Every finding on record at The Suites Rio Vista

Based on interview and record review, the facility failed to ensure residents were free from physical abuse for 1 (R #1) of 3 (R #1, #2 and #3) residents reviewed for abuse, when facility staff intentionally struck R #1 with a pillow and a blanket while providing personal care. If the facility fails to provide an environment free from abuse, then residents are at risk for physical injury and psychological harm. The findings are: A. Record review of R #1's face sheet revealed an admission date of 01/11/21. B. Record review of R #1's Annual Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 08/12/25, revealed a Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 11, moderate impairment. C. Record review of the facility's investigative report, dated 05/18/25, revealed the following:R #1 resided long term in the facility.R #1 filed a Grievance Report on 05/17/25, which stated the Certified Nursing Aide (CNA) who provided direct care for her, slapped her with her little pillow and then with a flowered blanket on 05/14/25.Facility investigated the incident and substantiated the abuse occurred. D. On 02/18/26 at 3:42 pm during an interview, R #1 stated she remembered the incident that occurred in May 2025, when a CNA was rude and abusive towards her. She stated the CNA was in her room providing care, and the CNA hit her with her pillow and blanket. R #1 stated she told the CNA to stop hitting her with the pillow, but the CNA grabbed the blanket and began hitting her with it as well. R #1 stated the CNA also struck personal items hanging on her wall with the blanket and tried to knock her personal belongings off the wall. R #1 confirmed she felt upset over the incident and filed a grievance report with the facility. E. On 02/18/26 at 12:09 pm during an interview, the Director of Nursing (DON) stated she was not employed with the facility at the time of this incident, but she was aware of R #1's grievance dated 05/17/25. The DON stated she reviewed the record of the incident, and the CNA was identified as an agency CNA. The DON stated the agency CNA was removed from the schedule during the investigation and eventually terminated from the facility. The DON stated R #1 was assessed on 05/14/25 and again on 05/21/25, without injuries noted. The DON stated the CNA should not have struck R #1 with her pillow and blanket. F. On 02/19/26 at 12:09 pm during an interview, the Administrator stated R #1 filed a grievance report on 05/17/25 stating the abuse incident occurred on 05/14/25 or 05/15/25. The Administrator stated R #1 did not have cognitive deficits and was a very good self-advocate. The Administrator stated the CNA involved in the incident was taken off the schedule and terminated after the facility's investigation. The Administrator stated there were not any witnesses to the incident; however, he believed R #1 was cognitively intact and did not have a reason to file the report if it did not occur. The Administrator stated he followed up with R #1 after the incident, and R #1 did not have any apparent injuries or distress from the incident. The Administrator stated the CNA should not have struck R #1 with a pillow and blanket.

Based on record review and interview, the facility failed to ensure a safe environment and provide adequate supervision to prevent accidents for 1 (R #88) of 1 (R #88) residents reviewed when staff left R #88's bed in the highest position, and R #88 fell from the bed. This deficient practice likely resulted in R #88 sustaining a right femur fracture (long bone that connects the hip to the knee) and spinal compression fractures (a break in a bone in your spine) which required hospitalization. Failure to ensure residents' beds are maintained in the appropriate position while occupied increases the likelihood of avoidable accidents, and places residents at risk for serious injury, significant harm, and potential death.The findings are: A. Record review of R #88's face sheet revealed an admission date of 01/23/23. B. Record review of R #88's care plan revealed the following: Dated 12/20/24: Focus: Impaired physical functioning. Interventions: Bed mobility, and two person substantial/max assist for activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating). Dated 07/10/24: Focus: R #88 is at risk for falls related to left above knee amputation (AKA). Interventions: Certified Nursing Aides (CNAs) to use Hoyer (mechanical lift used to transfer patients) lift with two persons assist to transfer. C. Record review of R #88's nursing progress notes revealed the following: Dated 10/08/25 at 6:30 am: R #88 experience a witnessed fall; encouraged use of bedrails; staff reminded to use caution during repositioning. Dated 10/08/25 at 8:11 pm: R #88 reports pain to lower back, right leg/hip, and left arm. Practitioner notified; orders for topical analgesic, Oxycodone (opioid pain medication), labs, and X ray (medical imaging test that uses a small amount of ionizing radiation to create pictures of the inside of the body, particularly bones and certain tissues). Dated 10/10/25 at 10:26 am: Physical Therapy note – R #88 is seen after a fall a few days ago; resident reports 10 out of 10 (worst pain possible) back pain and 5 out of 10 (moderately strong pain) aching pain to the right side of her head. Pain descriptions inconsistent. Higher level of care required due to decline in mobility and increased fall risk. Dated 10/11/25 at 6:17 pm: R #88 complains of lower back and right knee pain; pain worsens with position changes. Dated 10/12/25 at 12:07 pm: R #88 moaning in pain during care; increased right knee pain; right foot edema and bruising noted. CNAs instructed to minimize leg movement. Dated 10/12/25 at 1:23 pm: Provider requested diagnostic imaging; resident reports knee pain at 10 out of 10 despite medication. Dated 10/12/25 at 1:42 pm: Continued 10 out of 10 right knee pain; decline noted. Dated 10/13/25 at 6:00 pm: X ray of right knee ordered; large bruise noted on left hand. Dated 10/14/25 at 6:01 pm: X ray scheduled for completion. Dated 10/14/25 at 10:15 pm: X-ray to right knee completed. Dated 10/15/25 at 4:30 am: X-ray was positive for right femur fracture. R #88 was sent to the emergency room (ER). Dated 10/15/25 at 1:48 pm: Physical Therapy note – R #88 presents lying in bed, tearful, irritable, and wincing in pain. She reports having pain all over and states she is unable to rate or describe the pain further. Later in conversation, she reports having right leg pain, tenderness with palpation from right hip to toes on the right side. Nursing staff has reported patient yelling when rolled in bed. Dated 10/19/25 at 12:48 pm: Returned from hospital with closed distal femur fracture; computed tomography (CT scan; a noninvasive diagnostic imaging procedure that uses a computer to take data from several X-ray images of structures inside a human and converts them into pictures on a monitor) showed lumbar compression fractures; bruising to upper extremities. D. Record review of R #88's provider progress notes revealed the following: Dated 10/08/25: The chief complaint was for the follow-up of a fall. She denies hitting her head or having a change in level of consciousness. Dated 10/09/25: The chief complaint was lower back and knee pain. Yesterday patient had endorsed pain level 10 out of 10 to lower back however during interview R #88 said she did not report pain. Later in the day she was again reporting lower back and right knee pain. She was inconsistent in her description of pain. She was unable to describe pain; however, she was noted to be screaming loudly. Attempted muscle relaxer as pain would appear seemingly during rest and no movement. This did not relieve symptoms. Discussed starting low dose Oxycodone (opioid pain medication). Patient reports she believed the Oxycodone helped but is not sure. Dated 10/13/25: R #88 is seen today for follow up regarding pain after a fall. Lumbar x-ray reviewed with patient. She continues to endorse nonspecific pain. Patient has been followed closely after recent fall last week. She has appeared very depressed, hopeless, and indifferent. Dated 10/19/25: R #88 is examined at bedside. She has returned after a hospitalization for a right femoral fracture secondary to a fall in the facility. She is status post ORIF (Open Reduction and Internal Fixation; surgical procedure to treat serious bone fractures) on 10/16/25, and she currently has a knee immobilizer (a type of brace designed to keep the knee completely straight and prevent movement) on. E. Record review of R #88's hospital records revealed the following: Dated 10/15/25: Surgical treatment was discussed with R #88 regarding the femur fracture. Surgical interventions would allow R #88 to return to weight bearing and range of motion (the extent or limit to which a part of the body can be moved around a joint or a fixed point) as tolerated. Dated 10/16/25: Retrograde nail fixation (surgical technique used to repair femur fractures) to R #88's right distal femur fracture was completed. F. On 02/03/26 at 2:05 pm, during an interview, the Director of Nursing (DON) stated R #88 fell during care provided by one CNA, when R #88's bed was in highest position. The CNA asked R #88 to hold onto the handrails during repositioning, and R #88 fell to the floor. The DON stated R #88 was not sent to the ER immediately because R #88 did not report a head injury. She stated the resident did report back pain. The DON stated the nurse assessed R #88 and obtained orders for x rays of R #88's lower back and right distal femur. The DON stated the x-rays initially read as negative (no fracture). The DON stated a second X ray was ordered on 10/13/25 due to R #88's persistent knee pain, and the second x-ray was completed on 10/14/25. The DON stated the results from the second x-ray were received on 10/15/25 and showed a right femur fracture. The DON stated R #88 was transferred to the hospital, and the hospital identified a lumbar compression fracture (a collapse or break in one of the vertebrae in the lower spine, often causing back pain and changes in posture). The DON stated R #88's inconsistent pain reporting contributed to a delayed transfer to the ER. The DON stated R #88's bed should not have been in the highest position during care. G. On 02/10/26 at 2:26 pm, during an interview, the Nurse Practitioner (NP) stated she was aware R #88 reported a 10 out of 10 pain following the fall that occurred on 10/08/25. The NP stated initially the staff reported to her that the resident did not have any complaints of pain, so R #88 was not sent out to the ER immediately. The NP stated she recalled one or two X-rays were ordered for the resident. The NP stated the resident was sent to the hospital after the second x-ray identified R #88 had a fractured femur.

Based on record review, observation, and interviews, the facility failed to ensure the accuracy of the Minimum Data Set (MDS; a federally mandated comprehensive assessment of a resident's functional, medical, psychosocial and cognitive assessment completed by facility staff) assessments for 2 (R #15 and R #69) of 2 (R #15 and R #69) residents reviewed for MDS assessments, when: R #15's hearing and oxygen (O2) use MDS sections were not accurate,R #69's functional status (resident's ability to complete essential activities to meet one's basic needs and maintain health) MDS section was not accurate and a significant change MDS was not completed. If MDS assessments are not coded accurately, then the resident is at risk of receiving inappropriate or inadequate care due to inaccurate representation of functional abilities and care needs. The findings are: R #15: A. Record review of R #15's face sheet revealed an admission on [DATE] with the following diagnoses: Metabolic Encephalopathy (disruption in brain function without direct physical or structural damage to brain, caused by an underlying condition), Influenza (infection of the respiratory system caused by viruses) due to identified novel influenza A virus with other respiratory manifestations, Acute respiratory failure with hypoxia (condition when blood fails to be oxygenated by the respiratory system), Acute pulmonary edema (a sudden condition when the lungs become fluid filled). Hearing: B. On 02/02/26 at 9:19 AM during an attempted interview with R #15, he continuously responded with the phrase huh when asked questions, indicating he was unable to hear adequately. C. On 02/02/26 at 9:20 AM during an observation of R #15 interacting with another person, R #15 continued to respond with huh when attempting to communicate, indicating he was unable to hear adequately. D. Record review of R #15's MDS dated [DATE], revealed the following: R #15's ability to hear was documented as no difficulty in normal conversation, social interaction, listening to television, no hearing aid in use, and ability to understand others. R #15's hearing aid was documented as R #15 does not using a hearing device. R #15's signs and symptoms of Delirium (inattention, disorganized thinking, altered levels of consciousness) was documented as inattention being continuously present with no fluctuations. R #15's Therapy Services documentation of Speech-Language Pathology (services related to communication, speech, language, and swallowing disorders) and Audiology Services (services related to hearing, balance, and ear disorders) was documented as administered for at least 15 minutes a day for one or more days in the last seven days. E. Record review of R #15's physician's orders revealed no documentation regarding hearing aids, audiology assessments, or hearing services. F. Record review of R#15's physician's notes dated 01/13/26 to 02/05/26 revealed documented speech is clear; R #15 is able to understand and be understood while speaking. G. On 02/06/26 at 2:22 PM during an interview with Licensed Practical Nurse (LPN) #1, she stated R #15 was hard of hearing, he does not have hearing aids. She stated she believes he has them at home but did not bring them to the facility. H. On 02/12/26 at 4:09 PM during an interview with the Director of Nursing (DON), she stated she was unaware of any issues regarding communication and need or use of hearing aids for R #15. The DON stated it was her expectation regarding difficulty hearing, that the team be made aware and it should be included in the MDS. The DON confirmed if these issues are not in the MDS, it could impact communication and needs of the residents. The DON stated R #15's MDS regarding hearing was not accurate and should be. Oxygen (O2): I. Record review of R #15's physician's orders dated 02/02/26 revealed a room air trial (test conducted by removing O2 from resident to determine O2 saturations in room air) to establish if R #15 was still in need of O2 use. There was not active or discontinued orders related to O2 use for R #15. J. On 02/02/26 at 9:19 AM during an observation of R #15 while outside of his room, R #15 was not observed wearing O2. K. On 02/02/26 at 9:20 AM during an observation of R #15's room, an oxygen concentrator (a medical device that extracts oxygen from ambient air and delivers it at high concentrations to individuals who need supplemental oxygen) was present at R #15's beside without O2 tubing attached, and the machine was not on. L. Record review of R #15's physicians progress notes revealed the following: Dated 01/06/26: Physicians note documented to continue O2 use of one to four liters per minute (LPM) as needed to keep saturations above 90% (percent). Dated 01/07/26: Physicians note documented to continue O2 supplementation and wean as tolerated. Dated 01/09/26: Physicians note documented O2 saturations fluctuating between 77% to 91% on room air, nursing placed on two LPM of O2. O2 saturations recovered to 95%. Dated 01/22/26: Physicians note documented O2 as still low and at two LPM. Dated 01/25/26: Physicians note documented use of O2 via nasal cannula (a small, flexible tube that delivers oxygen to the nose through soft prongs). Dated 01/26/26: Physicians note documented use of O2 at two LPM. Dated 01/28/26: Physicians note documented R #15 on room air (no O2 use). Dated 02/02/26: Physicians note documented R #15 on room air. M. Record review of R #15's nursing progress notes dated 01/06/26 through 02/01/26 notes revealed the following: Dated 01/06/26: Nursing note documented no O2 in use. Dated 01/23/26: Nursing note documented no O2 in use. Dated 01/30/26: Nursing note documented R #15 was on room air. Dated 01/31/26: Nursing note documented O2 use via nasal cannula. Dated 02/01/26: Nursing note documented O2 use via nasal cannula. N. Record review of R #15's MDS dated [DATE], revealed there was no documentation regarding the use of O2. O. On 02/12/26 at 4:09 PM during an interview with DON, she stated it is her expectation for O2 use to be documented in the MDS, and if this was not completed it could impact respiratory needs for the residents. The DON confirmed R #15's MDS was not accurate regarding O2 use and should have been. R #69: P. Record review of R #69's face sheet revealed R #69 was admitted into the facility on [DATE] with the following diagnoses: Parkinson's disease without dyskinesia, without mention of fluctuations (disorder caused by loss of dopamine-producing cells in the brain. It is characterized by symptoms such as tremor, slowed movement (bradykinesia), muscle stiffness (rigidity), and impaired balance), Dysphagia (difficulty or discomfort in swallowing, as a symptom of disease), Scoliosis (as a spinal deformity and can occur in the thoracic, lumbar, or both regions of the spine). Q. Record review of R #69's nursing progress notes dated 09/18/25 through 12/24/25 revealed the following: Dated 09/18/25: R #69 is bedbound and is dependent on all activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating), Dated 09/28/25: R #69 is bedbound and is dependent on all ADL's, Dated 11/11/25: R #69 is bed bound, Dated 11/12/25: R #69 is bed bound status, Dated 12/24/25: R #69 is at baseline; she is bed bound. R. Record review of R #69's MDS dated [DATE] through 11/27/25, Section GG (Functional Abilities) revealed the following: Dated 08/27/25: Mobility devices normally used in the last 7 days (Section GG0120) was coded as wheelchair (manual or electric). Dated 11/27/25: Mobility devices normally used in the last 7 days (Section GG0120) was coded as wheelchair (manual or electric). S. On 02/04/26 at 10:37 AM during an observation of R #69, R #69 was observed to be bedbound. T. On 02/03/26 at 2:32 PM during an interview with the DON, she stated R #69's functional decline from wheelchair use to being bed bound should have been considered a change in condition but explained she could not determine when the change had occurred because she had not been present at the time. The DON stated functional decline had been documented in the nursing notes, noting transitioning from wheelchair use to being bed bound was a functional decline and should have been reported from therapy to nursing. The DON stated documentation revealed R #69 had been bed bound since 2023. U. On 02/04/26 at 2:53 PM during an interview with the Activities Director (AD), he stated he had begun his employment at the facility in 2023 and did not recall R #69 using a wheelchair, only remembering her in her bed. V. On 02/16/26 at 2:31 PM during an interview with the DON, she stated R #69's MDS dated [DATE] and 11/27/25 were documented incorrectly because R #69 cannot use a wheelchair and her required level of care is bed bound. The DON stated if MDS are not coded correctly, the residents can receive inadequate care.

Based on record review and interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR; a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) was accurate for 2 (R #3 and R #88 ) of 2 (R #3 and R #88) residents reviewed for PASARR accuracy.This deficient practice is likely to result in the facility not providing the services needed by residents who are identified in the screening process for additional care and services.The findings are: R #3: A. Record review of R #3's face sheet revealed R #3 was admitted into the facility on [DATE] with the following diagnoses: Anxiety disorder (a psychiatric condition characterized by excessive, persistent fear or anxiety accompanied by behavioral disturbances and physical (autonomic) symptoms, causing significant distress or impairment in functioning), Major depressive disorder, recurrent sever without psychotic features (a serious mood disorder where a person has repeated episodes of severe depression that greatly disrupt daily life, without hallucinations or delusions). B. Record review of R #3's Care Plan dated 11/14/25 revealed the following: Resident will be free of discomfort or adverse reactions related to antidepressant medication use, Monitor, document, report to Medical Director (MD) ongoing signs and symptoms of depression, crying, shame, worthlessness, agitation, irritability, suicide ideations, Resident uses antianxiety medication related to anxiety disorder, Resident uses antidepressant medication related to depression. C. Record review of R #3's PASARR Level I Identification Screening dated 09/16/25, revealed staff documented R #3 did not have a diagnosis of or a suspected mental illness. D. On 02/10/26 at 1:19 PM, during an interview with the Admissions Director (AD), she stated R #3's PASARR Level I Identification Screen did not include R #3's mental health diagnoses. The AD stated R #3 has diagnoses of anxiety disorder and major depressive disorder. She stated if the PASARR screening does not include all pertinent diagnoses, the resident may not be properly screened. R #88: E. Record review of R #88's face sheet revealed an admission date of 01/23/23 with several readmission dates following hospitalizations. R #88's face sheet included the following diagnoses: Generalized Anxiety Disorder (persistent feelings of fear or apprehension). Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). F. Record review of R #88's PASARR Level I Identification Screening dated 12/21/24, revealed staff documented R #88 did not have a diagnosis of a suspected mental illness; and neither major depressive disorder nor generalized anxiety were included as diagnoses. G. Record review of R #88's PASARR Level I Identification Screening dated 12/11/25 revealed that neither major depressive disorder nor generalized anxiety were included as diagnoses. H. Record review of R #88's care plan dated 10/21/25 revealed the following: R #88 uses Hydroxyzine (anti-anxiety medication) related to anxiety disorder. R #88 will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. R #88 will show decreased episodes of signs and symptoms of anxiety through next review date. R #88 is taking anti-anxiety medications which are associated with an increased risk of confusion, amnesia (memory loss), loss of balance, and cognitive impairment that looks like dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), falls, broken hips and legs. Give anti-anxiety medications as ordered by physician. Monitor and document side effects and effectiveness. I. On 02/11/26 at 3:27 pm during an interview with the AD, she confirmed R #88's PASARR did not reflect R #88's diagnoses of generalized anxiety disorder or major depressive disorder. The AD also stated if there are any missing diagnosis then the PASARR Level I Identification Screening process would be inaccurate. The AD confirmed if the PASARR is inaccurate, then residents may not receive all required services or may be improperly placed in the wrong type of facility and may not have all of their mental health issues addressed and treated.

Based on record review and interviews, the facility failed to develop and update a comprehensive, person-centered care plan for 2 (R #8 and R #15) of 2 (R #8 and R #15) residents reviewed for care planning, when staff failed to:Update R #8's care plan to include wound care treatment. Update R #15's care plan to include hearing limitations and oxygen use. These deficient practices are likely to result in residents not having needs met, decreased quality of life, and avoidable decline in physical and psychosocial well-being. The findings are: R #8: A. Record review of R #8's face sheet revealed R #8 was admitted into the facility on [DATE] with the following diagnoses: Localized Edema (swelling in one specific area of the body caused by extra fluid building up in the tissues), Morbid (severe) obesity due to excess calories (refers to a body weight that is significantly above the healthy range as a result of consuming more calories than the body uses. It is associated with increased health risks and can contribute to impaired mobility, delayed wound healing, and higher risk for pressure injuries), Chronic Diastolic Heart Failure (a long term condition where the heart becomes stiff and cannot relax well, which prevents it from filling with enough blood), Mixed Hyperlipidemia (a condition where a person has high levels of both cholesterol and triglycerides in the blood), Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), Essential hypertension (high blood pressure with no identifiable medical cause). B. Record review of R #8's Comprehensive MDS (MDS; a federally mandated assessment instrument completed by facility staff) dated 08/25/25 revealed R #8 is at risk of developing pressure ulcers (PU; an injury to skin and underlying tissue resulting from prolonged pressure on the skin). C. Record review of R #8's Physician Orders dated 09/13/2025 revealed R #8 had a wound to the sacrum (lower back) with wound care treatment ordered. D. Record review of R #8's Care Plan dated 09/14/25 revealed there was not wound care interventions documented for a wound identified on 09/13/25. E. On 02/06/2026 at 1:38 PM during an interview with R #8, she stated her wound was acquired in the facility sometime in September 2025. F. On 02/11/2026 at 11:17 AM during an interview with the Director of Nursing (DON), she stated R #8's sacrum wound was first identified on 9/11/25. She stated R #8 's Care Plan was not updated at the time of the wound's identification, and the first wound care plan entry for R #8 did not appear until 11/13/25. The DON confirmed R #8's sacrum wound should have been care planned sooner than it was. R #15: Hearing: G. Refer to F0641 for related findings. H. Record review of R #15's care plan dated 01/07/26, revealed there was no documentation available regarding problem, goal, or interventions related to auditory assessment or hearing aids. I. On 02/12/26 at 4:09 PM during an interview with the Director of Nursing (DON), she stated she was unaware of any issues regarding communication and need of hearing aids for R #15. The DON stated it was her expectation for R #15's difficulty of hearing to be placed in the care plan and the team be made aware. The DON confirmed if these issues are not in the care plan, then it could impact communication and needs of R #15. Oxygen (O2): J. Refer to F0641 for related findings. K. Record review of R #15's care plan dated 01/07/26, revealed there was no documentation regarding O2 use as an intervention. R #15's care plan revealed documentation of impaired gas exchange related to respiratory failure (life-threatening condition where the lungs are unable to properly move oxygen and carbon dioxide into and out of the blood) and pulmonary edema (condition when the lungs become fluid filled), with the following interventions: Adequate fluid intake Keep head of bed elevated to avoid shortness of breath while lying flat Monitor for signs of infection O2 use as an intervention was not included in the care plan. L. On 02/12/26 at 4:09 PM during an interview with DON, she stated it is her expectation for O2 use to be documented in the care plan. The DON confirmed R #15's O2 use was not care planned and should have been.

Based on observation, record review, and interview, the facility failed to provide quality care that meets professional standards for 4 (R #4, #14, #65, and #85) of 4 (R #4, #14, #65, and #85) residents reviewed when staff failed to: Complete an Abnormal Involuntary Movement Scale (AIMS; used to assess the severity of involuntary movements, particularly in patients taking antipsychotic medications) for R #4 and R #85. Assist R #14 with meals per physician orders and as directed in R #14's care plan. Use appropriate equipment to administer injectable medication (medications administered to body through means of syringe and needle) for R #65. These deficient practices are likely to result in residents not maintaining their optimal health as planned by their medical provider. The findings are: AIMS: R #4: A. Record review of R #4's face sheet revealed an admission date of 11/30/24 with a diagnosis of Schizophrenia (a disorder that affects an individual's ability to think, feel, and behave clearly). B. Record review of R #4's quarterly AIMS assessment dated [DATE] revealed the following: R #4's overall score was moderate (Mild to moderate involuntary movements; a provider may recommend monitoring the condition or conducting further evaluations, particularly if you are taking medications linked to tardive dyskinesia (TD is a movement disorder characterized by involuntary, repetitive movements, often resulting from long-term use of antipsychotic medications). The exam portion of the assessment revealed R #4 had uncontrolled arm movements noted, rapid, objectively purposeless, and spontaneous with frequent leg twitches. C. Record review of R #4's AIMS assessment dated [DATE], revealed an overall score of 0 (no, or minimal involuntary movements). The exam portion of the assessment revealed R #4 had uncontrolled bilateral abnormal upper extremity movements. For section B: Extremity Movements, it noted for the upper (arm, wrists, hands and fingers), include movements that are rapid, objectively purposeless, irregular and spontaneous: this was scored as none. D. Record review of R #4's physician orders indicated the following: Dated 12/09/25: Risperdal (used to treat schizophrenia) oral tablet, give 0.5 mg (milligrams) by mouth two times per day. Dated 02/11/25: Cogentin (used to treat abnormal movements) tablet, give 1 mg by mouth two times per day. E. Record review of R #4''s electronic health record (EHR) dated 02/05/26 revealed only two AIMS assessments (07/20/25 and 10/25/25) were completed since R #4's admission into the facility. F. On 02/05/26 at 9:35 am during an interview with the Director of Nursing (DON), she stated the AIMS assessments are completed quarterly. The DON stated R #4 should have more than two AIMS assessments completed, since he had been in the facility since 11/30/24 and was on an antipsychotic medication. She stated she was aware of R #4's abnormal involuntary movements, and those movements should be reflected on the AIMS assessment. R #85: G. Record review of R #85's face sheet revealed an admission date of 10/17/25 with the following diagnoses: Major depressive disorder (is a common and serious mental illness that affects your mood and interest in life), Dementia with severe behavioral disturbance (symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life and can cause agitation, aggression, mood issues), Suicidal ideations (thought process of having ideas or ruminations about the possibility of dying by suicide). H. Record review of R #85's physician orders dated 11/05/25 revealed the following: Dated 11/05/25: Aripiprazole (antipsychotic used to treat psychosis) Oral Tablet 2 mg, give 1 tablet by mouth in the morning. Dated 11/05/25: Escitalopram Oxalate (used to treat depression) Oral Tablet 20 mg, give 1 tablet by mouth in the morning. Dated 11/05/25: Mirtazapine (used to treat depression) Oral Tablet 15 mg, give 1 tablet by mouth. I. Record review of R #85's EHR dated 02/05/26 revealed an AIMS assessment has not been completed for R #85 since admitting into the facility on [DATE]. J. On 02/05/26 at 9:36 am during an interview with the DON, she confirmed R #85 has not had an AIMS assessment completed since she was admitted into the facility. The DON stated R #85 should have had an AIMS assessment completed due to her taking a antipsychotic medication. Meal Assistance: R #14: K. Record review of R #14's face sheet revealed R #14 was admitted into the facility on [DATE]. L. Record review of R #14's Care Plan dated 01/04/26 revealed R #14 had impaired physical functioning and required substantial/maximum assistance with eating. M. Record review of R #14's physician orders dated 01/09/26 revealed an order for staff to provide feeding assistance for R #14 with every meal. N. On 02/05/26 at 8:54 am during an observation of R #14's room, R #14 was observed eating her meal alone. Further observation revealed R #14's meal ticket showed R #14 required assistance/supervision for all meals. O. On 02/05/26 at 9:06 am during an interview with the Assistant Director of Nursing (ADON), she confirmed R #14 was care planned to receive assistance for all meals. The ADON acknowledged no staff member was present with R #14 during her morning meal and stated staff should have been present. P. On 02/06/26 at 2:10 pm during an interview with the DON, she stated residents with an order for assistance with all meals were expected to have staff present, and all facility staff were responsible for ensuring orders were followed. The DON confirmed feeding assistance during every meal for R #14 was ordered by a physician and care planned. The DON stated R #14 should have feeding assistance for every meal, and that did not happen. Medical Equipment: R #65: Q. Record review of R #65's physician orders dated 12/09/25 revealed an order for heparin (anticoagulant; blood thinner) 5,000 units per 1 mL (milliliter). R. On 02/05/26 at 9:03 AM during a medication administration observation for R #65, Licensed Practical Nurse (LPN) #1 prepared heparin 5,000 units per 1 mL in an insulin syringe and administered it to R #65 via subcutaneous (under the skin) tissue in R #65's abdomen (stomach). S. On 02/05/26 at 9:51 AM during an interview with LPN #1, she stated insulin syringes should only be used for insulin administration. LPN #1 stated she used the insulin syringes as she was not told to use other supplies and was unaware if there were other supplies to use for R #65's heparin injection, or where to locate them. LPN #1 stated she did give the correct dose of 5,000 units per 1mL as the insulin syringe is equivalent to 1mL and showed packaging of insulin syringe which stated 100 units per 1mL. T. On 02/12/26 at 4:09 PM during an interview with DON, she stated it was her expectation that insulin syringes are only to be used for administration of insulin and should not be used for other medications. The DON also stated there are other supplies for injections which should be used. The DON stated insulin syringes are designed for subcutaneous administration and noted she would have to research further outcomes which could arise if other medications such as heparin are administered with an insulin syringe. She stated their insulin syringes are 100 units per 1mL, so if the resident's dose was for 1mL, they would have received a correct dose. The DON confirmed LPN #1 should not have used an insulin syringe when administering heparin to R #65.

