes [REDACTED]. The resident developed weakness with the recurrent infections, and as a result his urinary continence declined. CARE PLAN: On 5/31/14 a Problem was initiated for an alteration in elimination related to the resident's multiple medical conditions including: [MEDICAL CONDITION] arthritis; hypertension; [MEDICAL CONDITION]; [MEDICAL CONDITION]; [MEDICAL CONDITION]; dementia; a history of [MEDICAL CONDITION] and [MEDICAL CONDITION]/pulmonary embolism; increased weakness and a history of falls. Additional information under the Problem section included that the resident was admitted from a hospital stay with [MEDICAL CONDITION], that he had recent urinary tract infections, and that he was usually continent of bowel and bladder, but that he "required extensive assistance with toileting at this time. " The following undated information was also added: "- Increased incontinence and weakness secondary to diarrhea and recurrent [MEDICAL CONDITION] - Expected to return to baseline " The Goals included the statement "will remain continent. " The Approaches were listed as: "- Provide assist with toileting as needed. - May wear pull ups or briefs for dignity as desired - Encourage good peri care and PRN (as needed)." c. INTERVIEWS: On 10/7/14 at 12:25 p.m., the MDS Coordinator/LPN #2 was interviewed regarding the resident's urinary continence. She stated that she completed the resident's most recent MDS assessment by reviewing the Nurses' Progress Notes and the certified nurse aide's (CNA's). The MDS Coordinator said that she had been unaware that the resident did not have a bladder assessment, but that the new Director of Nursing (DON) had implemented the use of bladder assessments recently. On 10/7/14 at 1:00 p.m., the Director of Nursing (DON) was interviewed regarding bladder assessments. She stated that she had been at the facility since the middle of July 2014, and since that time she has been requiring staff to start completing bladder and fall assessments. The DON said that the purpose of the assessments was to see where the resident was, and how to approach their care from that point on.