Based on record review, observation, and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for 3 (R #69, R #74, and R #88) of 3 (R #69, R #74, and R #88) residents reviewed when: Non-clinical facility staff was assisting residents with dysphagia (difficulty or discomfort in swallowing, as a symptom of disease) or impaired physical functioning had completed required training and competency validation to safely provide feeding assistance for R #69.The facility failed to provide pre-operative instructions for R #74. The facility failed to transfer R #88 to the hospital after experiencing a femur fracture for multiple days. If the facility fails to adequately train staff in providing feeding assistance, does not deliver essential pre-operative instructions prior to a medical procedure, or fails to timely identify and appropriately transfer a resident with a fracture to a hospital, then residents may receive substandard care and treatment, placing them at risk for preventable harm.The findings are: R #69: A. Record review of R #69's face sheet revealed R #69 was admitted into the facility on [DATE] with the following diagnoses: Parkinson's disease without dyskinesia, without mention of fluctuations (disorder caused by loss of dopamine-producing cells in the brain. It is characterized by symptoms such as tremor, slowed movement (bradykinesia), muscle stiffness (rigidity), and impaired balance), Dysphagia (difficulty or discomfort in swallowing, as a symptom of disease), Gastro-esophageal reflux disease without esophagitis (a condition characterized by typical symptoms of acid reflux due to the retrograde flow of gastric contents into the esophagus, without endoscopic evidence of esophageal mucosal injury), Unspecified protein-calorie malnutrition (a condition where a person is not getting enough protein and calories, causing poor nutrition, however the exact severity or type is not specified). B. Record review of R #69's Care Plan dated 05/19/23 revealed the following: Diet alterations related to easy to chew thin liquids, Feeding assistance with all meals in room. C. Record review of R #69's physician orders dated 03/22/25 revealed all medications were to be administered to R #69 whole in applesauce or pudding to make them easier to swallow. D. Record review of the facility Activities Department Feeding Assistance Training conducted on 06/13/25 revealed the following was presented: Set up/dignity of clothing protector and explain what you are doing, Drink first, moistens pathway, wakes up mechanism, Bite Size 1/3 to 1/2 at most, 1 item on the fork with each bite, Present food items to bottom lip and check for response, Place food items in mouth and scrape against top teeth/gums, Alternate solids/liquids. Training related to residents with dysphagia was not included. E. Record review of R # 69's Activities Participation Form dated December 2025, and January 2026 revealed the following: 12/18/25: An Activities Assistant (AA) fed R #69 chocolate, 12/24/25: An AA fed R #69 biscotti (traditional Italian twice-baked cookies, typically dry and crunchy) 01/08/26: An AA fed R #69 an unknown dessert. 01/14/26: An AA fed R #69 ice cream. 01/19/26: An AA fed R #69 a cookie. F. On 02/04/26 at 2:53 pm during an interview with the Activities Director (AD), he stated R #69 receives one-to-one support by the activities staff two to three times per week. The AD also stated the Activities Department staff assist with feeding R #69, along with other supportive tasks. The AD stated his department completed feeding assistance training last year and reported Activities Department staff assist R #69 with feeding. He stated staff received training conducted by the Speech Pathologist (a health professional who diagnoses and treats communication and swallowing disorders across all ages). G. On 02/04/26 at 1:58 pm during an interview with the Speech Pathologist (SP), she stated R #69 was on an easy to chew diet and has oral dysphagia related to chewing. She stated R #69's last swallowing assessment was completed on 5/22/23, and a physician ordered full evaluation dated 3/22/25 was not completed but should have been. The SP stated all non-clinical facility staff that assist residents with feeding, should be trained in the proper competencies and training. The SP confirmed the activities staff was not trained in feeding assistance for residents with dysphagia and should have been. H. On 02/06/26 at 2:59 pm during the interview with the Director of Nursing (DON), she stated activities staff should receive specialized training before being permitted to assist with feeding residents with a diagnosis of dysphagia. She stated a competency evaluation and training should be completed for any non-clinical staff who would be assisting residents with feeding. The DON stated if staff feed residents who have dysphagia or other swallowing issues, the residents could choke. R #74: I. Record review of R #74's face sheet revealed R #74 was admitted into the facility on [DATE] with the following diagnoses: Other injury of muscles and tendons of the rotator cuff of left shoulder. Chronic pain. J. Record review of R #74's electronic health record (EHR) revealed the following: A physician order dated 01/30/26 for shoulder surgery appointment on 02/02/26 was present. Documentation was not present for pre-operative (pre-op) instructions. No documentation was present that indicated R #74 was educated on pre-op instructions. K. On 02/04/26 at 11:30 am during an interview with R #74, he stated he had scheduled surgery for his shoulder on 02/02/26, but he was unable to have the surgery because he had eaten prior to the appointment. R #74 also stated he was upset staff had not informed him of any pre-operative instructions and noted he would now have to wait for surgery while continuing to experience pain from his shoulder. L. On 02/06/26 at 2:00 pm during an interview with the DON, she confirmed R #74 was scheduled for shoulder surgery on 02/02/26, which was rescheduled because he had eaten prior to the appointment. The DON stated the facility received pre-operative instructions for nothing by mouth before surgery (NPO), which she expected would have been entered into R #74's EHR. She further stated it was her expectation staff would educate R #74 on pre-operative instructions, and document education was given to R #74. The DON confirmed R #74's pre-operative instructions and documentation indicating staff educated R #74 on those pre-operative instructions was not present in R #74's EHR and should have been. R #88: M. Refer to F0689 for related findings. N. Record review of R #88's nursing progress notes dated 10/08/25 through 10/15/25 revealed the following: Dated 10/08/25 at 6:30 am: R #88 experienced a witnessed fall. Resident encouraged to utilize bedrails to hold on to during care. Staff to be more cautious with repositioning of resident during care. Dated 10/08/25 at 8:11 pm: R #88 complains of pain to lower back, right leg and hip, and left arm. Practitioner notified and new orders for topical pain reliever, Oxycodone (opioid pain medication), labs and x-ray (a technique that creates pictures of the inside of the body) given. Will continue to monitor. Dated 10/15/25 at 4:30 am: X-ray follow up was positive for right femur fracture. R #88 sent to the emergency department (7 days after experiencing the fall). O. Record review of R #88's provider progress notes dated 10/19/25 revealed the following: Dated 10/19/25: R #88 is examined at bedside. She has returned after a hospitalization for a right femoral fracture secondary to a fall in the facility. She is status post ORIF (Open Reduction and Internal Fixation; surgical procedure to treat serious bone fractures) on 10/16, she currently has a knee immobilizer (a type of brace designed to keep the knee completely straight and prevent movement) on. P. On 02/03/26 at 2:05 pm during an interview with the DON, she stated R #88 was not sent to the emergency room (ER) immediately following the fall. The DON stated this decision was based on the absence of a reported head injury, though the resident did report immediate back pain. She further stated after the fall, a nurse performed a full assessment and notified the provider. Orders were obtained for X-rays of the lower back and the right distal femur. The DON stated these initial X-rays were reported as negative for acute injury to the back and right knee. The DON stated R #88 was complaining of pain in her back immediately after the fall, and due to persistent knee pain, a second X-ray was requested on 10/13/25 and completed on 10/14/25. Results for this x-ray were received on 10/15/25 and revealed a right femur fracture, and R #88 was transferred to the hospital on [DATE]. She stated R #88 wasn't sent out sooner due to her being inconsistent with reporting where her pain was as well as being unable to describe the pain. The DON confirmed residents who experience significant injuries, like a femur fracture, should be sent to the hospital immediately. Q. On 02/10/26 at 2:26 pm during an interview, the Nurse Practitioner (NP), she stated she recalled the fall involving R #88 that occurred in October 2025, which resulted in a femur fracture. The NP clarified that she was not a witness to the event and her knowledge was based solely on facility reports. She stated R #88 reported pain, however, the resident's reporting was inconsistent. The NP stated R #88 was not sent to the ER immediately, but after the second x-ray revealed R #88 had a femur fracture, she was sent to the ER. The NP confirmed residents who experience significant injuries, like a femur fracture, should be sent to the hospital immediately.

Based on observations and interviews, the facility failed to ensure the proper storage and security of medications and medical supplies located in the medication carts and medication storage rooms, when: R #14's medications were left unattended on top of the medication cart in the 500-hall. Lancets (small needles designed to puncture skin to obtain blood samples for testing) were removed from original packaging and placed in a large bin without labeling or expiration dates. This deficient practice is likely to result in exposure to infectious agents through the ingestion of expired lancets. Additionally, the failure to properly secure medications may result in unauthorized access or diversion by staff, residents, or visitors, potentially leading to adverse outcomes.The findings are: R #14's Medications: A. On [DATE] at 8:39 am during an observation of the medication cart located in the 500-hall, several packs of R #14's medications were observed to be left on top of the medication cart unattended and without nursing staff present. The medications left on top of the cart were Pravastatin (used to lower cholesterol), Methocarbamol (muscle relaxer), and Buspirone (used for depression). B. On [DATE] at 8:41 am during an interview with the Assistant Director of Nursing (ADON) #1, the ADON confirmed R #14's medications should not have been left on top of the medication cart unattended. C. On [DATE] at 8:42 am during an interview with Certified Medication Assistant (CMA) #3, she stated she should have locked up the medications before she walked away from the medication cart. CMA #3 confirmed R #14's medications should not have been left unattended. Lancets: D. On [DATE] at 2:36 pm during an observation of the 200, 300, and 400 halls' medication storage room, lancets were observed to be removed from the original packaging and being stored loosely in a large bin. E. On [DATE] at 2:37 pm during an interview with the Director of Nursing (DON), she stated when the facility receives a new shipment of lancets, they are removed from packaging and placed into a large bin. The DON confirmed storing the lancets like that is unacceptable and should not be done.

Based on record review and interview, the facility failed to ensure advanced directives (documents providing an individual's wishes for emergency and lifesaving care) were accurate within the Electronic Health Record (EHR) for 1 (R #69) of 2 (R #60 and #69) residents reviewed for advance directives, when: The facility failed to ensure that the advance directive forms and face sheets contained matching and consistent information regarding the residents' end-of-life wishes. This deficient practice is likely to cause confusion and delay potentially lifesaving procedures. The findings are: A. Record review of R #69's face sheet revealed was admitted into the facility on [DATE] with R #69's code status (information that lets the resident's medical team know what they want and do not want in the event of a medical emergency such as their heart stopping) being a Full Code (lifesaving procedures desired). B. Record review of R #69's New Mexico Medical Orders for Scope of Treatment (NM MOST; a legal document which outlines the care the resident wants when they become incapacitated and unable to speak for themselves) form dated 05/05/23, revealed R #69 was a Do Not Resuscitate (DNR; lifesaving measures are not desired) status (lifesaving measures are not desired). C. Record review of R #69's Care Plan dated 11/03/25, revealed R #69 was a Full Code. D. On 02/06/26 at 2:57 pm during an interview with the Director of Nursing (DON), she stated R #69's NM MOST form identified the resident as DNR, while R #69's face sheet and care plan documented R #69 as a Full Code. The DON confirmed R #69's correct code status was Full Code and stated her expectation is a resident's code status be accurate and consistent across all documentation. The DON stated R #69's NM MOST form was inaccurate and should not have been.

Based on record review and interview, the facility failed to complete a significant change in condition (major decline or improvement in the patient's health status) Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) for 1 (R #88) of 2 (R #60 and R #88) residents reviewed for falls with major injuries. This deficient practice likely resulted in an inaccurate assessment of a resident's injuries and a delay in treatment of a higher level of care. The findings are: A. Record review of R #88's face sheet revealed an admission date of 01/23/23, a readmission date of 12/11/25, and included the following diagnoses: Collapsed vertebra, lumbar region (when one of the bones in the spine loses height due to pressure, weakness, or trauma in the lower back).Disorders of bone density and structure, multiple sites (conditions where bones become weaker, thinner and abnormally shaped affecting more than one area).Displaced condyle fracture of lower end of femur (break in thigh bone that directly affects the knee joint).Wedge compression fracture of T11-T12 vertebra (one or both of the vertebrae in the lower part of the middle of the back have partially collapsed in the front).Wedge compression fracture of first lumbar vertebra (the front part of the first bone in the lower back has been squeezed or crushed down).Wedge compression fracture of fifth lumbar vertebra (the front part of the lowest bone in the lower back has been squeezed or crushed down). B. Record review of R #88's nursing progress notes revealed the following: Dated 10/08/25 at 6:30 am: Witnessed fall.Dated 10/08/25 at 8:11 pm: Resident complains of pain to lower back, right leg and hip, and left arm. Practitioner notified and new orders for topical pain reliever, Oxycodone (opioid pain medication), labs and x-ray (a technique that creates pictures of the inside of the body) given.Dated 10/10/25 at 10:26 am: Physical Therapy note - Primary care nurse practitioner asked to have resident seen after a fall a few days ago when patient started complaining of 10/10 (pain scale: 0-no pain, 1-very mild pain, 2-minor pain, 3-noticeable pain, 4-moderate pain, 5-moderately strong pain, 6-moderately severe pain, 7-severe pain, 8-very strong pain, 9-excruciating (extremely difficult to bear) pain, 10-worst possible pain) back pain. Resident reports she continues to have 5/10 aching pain to the right side of her head. Higher level of care required secondary to the above diagnosis causing decline in function, mobility, and independence, contributing to an increase in risk of falls, pressure injuries, and poor outcomes. Dated 10/15/25 at 4:30 am - X-ray follow up was positive for right femur fracture. Resident sent to the emergency department.Dated 10/19/25 at 12:48 pm - Resident returned to the facility from the hospital at 12:30 via transport in her wheelchair. Resident had a closed fracture of distal femur, and a computed tomography scan (CT scan; a noninvasive diagnostic imaging procedure that uses a computer to take data from several X-ray images of structures inside a human and converts them into pictures on a monitor) of her spine also showed compression fractures. Resident has bruising to her upper extremities. C. Record review of R #88's provider progress notes revealed the following: Dated 10/19/25 - Resident is examined at bedside. She has returned after a hospitalization for a right femoral fracture secondary to a fall in the facility. She is status post ORIF (Open Reduction and Internal Fixation; surgical procedure to treat serious bone fractures) on 10/16, she currently has a knee immobilizer (a type of brace designed to keep the knee completely straight and prevent movement) on. D. Record review of R #88's MDS assessment reports dated 08/03/25 and 12/01/25 revealed, (despite the major decline in functional status, the surgical intervention, and the diagnosis of multiple fractures) the facility failed to complete a Significant Change MDS until 12/01/25 (approximately one and half months after the injury). E. On 02/03/26 at 2:05 pm during an interview with the Director of Nursing (DON), she stated R #88 was transferred to the hospital on [DATE], and upon evaluation at the emergency room (ER), a compression fracture of the lumbar spine was also discovered. The DON confirmed a Change in Condition MDS for R #88 was not completed following the discovery of these major injuries. The DON stated it was her professional expectation that a Change in Condition MDS for R #88 should have been completed and submitted within 14 days, as the injuries sustained by R #88 were significant.

Based on record review and interview, the facility failed to ensure a discharge Minimum Data Set (MDS; a comprehensive review of the resident's health and functional status) assessments were submitted for finalization within 14 days for 1 (R #7) of 2 (R #'s 7 and 87) residents reviewed for Minimum Data Set. If MDS assessments are not completed and submitted in a timely manner, then the resident is likely to receive less than optimal care.The findings are: A. Record review of R #7's face sheet revealed R #7 was admitted into the facility on [DATE] and was discharged to the hospital on [DATE]. B. Record review of R #7's electronic health record (EHR) revealed R #7's discharge MDS was not submitted and accepted until 02/10/26 (123 days after R #7's discharge from the facility). C. On 02/12/26 at 11:46 am during an interview with MDS Coordinator (MDSC), she stated R #7's discharge MDS was late and was not completed until 2026. The MDSC confirmed R #7's discharge MDS should have been submitted within 14 days of R #7's discharge, but it was not.

Based on record review and interview, the facility failed to ensure staff revised the care plan for 1 (R #60) of 1 (R #60) residents reviewed when staff failed update R #60's plan of care to include an accurate advanced directive code status. This deficient practice is likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are: A. Record review of R #60's face sheet revealed an admission date of 12/12/25, with R #60's code status (information that lets the resident's medical team know what they want and do not want in the event of a medical emergency such as their heart stopping) being Do Not Resuscitate (DNR; lifesaving measures are not desired) status (lifesaving measures are not desired). B. Record review of R #60's New Mexico Medical Orders for Scope of Treatment (NM MOST; a legal document which outlines the care the resident wants when they become incapacitated and unable to speak for themselves) form dated 01/28/26, revealed R #60 was a DNR. C. Record review of R #60's Care Plan dated 01/26/26, revealed a code status of Full Code (wishes to receive all possible life-saving interventions). D. On 02/06/26 at 2:10 pm during an interview with the Director of Nursing (DON), she confirmed R #60's advanced directive care plan was inaccurate and should have been updated to match R #60's MOST form dated 01/28/26.

Based on record review and interviews, the facility failed to ensure residents received the necessary treatment and services to promote healing of a surgical wound (a cut or incision in the skin that is usually made by a scalpel during surgery) for 1 (R #66) of 1 (R #66) resident reviewed when the facility failed to: Ensure hospital discharge orders for a wound VAC (vacuum-assisted closure; a medical device that uses negative pressure to promote wound healing) were implemented as prescribed. Prevent unauthorized modification of a wound VAC order without provider approval. These deficient practices resulted in R #66's wound care therapy not being delivered as intended, leading to ineffective wound care management. The findings are: Past Non-Compliance Compliance Date: 01/29/26 A. Record review of R #66's face sheet revealed R #66 was admitted into the facility on [DATE] with the diagnosis of an infection following a procedure, deep incisional surgical site. B. Record review of R #66's Care Plan dated 01/23/26 revealed R #66 had skin integrity related to a surgical wound and directed staff to provide wound care as ordered. C. Record review of R #66's Electronic Health Record (EHR), revealed hospital discharge orders dated 01/20/26 to keep the wound VAC on the incision continuously for 6 days at 125 millimeters of mercury (mmHg; a unit of pressure; a setting for the machine.) D. Record review of R #66's Physician Orders revealed an order dated 01/22/26 to remove the wound VAC dressing and foam, cleanse the wound with wound cleanser, and pat dry. The order further directed staff to attach the hose to the wound VAC device, initiate therapy at 125 mmHg continuous suction, and ensure proper function. Staff were instructed to check for leaks each day shift and to provide wound care every Monday, Wednesday, and Friday to the wound. The order also directed staff to assess the wound for any changes and report concerns to the Assistant Director of Nursing (ADON) #2. This order was changed from the hospital discharge orders. E. Record review of R #66's Treatment Administration Record (TAR) dated January 2026, revealed R #66's wound care order was followed only one time on 01/26/26. F. Record review of R #66's Nursing Notes revealed dated 01/25/26 revealed R #66's wound VAC device was set at 190 mmHg; however, no suction was present at the wound site and drainage was observed under the dressing. R #66 notified her surgeon who provided new treatment orders for the facility to discontinue the wound VAC and initiate Xeroform (a sterile, non-adhering gauze dressing) with ABD (thick gauze dressing) until R #66's follow-up appointment on 01/26/26. The surgeon also ordered Linezolid (antibiotic) to be obtained from an outside pharmacy and directed R #66 receive a dose of vancomycin (antibiotic) the morning prior to discharge for the scheduled appointment. The facility provider was notified of the change in order G. On 02/03/26 at 1:45 pm during an interview with the Director of Nursing (DON), she stated she had gone into R #66's room to check-in and R #66 was on the phone with her surgeon. The DON stated she observed R #66's wound VAC device was set at 190 mmHg though no suction was present at the wound site and drainage was observed under the dressing. The DON further revealed the wound had worsened as the sutures of the wound had dehisced (when a surgical incision reopens). The DON stated R #66 knew her wound did not look right and had called her surgeon to discuss. The DON also stated R #66 did not look like her normal self, and R #66 declined to go to the hospital because she wanted to wait until her appointment with her surgeon that was scheduled for the following day. The DON stated she believed the change in orders caused harm to R #66. The DON stated R #66 arrived at the facility on a Wednesday and had her surgical follow-up appointment on the next Monday, which would have been six days, aligning with the hospital orders for the wound VAC to remain in place for six days, but the ADON #2 changed this order. The DON stated this was when she discovered the ADON #2 acted outside his scope of practice by independently changing wound care orders without provider authorization. The DON also stated the ADON #2 confirmed he had changed the orders without authorization. The DON confirmed ADON #2 was immediately placed on suspension, an investigation was conducted, and the ADON #2 was terminated. H. On 02/10/26 at 1:40 pm during an interview with the Nurse Practitioner (NP), she stated she was not aware R #66's wound had worsened. The NP stated it was her expectation orders would be entered as they were received from the hospital unless a provider approved changes to an order. The NP stated ADON #2 should not have changed the orders himself for R #66. The NP confirmed the power for the wound vac should not have been altered, adding not even she herself would have made any changes unless she received instructions from R #66's surgeon. Evidence for Past Non-Compliance Provided by the Facility: Record review of facility documentation revealed the following: Dated 01/25/26: DON completed immediate review of R #66 hospital transfer order, staff nurse called on call provider with wound status update and order update. New orders were received to align with the prescribed orders. Dressing order was completed as ordered by DON designee. Dated 01/26/26: DON designee completed facility-wide audit to identify any additional residents at risk with wound VACs and verified accuracy of orders. ADON #2 was immediately terminated for failure to follow order changes outside of scope. Report was made to the Board of Nursing. Interdisciplinary Team (IDT; includes but is not limited to the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of the food and nutrition services staff, resident or resident representative, and other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident) adopted new standard process to review all new admissions with wound VACs to confirm orders, settings, and care plan accuracy. DON to conduct weekly audits of all new admissions with wound VAC orders and all newly prescribed wound VAC orders outside of new admissions to ensure accuracy of orders for 8 Weeks. Dated 02/10/26: During review of facility documentation, there were no new admits with wound VACs. Two (R #55, R#99) of two (R #55, R#99) residents with wound VACs in house, had orders verified with no issues. Scope of Practice, Provider Orders, and Wound Care Compliance In-Service: Dated 01/25/26-01/26/26: Employee acknowledgment forms showed a total of seven Licensed Practical Nurses (LPN) and Registered Nurses (RN) were provided education. Education given included appropriate order entry, specifically related to wound VACs, and ensuring all nursing staff practice within their licensed scope. Dated 02/11/26: Four (RN #1, RN #2, LPN #2, LPN #3) of Four (RN #1, RN #2, LPN #2, LPN #3) nurses interviewed confirmed they received education and were able to describe the education they received in detail. All nurses interviewed stated they knew not to make any changes to orders, to consult with a provider, and to defer to the wound care nurse for any residents with a wound VAC. The nurses further stated they felt comfortable reporting if any orders in a resident's chart did not align with orders received from the hospital or other providers.

Based on observation, record review, and interview, the facility failed to provide respiratory care in accordance with professional standards for 2 (R #15 and R #69) of 2 (R #15 and R #69) residents reviewed for respiratory care when the facility failed to: Administer oxygen (O2) therapy per physician orders for R #15.Provide the necessary respiratory equipment to ensure O2 was readily available for R #69.These deficient practices are likely to result in residents receiving too much or not enough oxygen and can lead to worsening of their conditions.The findings are: R #15: A. Record review of R #15's physician's orders dated 02/02/26 revealed a room air trial (test conducted by removing O2 from resident to determine O2 saturations in room air) to establish if R #15 was still in need of O2 use. There were not active or discontinued orders related to O2 use for R #15. B. On 02/02/26 at 9:19 AM during an observation of R #15 while outside of his room, R #15 was not observed wearing O2. C. On 02/02/26 at 9:20 AM during an observation of R #15's room, an oxygen concentrator (a medical device that extracts oxygen from ambient air and delivers it at high concentrations to individuals who need supplemental oxygen) was present at R #15's beside without O2 tubing attached, and the machine was not on. D. Record review of R #15's physicians progress notes revealed the following: Dated 01/06/26: Physicians note documented to continue O2 use of one to four liters per minute (LPM) as needed to keep saturations above 90% (percent). Dated 01/07/26: Physicians note documented to continue O2 supplementation and wean as tolerated. Dated 01/09/26: Physicians note documented O2 saturations fluctuating between 77% to 91% on room air, nursing placed on two LPM of O2. O2 saturations recovered to 95%. Dated 01/22/26: Physicians note documented O2 as still low and at two LPM. Dated 01/25/26: Physicians note documented use of O2 via nasal cannula (a small, flexible tube that delivers oxygen to the nose through soft prongs). Dated 01/26/26: Physicians note documented use of O2 at two LPM. Dated 01/28/26: Physicians note documented R #15 on room air (no O2 use). Dated 02/02/26: Physicians note documented R #15 on room air. E. Record review of R #15's nursing progress notes revealed the following: Dated 01/06/26: Nursing note documented no O2 in use. Dated 01/23/26: Nursing note documented no O2 in use. Dated 01/30/26: Nursing note documented R #15 was on room air. Dated 01/31/26: Nursing note documented O2 use via nasal cannula. Dated 02/01/26: Nursing note documented O2 use via nasal cannula. F. Record review of R #15's care plan dated 01/07/26, revealed there was no documentation regarding O2 use as an intervention. R #15's care plan revealed documentation of impaired gas exchange related to respiratory failure (life-threatening condition where the lungs are unable to properly move oxygen and carbon dioxide into and out of the blood) and pulmonary edema (condition when the lungs become fluid filled), with the following interventions: Adequate fluid intake Keep head of bed elevated to avoid shortness of breath while lying flat Monitor for signs of infection O2 use as an intervention was not included in the care plan. G. Record review of R #15's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 01/13/26 revealed there was no documentation regarding the use of O2 for R #15. H. On 02/12/26 at 4:09 pm during an interview with Director of Nursing (DON), she stated it is her expectation for O2 use to be ordered through a provider's order in the electronic health record (EHR). The DON stated it was also her expectation for O2 to be documented in the care plan and in the MDS, and if this was not completed it could impact respiratory needs for the residents. R #69: I. Record review of R #69's face sheet revealed the resident was admitted into the facility on [DATE] with the following diagnoses: Parkinson's disease without dyskinesia, without mention of fluctuations (disorder caused by loss of dopamine-producing cells in the brain. It is characterized by symptoms such as tremor, slowed movement (bradykinesia), muscle stiffness (rigidity), and impaired balance), Dysphagia (difficulty or discomfort in swallowing, as a symptom of disease), Weakness (a reduction in muscle strength or the ability to generate force. J. Record review of R #69's Physician Orders dated 01/21/25, revealed O2 at 1 to 4 LPM per nasal cannula as needed. K. On 02/04/26 at 2:55 pm, during an observation of R #69's room, O2 equipment was not present in R #69's room. L. On 02/05/26 at 10:32 am during an observation of R #69's room, O2 equipment was not present in R #69's room. M. On 02/10/26 at 2:02 pm during an interview with the DON, she stated R #69's physician order indicates O2 use at 1 to 4 LPM as needed. The DON stated it is her expectation the appropriate O2 equipment should be present and available in the resident's room.

Based on observations, record reviews, and interviews, the facility failed to ensure a resident had access to dental services and was seen for routine and emergency dental care for 1 (R #69) of 1 (R #69) residents reviewed for routine dental services.This deficient practice could likely result in residents experiencing tooth decay, tooth pain, and difficulty chewing. The findings are: A. Record review of the facility's Dental Services Policy dated 2018 revealed the following: Routine and emergency dental services are available to meet the resident's oral health services in accordance with resident's assessment and plan of care, Routine and 24-hour emergency dental services are provided to our residents through a contract agreement with a licensed dentist that comes to the facility monthly. B. Record review of R #69's Face Sheet revealed the resident was admitted into the facility on [DATE] with the following diagnoses: Parkinson's disease without dyskinesia, without mention of fluctuations (disorder caused by loss of dopamine-producing cells in the brain. It is characterized by symptoms such as tremor, slowed movement (bradykinesia), muscle stiffness (rigidity), and impaired balance),Dysphagia (difficulty or discomfort in swallowing, as a symptom of disease),Gastro-esophageal reflux disease without esophagitis (a condition characterized by typical symptoms of acid reflux due to the retrograde flow of gastric contents into the esophagus, without endoscopic evidence of esophageal mucosal injury),Unspecified protein-calorie malnutrition (a condition where a person is not getting enough protein and calories, causing poor nutrition, however the exact severity or type is not specified). C. Record review of R #69's Physician Orders dated 05/19/23 revealed orders for dental evaluation and treatment as indicated. D. Record review of R #69's Care Plan dated 11/27/24 revealed the resident was dependent on assistance with oral hygiene. E. Record review of R #69's Progress Notes dated 12/29/25 revealed the following:Broken or loose fitting full or partial denture (chipped, cracked, uncleanable, or loose): Not Assessed.Abnormal mouth tissue (ulcers, masses, oral lesions, including under denture or partial if one is worn): Not Assessed,No natural teeth or tooth fragment(s) (edentulous) Not Assessed,Obvious or likely cavity or broken natural teeth: Not Assessed,Inflamed or bleeding gums or loose natural teeth: Not Assessed,Mouth or facial pain, discomfort or difficulty with chewing: Not Assessed. F. Record review of R #69's Quarterly MDS (MDS; a federally mandated assessment instrument completed by facility staff) dated 05/27/25 revealed R #69's oral hygiene was documented as resident needing supervision or touching assistance. G. Record review of R #69's Comprehensive MDS dated [DATE] revealed R #69's oral hygiene was documented as resident needing supervision or touching assistance. H. Record review of R # 69's Quarterly MDS dated [DATE] revealed R #69's oral hygiene was documented as resident needing supervision or touching assistance. I. Record review of R #69's electronic health record (EHR) dated 02/04/26 revealed there was no documentation present that indicated R #69 has had a dental evaluation or treatment completed. J. On 02/04/26 at 9:35 am during an observation of R #69, she was observed to have broken teeth with visible plaque buildup and discoloration. K. On 02/04/26 at 11:54 am during an interview with R #69, she stated she has not seen a dentist since before admission and she was experiencing dental pain that staff were aware of. L. On 02/10/26 at 2:50 pm during an interview with the Director of Nursing (DON), she stated R #69 had not received dental services since admission into the facility due to the facility's inability to secure mobile dental services. The DON stated R #69 is bedbound and unable to transfer into a wheelchair for outside dental appointments. The DON also stated it is her expectation for residents to receive routine dental services in a timely manner regardless of their level of care. The DON stated residents who do not receive routine dental care, may be at risk for complications related to poor oral hygiene. The DON confirmed R #69 should have had a dental evaluation and/or treatment provided, but that did not happen.

Based on record reviews and interviews, the facility failed to ensure medical records consistently reflected the correct code status for 1 (R #5) of 3 (R #5, #6, and #7) residents. If code status is not accurately documented in resident records, then the resident is at risk of a life-threatening medical error. The findings are: A. Record review of R #5's face sheet revealed an admission date of 06/11/25. Further review revealed the resident's code status was not documented in the record. B. Record review of R #5's hospital discharge documentation, dated 06/07/25, revealed a code status of Do Not Resuscitate (DNR; lifesaving measures are not desired). C. Record review of R #5's New Mexico Medical Orders for Scope of Treatment (NM MOST; a legal document which outlines the care the resident wants when they become incapacitated and unable to speak for themselves) form, dated 06/11/25, revealed a DNR code status. D. Record review of R #5's Care Plan, dated 06/23/25, revealed a Full Code Status. E. On 08/21/25 at 8:30 am, during an interview, Family Member (FM) #1 stated a nurse told her R #5 was a full code status when she inquired about R #5's code status during the admission process. FM #1 stated she was concerned, because she was aware R #5's status was DNR when she was discharged from the hospital. F. On 08/21/25 at 2:33 pm during an interview, the Director of Nursing (DON) stated the facility presumed residents were a Full Code status if nothing was documented on the resident's face sheet. The DON verified the conflicting information within R #5's records and stated it was the facility's expectation for code status to be consistent throughout the medical record.

Based on observation, interview, and record review, the facility failed to maintain the resident environment free from the potential for accidents and hazards when staff left: - An electrical junction box unsecured. - Electrical cords stretched across the hallway floor. - A fire alarm control panel open. These failures had the potential to affect all residents in the facility. If the facility fails to secure electrical panels and equipment and to remove tripping hazards from resident areas, then residents are at risk of injury. The findings are: A. Review of the facility’s Hazardous Areas, Devices, and Equipment policy, revised 2018, revealed the following: - All hazardous areas, devices, and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. - Hazard was defined as anything in the environment that has the potential to cause injury or illness. - Examples included: Equipment and devices left unattended or malfunctioning, Open areas or items that should be locked when not in use, Irregular floor surfaces (cords, buckled carpeting, etc.). Any element of the resident environment that has the potential to cause injury and is accessible to a vulnerable resident. B.On 08/21/2025 at 12:00 p.m., observation revealed a small white electrical box mounted on the wall at the end of the hallway. The door of the box was unsecured and partially open, which exposed the internal wires and circuit boards. The box was located within reach of residents who utilized the hallway handrail. Further observation revealed staff were not present in the area. C. On 08/21/2025 at 12:01 p.m., observation revealed multiple cords for a power wheelchair, including a black power cord and a white coaxial cable attached to a battery box, lay unattended across the carpeted hallway floor. There were no staff or residents in the hallway. D. On 08/21/25 at 12:15 p.m., observation revealed the facility’s fire alarm control panel in the main hallway was open, and the wires and control components were exposed. The panel was accessible to residents, and staff were not present in the immediate area. F. On 08/21/25 at 3:00 p.m., observation of R #2’s room revealed a large kitchen knife on the desk and an open can of WD-40 sat on the resident's nightstand. G. On 08/21/25 at 3:00p.m., during an interview, R #2 stated the large kitchen knife was to cut up his pineapple. He stated he brought it when he came to the facility. R #2 stated the WD-40 was for his wheelchair. G. On 08/21/25 at 1:25 p.m., during an interview, the Assistant Director of Nursing (ADON) stated the fire alarm control panel should be shut and locked at all times; because residents could open it, push buttons, and possibly disarm the alarm system. He stated R #2 should not have a large kitchen knife in his room. He stated it was a hazard for the resident to have the knife in his room; because he could injure himself, staff, or other residents. The ADON stated the can of WD-40 was for R #2’s wheelchair. He stated he took the WD-40 out of R #2’s room, because it could be used to harm residents or staff. H. On 08/21/25 at 1:40 p.m., during an interview, the Maintenance Director (MD) stated the electrical boxes and fire alarm panel should be kept closed and secured at all times to prevent tampering and injury. He stated unsecured cords across the floor presented a fall hazard to the residents.

Based on observation and staff interviews, the facility failed to ensure the physical environment was free of hazards when staff failed to: - Ensure the electrical cord and cord protector for an electronic game table in a common area were secured to prevent tripping. - Ensure an outlet casing box was secured to the wall without electrical wires exposed. - Ensure a medication treatment cart was locked. If the facility fails to maintain a hazard-free environment, then residents are at increased risk for injury and compromised well-being. The findings are: Cord Protector A. On 07/16/25 at 10:13 a.m. and 07/17/25 at 8:05 a.m., an observation of the common area revealed an electronic, touchscreen game table. Further observation revealed the electrical cord to the game table was enclosed in a cord protector which stretched across the room. The cord protector measured 3 inches in diameter, was flipped on its side, and did not lie flat on the ground. B. On 07/17/25 at 11:25 a.m., during an interview, the Assistant Director of Nursing (ADON) stated the cord should not stretch across the floor, and the cord protector posed a trip hazard to residents and staff. C. On 07/17/25 at 12:06 p.m., during an interview, the Administrator stated the cord protector should not be flipped up, because it was a trip hazard. The Administrator stated it is all staff's responsibility to ensure the cord protector lay flat on the ground. Electrical Box D. On 07/17/25 at 9:25 am, an observation of R #2's and #3's room revealed an electrical casing box for the call lights was not secured to the wall and had exposed electrical wiring. E. On 07/17/25 at 9:35 am during an interview, RN #1 stated the call light casing box located between the resident beds should not hang off the wall with exposed wires. Medication Cart F. On 07/17/25 at 10:17 am during an observation, a medical treatment cart on the 500 unit was unattended and unlocked. G. On 07/17/25 at 10:19 am during an interview, Licensed Practical Nurse (LPN) #1 stated the treatment cart was unattended and unlocked. LPN #1 stated the treatment cart should always be locked if not in use.

Based on record review and interviews, the facility failed to report a significant medication-related event to the State Survey Agency (SSA) for 1 (R #1) of 1 (R #1) resident, when R #1 experienced a suspected opioid overdose which required an emergency administration of Narcan and Code Blue activation. If a facility fails to report suspected overdoses and life-threatening incidents to the State Survey Agency (SSA), then the SSA cannot ensure the health and safety of the residents. The findings are: A. Record review of R #1's face sheet revealed an admission date of 06/02/25 with a diagnosis of long-term use of opiate analgesics (ongoing use of opioid medications for pain management). B. Record review of R #1's progress notes, dated 06/11/2025, revealed R #1 sat on the edge of her bed and swayed back and forth. The resident had low and unstable oxygen saturation (the amount of oxygen in the blood) in the low to mid-80s (normal oxygen saturation 95 to 100). The provider increased oxygen to five liters with minimal effect. Narcan (naloxone; medication used to reverse opioid overdose) was administered for a possible overdose. The first dose proved ineffective. The second dose appeared effective and led to increased alertness and stable oxygen saturation at 94 to 96 percent (%). R #1 was reassessed and lay on the edge of her bed, confused and agitated. The facility called Code Blue (an emergency code used in hospitals and other medical facilities to indicate a patient is experiencing a cardiopulmonary arrest or other life-threatening medical emergencies). C. Record review of facility 's incident reports, dated 06/11/25, revealed there was not documentation in the clinical record, 24-hour report, or the facility incident log to show the facility reported the event to the SSA. D. On 07/17/25 at 10:15 a.m., during an interview with the Assistant Director of Nursing (ADON), he stated R #1 had her Significant Other bring her methadone (an opioid medication used to treat pain and opioid use disorder). He stated R #1 also received a prescribed 10 milligrams of methadone. He stated taking more than a prescribed dose could cause R #1 to overdose. He stated he reported R #1's overdose and Narcan administration to the Administrator. He stated he was not sure if the incident report was filed with the SSA. E. On 07/17/25 at 11:15 a.m., during an interview, the Administrator stated he submitted a Facility Initiated Report on 06/11/25, but he did not have an email or fax verification to confirm he submitted it to the SSA.

Based on record review and interviews, the facility failed to provide a written discharge notice, including the reason for discharge, effective date, location, appeal rights, and contact information for the State Ombudsman to 1 (R #1) of 1 (R #1) resident. If the facility fails to provide a complete, written discharge notice to the resident, then the resident may be unable to appeal the discharge, lose access to their rights and due process protections, experience abrupt care discontinuity, or suffer from unsafe or uncoordinated transitions of care. The finding are: A. Record review of R #1's face sheet revealed an admission date of 06/02/25. B. Record review of R #1's progress notes, dated 06/11/25, the resident was transferred to the hospital on [DATE], following administration of Narcan for a suspected overdose. The facility did not enter a discharge summary, discharge plan, or written discharge notice into the medical record. C. Record review of R #1's electronical medical records revealed there was not any documentation to show the resident had a discharge plan, received a written notification of discharge, and staff sent a notice to the State Long-Term Care Ombudsman. D. Record review of the facility's discharge and grievance logs, dated 06/11/25 through 07/17/25, revealed R #1 was not listed as discharged from the facility. E. On 07/17/25 at 10:15 a.m., during an interview, the Assistant Director of Nursing (ADON) stated the facility decided not to have R #1 return to the facility, because R #1 did not listen to the rules. F. On 07/17/25 at 10:45 a.m., during an interview, the Social Worker Assistant stated she and the Social Worker spoke with R #1 about a discharge plan, but she did not believe it was provided to the resident in writing. She stated the Administrator made the discharge decision. G. On 07/17/25 at 11:15 a.m., during an interview, the Administrator stated R #1 was unconscious at the time of hospital transfer, so the facility did not provide a written discharge notice. He stated the hospital Case Worker was informed of the discharge decision. The Administrator stated R #1 was her own responsible party. He stated he and the Social Worker spoke to R #1 by phone and explained to R #1 that she could not return to the facility due to violating the facility rules, to include permitting friends and family to bring in illegal substances.

Based on observation, record review, and interview, the facility failed to ensure that residents are free from abuse for 1 (R #1) of 2 (R #'s 1 and 2) residents reviewed for abuse by not implementing adequate corrective measures to prevent further abuse. This deficient practice likely resulted in R #1 experiencing severe mental anguish, anxiety and fear that she may be threatened and assaulted. The findings are: 41988 A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] with the following diagnoses: 1. METABOLIC ENCEPHALOPATHY [a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body]. 2. OTHER SPEECH AND LANGUAGE DEFICITS FOLLOWING OTHER CEREBROVASCULAR DISEASE [Disease of the blood vessels and, especially, the arteries that supply the brain]. 3. DEMENTIA [A group of symptoms that affects memory, thinking and interferes with daily life] IN OTHER DISEASES CLASSIFIED ELSEWHERE, MILD, WITH OTHER BEHAVIORAL DISTURBANCE. 4. RESPIRATORY FAILURE, UNSPECIFIED WITH HYPOXIA [ below-normal level of oxygen in your blood]. 5. TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS 6. FIBROMYALGIA [A disorder that affects muscle and soft tissue characterized by chronic muscle pain, tenderness, fatigue and sleep disturbances]. 7. OTHER SEIZURES 8. ANXIETY DISORDER, UNSPECIFIED 9. MUSCLE WEAKNESS (GENERALIZED) B. Record review of R #2's face sheet revealed R #2 was admitted into the facility on [DATE] with the following diagnoses: 1. SPINAL STENOSIS [A condition where spinal column narrows and compresses the spinal cord] LUMBAR REGION WITHOUT NEUROGENIC CLAUDICATION [Leg pain that occurs due to a compression of the spinal nerves]. 2. TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSPECIFIED 3. TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS 4. OPIOID [used for pain relief] DEPENDENCE, UNCOMPLICATED 5. OPIOID DEPENDENCE, IN REMISSION 6. DEPRESSION, UNSPECIFIED 7. MYOPATHY [diseases that affect the muscles that connect to your bones (skeletal muscles)] UNSPECIFIED 8. ESSENTIAL (PRIMARY) HYPERTENSION [high blood pressure] 9. OCCLUSION AND STENOSIS [he narrowing or restriction of a blood vessel or valve that reduces blood flow] OF RIGHT CAROTID ARTERY [pair of important blood vessels in your neck that supply blood to your brain]. 10. PYOGENIC ARTHRITIS [serious and painful infection of a joint] UNSPECIFIED 11. PAIN IN RIGHT KNEE 12. SPINAL STENOSIS, CERVICAL REGION 13. DYSPHAGIA [A condition with difficulty in swallowing food or liquid. This may interfere in a person' s ability to eat and drink], UNSPECIFIED 14. HOMELESSNESS UNSPECIFIED C. Record review of R #1's Grievance/Concern Report dated 04/20/23 revealed the following: 1. Describe in detail your concern: Rsd [Resident (R #1)] came to SSD [Social Services Director] office and stated that [Name of R #2] has been cussing [at] her and threatening her. Rsd [R #1] states she asked her husband what she should do and he told her to call police or talk w/ [with] Social Worker. Rsd [R #1] does say that she also called [Name of R #2] a punk. Rsd [R #1] says that [Name of R #2] told her [R #1] that he [R #2] was going to stab her [R #1]. 2. Findings of Investigation: SSD and [Name of Assistant Director of Nursing (ADON) #2] spoke to both rsd's [residents] and asked them to ignore each other and do not speak to each other. 3. Recommendation for corrective action: SW [Social Worker] asked [Name of R #1] if she wanted her [SW] to call the cops and press charges. 4. Results of action taken: [Name of R #1] asked if SSD could talk to [Name of R #2] and tell him to stay away from her. SW [Social Worker] also called husband [of R #1] and let him know about conversation. D. Record review of R #1's Neuro-Psychotherapy Encounter with Psychologist (PSY) #1 dated 04/24/23 revealed, Subjective: [Name of R #1] said 'He [R #2] (male peer) threatened to stab me. I told my husband and he called you and [Name of Administrator (ADM)] and now I feel safe. It feels good that people believed me [R #1]. When my [R #1] father tried to kill me and my [R #1] foster brother raped me, nobody believed me. I never felt safe anywhere but with [Name of R #1's husband]'. E. Record review of R #2's Neuro-Psychotherapy Encounter with PSY #1 dated 04/28/23 revealed, Subjective: [Name of R #2] said 'I just said that to make her leave me alone. She's always in every-bodies business. I would hurt no one.' 04/21/23: [Name of R #2] was reported by husband of female peer [R #1] threaten to stab her. Writer advised [R #1's] husband to call administrator immediately while writer notified DON [Director of Nursing], SW [Social Worker], and [Name of psychiatric Physician Assistant (PA)]. Writer was unable to interview pt [patient- R #2] at this time due to contagious flu illness. Writer will meet with Pt [patient] when she [PSY #1] can safely enter the facility. Medication evaluation requested. F. On 05/01/23 at 2:41 pm during, an interview with R #1, she stated, The first time, he [R #2] threatened to beat the you know what out of me a month ago. Now he [R #2] wants to stab me in the eye balls so I won't see. He [R #2] has looked at me with daggers in his eyes. [Name of R #2] came into my room the first time we met and he [R #2] tried to touch my butt. I said don't you dare or I will scream. He [R #2] said if I ever see your husband, I'm going to knock the holy hell out of him. I reported this to [Name of SSD and ADON #2]. I'm scared. They [SSD and ADON #2] told me that I could either call the cops or they can try to see if they can resolve it without the law. I've already had three threats [by R #2]. I hang out in my room or around the nursing station. People need to be on high alert to protect me here. I've never been like this in my life. They [facility] told him [R #2] to stay away from me and he doesn't. Nobody has done anything [about R #2's threats to R #1] and everyone is so scared of him. I have to sit up at the nurses stations or I hang out in my bedroom, that's the only way I can avoid him. During the interview R #1 was crying and appeared to be in distress. G. On multiple occasions from 05/01/23 and 05/05/23, R #1 went to the surveyor conference room and expressed having fear of R #2. R #1 confirmed that R #2 continues to try and speak with her when he see's her in the hallway. H. On 05/02/23 at 11:03 am during an interview with R #1's husband, he stated, [Name of R #1] doesn't feel safe there anymore. I don't know what to do about it [threats between R #1 and R #2]. Her [R #1] and him [R #2] got into an argument and they were told to leave each other alone. He [R #2] told other people there [in the facility] that he [R #2] is going to knife her [R #1]. I. Review of R #1's care plan printed on 05/02/23 revealed the following: 1. [Name of R #1] uses antidepressant medication r/t (related to) depression. 2. [Name of R #1] uses anti-anxiety medications r/t anxiety disorder. 3. Did not identify any allegations of abuse or behaviors related to the allegations between R #1 and R #2. No interventions were identified on the care plan for staff to keep R #1 and R #2 away from one another. J. On 05/03/23 at 11:43 am during an interview with Registered Nurse (RN) #1, she stated, She [R #1] said he [R #2] said she [R #1] needs to stop spreading rumors about her [R #1] roommate or he [R #2] will hurt her. She [R #1] told me and [Name of Licensed Practical Nurse (LPN) #1], and we reported it to [Name of ADON #2]. K. On 05/03/23 at 11:47 am during an interview with Certified Nursing Assistant (CNA) #2, he stated, I know when you [State Agency] got here, [Name of R #1] started saying things [R #2's threats towards R #1], but I had no idea. She [R #1] never told me that and I work with her every shift. CNA #2 confirmed he was not told by the facility or nursing staff about R #2's threats towards R #1 or that he should ensure that R #1 and R #2 were kept away from one another. L. On 05/03/23 at 11:51 am during an interview with CNA #1, she stated, She [R #1] came up to me and said that [Name of R #2] said he [R #2] was going to stab her [R #1]. It was last month [April 2023]. She [R #1] had brought it to our attention at the nurses station. It was me and the charge nurse that day [day when R #1 reported threats by R #2] and [Name of License Practical Nurse (LPN) #1] reported it to the unit manager [ADON #2]. She [R #1] did mention a couple of times to me if I can keep an eye out for her [R #1 while in the facility]. I told her that she [R #1] is safe. M. On 05/03/23 at 12:02 pm,during an interview with LPN #1, she stated, [Name of R #1] has approached me and said that if she [R #1] didn't leave the girls alone, he [R #2] was going to stab her. She [R #1] has told that story many times. She [R #1] told me and I went directly to management. I told [Name of ADON #1] and [Name of ADON #2] of the incident. They [ADON #1 and ADON #2] said they were going to look into it. LPN #1 confirmed that R #1 has informed her of threats made by R #2 several times, but it was not documented. LPN #1 also confirmed she did not remember the dates when R #1 reported the threats or when LPN #1 reported it to her managers. N. On 05/03/23 at 3:13 pm, during an interview with ADON #1, she stated, She's [R #1] claimed that he [R #2] threatened to stab her [on 04/20/23]. We offered if she [R #1] wanted us to call the cops and she declined. We [facility] did a grievance on it too. [Name of ADON #2] did the investigation [on 04/20/23]. [Name of R #1] was telling everyone about it [threat by R #2]. We told them [R #1 and R #2] to stay separate from one another and stay cordial. He [R #2] threatened to stab her [R #1], that's what she was told. While the investigation was happening, I just told them [R #1 and R #2] to stay away while [Name of ADON #2] is handling it. O. On 05/03/23 at 3:36 pm during an interview with ADON #2, she stated, We did an investigation [regarding R #1 and R #2's incident on 04/20/23]. We were unable to get anything captured on the cameras. I haven't been able to get anyone to say they heard this, staff or residents. We take these things very seriously. We spoke to [Name of R #2] and he denied ever saying that type of thing. We told [Name of R #1] that if she feels threatened, we can file a complaint with the police. We are unable to find any evidence. It's kind of like a he said, she said type of thing. I don't recall the exact date [of incident between R #1 and R #2]. A few of us were involved [in the investigation]. [Name of SSD] did some interviews. Everyone is keeping an eye out, but no staff or residents had pointed anything out. The conversation I had with her [R #1] and her [R #1's] husband was a few days ago. She [R #1] told me [about R #2 threatening her] and she [R #1] told the nurse that day [when incident with R #2 occurred]. I wasn't here and I was just trying to follow up with the information I can gather. If I get some information, I will look into it. There was some information I got two days ago [on 05/01/23 about incident between R #1 and R #2], but I have not documented it. I don't know where to document it because it's like hearsay. It was more like a conversation [with Name of R #1]. She [R #1] didn't have new information and she [R #1] didn't want to do anything about it. She [R #1] just wanted to give [Name of R #2] a message to not look at her [R #1] or talk to her [R #1]. [Name of R #2] said he doesn't have an issue with [Name of R #1] and he [Name of R #2] does not go around her [R #1]. We have never seen this happened. She [R #1] told me she wants him [R #2] gone. I did not [interview] anyone else. I'm out on the floors a lot and I watch what he [R #2] does and his routine. They [R #1 and R #2] were told to avoid each other. She [R #1] said they both [R #1 and R #2] got into an argument and raised their voices to one another. He [R #2] said he didn't have any problem with her [R #1]. He [R #2] said he doesn't bother with her [R #1]. I've never seen them [R #1 and R #2] go at each others throats. P. On 05/03/23 at 4:01 pm, during an interview with the SSD, she stated, [Name of R #1] came to my office and told me her side of what happened, and that's what was on the grievance [dated 04/20/23. I asked her [R #1] if she wanted to call the cops and press charges, she [R #1] said no. She [R #1] asked if I could talk to him [R #2], but they [R #1 and R #2] had to stay away from each other. She [R #1] said they both yelled at each other that day. I told them [R #1 and R #2] that they would both have to stay away. [R #2] said he never said that and he [R #2] argues with her [R #1] because she instigates. He [R #2] told her [R #1], he would never stab her and he needs to stay away from her [incident on 04/20/23]. Pretty much daily, [Name of R #1] tells me [about issues with R #2]. The only other thing was the day before [05/01/23], he [R #2] was staring and glaring at her [R #1] and she [R #1] said he [R #2] was following her. I told her [R #1] we can watch cameras and she [R #1] said today [05/03/23] that he [R #2] told other ladies that he [R #2] was going to stab her [R #1]. She [R #1] said she does not feel safe around him [R #2]. Everybody [staff] knows and [Name of R #1] tells everybody. I haven't been there to witness it [R #1 and R #2 interactions with one another]. I wrote the grievance [R #1's grievance on 04/20/23], but I don't know the date. She [R #1] said that he [R #2] said he was going to stab her. He [R #2] said he didn't say anything like that to her [R #1]. It [R #2 threatening R #1] wasn't an investigation, it was either she [R #1] called the cops and press charges, or I talk to [R #2]. SSD confirmed that R #1 is on the case load to receive therapy services and after the incident, both R #1 and R #2 met with the psychotherapist (refer to finding E and F). Q. On 05/04/23 at 2:08 pm during an interview with CNA #3, she stated, She's [R #1] told me that he's [R #2] making threats [to R #1]. I haven't seen it though. She's [R #1] the only one that has said that to me. CNA #3 confirmed that she was not notified of the incident by other facility staff. R. On 05/04/23 at 3:03 pm during an interview with the Activities Director (AD), she confirmed that she was aware of the abuse allegation. She stated, I asked her [R #1] who she already talked to [about threats by R #2] and she [R #1] said she talked to [Name of SSD and ADON #2]. They [SSD and ADON #2] said they have heard about what she [R #1] was saying, that [Name of R #2] was threatening her [R #1]. They [SSD and ADON #2] were investigating it [incident between R #1 and R #2]. AD confirmed she was not instructed by facility staff to keep R #1 and R #2 separated from one another. The AD reported that R #1 used to attend activities but doesn't attend activities anymore since the incident occurred. S. During multiple observations from 05/02/23 through 05/05/23, R #1 was observed sitting alone in her wheelchair by 500, 600, and 700 nurses station or alone in her room. T. Record review of the Medication Administration Record for April 2023 through 05/05/23 revealed that R #1 is administered Fluxetine (anti-depressant) 40 mg daily for depression and Trazadone (anti-anxiety medication) 50 mg every night for insomnia, and Buspirone (anti-anxiety medication) 10 mg three times a day for anxiety. There was no as needed anxiety medication ordered or administered. U. On 05/04/23 at 4:43 pm during an interview with the DON, she stated, From my understanding, [Name of SSD and ADON #2] had multiple conversations with both of them [R #1 and R #2]. [Name of R #1] has declined to report it [incident with R #2] to the police. From my understanding, it was one incident that she [R #1] keeps bringing up. We asked her [R #1] if she wants to report it [incident with R #2 to the police]. From my understanding, he [R #2] said that he [R #2] was going to stab her [R #1] in the eye. We [facility] talked to her [R #1] and talked to him [R #2]. If [Name of R #1] was to tell the ADON's [ADON #1 and #2] the same story or situation, they [ADON #1 and #2] can do something immediately. I don't know what else they can do except for maybe comfort the patient. I have literally no idea what else we can do. We don't have that ability to keep them [R #1 and R #2] separate. We talked about it [incident with R #1 and R #2] in our IDT [Interdisciplinary Team] meeting before that [Name of R #1] felt that way [afraid of R #2]. I would probably say that not everyone is [aware of issue between R #1 and R #2]. If there is a verbal altercation that is reported, we can call the cops. I have no proof that he [R #2] is a threat to her [R #1]. A verbal behavior is completely different than a physical behavior. We have addressed him [R #2] and he's seeing psych [due to previous aggressive behaviors with other residents]. With that grievance [R #1's grievance dated 04/20/23], there's no way for us to watch the camera. I didn't watch camera. I was never able to understand a date [for incident between R #1 and R #2]. I do watch a lot of cameras when incidents happen. V. On 05/05/23 at 10:37 am during an interview with the ADM, he stated, We did talk repeatedly in IDT on how we were resolving it. We didn't know how to approach it [R #1's issues with R #2]. Nobody has any clue with what was going on. She [R #1] is always accusing someone of something [but it is not documented]. Verbal altercations happen all of the time and [Name of R #2] has not hurt anybody physically. To a certain extent, we maybe have become numb [to allegations stated by R #1]. The staff role is if they see something ramping up to take action. That was advice for them to avoid confrontation with each other.

Based on record review and interviews, the facility failed to prevent accidents by not implementing interventions to prevent falls for 1(R #77) of 1 (R #77) resident reviewed for multiple falls with injuries. This deficient practice likely caused resident to have multiple falls and also put resident at increased risk to have increased falls and sustaining further injuries. The findings are: A. Record review of R #77's face sheet revealed R #77 was admitted to facility on 12/18/21 with the following diagnosis: 1. Unspecified dementia without behavioral disturbances [a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems.] 2. Major Depressive Disorder, Single Episode, Severe with psychotic features [an extremely serious mental health condition which includes overwhelming lows of depression including frightening delusions and hallucinations (seeing objects or experiencing feelings that are not real)] 3. Other specified anxiety disorders [sense of uneasiness, stress or dread] 4. Muscle weakness (generalized) [a symptom that reduces your muscles ability to perform over time] 5. Unspecified lack of coordination [uncoordinated movement that may affect walking, speech, ability to swallow, eye movements, and other forms of movement.] B. Record review of R #77's Care Plan dated 12/29/21 with revision on 06/17/22 indicated that resident is at risk for falls due to generalized weakness and poor safety awareness. Listed in this category were documented falls for the following dates: 03/05/22, 04/04/22, 04/07/22, 04/17/22, 04/21/22, 05/22/22, 06/02/22, and 06/10/22. C. Record review of R #77's Progress note dated 03/05/22 revealed a fall note which indicated: R #77 was trying to self -transfer [get out of bed] without assistance [help from staff] and got caught on her bedsheet and blanket causing her to fall. She [R #77] was found next to bed no injury noted or pain. D. Record review of R #77's Progress note dated 04/04/22 revealed a fall note: CNA (Certified Nurse Assistant) was changing roommate when she heard something. When CNA went to look resident [R #77] was sitting next to her bed on the floor. Resident [R #77] stated she was trying to walk to her table. E. Record review of R #77's Progress note dated 04/08/22 revealed a fall note which indicated: pt.[patient R #77] noted on the floor next to her bed, alert and oriented denied pain. Pt. [R#77] aware of situation and said she fell , on assessment a skin tear noted to right elbow measured 6 cm (centimeter) x (by) 1 cm. F. Record review of R #77's Progress note dated 04/17/22 revealed a fall note which indicated: Resident [R #77] had an unwitnessed fall this morning at about 6:06 am, she was assessed and helped back into her bed, on assessment there was a bump on the head, nil bleeding [no bleeding], the resident [R #77] said it was there before but not sure. Denied pain. G. Record review of R #77's Progress note dated 04/22/22 revealed a fall note which indicated: pt. [R #77] noted on the floor next to her bed, lying on her side with both legs straight no shoes nor socks on, no briefs on but pt [R #77] wearing gown, head to toe assessment done with no injuries nor bruise noted pt.[ R #77] denied pain and did not explain what happen. H. Record review of R #77's Progress note date 05/22/22 revealed a fall note which indicated: Resident [R #77] was met on the floor, she was assessed, [examined by nurse for injury] and no injury or fracture noticed except little hematoma [bump caused by a collection of clotted blood in the tissues] on the right forehead, resident unable to give description. Resident [R #77] continues to be impulsive I. Record review of R #77's Progress note date 06/02/22 revealed a fall note which indicated: patient[R #77] has had a fall in another patient room, patient [R#77] showed great amount of blood coming from the head and a visible laceration [cut] on the forehead and possible laceration in the back of head followed protocols and was admitted to hospital. Follow up note indicated that R #77 returned from the hospital with stitches (special type of thread used to hold wound edges together while they heal) to forehead. J. Record review of R #77's Progress note dated 06/16/22 at 10:14 am revealed fall note which indicated: Nurse heard resident [R #77] down hall calling out in distress and when entering the room nurse noticed resident [R #77] laying on floor by sink. No new injuries noted on resident [R #77] at this time. Will continue to monitor resident for changes in condition and will have mats placed on floor of residents bed as recommended by hospice. K. Record review of R #77's Progress note dated 08/20/22 revealed fall note which indicated: Resident's roommate rang the call light to inform that resident [R #77] had fallen off her bed. We [facility staff] went in and found her laying on the floor on her back, calling for help. L. Record Review of R #77's Care Plan dated 12/18/21 documented that the following fall risk prevention measures were implemented: 6/12/20, remind resident to call for assistance prior to transferring, 12/29/21, encourage resident to use environmental devices such as hand grips and hand rails, 12/29/21, give resident verbal reminders not to ambulate/transfer without assistance, 12/29/21, provide an environment free of clutter. M. On 08/24/22 at 9:42 am during phone interview with R #77 family member and Power of Attorney, she stated that she feels facility staff are not taking precautions to prevent falls. She informed that R #77 has had about 9 falls since March of 2022 and the last fall resulted in R #77 being sent to the emergency room . Hospice nurse requested a fall mat, was told it would not be used due to increased risk of fall because of R #77 attempting to get to her wheelchair. Also requested a Pressure pad [a pad that alarms when a person tries to get off can be placed in bed or on chair], was told pad was not used because it would be considered a restraint. Family member and Power of Attorney also informed that R #77 was prescribed [MEDICATION(S)] [a medication that is used to treat anxiety [excessive stress and worry] in June 2022, she [R #77] often refuses medications so it was asked that medication be put into and drink, this was not done. N. On 8/25/22 at 8:13 am during staff interview with MT (Medical Tech/CNA) #6, MT/CNA #6 stated that R #77 falls occur mostly at night, R #77 likes to sleep at the edge of the mattress and will become combative [ready to fight] when staff try to move her away from edge [of the bed]. The Physician has ordered [MEDICATION(S)] [also known as [MEDICATION(S)] a medication to treat anxiety and stress] to try to calm her [R #77]. R #77 often overestimates her ability to stand and ambulate [walk]. R #77 is on hospice, so MT/CNA #6 is not sure why R #77 does not have a fall mat [a mat which is placed on the floor as part of fall prevention protocol] but knows they [facility staff] try to keep R #77 up out of bed in wheelchair most of day to keep an eye on R #77. O. On 08/25/22 at 8:35 am during an observation and interview R #77 was observed lying in bed eating breakfast, when interviewed R #77 was asked what the call light [a device used to request assistance from staff] was, and R #77 stated, the bell. R #77 was then asked what happens when you press the bell? R #77 stated, the nurse comes. R #77's room was observed for any fall prevention measures [fall mats, non- skid strips, scoop mattress]. No signage to remind resident to use the bell or other fall interventions [precautions that are taken to reduce the instance of a fall can include approved devices such as mats] were observed at this time. P. On 8/25/22 at 9:58 am during a phone interview with hospice nurse she stated that R #77 has had multiple falls, they [staff] tried floor mats but was informed this was creating a fall hazard [increasing risk for falls], hospice nurse tried to institute [put into use] scoop mattress [a mattress with raised sides to prevent falls from bed. Has a flat area on each side where a person can exit bed safely] which was ordered and received on 07/01/22. She [Hospice nurse] asked the two head nurses Director of Nursing and Assistant Director of Nursing [DON and ADON#1] multiple times why it was not on the bed. Hospice nurse informed even when she increased R #77's weekly visits from twice a week to three times a week the scoop mattress sat [remained] in the box and wasn't on bed when she came in. It sat [remained] there in the box to the point where it was returned. The mattress was not reordered. Hospice nurse also informed that R #77's last fall occurred early in the morning while R #77 was trying to get out of bed. It was reported that she rolled out of bed. Q. On 8/25/22 at 5:07 pm during an interview with DON [Director of Nursing], DON stated that a scoop mattress would be an appropriate measure for residents who sustain multiple falls. She also stated that she did not have any concerns for safety of the resident regarding the use of a scoop mattress. When questioned as to why the scoop mattress was not put on R #77's bed DON also stated I cannot remember if they [ facility nursing staff] tried one or not. The scoop mattress was ordered by the Hospice Nurse and I am not sure why it is not on the bed. If it is an order it should be on the bed and it is not.

Based on observation, record review and interview, the facility failed to ensure that 1 (R #48) of 1 (R #48) residents received care consistent with professional standards to treat and prevent pressure injuries by not ensuring R #48's pressure relieving devices were utilized as ordered (Prevelon boots, Air Mattress, off lifting Cushion while in bed). R #48 was admitted with a Stage 2 pressure injury (Partial thickness loss of skin which presents as a shallow open ulcer with red/pink wound bed without slough) to his right heel which progressed to a Stage 3 pressure [Open wound due to full thickness tissue loss. May include tunneling [creating a curved tunnel that makes the wound difficult to heal] injury (injury to the skin or tissue over a bony area). These deficient practices likely resulted in delayed healing, increased pain and discomfort, and affected R #48's ability to ambulate (walk with out wheelchair assistance). The Findings are: A. Record review of R #48's face sheet revealed R #48 was admitted into the facility on [DATE] with the following pertinent Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] 1. TYPE 2 DIABETES MELITIUS WITH DIABETIC NUEROPATHY [A disorder that causes the body to have high sugar levels for prolonged periods of time. Diabetic [CONDITION(S)] is [a type of nerve damage caused by high sugar levels in the blood.] 2. TYPE 2 DIABETES MELITIUS WITH HYPERGLYCIEMIA [High blood sugar occurs when there is too much sugar in the blood. High sugar levels cause injury to the nerves in the body, most commonly in the legs and feet.] 3. [CONDITION(S)] [a condition where your heart doesn't pump blood as well it should which causes a person to be tired and short of breath. B. Record review of R #48's Hospital discharge to: SNF (Skilled Nursing Facility) Orders dated 07/11/22 revealed Instructions from Wound Care Team to Bedside Staff which included: Pressure Ulcer Interventions as follows: (a) Skin Guard LAL/AP (Low Air Loss/Alternating Pressure) mattress for management of skin microclimate (skin surface or tissue temperature and humidity) and pressure redistribution (a specialized device which redistributes pressure across the body in order to prevent issues in bed ridden patients or patients with pressure wounds). (b) Continue pressure ulcer prevention, elevate heels on pillows (c) Keep off heels, sacrococcygeal (tailbone), gluteal (buttocks) skin surface, except for medical procedures or medically contraindicated (reason not to take a certain medical treatment due to harm that it would cause the patient). (d) Prevalon boots (a device used to lift heels off of mattress) for heel off loading (e) Patient repositioned every 2 hours per PUP (Pressure Ulcer Prevention) policy C. Record review of R #48's Admission and Baseline Care Plan Summary dated 07/13/22 Section 1, sub category 2a.Skin issues which was completed by the admitting nurse revealed, Stage II Pressure Injury to Right Heel measuring 3 cm [centimeters] in length x [by] 4 cm in width x 0 cm in depth. R #48 is identified as being at risk for impaired skin integrity. Interventions include weekly measurements and wound care. D. Record review of R #48's Weekly Head to Toe Skin Check dated 8/15/22 at 10:03 am documents that the right heel appears boggy (tissue that is painful, firm, mushy, warmer, or cooler to the touch compared with surrounding tissue), discolored and has an open area. Based on this documentation the pressure injury to the right heel is worsening. Pressure Ulcer Intervention orders include: (a) Skin Guard LAL/AP (Low Air Loss/Alternating Pressure) mattress for management of skin microclimate (skin surface or tissue temperature and humidity) and pressure redistribution (a specialized device which redistributes pressure across the body in order to prevent issues in bed ridden patients or patients with pressure wounds). (b) Continue pressure ulcer prevention, elevate heels on pillows (c) Keep off heels, sacrococcygeal (tailbone), gluteal (buttocks) skin surface, except for medical procedures or medically contraindicated (reason not to take a certain medical treatment due to harm that it would cause the patient). (d) Prevalon boots (a device used to lift heels off of mattress) for heel off loading (e) Patient repositioned every 2 hours per PUP (Pressure Ulcer Prevention) policy E. During observation of R #48's room the Prevalon boots are not in the room and there is no Skin Guard LAL/AP mattress on the bed. The pillow used to elevate heels is not in the bed with R #48 it was observed sitting on the dresser. R #48 stated that the Prevalon boots have been missing for a week now. These observations confirm that the pressure ulcer interventions were not being followed as ordered. F. Record review of R #48's Weekly Skin and Weight Review section 2, subsection 10b. assessment findings dated 8/30/22 at 4:32 pm revealed Right Heel-Stage 3 [Open wound due to full thickness tissue loss. May include tunneling [creating a curved tunnel that makes the wound difficult to heal]. G. On 08/29/22 at 3:35 pm during an observation of R #48's room the cushion used to off load (relieve pressure from) heels was located on R #48's dresser and was not in the bed being utilized as ordered. During interview with Certified Nursing Assistant (CNA) #11, she stated, The black cushion, which is sitting on the dresser, should be on bed all the time. It is used to relieve pressure from his heels. CNA #1 stated oh, he is in the bed? [R #48], it (black cushion) should be on the bed then. CNA #1 confirmed that black cushion observed on R #48's dresser, while R #48 was in bed, should be in the bed with him, as it is used to relieve pressure from heels. H. On 08/30/22 at 12:22 pm during observation of R #48's room the Prevalon pressure relieving boots are not in the room. R #48 stated the boots have been missing for about a week now. During an interview with Registered Nurse Manager (RNM) #1, he stated, resident [R #48] has pressure relieving boots. RNM was asked if he was aware that the boots for R #48 were missing [not in R #48's room], he said no. RNM #1 confirmed that he was unaware that R #48's pressure relieving boots were missing from the resident's possession and was unaware as to when they had gone missing. I. On 08/22/22 to 08/31/22 during random observations R #48 was observed self-propelling [using heels of feet to move wheelchair forward], throughout the facility on his bare feet and at times the bandage was observed to be dirty and hanging off residents foot. J. On 08/31/22 at 3:35 pm during an interview with Director of Nursing (DON), she stated, We don't encourage the use of devices [pressure relieving boots] we would float the heels, or that sort of thing. If the resident with a pressure injury to heels is self-propelling, I would encourage them to stop, you can't force them [resident's] to do what you want them to do. DON confirmed residents with pressure injuries to heels, should not be using heels, to move around in wheelchair. This action could place pressure on heels and cause further injury. DON stated that the resident would be encouraged to stop this action, also stated she does not encourage the use of pressure relieving devices [pressure relieving protective boot]. K. On 8/31/22 at 5:55 pm during an observation of R #48's bed a regular mattress was in place and not the Skin Guard LAL/AP mattress as ordered in resident's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . DON stated, R #48 should have an air mattress. Observation of residents bed revealed that R #48 was laying on a regular mattress [non pressure relieving]. DON then stated. This is the first time I am hearing of this, yes, R #48 should have an air mattress. DON confirmed that R #48 did not have an air mattress as ordered upon admission.

Based on record review and interview, the facility failed to provide the necessary care to effectively manage pain for 1 (R #232) of 2 (R #'s 231 and 232) residents reviewed for pain. This deficient practice resulted in R #2 experiencing significant (long) periods of pain without sufficient relief. The findings are: A. Record review of R #232's face sheet revealed R #232 was admitted into the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] 1. POSTPROCEDURAL HEMATOMA OF SKIN AND SUBCUTANEOUS TISSUE FOLLOWING OTHER PROCEDURE [a solid swelling of clotted blood within the tissues]. 2. OTHER PULMONARY EMBOLISM [a condition in which one or more arteries in the lungs become blocked by a blood clot] WITHOUT ACUTE COR PULMONALE [a form of acute right heart failure produced by a sudden increase in resistance to blood flow in the pulmonary circulation] 3. UNSPECIFIED [CONDITION(S)] [an irregular, often rapid heart rate that commonly causes poor blood flow] 4. [CONDITION(S)], UNSPECIFIED [high cholesterol] 5. UNSPECIFIED SYSTOLIC (CONGESTIVE) HEART FAILURE 6. UNSPECIFIED FALL, SUBSEQUENT ENCOUNTER 7. OTHER SPECIFIED ARTHRITIS, UNSPECIFIED SITE 8. CHRONIC SINUSITIS, UNSPECIFIED [swelling of the lining of your sinuses] B. Record review of R #232's ER (emergency room ): SNF (Skilled Nursing Facility) Discharge Orders dated 08/19/22 revealed, Other medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . C. Record review of R #232's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . D. Record review of R #232's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 650 mg by mouth every 4 hours as needed for mild pain and fever. E. Record review of R #232's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #232]. Nursing staff called to request pain medication [MEDICATION(S)] refill. I reviewed the patient's vital signs with the patient's nurse, and reviewed the patient's medical record. Assessment prescription refill Plan of Care prescription E [electronic] scribed to pharmacy. F. On 08/23/22 at 11:58 am during an interview with R #232, she stated, That's [pain medication administration] been an issue. I'm here because my trailer fell on to my leg. Luckily, I didn't break my leg, but I have a lot of tissue damage. They [facility nursing staff] said yesterday [08/22/22] they ran out [of R #232's pain medication]. I [R #232] got my last one [[MEDICATION(S)]] yesterday [in the morning] and they [facility] couldn't give me them [until the evening]. There was a big chunk of time I couldn't sleep. It was a 10 out of 10 [on the pain scale]. That's not a right thing to be in here without pain medication. That's why I'm here. I know I went at least 12 hours without pain pills and I was hurting. G. Record review of R #232's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . H. Record review of R #232's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . I. On 08/24/22 at 5:06 pm during an interview with Certified Nursing Assistant (CNA) #1, she stated, I think she [R #232] did [go an extended time without receiving pain medications]. I think she [R #232] did [go without pain medication] for a little bit because they [R #232's pain medication] didn't come in yet. The hard [copy] script [prescription] wasn't sent with her [R #232]. A lot time the hard script won't come for pain medications. She [R #232] asked about her medications and I told her I would ask the med tech [technician]. CNA #1 confirmed R #232 went an extended period of time without receiving [MEDICATION(S)] because the facility ran out. CNA #1 confirmed R #232 was in pain and was asking for her medication and was told it was not available. K. On 08/25/22 at 5:49 pm during an interview with Licensed Practical Nurse (LPN) #1, she stated, There is a possibility they [R #232's pain medication] did not come in. When we do admissions on the weekends, [Name of prescription delivery company] sometimes doesn't deliver. I've spoken with management to get medications because they [medications] come late and it's an ongoing battle. L. On 08/29/22 at 4:39 pm during an interview with Registered Nurse (RN) #1, she stated, On Sunday [08/21/22], we ran out of the [R #232's pain] medication. We had to use the Pyxis [automated medication dispensing system] for that [to give R #232 more pain medication prior to 08/22/22]. I remember there was a problem with her [R #232 pain] medication and we called the pharmacy and they [pharmacy] said they don't deliver on Sunday. I had to do a hard script on Monday [08/22/22] in the morning, but they [prescription delivery company] only brought it [R #232's pain medication] in the afternoon [on 08/22/22]. Sunday [08/21/22] was really bad and she [R #232] had a lot of pain and asked me for pain medication. [Name of RN Manager], called the provider because he [RN Manager]tried to get it [R #232's new pain medication prescription] over the phone, but it didn't happen. Acetaminophen wouldn't do anything [for the amount of pain R #232 was experiencing]. RN #1 confirmed R #232 ran out of pain medication from her prescription and the Pyxis and R #232 was not administered Acetaminophen for break through pain. M. On 08/30/22 at 11:47 am during an interview with the RN Manager (RNM) #1, he stated, We [facility] faxed the [R #232's [MEDICATION(S)] prescription] script and we also got some coverage from the Cubex [automated medication dispensing system] and that worked for awhile. When we went to get more [of R #232's [MEDICATION(S)]] from the Cubex, there wasn't any [[MEDICATION(S)]] left. We were supposed to be covering her [R #232's break through pain] with Tylenol. We don't get anything [medication prescriptions] in the afternoon on Saturday's and nothing on Sunday. A lot of times they [hospitals] just send them [residents] over and the orders [for medications] arrive later. We should be doing that [having medications available]. We fax the on call [provider if residents run out of medications], then we pull from the Cubex [to get more medications if new prescriptions have not arrived]. I'm new here and don't know that process to get it [resident medications] from them [providers] to here [facility]. I thought we were covering her [R #232] with the Acetaminophen until the medications arrived. I put it on my nurse on the floor to cover [R #232's break through pain with Acetaminophen]. I don't think they [nursing staff] administered the Acetaminophen [to R #232]. I should have made sure they [nursing staff] covered it [R #232's break through pain] with the [Name of Acetaminophen maker]. I'm going to make sure we have a back up pharmacy, but I need to find out the process on getting the medications. I'll ask my director because I don't know. RNM #1 confirmed R #232 ran out of [MEDICATION(S)] for an extended period of time, was not administered Acetaminophen as needed, and overall pain was not managed appropriately. N. On 08/31/22 at 4:20 pm during an interview with the Director of Nursing (DON), she stated, The hospitals are supposed to send their [residents] scripts [prescriptions]. Sometimes it's [residents arriving to the facility without medications] an issue and sometimes it's not. We have ways to get their [residents] medication regardless. From my understanding, the Cubex was out [[MEDICATION(S)] for R #232]. I have educated [Name of RNM #1] on that process. The process of how we get the orders when the patient is accepted, we will fax the orders, and there is a lot of times we won't get the scripts until the patient is in the building. She [R #232] was ordered [Name of Acetaminophen maker] and that was part of the education that they [residents] should get breakthrough pain medication when they are awaiting those orders [for pain medications to be received]. She [R #232] had [Name of Acetaminophen maker], but it wasn't given. If they [residents] have the PRN [as needed] medication, they should get the breakthrough [medication] or they [nursing staff] should call the on call to get something. DON confirmed R #232 ran out of [MEDICATION(S)] and was not given Acetaminophen as needed and should have.

Based on record review and interview, the following was identified: 1. A resident began to require oxygen (O2) use more frequently after arrival to the facility, and neither the resident's Power of Attorneys (POA's) or the residents primary physician was notified of use. 2. The resident required additional O2 therapy after a physical therapy session and also stated to the Physical Therapist (PT) that he did not feel himself. PT reported changes to nursing staff, but nursing staff did not notify resident POA's or residents primary physician. 3. The facility failed to notify appropriate and responsible parties of the residents change. These deficient practices resulted in Immediate Jeopardy being called on [DATE] at 5:32 pm. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were notified at this time. A first plan of removal was received on [DATE] at 12:05 am and was rejected. A second plan of removal was received and accepted on [DATE] at 12:48 pm. Implementation of the Plan of Removal was validated onsite. The scope and severity was reduced from Level 4, to Level 2. The Plan of Removal Included: 1. The facility will implement re-education of staff to follow the established policy and procedure for identifying change of condition including prompt notification of the attending Physician, resident, and representative of changes in the resident's medical/mental condition and/or status, (including proper documentation of such). This will be completed through review and re-education by DON/Designee. Staff will notify the attending Physician when there has been a significant change in the resident's physical/emotional/mental condition, both observed and reported by the resident. A significant change of condition is a major decline or improvement in the resident's status that: - Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting) - Impacts more than one area of the resident's health - Requires interdisciplinary review and/or revision to the care plan. This will begin immediately on [DATE] and will continue until all licensed nursing staff have received training on policy and process, prior to the start of their work shift. 2. The facility will implement re-education of staff to follow the established policy and procedure for oxygen administration, including evaluation of the resident for the following as applicable: - Signs or symptoms of cyanosis (i.e., blue tone to the skin and mucous membranes); - Signs or symptoms of [CONDITION(S)]/air hunger (i.e., rapid breathing, rapid pulse rate, restlessness, confusion); - Signs or symptoms of oxygen toxicity (i.e., tracheal irritation, difficulty breathing, or slow, shallow, rate of breathing); - Vital Signs; - Lung sounds; - Oxygen saturation, if applicable; - Other laboratory results if applicable 3. If the evaluation of the resident identifies any of the problems listed above, the attending Physician will be notified promptly and orders for treatment obtained as applicable. Resident and representative notifications will also be made and documented, as per the procedure for reporting a significant change in condition. The resident's care plan will also be reviewed to assess for any pertinent [relevant] special needs of the resident. 4. DON (Director of Nursing)/Designee will educate licensed nursing staff on process of identifying change of condition and oxygen administration, as stated above, according to facility policy. This will begin immediately on [DATE] and will continue until all licensed nursing staff have received training on policy and process, prior to the start of their work shift. The findings are: A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] 1. UNSPECIFIED [CONDITION(S)] SPONDYLOPATHY, LUMBAR REGION (an [CONDITION(S)] disease when the immune system attacks the spine and sometimes the joints of the arms and legs) 2. ACUTE SYSTOLIC (CONGESTIVE) HEART FAILURE (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues) 3. POUCHITIS (inflammation that occurs in the lining of a pouch created during surgery to treat [CONDITION(S)] or certain other diseases) 4. RESPIRATORY FAILURE (condition in which the blood doesn't have enough oxygen or too much carbon [MEDICATION(S)]), UNSPECIFIED, UNSPECIFIED WHETHER WITH [CONDITION(S)] (deficiency in the amount of oxygen reaching the tissues) OR HYPERCAPNIA (excessive carbon [MEDICATION(S)] in the bloodstream) 5. COGNITIVE COMMUNICATION DEFICIT 6. UNSPECIFIED [CONDITION(S)] (an irregular, often rapid heart rate that commonly causes poor blood flow) 7. UNSPECIFIED SEVERE PROTEIN-CALORIE MALNUTRITION 8. [CONDITION(S)] HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT [CONDITION(S)] PECTORIS (the build-up of fats, cholesterol, and other substances in and on the artery walls) 9. ACUTE EMBOLISM AND [CONDITION(S)] OF UNSPECIFIED DEEP VEINS OF UNSPECIFIED LOWER EXTREMITY (occurs when a blood clot (thrombus) forms in one or more of the deep veins in your body, usually your legs) 10. ACUTE PULMONARY [CONDITION(S)] (a condition caused by excess fluid in the lungs) 11. [CONDITION(S)] DISEASE, UNSPECIFIED, WITHOUT COMPLICATIONS (a chronic [CONDITION(S)] bowel disease that affects the lining of the digestive tract) 12. IRRITANT CONTACT [CONDITION(S)], UNSPECIFIED CAUSE (nonallergic skin reaction occurs when a substance damages your skin's outer protective layer) 13. ACUTE KIDNEY FAILURE, UNSPECIFIED 14. CYST OF KIDNEY, ACQUIRED 15. [CONDITION(S)], UNSPECIFIED (slow heart rate) 16. LACK OF PHYSICAL EXERCISE 17. PRESENCE OF CARDIAC PACEMAKER 18. SEVERE [CONDITION(S)] WITH SEPTIC SHOCK (a widespread infection causing organ failure and dangerously low blood pressure) 19. WEDGE COMPRESSION FRACTURE OF SECOND LUMBAR VERTEBRA, SUBSEQUENT ENCOUNTER FOR FRACTURE WITH DELAYED HEALING B. Record review of R #1's Oxygen (O2) Saturations Summary revealed R #1 required O2 on [DATE], [DATE], and [DATE]. R #1's O2 Saturations Summary did not include O2 liters per minute used by R #1. C. Record review of R #1's Physical Therapy Treatment Encounter Note(s) dated [DATE] revealed, Patient Remarks/Goals: Pt [patient] agreeable to treatment. Pt denied pain. Pt reported feeling dizzy and dopey today. Pt stated he wasn't feeling this way yesterday. : Monitored Pt vitals, ,d+[DATE] [blood pressure], HR [Heart Rate] 80, O2 [saturations] ,d+[DATE] on RA [Room Air]. Spoke with nursing regarding medications. Pt is not taking any new medications. Provided patient with oxygen concentrator at 1L [Liter] supplemental. O2 [saturations] improved to ,d+[DATE]% [percent] after 1 min [minute]. Spoke with nursing regarding patient status. Pt stated he felt better after, but still 'dopey'. Pt was left supine in bed with all needs in reach, set up lunch, notable tremor with feeding. D. Record review of R #1's physician orders did not reveal an order for [MEDICAL RECORD OR PHYSICIAN ORDER] E. Record review of R #1's nursing progress notes did not reveal a progress note by facility nursing staff regarding R #1's Physical Therapy note on [DATE], indicating R #1's provider and/or family was not notified of R #1's change in condition. F. Record review of R #1's nursing progress notes dated [DATE] at 7:07 am revealed, Was called earlier to pt bedside where pt was found in severe resp [respiratory] distress. RR [respirations] was 32 and labored O2 sat 74% on 5L nc [nasal cannula- tubing to provide O2] bilat [bilateral] crackles in upper and middle lobes. Pt was struggling to breathe. Placed on NRB [nonrebreather- mask used to provide O2] at 10 L sat [saturations] only 82% after 10 min. 911 was called and awaiting them. Daughter was called and informed of cond [condition]. G. Record review of R #1's nursing progress notes dated [DATE] at 11:33 am revealed, Was called to speak with the POA [Power of Attorney] regarding patient. POA states that patient was neglected on the night of ,d+[DATE] [[DATE]] to the morning of ,d+[DATE] [[DATE]]. Per the roommate [Name of R #1's roommate]. When I spoke to [Name of R #1's roommate] who is in room [ROOM NUMBER] [sic] bad day he denies that he says that the patient was on the call light frequently during the night about abdominal discomfort and was answered by nursing staff that night multiple times and that staff was in there multiple times. During the night in question. And that he did not notice that the patient was in respiratory distress But that he did cough several times during the night. He was aware that the patient went in to respiratory distress early in the morning when the staff came in there and started increasing his oxygen. And that he did recognize that I was the one myself [Name of previous Assistant Director of Nursing (ADON)] was the 1 that came in in around 6 o'clock approximately in the morning of the 16th [[DATE]] and started calling 911. See progress note dated 3 16 2022. Early morning when I arrived there [The facility] I initiated a non rebreather mask at 10 L And called for the crash cart to be brought down which was outside the room. 911 arrived and patient was transported to [name of local hospital emergency room ] in respiratory distress. H. On [DATE] at 4:59 pm during an interview with Certified Nursing Assistant (CNA) #2, she stated, We [CNA #2 and oncoming day shift CNA] walked by his [R #1] room and I saw him [R #1] fall. I yelled for the nurse and the nurse came running and he [R #1] was blue. We got the [oxygen] concentrator that went to 10 LPM [Liters Per Minute] and he [R #1] was blue [cyanotic] and he [R #1] never got his [normal] color back. I told the nurse that he [R #1] fell . I took care of him [R#1] throughout the night and the only thing he [R #1] complained about was he wanted to throw up and I told the nurse [Name of Licensed Practical Nurse (LPN) #1]. All he [R #1] was complaining about was he had an upset stomach. He [R #1] just wanted to throw up and he wanted his [R #1] O2 off [of R #1's face]. He [R #1] wasn't blue [cyanotic] throughout the night, just the morning. He [R #1] only complained about stomach pain and wanting to throw up [vomit], but he [R #1] never complained about not being able to breathe. CNA #2 confirmed R #1 complained of nausea and abdominal pain the night of [DATE]. I. On [DATE] at 9:28 am during an interview with R #1's Power Of Attorney (POA) #1, she stated, There was no communication. He [R #1] was beginning to become altered. I've never dealt with a place that doesn't communicate with family and I wanted to make sure he [R #1] was getting good care. I found out he [R #1] had a change in mental status and on Wednesday [[DATE]]. They [facility] said he was loopy and he needed to be back on O2. Come Tuesday [[DATE]], he [R #1] was not himself and he was disoriented. By that evening [[DATE]], he [R #1] had become very disoriented and they [facility] had to crank up the O2. Nobody communicated this [R #1 being disoriented and requiring O2] with me. They [facility] didn't tell me he [R #1] had a mental status change and needed to be placed on O2, otherwise I would have gone up there and had him sent to the hospital right away. I called four times and I couldn't get anyone to answer the phone. I called my sister [POA #2] and she [POA #2] started calling and she couldn't get a hold of anyone either. He [R #1] was complaining that day that his stomach was bothering him. He [R #1] told my sister [POA #2] at 10:53 pm [on [DATE]] and he [R #1] said he was on O2 and was having trouble breathing and he was having stomach pain. There was no communication. It didn't matter if I called at 2 am or 2 pm, it didn't matter. POA #1 confirmed R #1 was sent to the emergency room (ER) on [DATE] and died in the hospital later that night. J. On [DATE] at 10:42 am during an interview with R #1's POA #2, she stated, My dad [R #1] called me several times that late afternoon [on [DATE]] complaining about burning pain in his abdomen. I tried to call the nurses station again and no answer. The next morning, my sister [POA #1] got the call that they [facility] found him [R #1] in respiratory distress and they were going to call 911. Every time I called the nurses station, it was very hard to reach anyone. I had to call several times. There was a change there because all of a sudden he [R #1] needed O2. The Physical Therapist said on Tuesday [[DATE]] he [R #1] was feeling 'dopey' and he [R #1] had to be put on O2. I didn't know about them [facility] putting him [R #1] on O2 on and off. There was a change in status and nobody told us. If the Physical Therapist tells the nurse that there is a change in O2 and mental status, we should know about that. Whenever there's a change in status you report it and when your Physical Therapist reports that he needed O2 and was not feeling normal, that should have been reported to us [POA #1 and POA #2]. K. On [DATE] at 2:25 pm during an interview with Physical Therapist (PT) #1, she stated, I do remember the patient [R #1] and recalled him [R #1] saying he felt a little dopey. I couldn't tell you the name of the nurse that I reported it [R #1 requiring O2 and feeling 'dopey'] to, it was the nurse on the unit at the time. I always speak with the nurse when there's a change in the patient like that. I'm doing my duty to report and I trust them [facility nursing staff] to take care of whatever is needed. PT #1 confirmed she reported to the unit charge nurse of R #1's change in condition on [DATE]. L. On [DATE] at 2:45 pm during an interview with the Director of Nursing (DON), she stated, Depending on what's going on [with the resident], I would expect them [nursing staff] to check vital signs, and contact the provider and family. No, I don't see a note [that demonstrated facility nursing staff contacted R #1's physician and/or family after R #1's status change on [DATE]]. M. On [DATE] at 2:48 pm during an interview with the Assistant Director of Nursing (ADON), she stated, A change of condition should have been done [for R #1] and the family should have been notified. ADON confirmed R #1's family was not notified of R #1's change in condition on [DATE] and R #1's family should have been notified. N. On [DATE] at 1:40 pm during an interview with Certified Nurse Practitioner (CNP) #1, she stated, We [facility physician provider group] have a team of people that if we're [providers] not in the building, we have a CNP team, that's a national group, that can be called [by the facility]. We're [facility physician provider group] primary care providers, but if there's a change in condition [for a resident], that [change in condition notification] goes directly to the on call provider. CNP #1 confirmed any resident change of condition should be reported to the provider in the facility or the on-call providers. CNP #1 stated the provider and the facility should both document contact during resident change of condition. O. On [DATE] at 2:01 pm during an interview with the Medical Records Director (MRD), she stated, It [R #1's progress notes] just shows the nurses note on [DATE] [progress notes indicating R #1 was in respiratory distress]. If they [facility nursing staff] did call [the on-call providers], the doctors from [facility physician provider group] would have noted that and the [facility] nurses would have noted that [in R #1's progress notes], and I don't see that. MRD confirmed there was no communication notes between the facility and on-call providers or Facility Medical Director (FMD) for R #1's change of condition and there should have been if the on-call providers of FMD were contacted. P. On [DATE] at 2:18 pm during an interview with Registered Nurse (RN) #2, she stated, I did work with him [R #1] that day [[DATE]]. I'm the only nurse on the floor and unit at that time. We [nursing staff] will usually talk to one of the physician's and put a PRN [as needed] order and if they [residents] need continuous O2, we will get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . It [documentation of POA and/or physician contact during resident change of condition] should be noted. RN #2 confirmed she was unaware of R #1 increased O2 use and RN #2 did not recall being notified by PT on [DATE] regarding R #1's change of condition. RN #2 also confirmed she did not notify R #1's POA's or the physician of R #1's change of condition. Q. On [DATE] at 3:05 pm during an interview with Facility Medical Director (FMD), she stated, If there's not a provider in the building, they [nursing staff] would go to [call] our on-call providers. If they [nursing staff] can't get a hold of the on-call providers, they [nursing staff] can call me. I'm aware of this case. There should be a nursing note in [Name of Electronic Health Record (EHR)] where they [facility nursing staff] documented who they contacted [regarding R #1's change of condition]. The assumption would be nobody was contacted or it [facility to provider communication] wasn't documented [during R #1's change of condition]. Yes, this [R #1's] change should have absolutely been called to a provider in house, a provider on-call, or me. I just don't know if that [facility contacting providers] happened. MD #1 confirmed R #1 had a significant change of condition that should have been communicated to R #1's POA's and on-call providers prior to the morning of [DATE] (date R #1 was discharged to the hospital).

Based on record review and interview, the facility failed to provide the necessary care to effectively manage pain for 1 (R #2) of 2 (R #1 and 2) residents reviewed for pain. This deficient practice likely resulted in R #2 experiencing significant (long) periods of pain without sufficient relief. The findings are: A. Record review of R #2's face sheet revealed R #2 was admitted into to the facility on [DATE]. B. Record review of R #2's CNA (Certified Nursing Assistant) Admission Flow Sheet dated 04/09/22 revealed R #2 arrived to the facility at 6:50 pm. C. Record review of R #2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . D. Record review of R #2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 1. R #2 was administered 1- Acetaminophen Tablet 500 mg on 04/10/22 at 2:37 am 2. The first dose of 10 mg [MEDICATION(S)] was administered to R #2 on 04/10/22 at 10:41 pm, indicating R #2 did not receive physician ordered [MEDICATION(S)] by the facility for approximately 27 hours and 9 minutes after admission. E. On 04/18/22 at 1:17 pm during an interview with R #2, she stated, When I came here, I didn't have any pain medications and my knee was on fire. I asked for pain meds [medications] and she [Registered Nurse (RN) #1] said I didn't have any prescriptions for pain meds [medications]. My leg was thumping [pounding or throbbing in a heavy continuous way] because it was freshly done [after a surgical procedure]. They [facility nursing staff] said they didn't have any paperwork from the hospital and they couldn't give me pain meds. My doctor before I had this surgery prescribed me medication, we paid for it [pain medication] and it was sitting at home in my pharmacy cabinet. My husband brought it [[MEDICATION(S)] to the facility on [DATE]], so I took two pills. Then [Name of RN #2] came in and started yelling at me because I had taken the medication my husband had brought me from home. I had to beg for pain medication for the rest of the day. The aides [CNA's] would come in and say we are telling her [RN #2] about your pain medication. I called my daughter crying because I felt like they weren't giving me proper care. R #2 confirmed she was not given her prescribed [MEDICATION(S)] after arriving in the facility and asked her husband to bring in her [MEDICATION(S)] from home to help treat pain on 04/10/22. F. On 04/18/22 at 3:45 pm during an interview with the Director of Nursing (DON), she stated, Since we don't have a pharmacy here, it [prescribed medication] can be delayed because we have the medications shipped to us, especially on the weekend. [Name of prescription medication company] sends our scripts to it. Our [nursing] staff and our very common agency [nursing] staff does have access to the pyxis [automated medication dispensing system]. You have to have two nurses to get narcotics from the pyxis. They [nursing staff working on 04/09/22] should have called us [DON to notify about requiring pain medication for R #2]. G. On 04/19/22 at 11:30 am during an interview with CNA #1, she stated, The first thing she [R #2] complained about [on 04/10/22] was a pain in the knee and I told my nurse [RN #2]. When I came back [into R #2's room], she [R #2] said her stomach was hurting real bad, so I let my nurse [RN #2] know. As the day went on, it seemed like her [R #2] pain worsened. I don't know [if pain medication was administrated to R #2]. She [R #2] went on to refuse her lunch because she [R #2] was in too much pain [on 04/10/22] and she [R #2] began to cry. I went to let my nurse [RN #2] know again and I don't know if she [R #2] got her pain medications. I went back in [R #2's room] around 2 pm and she [R #2] was grabbing her stomach and crying. I went to let my nurse [RN #2] know. I told her [RN #2] that she [R #2] needed something because she [R #2] was in pain. She [RN #2] said she [RN #2] would get down there [to R #2's room] when she [RN #2] could. It [RN #2 not giving R #2 pain medication] was very frustrating. The med tech [medication technician] was also busy, so I could only ask my nurse [RN #2 for pain medication for R #2]. CNA #1 confirmed R #2 was in a lot of pain on 04/10/22 and CNA #1 reported R #2's pain to RN #2 multiple times throughout the day. H. On 04/19/22 at 2:48 pm during an interview with the DON, she stated, It's expected that they [facility nursing staff] should have called us [DON and/ or Assistant Director of Nursing (ADON) regarding R #2 pain medication]. DON confirmed R #2 did not receive [MEDICATION(S)] until 04/10/22 at 10:41 pm and R #2 should have received the pain medication sooner. I. On 04/19/22 at 2:50 pm during an interview with the Assistant Director of Nursing (ADON), she stated, She [R #2] told me she [R #2] called her husband because she needed her [MEDICATION(S)] and he [R #2's husband] brought her pill bottle and left it at her [R #2] bedside. I have no idea [why R #2 was not administered [MEDICATION(S)] on 04/09/22 and not until 10:41 pm on 04/10/22]. They've [facility nursing staff] been told they can call us [DON and ADON] at any time. ADON confirmed R #2's husband brought R #2's [MEDICATION(S)] to the facility on [DATE]. K. On 04/19/22 at 3:17 pm during an interview with R #2, she stated, I had pain and it intensified [on 04/09/22]. It [R #2's knee pain] was humming. They [facility nursing staff] told me they didn't have a script for it [[MEDICATION(S)] pain medication]. They [facility nursing staff] gave me one Tylenol but it [Tylenol] didn't work. The next morning they [facility nursing staff] gave me my AM [morning] medications. My leg was killing me and I needed something. [Name of RN #2] sent a CNA in here I said I'm in pain. I said if I would have known they [facility] weren't going to give me anything for pain, that I would have brought my own pain medications in. That's what I did. They act like this whole thing was my fault. L. On 05/04/22 at 2:23 pm during an interview with Registered Nurse (RN) #2, she stated, I was the one notified by the med [medication] tech that she [R #2] had her [pain] medication with her. I explained to her [R #2] that we needed to keep track of them [narcotic pain medication] when she [R #2] was using them. I found a prescription in her [R #2] room and saw a script [written order from the Physician] for medications and I faxed it to pharmacy. We [facility] are supposed to fax the packet [containing medication prescriptions] upon admission. I called the on-call [provider] and faxed in a script to pharmacy. That does happen where they [residents] use their own pain medications until they get a script. RN #2 confirmed R #2's narcotic pain medication prescription should have been sent to pharmacy prior to R #2 admission and it was not. M. On 05/04/22 at 3:10 pm during an interview with the Facility Medical Director (FMD), she stated, When a patient comes to us from a hospital, they [resident] come with orders and it is reviewed and there should be an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . We ask for the hospital to send us a script [prescription for pain medications]. If the hospital does send a script, our providers will write it. My expectation as the medical director would be as the patient arrives, so does the medication. If they [facility nursing staff] don't have a script [prescription for pain medication], they [facility nursing staff]should call the on-call or in-house providers. FMD confirmed R #2 should not have gone an extended period of time without pain medication and R #2 should not have had to bring in her own narcotic pain medication.

This is a repeat deficiency from the complaint survey on [DATE]. The facility failed to ensure that there were sufficient nursing staff that have the appropriate competencies and skills set to assure the following: 1) Nursing staff were documenting, admitting and assessing residents to and on the units in a timely manner; 2) On [DATE] there were two residents (R #245 and 247) that had each passed away at the facility within minutes of each other, each requiring cardiopulmonary resuscitation back-to-back. R #247 had been in the facility for a couple of days, and had passed away unexpectedly. R #245 had been admitted to the facility that afternoon at 3:00, and by 8:30 pm was being resuscitated and thus passing away. The 6:00 am to 6:00 pm nurse and the 6:00 pm to 6:00 am nurse following the day nurse, were not aware that the resident was in the facility and in the room; 3) R #292 was brought to hospital by ambulance from (Name of facility) on [DATE]. On [DATE] R #292 developed septic shock (an infection in the blood stream) requiring pressors (intravenous medications to raise the blood pressure) and transfer to the Intensive Care Unit (ICU). He did stabilize and was transferred out of ICU on [DATE]. On [DATE] R #292's respiratory status declined again requireing Bi-PAP (a respiratory device to assist in breathing) . Hospital records indicated that R #292 died on [DATE] with the cause of death as acute hypoxic [MEDICAL CONDITION], septic shock and urinary tract infection. 4) That Agency staff were oriented and trained to the nursing units, the use of PCC (point click care) (their documentation software), the facility's admission checklist, and discharge processes; 5) Resident's call lights were answered, residents repositioned, and incontinence care being provided in a timely manner; and 6) Communicating the care of residents with other staff members and to their families. These deficient practices resulted in an Immediate Jeopardy (IJ) at a Scope and Severity of L as being identified on [DATE] at 11:20 am. The Administrator was notified at that time and a Plan of Removal was requested. The facility took corrective action by providing an acceptable Plan of Removal on [DATE] at 5:30 pm. This resulted in the scope and severity being reduced from level L to level G. The Plan of Removal consisted of four concerns for Insufficient Staffing: Nursing Documentation, Investigating In House Death, Monitoring of Admissions, and Orienting/Training of Agency Staff, which are included in the following: Overall Insufficient Staffing: -Resident(s) found to be affected by identified: R #245 passed away at this facility on [DATE], no further action required. R #247 passed away at this facility on [DATE], no further action required. -Potential residents to be affected by identified practice: 82 Current Residents have the potential to be affected. Nursing Documentation: -Corrective action implemented so identified practice will not recur: · Licensed Nurses will be oriented by the Director of Nursing (DON)/DON Designee on how to document in Point Click Care (PCC) (computer charting system) and assessments that should be completed prior to end of shift. · The DON/Designee will validate their training by providing a quiz at the completion of their orientation. · DON/Designee will contact nurses every shift to validate completion of documentation prior to end of shift. A log will be kept for ongoing monitoring. · Any areas found to be out of compliance will be corrected immediately. · Results of logs will be brought to the monthly Quality Assessment Performance Improvement (QAPI) meeting for review and recommendations . Investigate In House Death: -Corrective action implemented so identified practice will not recur: · The Administrator/Designee will review timeline of both incidents and complete an investigation of both deaths. · The Administrator/Designee will self-report to Department of Health if there are two or more unexpected deaths in the facility within 24 hours and complete an investigation. · Any areas found to be out of compliance will be corrected immediately . Monitoring of Admissions: -Corrective action implemented so identified practice will not recur: · The DON/Designee will assess for acuity prior to admitting a resident to this facility until adequate staffing has been established. Readmissions will be accepted back at this facility if their needs can be met at the facility. · The DON/Designee will review new admission packets and prior to admission will ensure that staffing is in place and the needs of the resident can be met. · The DON/Designee will complete an acuity audit of residents that are accepted into the facility. · Any areas found to be out of compliance will be corrected immediately. · Results of audits will be brought to he monthly QAPI meeting for review and recommendations . Orienting/Training of Agency Staff: -Corrective action implemented so identified practice will not recur: · The DON/Designee will orientate/train agency nursing staff on PCC, admission checklist, pharmacy, incident/accidents, notification, skin system, [MEDICATION NAME] (blood thinner) monitoring, abuse prevention, lab services, 24-hour report, discharge processes, change of condition and nursing documentation prior to working the floor alone · The DON/Designee will validate their training by providing a quiz at the completion of their orientation. · The DON/Designee will implement a mentorship for all agency staff to contact if they have questions or do not understand a process. · The Administrator will educate DON/Designee and ADON/Designee that agency staff should not orient new staff. · Any areas found to be out of compliance will be corrected immediately. · Results of audits will be brought to the monthly QAPI meeting for review and recommendations . Based on record review, observations and interviews, the facility failed to ensure that there were sufficient nursing staff numbers that have the appropriate competencies and skills set that would assure and promote resident's right and physical, mental & psychosocial well-being for all 82 residents identified on the alphabetical resident census list provided by the Administrator on [DATE]. This deficient practice has the potential to negatively impact resident safety and comfort, and to impede processes such as assessing residents in a timely manner, answering call lights in a timely manner, and ensuring the physician orders [REDACTED]. A. On [DATE] at 8:35 am, during a tour of the facility, the long-term care units which included: the 500 unit that had 24 residents, the 600 unit that had 24 residents and the 700 unit that had 22 residents, for a total of 70 residents. There was 1 RN (Registered Nurse) #3, 2 CMAs (certified medication aide) and 6 CNAs (certified nursing assistants). B. On [DATE] at 9:15 am, during interview, RN #3 stated that when she came on that morning at 6;00 am, she did not receive any orientation to the units. She stated, I know how to get into the computer, but I don't know how to enter notes yet .there are two CMAs to pass meds, no other nurses here (on the long term care side) but me. C. On [DATE] at 8:35 am, during interview, R #23 (long-term care resident) stated, been here since last year. The nurses and CNAs are kind .should be more staff .at night aren't too many nurses on duty. D. On [DATE] at 2:55 pm, during a requested interview, R #33's family member stated that she visits her husband daily. She stated, Last few months, since new administration, things have been hot and cold .I'm here every day with my husband .weekends really hard .under staffing .earlier this week .(at the evening meal) there were no CNAs and no nurses to help (residents that needed help to eat) .just Restorative Aide (RA) #1 .I told them at the desk .it took 45 minutes to get a couple of CNAs in. Two or three weeks ago we had some agency nurses and no one could understand them .we had a situation where one nurse was banned .(Name of Administrator) has encouraged us to come to her .the nurse (RN #12, an agency nurse) .did not flush my husband's catheter and she told me, that will just drive the bacteria up the tube, what do you want me to do and once there was one medicaion technician doing all three halls (on the long term care unit). E. On [DATE] at 10:00 am, during interview, R #34 stated, .here for 3 years . When asked if nurses and CNAs were knowledgeable about her care? She answered, sometimes. R #34's only complaint was there was not enough staff .not enough CNAs at night .there is hardly nobody here at night .it takes a little longer to answer the lights at night . F. On [DATE] at 3:30 pm, during a requested interview, R #58's daughter stated that she comes almost daily and spends the morning with her dad, then leaves for a couple of hours and comes to spend a few hours in the afternoon with him. If she can't be there, her sister comes in. They (she and her sister) do most of all the care for her dad. She said, I think, perhaps I have a different perspective .we have no confidence in the care here .since the new administration came .there have been so many CNAs that left .and nurses .a lot of them were good .They were be-littled, treated rudely, mistreated .some were targeted .if there was only one CNA on a floor one of the administrators would leave a card and it would say, if you didn't find this you didn't do your job .knowing there was only one CNA .My biggest complaint, Agency staff, that is a big problem, they don't care as much, make medication errors .if I wasn't sitting in dad's room he would get the wrong dose .I asked one (Agency staff) for his medication that was late and she said she had given it to him but I told her, I am sitting here and you didn't .some of the agency CNAs just are on their phones .the administration is not friendly .I went to tell them about an agency nurse (RN #12) .I went home about 2 pm and when I came back about quarter to 6 (5:45 pm), I couldn't wake my dad .it was on Saturday .I told her (RN #12), 'I can't wake my dad, I need your help,' she just sat there, when she came she took his blood pressure .she turns to me and just cold as can be said, he's dying, call your family .two CNAs who know him took his vital signs and he was okay .weekends are very very bad .one CNA for the whole hall .My dad has two specific complaints, he gets up super early because he was a farmer .he gets a shower every day .then he goes back to bed and sleeps .they bring his breakfast and leave it but don't wake him up .his is upset because then it is cold and he wants them to wake him up .He takes his medication at 6:30 pm .[MEDICATION NAME] (a sedative to treat anxiety) .he goes to sleep but he wakes up later and needs his [MEDICATION NAME] (sedative and antidepressant) .he puts on his light between 9:30 pm and midnight .he is a clock watcher .no one comes .it is not once in a while it is almost every night .I went through the steps .I went to them (nurse and administration) first, then the Ombudsman .on the morning of [DATE] from 6:00 am to 8:00 am, there were no CNAs. G. On [DATE] at 10:15 am, during an interview, R #65 stated, the CNAs, there are the good and the bad .(Name of CMA #2) is the best .everyone loves her .the good ones are all leaving .the new administrator I think (is the reason) .we have the agency ones .don't know us .last night for example, there were 3 residents still in the dining room and the CNAs left. (Name of R #44) hadn't eaten .the housekeeper had to feed him .yes, the food had been there for 45 minutes .I think she went and got him warm food .two other residents needed to go back to their rooms .they ran out of [MEDICATION NAME] (a sedative) .I need it to sleep .they have an emergency box .the nurse was agency and I understand it came later that night but she didn't give it to me .I didn't sleep at all . H. On [DATE] at 10:30 am, during an interview, R #87 stated, I have been here for 3 years .thank you for coming to visit sometimes, we have lots of help now but normally, we are always short staffed. I. On [DATE] at 3:00 pm, during interview, the Administrator stated that that when they are short staffed We do and we don't admit residents. They have put a hold on admissions due to staffing .if a resident is discharged we fill those beds of course .we don't admit otherwise unless we have enough agency staff to cover a new admission .we make sure the agency will be able to cover for a 7-day period .we have to look that far out . J. On [DATE] at 5:30 am, during an interview, LPN #3 stated, When an agency nurse comes on duty (referring to the day of [DATE], the nurse having 70 residents by herself) they know what they are signing up for. Findings for R #245: K. Record review of R #245's Discharge Summary dated [DATE] from an acute care hospital revealed the following: (Name of R #245) is a [AGE] year-old gentleman with past medical history significant for [MEDICAL CONDITION] and other comorbid conditions admitted for [MEDICAL TREATMENT] (purification of blood by [MEDICAL TREATMENT], as a substitute for the normal function of the kidney) [MEDICATION NAME] syndrome (DDS) (symptoms include nausea, headache, vomiting and restlessness, more serious symptoms can result in [MEDICAL CONDITION] and coma. which could be attributed to cerebral [MEDICAL CONDITION] (swelling in the brain) during or following shortly after [MEDICAL TREATMENT] (a medical procedure to remove fluid and waste products from the blood, when the kidneys do not work properly)). The patient was not able to tolerate [MEDICAL TREATMENT] secondary to [MEDICAL CONDITION] (low blood pressure) related from poor oral intake and was also found to have possible [MEDICAL CONDITIONS] (in which there is a slow, progressive obstruction of airflow into or out of the lungs) exacerbation (to make the disease worse) and was treated with IV (intravenous) antibiotics. During his hospital course patient had significant dysphasia (difficulty speaking) that was hard to manage and patient was made npo (nothing by mouth) for liquids. This complicated his fluid balance situation with [MEDICAL TREATMENT] and prolonged his hospital course. MRI (Magnetic Resonance imaging, to form pictures of the brain) was performed and stroke workup was negative for his new onset dysphasia. An echocardiogram (picture of the heart) showed he had a moderate to large sized pleural effusion (excess fluid surrounding the lungs) initially due to the conservative [MEDICAL TREATMENT] (not getting a large amount of fluid off due to the low blood pressure) that he was receiving and the thought was possible compression of recurrent laryngeal nerve (supplies all the [MEDICATION NAME] muscles of the larynx) versus left vagus nerve (control of the heart, lungs, and digestive tract) as the patient also had hoarseness in his throat and voice. Over time the patient's pericardial effusion resolved .and the patient's dysphasia also started resolving. He was cleared for nectar thick liquids (a thickened liquid to help prevent choking and stop fluid from entering the lungs) but his dysphasia still persisted to some degree. At this point since the patient is able to tolerate [MEDICAL TREATMENT] and oral intake he was more stable and discharged to rehab . L. Record review of the admitting orders from the acute care hospital dated [DATE], included: Oxygen at 5 L (liters), Renal diet, Pureed texture, Nectar consistency, Therapy: PT (Physical Therapy), OT (Occupational Therapy) and ST (Speech Therapy) evaluate and treat if indicated, Weekly skin assessments by a licensed nurse every Sunday on Day shift and Braden scale (used to predict pressure sore risk) weekly times 4 weeks, one time a day every Thursday. M. Record review of R #245's Nurses Notes dated [DATE] revealed the following: 1. [DATE] at 22:40 (10:40 pm) - Note Text: Received call from facility nurse at 2050 (8:50 pm) stating he had entered the residents room and was (sic) found resident unresponsive 911 was called and CPR (Cardiopulmonary Resuscitation) was initiated. EMS (Emergency Medical Service) was in facility and responded to resident they called the code at approximately 2135 (9:35 pm). Assessment of resident revealed resident did not respond to verbal tactile or painful stimulation, skin was dry pale and cool to the touch. Pupils fixed and dilated breath sounds absent. Apical (located on the chest near the heart), carotid (pulse felt on the neck) and radial (located on the wrist (radial artery))pulses absent, bowel sounds absent capillary refill absent. Time of death 2142 (9:42 pm). Call placed to emergency contact and to OMI (Office of Medical Investigation). Author: Director of Nursing (DON)(e-Signed) 2. Nurses Notes [DATE] at 23:22 (11:22 pm) - Note Text: The Nurse spoke with (Name of Medical Examiner from OMI), he reviewed the resident information and stated they would not pick up the case and that the body of (R #245) could be released to the funeral home of the families choice .Author: DON (e-Signed) N. On [DATE] at 2:45 pm, during interview, the DON confirmed that there should have been an admission note in the nurses notes for R #245. She stated that she expects the nurses to chart as soon as they can on an admission, but that the nurses do have 24 hours to complete the admission paperwork. She stated that her expectations of what the nurses should chart in the admission note would include when the patient/resident arrived at the facility, if patient/resident were stable or not, if the patient/resident was comfortable or not, document some sort of an assessment, document something about their skin and falls and that the admitting orders were verified by the physician. She stated that there was no process in place to orient agency nursing staff to the floors. She stated, I believe that (Name of RN #2) took report on R #245, but was not made aware when R #245 was physically here in the room. O. On [DATE] at 1:40 pm, during interview, the daughter of R #245 stated that on Thursday (MONTH) 1st (2018), at around 2:30 pm that afternoon, they being her grandmother and uncle were waiting for her dad (R #245) to be transferred to the nursing facility. (The Visitor's Sign-In Sheet indicates that family signed in at 3:15 pm.) She said that there was a random nurse, in black scrubs, that told the family that his nurse will be in the room shortly. She said that there was a nurse, in blue scrubs, who brought in a pitcher of water into the room, and she told the nurse that her dad needed a thickener to be put into the water or else he could choke on the water. She said that she even had a packet of thicker that the nurse from the hospital had given her, which she offered to the staff member but that the staff member didn't take it. She said that she had set up her dad's room for him and left the nursing facility around 6:30 pm or 6:45 pm that evening. She said that she called her dad at around 7:30 pm that night and told him good night and that she loved him. She stated that around 10:30 pm that night, that she got the call that her dad was dead. She stated that on her dad's Death Certificate indicated that the time of her dad's death was at 9:46 am in the morning, and that she was confused about that. When she was asked if she remembers if her dad had received a dinner tray that evening? She stated that he did not and that the last time that he had eaten was at the hospital. P. On [DATE] at 10:15 am, during interview, the DON stated that R #245 had shortly arrived from (Name of local hospital), he coded around 8:30 pm. She stated that when the hospital packets for the new admissions had arrived, that she took the paperwork to the nurses station on the Skilled Nurses Unit. She further stated that the evening shift 6:00 pm to 6:00 am nurse had told her that she did not know that R #245 was here, the ambulance must have dropped him off. Q. On [DATE] at 2:45 pm, during interview, Nurse Practitioner (NP) #1 stated that there was a day when two residents had died within 8 hours. She stated that they were full codes, and that the EMS was working on the first code and then there was another code (name of R #245). She said, No one told me that he was here (in the facility), I knew that he was going to be on the Skilled Nursing Unit and that he had [MEDICAL CONDITION]. R. On [DATE] at 3:45 pm, during interview, RN #2 (agency nurse, who was working the day shift on [DATE]) stated, No one told me he (name of R #245) was here. She said that there were 23 patients on the Skilled Nursing Unit, she was the only nurse on for the day and that it was real busy that day. She stated that the hospital nurse had called her at 1:15 pm to give her report on R #245, but that she didn't take report because she wanted to review the hospital records that she had on R #245. She said that she called the hospital nurse back, and left her a message to call her on her cell phone, but that the hospital nurse never called her back to give her report on R #245. She said, I guess the hospital still sent the patient, even though I never got report. RN #2 said that she was still in the facility around 8:30 pm that night finishing up her paperwork (her shift ended at 6:30 pm), she said my gut told me that he was there - he was vomiting, diaphoretic (sweating heavily) and was a diabetic. She said that I know that my documentation sucked that day, and said, that was the worst day of my nursing career. S. On [DATE] at 4:05 pm, during interview, the Transportation Driver stated that he had received a text message from the Medical Records Staff member to pick up a patient at the local hospital. A nursing staff member will take the patient to their room. He said that he brought R #245 to the nurses station on the Skilled Unit and waited as he did not have a room number as to where R #245 was going to be placed. A nursing staff member showed up, but he did not know her name, accepted the patient and took R #245 to his room. T. On [DATE] at 11:20 am, during interview, RN #2 stated that on that Thursday of (MONTH) 1st (2018), that it was her second day of working in the facility as an agency nurse. She stated that she remembered that as the day was going on, she was asking the DON for help. The Administration sent another nurse, but that this other nurse did not have computer access. RN #2 stated that she was aware that there were three pending admissions that day, but that she could not do the admission paperwork, as she had not been trained to do that. RN #2 stated that she remembered asking the DON specifically, if she could admit the incoming patients. She said, there was no way that I could have handled all that was going on in the unit. She stated that when the next shift came on at six, they did walking rounds as I didn't know who had arrived yet from the hospital. U. On [DATE] at 2:15 pm, during interview, Licensed Practical Nurse (LPN) #2 (staff nurse who worked the evening shift) stated that on Thursday (MONTH) 1st (2018), remembered that night there were back-to-back codes. She said that she was orienting another nurse that night and said that she was not aware that there was a patient in room [ROOM NUMBER]. She said that she did not get report on anybody in that room. She said, I remembered going down the hall and hearing a noise and thought, who is this patient. She said, I asked him if he was OK, and if he was a diabetic. I told him that I will be right back. I went back to the nurses station and called the doctor. I just didn't know who he was (meaning R #245). She said that the DON was trying to bring up his name (R #245) up in the computer and his name wasn't in there. LPN #2 stated that the next morning to told the DON and ADON that this event should not have happened. She said they brought him in and he was just left there, nobody was told. She said that RN #2 (the day nurse from the day before) who was an agency nurse, was very overwhelmed that day. She stated, That night bothered me a lot and that I had thought about calling the State. LPN #2 stated that during the codes that night, there was a key that was missing for the oxygen tank located on the emergency cart, and that the CNA's were not trained in CPR and were not helping the nurses. She said, Things should not go that way. Findings related to R #247: GG. Record review of, R #247's New Admission Meeting Form, with attached hospital notes, dated [DATE] at 2:30 pm indicated the resident's date of birth was [DATE], she was admitted to the facility on [DATE] at 2:30 pm from a local acute care facility where she had been treated starting on [DATE] for, acute [MEDICAL CONDITION] (a condition where too little oxygen is transported from the lungs to the blood stream) with [MEDICAL CONDITION] (not enough oxygen reaching the body's cells) community acquired pneumonia (an infection that inflames the air sacs in one or both lungs),[MEDICAL CONDITION] (an infection in the blood) due to pneumonia and acute on chronic (an exacerbation of an a chronic medical problem) [MEDICAL CONDITION] ([MEDICAL CONDITION], a condition where the heart does not pump blood as efficiently as normal often resulting in excess fluid build up in the body). Her medical history included, diabetes mellitus type 2, (disorder that is characterized by high blood sugar, decreased response to insulin and a relative lack of insulin). She was blind. She was alert and oriented X (times) 4 but with decreased awareness of need for assistance. HH. Record review of R #247's progress note in the admission paperwork dated [DATE] at 4:00 pm, indicated, Patient was found sitting in the chair with SaO2 (oxygen saturation on red blood cells) 66% (various normal ranges should be above 90%) she stated she forgot to put her cannula (tube attached to oxygen source) back on her nose. It took between 5 to 8 minutes for oxygen to reach 90% oxygen flow was increased to 3 liters. II. Record review of R #247's nursing assessment reveals the first documentation at 6:53 pm on [DATE]. It was never completed in the approximately 54 hours ([DATE] to [DATE]) that R #247 was in the facility prior to death. JJ. On [DATE] at 1:15 pm, during an interview with RN #2, she stated she was the nurse on the skilled unit on [DATE] during the day shift. She further stated she had 23 residents that day. She recalled that R #247 was on oxygen therapy, she was unsure of the rate it was set at but stated, between 2 and 4 (liters per minute) or it would have set off an alarm for me .she kept taking it off .I caught her at least twice with it off .we never can find an oximeter here (device to measure oxygen saturation, the percent of hemoglobin molecules on red blood cells carrying oxygen in the blood stream) .they all disappear .that may be why there were not any (oximeter) readings. KK. On [DATE] at 1:30 pm, during an interview, RN #12, stated that, when R #247 was found dead, I think it was off (the oxygen cannula was not in the residents nares (nostrils)) .(the resident had previously told him) .I don't need it. He stated that he was not sure what flow rate of the oxygen was set at. LL. On [DATE] at 11:45 am, during an interview, with the DON she related, there is no policy for skilled nursing care that directs the assessment timing .they have to do an assessment within 24 hours and they usually have the CNAs (Certified Nursing Assistants) do vital signs for them for their daily note. Findings for R #292: MM. Record review of R #292's Skin Observation form dated [DATE] indicated R #292 had reddened areas on his body which included his right buttock and left buttock. The form also noted he had an [MEDICAL CONDITION] (medical condition in which patches of skin become rough and inflamed) rash but did not specify where. NN. Record review of R #292's medical record revealed he did not have any skin checks or wound measurements from [DATE] to [DATE]. R #292's skin was not assessed for 31 days and did not receive the appropriate skin integrity interventions which included a Low Air Loss (LAL) mattress (a mattress that provides alternating pressure and is designed to be used in the prevention, treatment and management of pressure ulcers) and was not being appropriately turned/repositioned every two hours. OO. Record review of R #292's Skin Observation form dated [DATE] indicated R #292 had an unstageable (which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) wound measuring 8 centimeters (cm) long by 3.4 cm wide on his left buttock and a wound measuring 3.7 cm long by 1.4 cm wide and a depth of 1.2 cm on his right gluteal fold (lower buttock). PP. Record review of the hospital record dated [DATE] at 9:24 pm, indicated that R #292 was admitted with two stage 4 pressure ulcers (Full thickness tissue loss with exposed bone, tendon or muscle): one on his right ischial (lower hip bone) measuring 3.0 cm long by 3.0 cm wide with a depth of 3.0 cm where bone was palpated (examined by touch) and one on his sacral/coccyx (tail bone) measuring 6.0 cm long by 3.0 cm wide. The hospital records indicated the wounds had been present for an unknown time frame. QQ. Record review of the History & Physical dated [DATE], revealed, .Brought in by ambulance from (Name of facility) on [DATE] for fever and penile bleeding following a failed attempt at Foley catheter (a tube inserted into the bladder) insertion. Workup revealed acute Urinary Tract Infection with concern [MEDICAL CONDITION] (infection in the blood). admitted for further evaluation and treatment. On [DATE] R #292 developed septic shock (an infection in the blood stream) requiring pressors (intravenous medications to raise the blood pressure) and transfer to the Intensive Care Unit (ICU). He did stabilize and was transferred out of ICU on [DATE]. On [DATE] R #292's respiratory status declined again requiring Bi-PAP (a respiratory device to assist in breathing) Hospital records indicated that R #292 died on [DATE] with the cause of death as acute hypoxic [MEDICAL CONDITION], septic shock and urinary tract infection. RR. On [DATE] at 2:12 pm, during interview, RN #9 stated that she worked at the facility (but not currently) between (MONTH) (YEAR) until the end of (MONTH) (YEAR). RN #9 stated that the facility did not use med techs (CMAs) during her time which meant she had to pass medications to about 34 to 38 residents. She stated she passed the morning, lunch and evening medications which required her entire shift to complete, this did not leave her any time to do skin checks for residents. She stated that during her shift on [DATE], she did not have enough time to complete R #292's weekly skin check that was due to be completed that day. RN #9 stated that her supervisor instructed her that they operate 24-hour facility and to pass on any uncompleted work to the next shift. RN #9 stated she informed the night nurse that day that R #292's skin check still needed to be done but was not sure it was ever done. She stated that she quit her job at the facility because she thought they were understaffed and because the facility did not operate like how they taught her as it should be in nursing school. SS. Record review of Nurse Note dated [DATE] completed by RN #9 stated, unable to assess skin night nurse notified. TT. On [DATE] at 3:03 pm, during an interview with Physical Therapist #1, stated that he worked with R #292 several times doing various physical exercises/therapies. He stated that at one point he did see the resident's wounds alongside the wound care nurse but does not remember what day that was. Stated that he advocated for R #292 needing a Low Air Loss (LAL) mattress but was told by nursing staff that he had fallen out of one previously and it was too dangerous for him to have one. He stated that he responded that there are LAL mattresses that have inflated sides to pre (TRUNCATED)

Based on interviews and record reviews, the facility failed to ensure that agency staff members possessed the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely and in a manner that promotes confidence in physicians, as well as residents and their families. These deficient practices resulted in the following: 1. Nursing staff were failing to document, admit and assess residents who were brought into the facility and residents being treated or living in the facility in a timely manner; 2. On [DATE] there were two residents (R #245 and 247) that had each passed away at the facility within minutes of each other, each requiring cardiopulmonary resuscitation back-to-back. R #247 had been in the facility for a couple of days, and had passed away unexpectedly. R #245 had been admitted to the facility that afternoon ([DATE]) at 3:00 pm, and by 8:30 pm was being resuscitated and thus passing away. The 6:00 am to 6:00 pm nurse and the 6:00 pm to 6:00 am nurse following the day nurse, were not aware that the resident was in the facility and in the room; 3. R #292 was brought to hospital by ambulance from (Name of facility) on [DATE]. On [DATE] R #292 developed septic shock (an infection in the blood stream) requiring pressors (intravenous medications to raise the blood pressure) and transfer to the Intensive Care Unit (ICU). He did stabilize and was transferred out of ICU on [DATE]. On [DATE] R #292's respiratory status declined again requiring Bi-PAP (a respiratory device to assist in breathing) Hospital records indicated that R #292 died on [DATE] with the cause of death as acute hypoxic [MEDICAL CONDITION], septic shock and urinary tract infection. 4. That Agency staff were oriented and trained to the nursing units, the use of PCC (point click care) (their documentation software), the facility's admission checklist, and discharge processes; 5. Communicating the care of residents with other staff members and to their families. These deficient practices resulted in an Immediate Jeopardy (IJ) at a Scope and Severity of L as being identified on [DATE] at 11:20 am. The Administrator was notified at that time and a Plan of Removal was requested. The facility took corrective action by providing an acceptable Plan of Removal on [DATE] at 5:30 pm. This resulted in the scope and severity being reduced from level L to level G. The Plan of Removal consisted of four concerns for Insufficient Staffing: Nursing Documentation, Investigating In House Death, Monitoring of Admissions, and Orienting/Training of Agency Staff, which are included in the following: Overall Insufficient Staffing: -Resident(s) found to be affected by identified: R #245 passed away at this facility on [DATE], no further action required. R #247 passed away at this facility on [DATE], no further action required. -Potential residents to be affected by identified practice: 82 Current Residents have the potential to be affected. Nursing Documentation: -Corrective action implemented so identified practice will not recur: Licensed Nurses will be oriented by the Director of Nursing (DON)/DON Designee on how to document in Point Click Care (PCC) (computer charting system) and assessments that should be completed prior to end of shift. The DON/Designee will validate their training by providing a quiz at the completion of their orientation. DON/Designee will contact nurses every shift to validate completion of documentation prior to end of shift. A log will be kept for ongoing monitoring. Any areas found to be out of compliance will be corrected immediately. Results of logs will be brought to the monthly Quality Assessment Performance Improvement (QAPI) meeting for review and recommendations . Investigate In House Death: -Corrective action implemented so identified practice will not recur: The Administrator/Designee will review timeline of both incidents and complete an investigation of both deaths. The Administrator/Designee will self-report to Department of Health if there are two or more unexpected deaths in the facility within 24 hours and complete an investigation. Any areas found to be out of compliance will be corrected immediately . Monitoring of Admissions: -Corrective action implemented so identified practice will not recur: The DON/Designee will assess for acuity prior to admitting a resident to this facility until adequate staffing has been established. Readmissions will be accepted back at this facility if their needs an be met at the facility. The DON/Designee will review new admission packets and prior to admission will ensure that staffing is in place and the needs of the resident can be met. The DON/Designee will complete an acuity audit of residents that are accepted into the facility. Any areas found to be out of compliance will be corrected immediately. Results of audits will be brought to he monthly QAPI meeting for review and recommendations . Orienting/Training of Agency Staff: -Corrective action implemented so identified practice will not recur: The DON/Designee will orientate/train agency nursing staff on PCC, admission checklist, pharmacy, incident/accidents, notification, skin system, [MEDICATION NAME] monitoring, abuse prevention, lab services, 24-hour report, discharge processes, change of condition and nursing documentation prior to working the floor alone. The DON/Designee will validate their training by providing a quiz at the completion of their orientation. The DON/Designee will implement a mentorship for all agency staff to contact if they have questions or do not understand a process. The Administrator will educate DON/Designee and ADON/Designee that agency staff should not orient new staff. Any areas found to be out of compliance will be corrected immediately. Results of audits will be brought to the monthly QAPI meeting for review and recommendations . Based on record review, observations and interviews, the facility failed to ensure that there were sufficient competent nursing staff members that have the appropriate competencies and skills set that would assure and promote each resident's right, physical, mental and psychosocial well-being for all 82 residents identified on the alphabetical resident census list provided by the Administrator on [DATE]. This deficient practice has the potential to negatively impact resident safety and comfort, and to impede processes such as assessing residents in a timely manner, answering call lights in a timely manner, turning/repositioning residents every 2 hours and ensuring that physician orders [REDACTED]. A. On [DATE] at 9:15 am, during interview, RN #3 (an agency nurse) stated that when she came on that morning at 6:00 am, she did not receive any orientation to the units. She stated, I know how to get into the computer, but I don't know how to enter notes yet .there are two CMA's to pass meds, no other nurses here (on the long term care side) but me. B. On [DATE] at 10:00 am, during interview, R #34 stated, .here for 3 years .take care of me real good. When asked if nurses and CNAs were knowledgeable about her care? She answered, sometimes. R #34's only complaint was there was not enough staff .not enough CNAs at night .there is hardly nobody here at night .it takes a little longer to answer the lights at night . C. On [DATE] at 3:30 pm, during a requested interview, R #58's daughter stated that she comes almost daily and spends the morning with her dad, then leaves for a couple of hours and comes to spend a few hours in the afternoon with him. If she can't be there, her sister comes in. They (she and her sister) do most of all the care for her dad. She said, I think, perhaps I have a different perspective .we have no confidence in the care here .My biggest complaint, Agency staff, that is a big problem, they don't care as much, make medication errors .if I wasn't sitting in the dad's room he would get the wrong dose .I asked one for his medication that was late and she said she had given it to him but I told her, I am sitting here and you didn't .some of the agency CNAs just are on their phones .the administration is not friendly .I went to tell them about an agency nurse (RN #12) .I went home about 2 pm and when I came back about quarter to 6, I couldn't wake my dad .it was on Saturday .I told her (RN #12), 'I can't wake my dad, I need your help,' she just sat there, when she came she took his blood pressure .she turns to me and just cold as can be said, he's dying, call your family .two CNAs who know him took his vital signs and he was okay .weekends are very very bad .one CNA for the whole hall. D. On [DATE] at 10:15 am, during interview, R #65 stated, the CNAs, there are the good and the bad .(Name of CMA #2) is the best .everyone loves her .the good ones are all leaving .the new administrator I think (is the reason) .we have the agency ones .don't know us .How soon can they order your pills .they ran out of [MEDICATION NAME] (a sedative) .I need it to sleep .they have an emergency box .the nurse was agency and I understand it came later that night but she didn't give it to me .I didn't sleep at all . E. On [DATE] at 3:00 pm, during interview, the Administrator stated that that when they are short staffed We do and we don't admit residents. They have put a hold on admissions due to staffing .if a resident is discharged we fill those beds of course .we don't admit otherwise unless we have enough agency staff to cover a new admission .we make sure the agency will be able to cover for a 7-day period .we have to look that far out . F. On [DATE] at 5:30 am, during interview, Licensed Practical Nurse (LPN) #3 stated, When that agency nurse comes on duty (referring to the day of [DATE], the nurse having 70 residents by herself) they know what they are signing up for. G. On [DATE] at 3:06 pm, during interview, the Nurse Practitioner (NP) #2, stated that there had been staffing issues at the facility. She stated that it had started three or four months ago. She stated that they had staff leave so they had fewer staff and they had been using a lot of agency staff. Which is hard because agency staff just aren't as familiar with procedures and come in at a disadvantage. Findings for R #245: H. Record review of R #245's Discharge Summary dated [DATE] from an acute care hospital revealed the following: (Name of R #245) is a [AGE] year-old gentleman with past medical history significant for [MEDICAL CONDITION] and other comorbid conditions admitted for [MEDICAL TREATMENT] [MEDICATION NAME] syndrome (DDS) (symptoms include nausea, headache, vomiting and restlessness, more serious symptoms can result in [MEDICAL CONDITION] and coma. which could be attributed to cerebral [MEDICAL CONDITION] (swelling in the brain) during or following shortly after [MEDICAL TREATMENT] (a medical procedure to remove fluid and waste products from the blood, when the kidneys do not work properly)). The patient was not able to tolerate [MEDICAL TREATMENT] secondary to [MEDICAL CONDITION] (low blood pressure) related from poor oral intake and was also found to have possible [MEDICAL CONDITIONS] (in which there is a slow, progressive obstruction of airflow into or out of the lungs) exacerbation (to make the disease worse) and was treated with IV (intravenous) antibiotics. During his hospital course patient had significant dysphasia (difficulty speaking) that was hard to manage and patient was made npo (nothing by mouth) for liquids. This complicated his fluid balance situation with [MEDICAL TREATMENT] and prolonged his hospital course. I. On [DATE] at 2:45 pm, during interview, the DON confirmed that there should have been an admission note in the nurses notes for R #245. She stated that she expects the nurses to chart as soon as they can on an admission, but that the nurses do have 24 hours to complete the admission paperwork. She stated that her expectations of what the nurses should chart in the admission note would include when the patient/resident arrived at the facility, if patient/resident were stable or not, if the patient/resident was comfortable or not, document some sort of an assessment, document something about their skin and falls and that the admitting orders were verified by the physician. She stated that there was no process in place to orient agency nursing staff to the floors. She stated, I believe that (Name of RN #2) took report on R #245, but was not made aware when R #245 was physically here in the room. J. On [DATE] at 1:40 pm, during interview, the daughter of R #245 stated that on Thursday (MONTH) 1st (2018), at around 2:30 pm that afternoon, they being her grandmother and uncle were waiting for her dad (R #245) to be transferred to the nursing facility. (The Visitor's Sign-In Sheet indicates that family signed in at 3:15 pm.) She said that there was a random nurse, in black scrubs, that told the family that his nurse will be in the room shortly. She said that there was a nurse, in blue scrubs, who brought in a pitcher of water into the room, and she told the nurse that her dad needed a thickener to be put into the water or else he could choke on the water. She said that she even had a packet of thicker that the nurse from the hospital had given her, which she offered to the staff member but that the staff member didn't take it. She said that she had set up her dad's room for him and left the nursing facility around 6:30 pm or 6:45 pm that evening. She said that she called her dad at around 7:30 pm that night and told him good night and that she loved him. She stated that around 10:30 pm that night, that she got the call that her dad was dead. She stated that on her dad's Death Certificate indicated that the time of her dad's death was at 9:46 am in the morning, and that she was confused about that. When she was asked if she remembers if her dad had received a dinner tray that evening? She stated that he did not and that the last time that he had eaten was at the hospital. K. On [DATE] at 10:15 am, during interview, the DON stated that R #245 had shortly arrived from (Name of local hospital), he coded around 8:30 pm. She stated that when the hospital packets for the new admissions had arrived, that she took the paperwork to the nurses station on the Skilled Nurses Unit. She further stated that the evening shift 6:00 pm to 6:00 am nurse had told her that she did not know that R #245 was here, the ambulance must have dropped him off. L. On [DATE] at 2:45 pm, during interview, NP #1 stated that there was a day when two residents had died within 8 hours. She stated that they were full codes, and that the EMS was working on the first code and then there was another code (name of R #245). She said, No one told me that he was here (in the facility), I knew that he was going to be on the Skilled Nursing Unit and that he had [MEDICAL CONDITION]. M. On [DATE] at 3:45 pm, during interview, RN #2 (agency nurse, who worked the day shift on [DATE]) stated, No one told me he (name of R #245) was here. She said that there were 23 patients on the Skilled Nursing Unit, she was the only nurse on for the day and that it was real busy that Thursday. She stated that the hospital nurse had called her at 1:15 to give her report on R #245, but that she didn't take report because she wanted to review the hospital records that she had on R #245. She said that she called the hospital nurse back, and left her a message to call her on her cell phone, but that the hospital nurse never called her back to give her report on R #245. She said, I guess the hospital still sent the patient, even though I never got report. RN #2 said that she was still in the facility around 8:30 pm that night finishing up her paperwork (her shift ended at 6:30 pm), she said my gut told me that he was there - he was vomiting, diaphoretic and was a diabetic. She said that I know that my documentation sucked that day, and said, that was the worst day of my nursing career. N. On [DATE] at 11:20 am, during interview, RN #2 stated that on that Thursday of (MONTH) 1st (2018), that it was her second day of working in the facility as an agency nurse. She stated that she remembered that as the day was going on, she was asking the DON for help. The Administration sent another nurse, but that this other nurse did not have computer access, so the nurse did the CBGs (capillary blood glucose levels, the level of the number is needed before a patient can receive their insulin (injection medication needed to treat high blood sugars)) on the patients that needed them. RN #2 stated that she was aware that there were three pending admissions that day, but that she could not do the admission paperwork, as she had not been trained to do that. RN #2 stated that she remembered asking the DON specifically, if she could admit the incoming patients. She said, there was no way that I could have handled all that was going on in the unit. She stated that when the next shift came on at six, they did walking rounds as I didn't know who had arrived yet from the hospital. O. On [DATE] at 2:15 pm, during an interview, LPN #2 (staff nurse who worked the evening shift) stated that on Thursday (MONTH) 1st (2018), remembered that night there were back-to-back codes. She said that she was orienting another nurse that night and said that she was not aware that there was a patient in room [ROOM NUMBER]. She said that she did not get report on anybody in that room. She said, I remembered going down the hall and hearing a noise and thought, who is this patient. She said, I asked him if he was OK, and if he was a diabetic. I told him that I will be right back. I went back to the nurses station and called the doctor. I just didn't know who he was (meaning R #245). She said that the DON was trying to bring up his name (R #245) up in the computer and his name wasn't in there. LPN #2 stated that the next morning to told the DON and Assistant Director of Nursing (ADON) that this event should not have happened. She said they brought him in and he was just left there, nobody was told. She said that RN #2 (the day nurse from the day before) who was an agency nurse, was very overwhelmed that day. She stated, That night bothered me a lot and that I had thought about calling the State. LPN #2 stated that during the codes that night, there was a key that was missing for the oxygen tank located on the emergency cart, and that the CNA's were not trained in CPR and were not helping the nurses. She said, Things should not go that way. When she was asked if she can chart in PCC? She said that she has never been trained, and that she has had a hard time charting. She said that I want to tell the Administration that I'll even come in on my own time to learn the computer and said, I'm just real uncomfortable with charting in the nursing facility. I don't even know how to put orders into the computer. P. On [DATE] at 3:25 pm, during an interview, CMA #1 (who worked the day shift on [DATE]) stated when asked if she takes patients to their rooms when the Transportation Driver brings the patients to the nurses station? She said, I have, but that I didn't that day. I remember the patient. I took an oxygen concentrator to his room and hooked it up with water and tubing. Q. On [DATE] at 1:30 pm, during interview, NP #2 when asked if she saw R #245 on Thursday (MONTH) 1st (2018), stated that what she remembered of that day was that a patient had arrived from the hospital and was in the building. She said that usually she is just given a piece of paper that has orders from the hospital and that she approves the orders, without seeing the patient. She stated that after (MONTH) 1st, she requested not to go back to this nursing home, because it was not safe. She said that there were back-to-back codes and that it was a traumatic day. Findings related to R #247: R. Record review of, R #247's New Admission Meeting Form, with attached hospital notes, dated [DATE] at 2:30 pm indicated the resident's date of birth was [DATE], she was admitted to the facility on [DATE] at 2:30 pm from a local acute care facility where she had been treated starting on [DATE] for, acute [MEDICAL CONDITION] (a condition where too little oxygen is transported from the lungs to the blood stream) with [MEDICAL CONDITION] (not enough oxygen reaching the body's cells) community acquired pneumonia (an infection that inflames the air sacs in one or both lungs),[MEDICAL CONDITION] (an infection in the blood) due to pneumonia and acute on chronic (an exacerbation of an a chronic medical problem) [MEDICAL CONDITION] ([MEDICAL CONDITION], a condition where the heart does not pump blood as efficiently as normal often resulting in excess fluid build up in the body). Her medical history included, diabetes mellitus type 2, (disorder that is characterized by high blood sugar, decreased response to insulin and a relative lack of insulin). She was blind. She was alert and oriented X (times) 4 but with decreased awareness of need for assistance. S. Record review of R #247's progress note in the admission paperwork dated [DATE] indicated, Patient was found sitting in the chair with SaO2 (oxygen saturation on red blood cells) 66% (various normal ranges should be above 90%) she stated she forgot to put her cannula (tube attached to oxygen source) back on her nose. It took between 5 to 8 minutes for oxygen to reach 90% oxygen flow was increased to 3 liters. T. Record review of R #247's nursing assessment reveals the first documentation at 6:53 pm on [DATE]. It was never completed in the approximately 54 hours ([DATE] to [DATE]) that R #247 was in the facility prior to death. U. Record review of R #247's New Admission Meeting Form dated [DATE] revealed, Oxygen .4L (liters). V. Record review of R #247's physician orders [REDACTED]. W. Record review of R #247's medical record found no oximeter (device to measure oxygen saturation, the percent of hemoglobin molecules on red blood cells carrying oxygen in the blood stream) readings for the resident at any time in the facility. X. On [DATE] at 1:15 pm, during an interview with RN #2, she stated she was the nurse on the skilled unit on [DATE] during the day shift. She further stated she had 23 residents that day. She recalled that R #247 was on oxygen therapy, she was unsure of the rate it was set at but stated, between 2 and 4 (liters per minute) or it would have set off an alarm for me .she kept taking it off .I caught her at least twice with it off .we never can find an oximeter here .they all disappear .that may be why there were not any (oximeter) readings. Y. On [DATE] at 1:30 pm, during an interview, RN #12, stated that, when R #247 was found dead, I think it was off (the oxygen cannula was not in the residents nares (nostrils)) .(the resident had previously told him) .I don't need it. He stated that he was not sure what flow rate of the oxygen was set at. Z. On [DATE] at 11:45 am, during an interview, with the DON she related, there is no policy for skilled nursing care that directs the assessment timing .they have to do an assessment within 24 hours and they usually have the CNAs (Certified Nursing Assistants) do vital signs for them for their daily note. Findings for R #292: AA. Record review of R #292's Skin Observation form dated [DATE] indicated R #292 had reddened areas on his body which included his right buttock and left buttock. The form also noted he had an [MEDICAL CONDITION] (medical condition in which patches of skin become rough and inflamed) rash but did not specify where. BB. Record review of R #292's Skin Observation form dated [DATE] indicated R #292 had an unstageable wound measuring 8 centimeters (cm) long by 3.4 cm wide on his left buttock and a wound measuring 3.7 cm long by 1.4 cm wide and a depth of 1.2 cm on his right gluteal fold (lower buttock). CC. Record review of the hospital record dated [DATE] at 9:24 pm, indicated that R #292 was admitted with two stage 4 pressure ulcers (Full thickness tissue loss with exposed bone, tendon or muscle): one on his right ischial (lower hip bone) measuring 3.0 cm long by 3.0 cm wide with a depth of 3.0 cm where bone was palpated (examined by touch) and one on his sacral/coccyx (tail bone) measuring 6.0 cm long by 3.0 cm wide. The hospital records indicated the wounds had been present for an unknown time frame. DD. Record review of the History & Physical dated [DATE], revealed, .Brought in by ambulance from (Name of facility) on [DATE] for fever and penile bleeding following a failed attempt at Foley catheter (a tube inserted into the bladder) insertion. Workup revealed acute Urinary Tract Infection with concern [MEDICAL CONDITION]. admitted for further evaluation and treatment. On [DATE] R #292 developed septic shock (an infection in the blood stream) requiring pressors (intravenous medications to raise the blood pressure) and transfer to the Intensive Care Unit (ICU). He did stabilize and was transferred out of ICU on [DATE]. On [DATE] R #292's respiratory status declined again requiring Bi-PAP (a respiratory device to assist in breathing) Hospital records indicated that R #292 died on [DATE] with the cause of death as acute hypoxic [MEDICAL CONDITION], septic shock and urinary tract infection. EE. On [DATE] at 2:12 pm, during interview, RN #9 stated that she worked at the facility (but not currently) between (MONTH) (YEAR) until the end of (MONTH) (YEAR). RN #9 stated that the facility did not use medication technicians (CMAs) during her time which meant she had to pass medications to about 34 to 38 residents. She stated she passed the morning, lunch and evening medications which required her entire shift to complete, this did not leave her any time to do skin checks for residents. She stated that during her shift on [DATE], she did not have enough time to complete R #292's weekly skin check that was due to be completed that day. RN #9 stated that her supervisor instructed her that they operate 24-hour facility and to pass on any uncompleted work to the next shift. RN #9 stated she informed the night nurse that day that R #292's skin check still needed to be done but was not sure it was ever done. She stated that she quit her job at the facility because she thought they were understaffed and because the facility did not operate like how they taught her as it should be in nursing school. FF. Record review of R #292's care plan dated [DATE] indicated that R #292 had the potential for impaired skin integrity and one of the interventions listed was to reposition at least Q (every) 2 hours as tolerated. Another intervention listed was skin checks on shower days. GG. On [DATE] at 2:40 pm, during interview, the NP #1 stated that the nursing staff failed to communicate R #292's wound progression to her. She stated she knew that R #292 had [MEDICAL CONDITION] rashes in several places on his body including his buttocks and coccyx area but that it wasn't until around [DATE] when the staff let her know that the resident had 2 unstageable pressure ulcers to his left buttocks and right gluteal fold. She stated that the resident did have conditions that put him at risk for pressure ulcers including his lack of mobility but stated that his two pressure ulcers were avoidable. She stated that if the nursing staff was turning the resident every 2 hours, providing timely incontinence care and providing appropriate preventative skin care the resident should not have developed such severe pressure ulcers in a relatively short period of time. HH. On [DATE] at 10:08 am, during an interview, the Medical Director (MD) stated that she saw R #292 on [DATE] and noted the two pressure wounds on the sacrum and right ischial and noted that he had lost 34 pounds. She stated that she had not seen him prior to [DATE] as NP #1 was seeing him. She stated that NP #1 saw him on [DATE] and the resident most likely had the wounds at that time but they were not communicated to her. The MD verified that the ulcers were avoidable considering R #292's [DIAGNOSES REDACTED]. II. On [DATE] at 10:07 am, during interview, RN #10 stated that he used to work at the facility as an Assistant Director of Nursing from (MONTH) (YEAR) to (MONTH) (YEAR). He stated he never completed a skin check for R #292 despite signing off on the Treatment Administration Record (TAR) that he had completed a skin check on [DATE]. He stated that either the Former Director of Nursing or the Former Wound Care Nurse told him to sign off that the skin check had been completed that day ([DATE]) even though he did not do it himself. RN #10 stated that the management routinely made him complete documentation for things he had not done himself and was not sure anyone else had done either. RN #10 stated that he quit after his 90-day orientation because he was scared that he would get some kind of negative action taken against his license if he kept documenting as he was. RN #10 also stated that the facility was severely understaffed. He stated they hired nurses who spent most of their work day in an office yet the facility included them in their PPD (Per Patient Day - a calculation used to determine how many direct care staff hours, on average, are devoted to a single resident each day). He stated that if you only included the staff who actually worked directly with the resident in the facility it would have been between a 1.8 to 2.2 PPD.

The facility failed to ensure that residents were free of neglect, indicated by the following: 1. Resident (R)#245 was transferred to the facility from an acute care facility in the afternoon of [DATE]. By that evening the resident complained of nausea, the resident was later found to be in bed unresponsive and later passing away, less than six (6) hours of being in the facility. It was later discovered that the day shift Registered Nurse (RN) and evening shift RN were not made aware that the resident was in the room. 2. R #247 was admitted to the facility on [DATE] into skilled care for short term rehabilitation and died on [DATE]. She was found unresponsive in her room and resuscitative measures were not successful. The resident was oxygen dependent, oxygen was never ordered and oxygen levels were never assessed. The resident was a diabetic (a person suffering from diabetes, high blood glucose (blood sugar), either because insulin production is inadequate, or because the body's cells do not respond properly to insulin, or both) it was more than 24 hours after her admission when her blood glucose was assessed for the first time. The resident's nursing assessment was never completed. 3. R #292's skin was not assessed for 31 days ([DATE] to [DATE]) and he did not receive the appropriate skin integrity interventions which included a Low Air Loss (LAL) mattress (a mattress that provides alternating pressure and is designed to be used in the prevention, treatment and management of pressure ulcers) and being turned/repositioned every two hours. This resulted in R #292 developing two unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (devitalized tissue) and/or eschar (dead tissue)) ulcers which were later categorized as stage 4 (Full thickness tissue loss with exposed bone, tendon or muscle) ulcers when he was hospitalized on [DATE]. R #292 eventually died in the hospital on [DATE] due to other complications. These deficient practices resulted in an Immediate Jeopardy (IJ) at a Scope and Severity of K as being identified on [DATE] at 11:20 am. The Administrator was notified at that time and a Plan of Removal was requested. The facility took corrective action by providing an acceptable Plan of Removal on [DATE] at 5:30 pm. This resulted in the scope and severity being reduced from level K to level G. The Plan of Removal consisted of five concerns for Neglect: Nursing Documentation, Investigating In House Death, Monitoring of Admissions, Monitoring of Skin, and Orienting/Training of Agency Staff, which are included in the following: Neglect: -Resident(s) found to be affected by identified: · R #244 did not receive a guaiac testing (test to see if there is blood in the stool). · R #245 passed away at this facility on [DATE], no further action required. · R #247 passed away at this facility on [DATE], no further action required. · R #292 was discharged to the hospital on [DATE], no further action required. -Potential residents to be affected by identified practice: · 82 Current Residents have the potential to be affected. Nursing Documentation: -Corrective action implemented so identified practice will not recur: · Licensed Nurses will be oriented by the Director of Nursing (DON)/DON Designee on how to document in Point Click Care (PCC) (computer charting system) and assessments that should be completed prior to end of shift. · The DON/Designee will validate their training by providing a quiz at the completion of their orientation. · DON/Designee will contact nurses every shift to validate completion of documentation prior to end of shift. A log will be kept for ongoing monitoring. · Any areas found to be out of compliance will be corrected immediately. · Results of logs will be brought to the monthly Quality Assessment Performance Improvement (QAPI) meeting for review and recommendations. Investigate In House Death: -Corrective action implemented so identified practice will not recur: · The Administrator/Designee will review timeline of both incidents and complete an investigation of both deaths. · The Administrator/Designee will self-report to Department of Health if there are two or more unexpected deaths in the facility within 24 hours and complete an investigation. · Any areas found to be out of compliance will be corrected immediately. Monitoring of Admissions: -Corrective action implemented so identified practice will not recur: · The DON/Designee will assess for acuity prior to admitting a resident to this facility until adequate staffing has been established. Readmissions will be accepted back at this facility if their needs can be met at the facility. · The DON/Designee will review new admission packets and prior to admission will ensure that staffing is in place and the needs of the resident can be met. · The DON/Designee will complete an acuity audit of residents that are accepted into the facility. · Any areas found to be out of compliance will be corrected immediately. · Results of audits will be brought to he monthly QAPI meeting for review and recommendations. Monitoring Skin: -Corrective action implemented so identified practice will not recur: · Wound care nurse hired on [DATE] with a start date of [DATE]. Completed Skin sweeps on [DATE], [DATE], the week of [DATE] and [DATE]. · Internally, the facility reinitiated completion of internal pressure and non-pressure wound tracking. · In-serviced License Nursing Staff on responsibilities and roles regarding being proactive in the prevention of wounds and was initiated on [DATE]. Included but not limited to repositioning, showers, peri care and weekly skin checks. · New Treatment Nurse began orientation on the floor the week of [DATE] and the week of [DATE], she oriented with the certified wound nurse of a sister facility. · DON/Designee completes weekly audits to validate orders for weekly skin checks. · The wound care nurse/designee is completing a secondary wound skin assessment to validate findings. · DON/Designee is auditing Certified Nursing Assistant (CNA) shower sheets to validate completion of showers or refusals. · DON/Designee is auditing the Braden risk (Pressure Sore Risk) and implementing interventions if needed due to high risk of skin breakdown. · DON/Designee is completing an audit 5 times a week to validate turning and repositioning is occurring. · Any areas found to be out of compliance will be corrected immediately. · DON/Designee has incorporated weekly skin meetings and wounds are being audited. Orienting/Training of Agency Staff: -Corrective action implemented so identified practice will not recur: · The DON/Designee will orientate/train agency nursing staff on PCC, admission checklist, pharmacy, incident/accidents, notification, skin system, [MEDICATION NAME] (a blood thinning medication) monitoring, abuse prevention, lab services, 24-hour report, discharge processes, change of condition and nursing documentation prior to working the floor alone. · The DON/Designee will validate their training by providing a quiz at the completion of their orientation. · The DON/Designee will implement a mentorship for all agency staff to contact if they have questions or do not understand a process. · The Administrator will educate DON/Designee and ADON/Designee that agency staff should not orient new staff. · Any areas found to be out of compliance will be corrected immediately. · Results of audits will be brought to the monthly QAPI meeting for review and recommendations. Based on record review, and interviews, the facility failed to keep residents free from neglect for 4 (R #s 244, 245, 247, and 292) of 4 (R #s 244, 245, 247, and 292) residents reviewed for neglect. The facility failed to ensure the following: 1. R #245 was admitted to the facility on [DATE], there was no documentation that a licensed nurse assumed care of the resident. R #245 complained of nausea to the evening licensed nurse (who was not aware that R #245 was in that room), the nurse left the resident to find out more information and by the time she returned to the room, R #245 was unresponsive, and requiring cardiopulmonary resuscitation (CPR). R #245's time of death was 9:42 pm. This was approximately 6 (six) hours after being transferred to the facility. 2. R #247 was admitted to the facility on [DATE], into skilled care for short term rehabilitation and died on [DATE]. She was found unresponsive in her room and resuscitative measures were not successful. Resident was oxygen dependent, oxygen was never ordered by a physician and oxygen levels were never assessed. Resident was a diabetic, it was more than 24 hours after her admission when her blood glucose was assessed for the first time. Resident's nursing assessment was never completed. 3. R #292's skin was not assessed for 31 days ([DATE] to [DATE]) and he did not receive the appropriate skin integrity interventions which included a Low Air Loss (LAL) mattress (a mattress that provides alternating pressure and is designed to be used in the prevention, treatment and management of pressure ulcers) and being turned/repositioned every two hours. This resulted in R #292 developing two unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (devitalized tissue) and/or eschar (dead tissue)) ulcers which were later categorized as stage 4 (Full thickness tissue loss with exposed bone, tendon or muscle) ulcers when he was hospitalized on [DATE]. R #292 eventually died in the hospital on [DATE] due to other complications. 4. R #244 did not receive Guaiac Testing after being ordered by the physician multiple times and; the PT ([MEDICATION NAME] time test that indicates how long it takes for your blood to clot) was 18.3 seconds indicating that it was high, the normal range is 11XXX,[DATE].5 and the INR (International normalized ratio) (a calculation based on results of a PT that is used to monitor treatment with the blood-thinning medication) was not being completed as ordered by the physician resulting in R #244 being admitted to the emergency roiagnom on [DATE] and a few days later passing away. These deficient practices resulted in R #'s 245 and 247, both requiring cardiopulmonary resuscitation back-to-back, resulting in their passing away in the facility in a matter of minutes. R #292 being sent to an acute care hospital for stage 4 pressure ulcers and R #244 not receiving the proper laboratory testing and being admitted to the hospital and later passing away. The findings are: Findings related to R #245: A. Record review of R #245's Discharge Summary dated [DATE] from an acute care hospital revealed the following: (Name of R #245) is a [AGE] year-old gentleman with past medical history significant for [MEDICAL CONDITION] and other comorbid conditions admitted for [MEDICAL TREATMENT] [MEDICATION NAME] syndrome (DDS) (symptoms include nausea, headache, vomiting and restlessness, more serious symptoms can result in [MEDICAL CONDITION] and coma. which could be attributed to cerebral [MEDICAL CONDITION] (swelling in the brain) during or following shortly after [MEDICAL TREATMENT] (a medical procedure to remove fluid and waste products from the blood, when the kidneys do not work properly)). The patient was not able to tolerate [MEDICAL TREATMENT] (the clinical purification of blood by [MEDICAL TREATMENT], as a substitute for the normal function of the kidney) secondary to [MEDICAL CONDITION] (low blood pressure) related from poor oral intake and was also found to have possible [MEDICAL CONDITIONS] (in which there is a slow, progressive obstruction of airflow into or out of the lungs) exacerbation (to make the disease worse) and was treated with IV (intravenous) antibiotics. During his hospital course patient had significant dysphasia (difficulty speaking) that was hard to manage and patient was made npo (nothing by mouth) for liquids. This complicated his fluid balance situation with [MEDICAL TREATMENT] and prolonged his hospital course. A MRI (Magnetic Resonance imaging, to form pictures of the brain) was performed and stroke workup was negative for his new onset dysphasia. An echocardiogram (picture of the heart) showed he had a moderate to large sized pleural effusion (excess fluid surrounding the lungs) initially due to the conservative [MEDICAL TREATMENT] (not getting a large amount of fluid off due to the low blood pressure) that he was receiving and the thought was possible compression of recurrent laryngeal nerve (supplies all the muscles of the larynx,) versus left vagus nerve (control of the heart, lungs, and digestive tract) as the patient also had hoarseness in his throat and voice. Over time the patient's pericardial effusion (fluid around the heart) resolved .and the patient's dysphasia also started resolving. He was cleared for nectar thick liquids (a thickened liquid to help prevent choking and stop fluid from entering the lungs) but his dysphasia still persisted to some degree. At this point since the patient is able to tolerate [MEDICAL TREATMENT] and oral intake he was more stable and discharged to rehab . B. Record review of R #245's admitting orders from the acute care hospital dated [DATE], included: Oxygen at 5 L (liters), Renal diet, Pureed texture, Nectar consistency, Therapy: PT (Physical Therapy), OT (Occupational Therapy) and ST (Speech Therapy) evaluate and treat if indicated, weekly skin assessments by a licensed nurse every Sunday on day shift and Braden Scale (used to predict pressure sore risk) weekly times 4 weeks, one time a day every Thursday. C. Record review of R #245's Nurses Notes dated [DATE] revealed the following: 1. Nurses Notes [DATE] at 22:40 (10:40 pm) - Note Text: Received call from facility nurse at 2050 (8:50 pm) stating he had entered the residents room and was (sic) found resident unresponsive 911 was called and CPR was initiated. EMS (Emergency Medical Service) was in facility and responded to resident they called the code at approximately 2135 (9:35 pm). Assessment of resident revealed resident did not respond to verbal tactile or painful stimulation, skin was dry pale and cool to the touch. Pupils fixed and dilated breath sounds absent. Apical (chest), carotid (neck) and radial (wrist) pulses absent, bowel sounds absent capillary refill absent. Time of death 2142 (9:42 pm). Call placed to emergency contact and to OMI (Office of Medical Investigation). Author: Director of Nursing (DON)(e-Signed) 2. Nurses Notes [DATE] at 23:22 (11:22 pm) - Note Text: The Nurse spoke with (Name of Medical Examiner from OMI), he reviewed the resident information and stated they would not pick up the case and that the body of (R #245) could be released to the funeral home of the families choice .Author: DON (e-Signed) D. On [DATE] at 2:45 pm, during an interview, the DON confirmed that there should have been an admission note in the nurses notes for R #245. She stated that she expects the nurses to chart as soon as they can on an admission, but that the nurses do have 24 hours to complete the admission paperwork. She stated that her expectations of what the nurses should chart in the admission note would include when the patient/resident arrived at the facility, if patient/resident were stable or not, if the patient/resident was comfortable or not, document some sort of an assessment, document something about their skin and falls and that the admitting orders were verified by the physician. She stated that there was no process in place to orient agency nursing staff to the floors. She stated, I believe that (Name of RN #2) took report on R #245, but was not made aware when R #245 was physically here in the room. E. On [DATE] at 1:40 pm, during an interview, the daughter of R #245 stated that on Thursday (MONTH) 1st (2018), at around 2:30 (pm) that afternoon, they being her grandmother and uncle were waiting for her dad (R #245) to be transferred to the nursing facility. She said that her dad was in good spirits that day, as he had been in the hospital for a long time, he was joking and making faces at her. She said that it was about 3:00 (pm) when they arrived at the nursing home, we were unloading R #245's belongings. (The Visitor's Sign-In Sheet indicates that family signed in at 3:15 pm.) She said that there was a random nurse, in black scrubs, that told the family that his nurse will be in the room shortly. She said that she remembered that her dad usually needed help to get into the bed, but at the nursing home, he got into the bed by himself from the wheelchair. She said, We were so proud of him. She said that there was a nurse, in blue scrubs, who brought in a pitcher of water into the room, and she told the nurse that her dad needed a thickener to be put into the water or else he could choke on the water. She said that she even had a packet of thicker that the nurse from the hospital had given her, which she offered to the staff member but that the staff member didn't take it. She said that her dad had said that he wasn't thirsty at that time. She said that her grandmother and uncle had left the facility after an hour, which was at around 5:30 (pm) that evening. She stayed in the room with her dad and that they were going to watch TV, but they didn't have a remote for the TV. She said that she wandered around the nursing facility, asking for a TV remote. She said that a staff member had told her that the facility was short on TV remotes. They did find one, but that the TV remote didn't work, so she changed the TV stations for her dad to his favorite TV show. She said that she had set up her dad's room for him and left the nursing facility around 6:30 (pm) or 6:45 (pm) that evening. She said that she called her dad at around 7:30 (pm) that night and told him good night and that she loved him. She stated that around 10:30 (pm) that night, that she got the call that her dad was dead. She stated that on her dad's Death Certificate indicated that the time of her dad's death was at 9:46 (am) in the morning, and that she was confused about that. When she was asked if she remembers if her dad had received a dinner tray that evening? She stated that he did not and that the last time that he had eaten was at the hospital. F. On [DATE] at 10:15 am, during interview, the DON stated that R #245 had shortly arrived from (Name of local hospital), he coded around 8:30 pm. She stated that when the hospital packets for the new admissions had arrived, that she took the paperwork to the nurses station on the Skilled Nurses Unit. She further stated that the evening shift 6 pm to 6 am nurse (name unknown) had told her that she did not know that R #245 was here, the ambulance must have dropped him off. G. On [DATE] at 2:45 pm, during an interview, Nurse Practitioner (NP) #1 stated that there was a day when two residents had died within 8 hours. She stated that they were full codes, and that the EMS was working on the first code and then there was another code (name of R #245). She said, No one told me that he was here (in the facility), I knew that he was going to be on the Skilled Nursing Unit and that he had [MEDICAL CONDITION]. H. On [DATE] at 3:45 pm, during an interview, RN (Registered Nurse) #2 (agency nurse, who was working the day shift on [DATE]) stated, No one told me he (name of R #245) was here. She said that there were 23 patients on the Skilled Nursing Unit, she was the only nurse on for the day and that it was real busy that day. She stated that the hospital nurse had called her at 1:15 pm, to give her report on R #245, but that she didn't take report because she wanted to review the hospital records that she had on R #245. She said that she called the hospital nurse back, and left her a message to call her on her cell phone, but that the hospital nurse never called her back to give her report on R #245. She said, I guess the hospital still sent the patient, even though I never got report. RN #2 said that she was still in the facility around 8:30 pm that night finishing up her paperwork (her shift ended at 6:30 pm), she said my gut told me that he was there - he was vomiting, diaphoretic (sweating heavily) and was a diabetic. She said that I know that my documentation sucked that day, and said, that was the worst day of my nursing career. I. On [DATE] at 4:05 pm, during an interview, the Transportation Driver stated that he had received a text message from the Medical Records Staff member to pick up a patient at the local hospital. He stated that he gets their name, if the patient is on oxygen, how many liters and what size of a wheelchair. He said that he picks up the patient in a wheelchair, transports them to the facility, then takes the patient to either the Skilled Unit or the long term care nursing stations. At that point, a nursing staff member will take the patient to their room. He thought that on [DATE], he had picked up the patient roughly around 4 or 5 pm that day. He stated that he does not keep a transportation log, so he could not verify the exact time. He said that he brought R #245 to the nurses station on the Skilled Unit and waited as he did not have a room number as to where R #245 was going to be placed. A nursing staff member (name unknown) showed up, but he did not know her name, accepted the patient and took R #245 to his room. J. On [DATE] at 11:20 am, during an interview, RN #2 stated that on that Thursday of (MONTH) 1st (2018), that it was her second day of working in the facility as an agency nurse. She stated that she remembered that as the day was going on, she was asking the DON for help. The Administration sent another nurse, but that this other nurse did not have computer access, so the nurse did the CBGs (capillary blood glucose levels, the level of the number is needed before a patient can receive their insulin (injection medication needed to treat high blood sugars)) on the patients that needed them. RN #2 stated that she was aware that there were three pending admissions that day, but that she could not do the admission paperwork, as she had not been trained to do that. RN #2 stated that she remembered asking the DON specifically, if she could admit the incoming patients. She said, there was no way that I could have handled all that was going on in the unit. She stated that when the next shift came on at six, they did walking rounds as I didn't know who had arrived yet from the hospital. K. On [DATE] at 2:15 pm, during an interview, Licensed Practical Nurse (LPN) #2 (staff nurse who worked the evening shift) stated that on Thursday (MONTH) 1st (2018), remembered that night there were back-to-back codes. She said that she was orienting another nurse that night and said that she was not aware that there was a patient in room [ROOM NUMBER]. She said that she did not get report on anybody in that room. She said, I remembered going down the hall and hearing a noise and thought, who is this patient. She said, I asked him if he was OK, and if he was a diabetic. I told him that I will be right back. I went back to the nurses station and called the doctor. I just didn't know who he was (meaning R #245). She said that the DON was trying to bring up his name (R #245) in the computer and his name wasn't in there. LPN #2 stated that the next morning she told the DON and ADON (Assistant Director of Nurses) that this event should not have happened. She said they brought him in and he was just left there, nobody was told. She said that RN #2 (the day nurse from the day before) who was an agency nurse, was very overwhelmed that day. She stated, That night bothered me a lot and that I had thought about calling the State. LPN #2 stated that during the codes that night, there was a key that was missing for the oxygen tank located on the emergency cart, and that the CNAs were not trained in CPR and were not helping the nurses. She said, Things should not go that way. When she was asked if she can chart in PCC (Point Click Care electronic health record (EHR) provider for skilled nursing providers)? She said that she has never been trained, and that she has had a hard time charting. She said that I want to tell the Administration that I'll even come in on my own time to learn the computer and said, I'm just real uncomfortable with charting in the nursing facility. I don't even know how to put orders into the computer. L. On [DATE] at 3:25 pm, during an interview, Certified Medication Aide (CMA) #1 (who worked the day shift on [DATE]) stated when asked if she takes patients to their rooms when the Transportation Driver brings the patients to the nurses station? She said, I have, but that I didn't that day. I remember the patient. I took an oxygen concentrator to his room and hooked it up with water and tubing. M. On [DATE] at 2:55 pm, during an interview, the mother of R #245 stated that at 2:00 (pm) on [DATE], we were waiting for (name of R #245) to be transferred to the nursing home. She said that her and her other son thought that R #245 was fine and so they left the nursing home at about 5:30 (pm) that evening and that the facility was going to bring R #245 his dinner tray. She said that it was a shock when the facility called her to tell her that R #245 had died . She said we knew he was very sick while he was in the hospital, but that we were confident that he was going to be OK. She stated that her granddaughter was alarmed when the staff member brought in a water pitcher, when we knew he needed that thickener put into the water before he drank it. N. On [DATE] at 11:00 am, during an interview, the Dietary Manager confirmed that there was a diet tray ticket for R #245 on [DATE]. O. On [DATE] at 1:30 pm, during an interview, NP #2 when asked if she saw R #245 on Thursday (MONTH) 1st (2018), stated that what she remembered of that day was that a patient had arrived from the hospital and was in the building. She said that usually she is just given a piece of paper that has orders from the hospital and that she approves the orders, without seeing the patient. She stated that after (MONTH) 1st (2018), she requested not to go back to this nursing home, because it was not safe. She said that there were back-to-back codes and that it was a traumatic day. Findings for R #247: P. Record review of, the facility's, New Admission Meeting Form, with attached hospital notes, dated [DATE] at 2:30 pm revealed the resident's date of birth was [DATE], she was admitted to the facility on [DATE] at 2:30 pm from a local acute care facility where she had been treated starting on [DATE] for, acute [MEDICAL CONDITION] ( a condition where too little oxygen is transported from the lungs to the blood stream) with [MEDICAL CONDITION] (not enough oxygen reaching the body's cells) community acquired pneumonia,[MEDICAL CONDITION] (an infection in the blood) due to pneumonia and acute on chronic (an exacerbation of an a chronic medical problem) [MEDICAL CONDITION] ([MEDICAL CONDITION], a condition where the heart does not pump blood as efficiently as normal often resulting in excess fluid build up in the body). Q. Record review of the progress note dated [DATE] at 4:00 pm, indicated, Patient was found sitting in the chair with SaO2 (oxygen saturation on red blood cells) 66% (various normal ranges are quoted, for most people the percentage should be above 90%) she stated she forgot to put her cannula (tube attached to oxygen source) back on her nose. It took between 5 to 8 minutes for oxygen to reach 90%, oxygen flow was increased to 3 liters. R. Record review of facility nursing assessment reveals the first documentation at 6:53 pm on [DATE]. It was never completed in the approximately 54.2 hours that R #247 was in the facility prior to death. S. On [DATE] at 1:30 pm, during an interview, RN #2, shared that, when R #247 was found dead, I think it was off (the oxygen cannula was not in the residents nares (nostrils)) .(the resident had previously told him) .I don't need it. T. On [DATE] at 11:45 am, during an interview, the DON related, there is no policy for skilled nursing care that directs the assessment timing .they have to do an assessment within 24 hours and they usually have the CNAs (Certified Nursing Assistants) do vital signs for them for their daily note. Findings related to R #292: U. Record review of R #292's Skin Observation form dated [DATE] indicated R #292 had reddened areas on his body which included his right buttock and left buttock. The form also noted he had an [MEDICAL CONDITION] (medical condition in which patches of skin become rough and inflamed) rash but did not specify where. V. Record review of R #292's medical record revealed he did not have any skin checks or wound measurements from [DATE] to [DATE]. W. Record review of R #292's Skin Observation form dated [DATE] indicated R #292 had an unstageable wound measuring 8 centimeters (cm) long by 3.4 cm wide on his left buttock and a wound measuring 3.7 cm long by 1.4 cm wide and a depth of 1.2 cm on his right gluteal fold (lower buttock). X. Record review of a hospital record dated [DATE] at 9:24 pm indicated R #292 was admitted with two stage 4 pressure ulcers: one on his right ischial (lower hip bone) measuring 3.0 cm long by 3.0 cm wide with a depth of 3.0 cm where bone was palpated (examined by touch) and one on his sacral/coccyx (tail bone) measuring 6.0 cm long by 3.0 cm wide. The records stated the wounds had been present for an unknown time frame. Record review of hospital record H&P (History & Physical) dated [DATE] completed by a nurse practitioner stated .Brought in by ambulance from (Name of Nursing Home) on [DATE] for fever and penile bleeding following a failed attempt at Foley catheter (A flexible plastic tube inserted into the bladder to provide continuous urinary drainage) insertion. Workup revealed acute UTI (urinary tract infection) with concern [MEDICAL CONDITION] (an infection in the blood). admitted for further evaluation and treatment. On [DATE] (Name of R #292) developed septic shock (an infection in the blood stream) requiring pressors (a substance that elevates arterial blood pressure) and transfer to the ICU (Intensive Care Unit). He did stabilize and was transferred out of ICU on [DATE]. On [DATE] (Name of R #292) respiratory status declined again requiring Bi PAP (Bilevel Positive Airway Pressure - a non-invasive ventilation machine) The records indicated he died on [DATE] with the cause of death as acute hypoxic [MEDICAL CONDITION], septic shock and urinary tract infection. Y. On [DATE] at 10:54 am, during an interview with the Director of Nursing (DON), she stated she started working at the facility after R #292 had already been discharged . She stated that R #292 was being treated for [REDACTED]. The DON stated that for every skin check completed, the nurse should complete a skin observation form and if there are wounds they should also complete a skin integrity form which includes measurements of the wound. The DON verified that the nurses failed to complete any skin checks between [DATE] and [DATE]. The DON acknowledged that R #292's [MEDICAL CONDITION] did not turn into unstageable pressure ulcers overnight and that the resident most likely had pressure wounds prior to the first documentation of them on [DATE]. The DON verified that R #292 did not receive any wound care prior to [DATE]. Z. Record review of R #292's Treatment Administration Record (TAR) dated (MONTH) (YEAR) and (MONTH) (YEAR) revealed: 1. R #292's skin check on [DATE] is marked as completed but no skin observation or notes were documented. 2. R #292's skin check on [DATE] had a notation that RN #9 was not able to complete the skin check and notified the night nurse. 3. R #292's skin checks on [DATE] and [DATE] are marked as completed but no skin observation forms were completed. 4. R #292's skin check on [DATE] had a notation that the nurse was not able to complete th (TRUNCATED)

The facility failed to ensure that residents were free from missed medication doses. Physicians and other practitioners overseeing the residents' care were not notified of lapses in the delivery of medication. This deficient practice resulted in an Immediate Jeopardy declaration at Scope and Severity of K on [DATE] at 1:48 pm. The Administrator was notified at that time, and a Plan of Removal was requested. The facility took corrective action by providing an acceptable Plan of Removal on [DATE] at 4:38 pm. The Plan of Removal included the following: 1. The facility will educate licensed nursing staff and certified medication aides in person or via telephone on facility policies and procedures regarding Medication Administration, to begin immediately. 2. Nurses and certified medication aides will be in-serviced on notification to provider for missed medication and notification to DON (Director of Nurses) and/or designee to begin immediately. 3. The facility will run a computerized report of medication availability daily. The report will be reviewed by the Director of Nursing or designee, who will notify pharmacy and the physician. 4. The Assistant Director of Nursing or designee will audit the medication orders of new admissions by the first business day following admission regarding medications to be supplied by a third party, and will validate that the medications are available. 5. Any areas found to be out of compliance will be corrected immediately. 6. Results of audits will be brought to the monthly QAPI (Quality Assurance and Performance Improvement) meeting for review and recommendations. Upon acceptance of the Plan of Removal on [DATE] at 4:38 pm, the Scope and Severity was lowered to E. Based on interview and record review, the facility failed to ensure the routine administration of ordered medications to 4 residents (R #s 53, 60, 82 & 192) of 5 (R #s 53, 60, 82, 192 & 194) residents reviewed for delivery of medication. Documentation indicated multiple gaps in medication delivery, and physicians and other practitioners reported not having been informed of the lapses. This deficient practice resulted in inconsistent medication therapy for residents, and may have contributed to the decline and death of 1 resident (R #192) who endured significant interruptions in his [MEDICAL CONDITION] ( a type of treatment that includes a medication or combination of medications to [MEDICAL CONDITION]) treatments. The findings are: Findings related to R #192: A. Record review of Complaint Intake dated [DATE] found that a complainant described as a family member had reported that, prior to his discharge to a local hospital on [DATE], the family had overheard a nurse and medication aide discussing R #192, and stating that he had not received his oral [MEDICAL CONDITION] medication for over a month. B. Record review of a hospital Emergency Department (ED) note for R #192, dated [DATE], found a statement indicating (R #192) is a 66 y.o. (year old) male with a history of metastatic [DIAGNOSES REDACTED] (cancer of the blood and bone marrow) and prostate (a gland surrounding the neck of the bladder) cancer. Last chemo treatment yesterday Presents to the ED with worsening of his chronic right hip pain. Complains of decreased appetite secondary to pain. A physical examination section stated Neurological: He is alert and oriented to person, place and time. An Assessment and Plan section stated Pt (patient) presents for evaluation of intractable (unrelieved) right hip pain in setting of known bony mets (metastases) from [DIAGNOSES REDACTED] to the same area. He states that because of the worsening pain he does not have an appetite and has not been taking PO (food and fluids by mouth) very well over the last week. It does appear that he is currently on a cycle of oral chemo. C. Record review of a hospital Admission History and Physical document for R #192, dated [DATE], stated Admit for supportive care, hydration, pain control will include the use of IV (intravenous) narcotics . see if this will improve his status with pain. (MONTH) need to consider palliative care (specialized medical care for people with serious illness) consult. MM ([DIAGNOSES REDACTED]) advanced, consider ONC (oncology) to see too; [DATE] office note reviewed. Anorexia (a lack or loss of appetite for food) - hopefully will improve with pain control and hydration, consider nutritional consult. D. Record review of the facility medical record for R #192 found that he was noted to have a code status of full code, and [DIAGNOSES REDACTED]. Census information indicated that he was originally admitted to the facility on [DATE], on hospital leave beginning [DATE], and with a notation to stop billing on [DATE]. E. Record review of a Nurse Practitioner Progress Note for R #192, dated [DATE], indicated Patient seen today for follow-up after starting [MEDICAL CONDITION] for his [DIAGNOSES REDACTED]. History of Present Illness: [AGE] year-old male, admitted [DATE] from (previous long-term care facility). Patient initially admitted to previous facility for chronic severe pain due to [DIAGNOSES REDACTED] with metastasis to his lower back. He was unable to ambulate well or perform his own ADLs (Activities of Daily Living, such as hygiene, dressing and eating.) He was placed on high-dose opiates (narcotic pain medications) to help with his pain control which did have some efficacy (positive effect) and patient was able to have enhanced mobility and underwent physical therapy. Patient now undergoing [MEDICAL CONDITION] with Revlimid ([MEDICAL CONDITION] medication) for his [DIAGNOSES REDACTED]. He is being followed by (name of hospital oncologist) at (name of [MEDICAL CONDITION] center). Patient states his pain has been well controlled on the current regimen. His only complaint is he is experiencing generalized anasarca (widespread swelling of the skin) as a side effect. (Name of hospital oncologist) did order and place him on [MEDICATION NAME] (a medication to reduce fluid overload) 20 mg (milligrams) daily. He has no complaints of shortness of breath, chest pain, fever, chills, weakness, malaise, unusual fatigue or bleeding. A medication list in the note includes Revlimid 25 mg 21 days on and 7 days off per schedule. F. Record review of a Nurse Practitioner Progress Note for R #192, dated [DATE], found that Revlimid 25 mg (milligrams) p.o. (by mouth) per schedule remained in the medication list. G. Record review of a hospital oncology appointment After Visit Summary document for R #192, dated [DATE], found a section stating Complete list of medications you should be taking, which included lenalidomide (Revlimid) 25 mg capsule. 25 mg PO (by mouth) start on Day 1 of each new [MEDICAL CONDITION] cycle for 21 consecutive days (3 weeks on, one week off). H. Record review of a hospital oncology appointment After Visit Summary document for R #192, dated [DATE], found that Revlimid was still listed among the medications that he should be taking. I. Record review of an Order Summary Report for R #192, dated [DATE] and signed by the Medical Director on [DATE] as a monthly review/renewal of orders, found that Revlimid capsule 25 mg (lenalidomide.) Give 25 mg by mouth one time a day 21 days on and 7 days off [MEDICAL CONDITION]. Use gloves when handling medication-swallow whole. Ordered by (name of hospital oncologist) remained among active orders. J. Record review of physician's orders [REDACTED]. The dosing schedule on the order indicated the 21-days-on, 7-days-off dosing scheme. K. Record review of completed Medication Administration Records (MARs) for R #192 found that he missed 51 scheduled doses of Revlimid between (MONTH) (YEAR) and (MONTH) (YEAR). Documentation indicated that: 1. (MONTH) (YEAR), he did not receive Revlimid on 6 of 21 scheduled days. 2. (MONTH) (YEAR), he did not receive Revlimid on 5 of 21 scheduled days. 3. (MONTH) (YEAR), he did not receive Revlimid on 4 of 22 scheduled days. 4. (MONTH) (YEAR), he did not receive Revlimid on 8 of 24 scheduled days. 5. (MONTH) (YEAR), he did not receive Revlimid on 2 of 23 scheduled days. 6. (MONTH) (YEAR), he did not receive Revlimid on 2 of 24 scheduled days. 7. (MONTH) (YEAR), he did not receive Revlimid on 4 of 24 scheduled days. 8. (MONTH) (YEAR), he did not receive Revlimid on 20 of 21 scheduled days. 9. a key to administration codes indicated that Medication not available/ordered from pharmacy and Other/See Nurse Notes were the primary reasons given on the non-administration days. L. Record review of (med) administration notes related to R #192's Revlimid dosing found that notes were not written on a majority of the days. For the days on which an explanation of the non-administration was given: 1. On [DATE], Didn't receive from Px (pharmacy) was noted. 2. On [DATE], Still waiting for arrival from Px was noted. 3. On [DATE], Medication not available was noted. 4. On [DATE], Still waiting on arrival from Px was noted. 5. On [DATE], PHARMACIST STATED THAT THEY NEED NEW RX (prescription) AND FAMILY NEEDS TO PROVIDE THE MEDICATION was noted. 6. On [DATE], On order was noted. 7. On [DATE], Med not in stock; pt (patient) not taking currently was noted. 8. On [DATE], Medication not available order states the patient should be on medication one time a day 21 days on and 7 days off [MEDICAL CONDITION]. It was started on ,[DATE], needs verification was noted. 9. On [DATE], Medication has not been available to give notified nurse (name) on [DATE] also again today needs to be ordered from other pharmacy was noted. 10. On [DATE], Patient off of this medication for 7 days 1 of 7 (unclear) was noted. 11. On [DATE], Medication is not available will call pharmacy and notified nurse was noted. 12. On [DATE], Medication unavailable, called pharmacy to order medication, they said they need a hard script from the doctor so they can send the referral to the specialty pharmacy, notified charge nurse (name) was noted. 13. On [DATE], Called and was told by rep (representative) that answered, that the request is with the MA (medical assistant) and the DR (physician), to be filled. Rep stated that we would receive a call when it was filled and ready to be picked up at whichever facility. Staff will contact the specific pharmacy and see if it can be delivered was noted. M. Record review of a facility physician's progress notes related to R #192 were reviewed. The last physician's note was dated [DATE], and indicated that the resident was continuing with his 21-day-on, 7-day-off dosing of Revlimid. No notation of gaps in the delivery of the drug were found. N. Record review of R #192's physician's orders [REDACTED]. of hospital oncologist.) O. On [DATE] at 9:15 am, during a telephone interview with a Hospital Social Worker, who was another complainant, she reiterated that R #192 was unkempt when arriving from the facility for his oncology appointments, often with soiled clothing and an odor of urine. She had not been made aware that there were lapses in the facility's delivery of the [MEDICAL CONDITION] agent, Revlimid, to the resident. P. On [DATE] at 10:50 am, during an interview with the facility Director of Nursing, she confirmed that R #192 did not receive his [MEDICAL CONDITION] drug at all during February. She had not been Director of Nursing at the facility prior to that month, and had no direct knowledge of any lapses prior to February. She stated that there was some confusion about how the medication was to be supplied. She confirmed that [MEDICAL CONDITION] agents work by [MEDICAL CONDITION] cells in order to reduce the size of the tumor or slow its growth. She confirmed that failure to receive the medication could result in [MEDICAL CONDITION] cells continuing to multiply, or failing to reduce in number. She confirmed that R #192 did decline in late February, and was sent out to a hospital, where he died . Q. On [DATE] at 11:30 am, during an interview with the facility Director of Nursing, she stated that she had reviewed the MARs for R #192 during the previous months when he had been at the facility, and agreed that the documentation showed that he had not received [MEDICAL CONDITION] on all 51 of the dates identified. She confirmed that [MEDICAL CONDITION] was a crucial part of the plan of care for residents [MEDICAL CONDITION], and that failure to deliver the medication as ordered represented a medication error and a significant lapse in care. She stated that she had spoken with the facility's Medical Director about the resident's [MEDICAL CONDITION], but that it could not be determined whether failure to get his Revlimid had contributed to R #192's decline and death. R. On [DATE] at 11:50 am, during a telephone interview with the Hospital Oncologist, who was R #192's primary Oncologist, he indicated that he had not been aware that R #192 was not receiving his Revlimid as ordered. He stated that the facility was not sending the usual recap of medications taken with R #192 when he had his appointments, so that he (the oncologist) could not be sure what he was taking. The oncologist stated that it is impossible to know if failure to receive his Revlimid had contributed to R #192's decline and death, but that it is possible. S. On [DATE] at 2:00 pm, during an interview with the Hospital Social Worker, she indicated that she had discussed R #192's case with the Hospital Oncologist, and had confirmed that the oncology center had not been receiving medication lists from the facility when R #192 had had his appointments, despite having requested them many times. She reiterated that no one at [MEDICAL CONDITION] center had not been aware that R #192 had not been receiving his Revlimid as ordered. T. On [DATE] at 2:40 pm, during an interview with Nurse Practitioner #1, she stated that she oversaw R #192's care until (MONTH) (YEAR), when she temporarily relocated to another facility. She stated that the facility had never advised her about any missing Revlimid doses until (MONTH) (2017), shortly before she left. U. On [DATE] at 3:33 pm, during an interview with former facility Nurse Practitioner #2, she indicated that she had overseen R #192's care at the facility from (MONTH) (YEAR) until his discharge in (MONTH) (YEAR). She stated that she was never advised by the facility that he hadn't been receiving his ordered Revlimid. The only indication that she had had that there was a problem with the Revlimid was in late February, when the facility had called her to ask that she write a new prescription for it. She had been unable to do so, as [MEDICAL CONDITION] is a specialty drug which must be ordered by an oncologist. She stated that, even then, she wasn't told that he hadn't received it for a month at that point. V. On [DATE] at 4:30 pm, during an interview with the Director of Clinical Quality Management, she indicated that the problem with R #192's [MEDICAL CONDITION] is that it was not supplied by the facility's usual pharmacy. She did not provide an explanation of why the doctors and nurse practitioners responsible for R #192's care were never notified of the interruptions in his [MEDICAL CONDITION] dosing. Findings related to R # 53, 60 and 82: W. Record review of R #53's (MONTH) (YEAR) MAR found that it indicated that he had missed ordered doses of [MEDICATION NAME] (an antipsychotic medication) on three occasions [DATE], [DATE] and [DATE] X. Record review of R #60's (MONTH) (YEAR) MAR found that it indicated that she had not received ordered doses of [MEDICATION NAME] (an antifungal powder) on three occasions, on [DATE], 2 doses and [DATE]. Y. Record review of R #82's (MONTH) (YEAR) MAR found that it indicated that he had not received ordered doses of [MEDICATION NAME] (a drug to combat muscle spasms) on two occasions, on [DATE] and [DATE] Z. On [DATE] at 10:10 am, during an interview with the Director of Nursing, she confirmed that R #s 53, 60 and 82 had not received their doses of medication on the identified dates. She indicated that the rationale for the missed doses was sometimes absent, but that some indicated that the medication had run out. She could find no indication that the appropriate physician or nurse practitioner had been notified of the missed doses. She also stated that she had been unaware of R #192's missed [MEDICAL CONDITION] doses until right before he left.

This is a repeat deficiency from the recertification survey conducted on [DATE]. The facility failed to provide the necessary treatment and services to prevent the development of pressure ulcers for residents whose clinical condition demonstrates they were avoidable. This deficient practice resulted in an Immediate Jeopardy (IJ) at a scope and severity of J being identified on [DATE]. The facility was notified on [DATE] at 11:35 am. The facility took corrective action by providing an acceptable Plan of Removal on [DATE] at 5:42 pm. Based on the Plan of Removal, interventions included: 1. Hiring a wound care nurse with a start date of [DATE]. 2. Completed skin sweeps on [DATE], [DATE] and the week of [DATE] and [DATE]. 3. Reinitiated completion of internal pressure and non-pressure wound tracking. 4. In-serviced Licensed Nursing Staff on responsibilities and roles regarding being proactive in the prevention of wounds on [DATE] including repositioning, showers, peri care (maintenance of perianal skin integrity and relief of perineal discomfort), and weekly skin checks. 5. The wound care nurse or designee completing a secondary wound skin assessment to validate findings. 6. The Director of Nursing (DON) or designee completed audits to validate orders for weekly skin checks, completion of showers, completion of turning/repositioning of residents, completion of Braden risk (tool used to assess a patient's risk of developing a pressure ulcer) assessments and implementation of interventions. 7. Audit findings will be reported to the Interdisciplinary Team (IDT) and Quality Assurance and Performance Improvement (QAPI) Committee to determine if further monitoring is needed. Based on the Plan of Removal, the IJ was lifted on [DATE] at 5:42 pm. This resulted in the scope and severity being reduced from level J to level G. Based on record review and interview, the facility failed to provide the necessary treatment and services to prevent pressure ulcers for residents whose clinical condition demonstrated they were avoidable for 1 (R #292) of 1 (R # 292) resident reviewed for pressure ulcers. R #292's skin was not assessed for 31 days ([DATE] to [DATE]) and he did not receive the appropriate skin integrity interventions which included a Low Air Loss (LAL) mattress (a mattress that provides alternating pressure and is designed to be used in the prevention, treatment and management of pressure ulcers) and being turned/repositioned every two hours. This resulted in R #292 developing two unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (devitalized tissue) and/or eschar (dead tissue)) ulcers which were later categorized as stage 4 (Full thickness tissue loss with exposed bone, tendon or muscle) ulcers when he was hospitalized on [DATE]. R #292 eventually died in the hospital on [DATE] due to other complications. The findings are: A. Record review of R #292's Skin Observation form dated [DATE] indicated R #292 had reddened areas on his body which included his right buttock and left buttock. The form also noted he had an [MEDICAL CONDITION] (medical condition in which patches of skin become rough and inflamed) rash but did not specify where. B. Record review of R #292's medical record revealed he did not have any skin checks or wound measurements from [DATE] to [DATE]. C. Record review of R #292's Skin Observation form dated [DATE] indicated R #292 had an unstageable wound measuring 8 centimeters (cm) long by 3.4 cm wide on his left buttock and a wound measuring 3.7 cm long by 1.4 cm wide and a depth of 1.2 cm on his right gluteal fold (lower buttock). D. Record review of hospital record dated [DATE] at 9:24 pm indicated R #292 was admitted with two stage 4 (is very deep, reaching into muscle and bone and causing extensive damage) pressure ulcers: one on his right ischial (lower hip bone) measuring 3.0 cm long by 3.0 cm wide with a depth of 3.0 cm where bone was palpated (examined by touch) and one on his sacral/coccyx (tail bone) measuring 6.0 cm long by 3.0 cm wide. The records stated the wounds had been present for an unknown time frame. Record review of hospital record History & Physical (H&P) dated [DATE] completed by a nurse practitioner stated .Brought in by ambulance from (Name of Nursing Home) on [DATE] for fever and penile bleeding following a failed attempt at Foley catheter (A flexible plastic tube inserted into the bladder to provide continuous urinary drainage) insertion. Workup revealed acute UTI with concern [MEDICAL CONDITION] (the body's overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death). admitted for further evaluation and treatment. On [DATE] (Name of R #292) developed septic shock (an infection in the blood stream) requiring pressors (a substance that elevates arterial blood pressure) and transfer to the ICU (Intensive Care Unit). He did stabilize and was transferred out of ICU on [DATE]. On [DATE] (Name of R #292) respiratory status declined again requiring Bi PAP (Bilevel Positive Airway Pressure - a non-invasive ventilation machine) The records indicated he died on [DATE] with the cause of death as acute hypoxic [MEDICAL CONDITION], septic shock and urinary tract infection. E. On [DATE] at 10:54 am, during an interview with the Director of Nursing (DON), she stated she started working at the facility after R #292 had already been discharged . She stated that R #292 was being treated for [REDACTED]. The DON stated that for every skin check completed, the nurse should complete a skin observation form and if there are wounds they should also complete a skin integrity form which includes measurements of the wound. The DON verified that the nurses failed to complete any skin checks between [DATE] and [DATE]. The DON acknowledged that R #292's [MEDICAL CONDITION] did not turn into unstageable pressure ulcers overnight and that the resident most likely had pressure wounds prior to the first documentation of them on [DATE]. The DON verified that R #292 did not receive any wound care prior to [DATE]. F. Record review of R #292's Treatment Administration Record (TAR) dated (MONTH) (YEAR) and (MONTH) (YEAR) revealed: 1. Skin check on [DATE] is marked as completed but no skin observation or notes were documented. 2. Skin check on [DATE] had a notation that RN #9 was not able to complete the skin check and notified the night nurse. 3. Skin checks on [DATE] and [DATE] are marked as completed but no skin observation forms were completed. 4. Skin check on [DATE] had a notation that the nurse was not able to complete the skin check and notified the night nurse. G. On [DATE] at 2:12 pm, during an interview with Registered Nurse (RN) #9, she stated she does not currently work at the facility but did work there between (MONTH) (YEAR) until the end of (MONTH) (YEAR). RN #9 stated the facility did not use medication technicians (med techs) during her time which meant she had to pass medications to about 34 to 38 residents. She stated she passed the morning, lunch and evening medications which required her entire shift to complete and did not leave her any time to do skin checks for residents. She stated that during her shift on [DATE] she did not have enough time to complete R #292's weekly skin check that was due to be completed that day. RN #9 stated that her supervisor instructed her that they operate a 24-hour facility and to pass on any uncompleted work to the next shift. RN #9 stated she informed the night nurse that day that R #292's skin check still needed to be done but is not sure it was ever done. She stated that she decided to quit her job at the facility because she thought they were understaffed and because the facility did not operate like how they taught her it should in nursing school. H. Record review of R #292's Nurse's Note dated [DATE] completed by RN #9 stated, unable to assess skin night nurse notified. I. On [DATE] at 10:07 am, during an interview RN #10, stated that he used to work at the facility as an Assistant Director of Nursing from (MONTH) (YEAR) to (MONTH) (YEAR). He stated he never completed a skin check for R #292 despite signing off on the TAR that he had completed a skin check on [DATE]. He stated that either the Former Director of Nursing or the Former Wound Care Nurse told him to sign off that the skin check had been completed that day ([DATE]) even though he did not do it himself. RN #10 stated that the management routinely made him complete documentation for things he had not done himself and was not sure anyone else had done either. RN #10 stated he quit after his 90-day orientation because he was scared that he would get some kind of negative action taken against his license if he kept documenting as he was. When asked about R #292 and whether the Certified Nursing Assistants (CNAs) were turning/repositioning him every 2 hours he stated, I can tell you they definitely were not. He stated that in order to determine whether the CNAs were turning residents, he used turning cards which are small cards that he placed underneath the resident's body and the card had instructions to return it to him. He stated that he placed turning cards on several residents and would return 4 hours later to collect them all. RN #10 also stated that the facility was severely understaffed. He stated they hired nurses who spent most of their work day in an office yet the facility included them in their PPD (Per Patient Day - a calculation used to determine how many direct care staff hours, on average, are devoted to a single resident each day). He stated that if you only included the staff who actually worked directly with resident the facility had between a 1.8 to 2.2 PPD. J. On [DATE] at 3:03 pm, during an interview Physical Therapist #1, stated that he worked with R #292 several times doing various physical exercises/therapies. He stated that at one point he did see the resident's wounds alongside the wound care nurse, but does not remember what day that was. He stated that he advocated for R #292 needing a Low Air Loss (LAL) mattress but was told by nursing staff that he had fallen out of one previously and it was too dangerous for him to have one. He stated that he responded that there are LAL mattresses that have inflated sides to prevent the resident from falling out however they did not listen to him. K. On [DATE] at 9:45 am, during an interview with the DON, she stated that sometimes a task is created on the Activities of Daily Living (ADL) sheets regarding turning/repositioning residents every 2 hours for the CNAs to sign off. She stated that R #292 did not have that task listed on his ADL sheet. The DON also stated that based on the documentation on the ADL sheet for (MONTH) (2017) it appeared that R #292 had a LAL mattress that was discontinued on [DATE]. The DON stated she is not entirely sure why the LAL mattress was discontinued but believes that the Former Wound Care Nurse decided it was not appropriate for R #292 and spoke with the physician about discontinuing it. The DON verified that there should be a physician's orders [REDACTED].#292 does not have one in his medical record. L. Record review of R #292's ADL Sheet for (MONTH) (YEAR) revealed an entry for Check LAL mattress for proper functioning up until [DATE]. M. Record review of R #292's care plan dated [DATE] stated he had the potential for impaired skin integrity and one of the interventions listed was to reposition at least Q (every) 2 hours as tolerated. Another intervention listed was skin checks on shower days. N. On [DATE] at 2:40 pm, during an interview with Nurse Practitioner (NP) #1, she stated that the nursing staff failed to communicate R #292's wound progression to her. She stated she knew that R #292 had [MEDICAL CONDITION] rashes in several places on his body including his buttocks and coccyx area but that it wasn't until around [DATE] when the staff let her know that the resident had 2 unstageable pressure ulcers (Full thickness tissue loss in which the base of the ulcer is covered by slough (A layer or mass of dead tissue separated from surrounding living tissue, as in a wound, a sore, or an inflammation) and/or eschar (a collection of dead tissue within the wound bed and indicates full thickness tissue loss) in the wound bed) to his left buttocks and right gluteal fold. She stated that the resident did have conditions that put him at risk for pressure ulcers including his lack of mobility but stated that his two pressure ulcers were avoidable. She stated that if the nursing staff was turning the resident every 2 hours, providing timely incontinence care and providing appropriate preventative skin care the resident should not have developed such severe pressure ulcers in a relatively short period. O. On [DATE] at 10:08 am, during an interview with the Medical Director (MD), she stated she saw R #292 on [DATE] and noted the two pressure wounds on the sacrum and right ischial and noted he had lost 34 pounds. She stated she had not seen him prior to [DATE] as NP #1 was seeing him. She stated that NP #1 saw him on [DATE] and the resident most likely had the wounds at that time but they were not communicated to her. The MD verified that the ulcers were avoidable considering R #292's [DIAGNOSES REDACTED]. P. Record review of R #292's most recent Braden scale (tool used to assess a patient's risk of developing a pressure ulcer) assessment dated [DATE] indicated the resident was a Low Risk for developing pressure ulcers. Q. Record review of the facility's policy dated [DATE] stated, It is the policy of the center that any resident/guest who enters the center without pressure injuries does not develop pressure injuries unless the clinical condition makes the development unavoidable. Any resident who has a pressure injury will receive the necessary treatment and services to promote healing, prevent infections and prevent new injury development. Nursing staff along with other staff have the responsibility to promptly report any skin related problems to the charge nurse.

Based on interview, observation and interview, the facility administration failed to ensure that facility resources were effectively used to: 1. Resolve grievances in a timely manner (refer to tag F 585); 2. Prevent, report, and investigate allegations of neglect (refer to tags F 600, F 609 and F 610); 3. Provide quality of care to residents (refer to tag F 684); 4. Treat and provide services to prevent and heal pressure ulcers (refer to tag F 686); 5. Provide adequate and competent nursing staff to ensure that residents were receiving the assistance that they required (refer to tags F 725 and F 726); and 6. Provide routine administration of ordered medications, and notifying physicians and other practitioners of medication concerns, which may have contributed to the decline and death of 1 resident who endured significant interruptions in his [MEDICAL CONDITION] ( a type of treatment that includes a medication or combination of medications to [MEDICAL CONDITION]) treatments (refer to tag F 755). These deficient practices resulted in three (3) immediate jeopardy's (IJ's) in the areas of abuse/neglect, Insufficient Staffing, and Pharmacy Services; Substandard quality of care and eight (8) repeat deficiencies which impacted all 92 residents identified on the alphabetical resident census list provided by the Administrator on [DATE], of not achieving or maintaining their highest practicable physical, mental and psychosocial well-being. The findings are: Findings related to resolving grievances in a timely manner: Findings for R #59: A. On [DATE] at 3:45 pm, during an interview with R #59's Family Member (FM #1), he stated he filed a written grievance in (MONTH) (YEAR) and (MONTH) (YEAR) regarding several aspects of his mother's care which included lack of staff, not getting the help she needs to get in and out of her bed/wheelchair, not getting the help she needs to eat, her medications not being administered, medications being changed without notification, multiple urinary tract infections (UTI's) and lack of timely incontinence care. He stated the facility has still not responded to either of his grievances. B. On [DATE] at 10:21 am, during an interview, the Social Services Director (SSD) verified that the only documentation for resolution on the grievance dated [DATE] was hand written on the document and the Interdisciplinary Team (IDT) note from the care conference dated [DATE]. She stated that the grievance policy is to resolve the grievances in 72 hours and that did not happen for either of the two grievances. The SSD stated that the reason for the untimely response is due to the staff not getting her the grievances in a timely manner. She stated that the main complaint FM #1 had was about [MEDICATION NAME] (a medication that can treat depression, anxiety, and sleep disorders) and the majority of the time during the care conference held on [DATE], was spent addressing that. When asked about all the other issues in the grievances she was not aware if they were addressed and that they may have been talked about during the care conference. The SSD stated she forwarded this grievance to the Administrator as it contained an allegation of neglect. Findings related to resident being free of abuse and neglect: Findings for R #245: C. Record review of R #245's Discharge Summary dated [DATE] from an acute care hospital revealed the following: (Name of R #245) is a [AGE] year-old gentleman with past medical history significant for [MEDICAL CONDITION] and other comorbid conditions admitted for [MEDICAL TREATMENT] [MEDICATION NAME] syndrome (DDS) (symptoms include nausea, headache, vomiting and restlessness, more serious symptoms can result in [MEDICAL CONDITION] and coma. which could be attributed to cerebral [MEDICAL CONDITION] (swelling in the brain) during or following shortly after [MEDICAL TREATMENT] (a medical procedure to remove fluid and waste products from the blood, when the kidneys do not work properly)). The patient was not able to tolerate [MEDICAL TREATMENT] secondary to [MEDICAL CONDITION] (low blood pressure) related from poor oral intake and was also found to have possible [MEDICAL CONDITIONS] (in which there is a slow, progressive obstruction of airflow into or out of the lungs), significant dysphasia (difficulty speaking) that was hard to manage and patient was made npo (nothing by mouth) for liquids. He was cleared for nectar thick liquids (a thickened liquid to help prevent choking and stop fluid from entering the lungs) but his dysphasia still persisted to some degree. At this point since the patient is able to tolerate [MEDICAL TREATMENT] and oral intake he was more stable and discharged to rehab . D. Record review of the admitting orders from the acute care hospital dated [DATE], included: Oxygen at 5 L (liters), Renal diet, Pureed texture, Nectar consistency, Therapy: PT (Physical Therapy), OT (Occupational Therapy) and ST (Speech Therapy) evaluate and treat if indicated, Weekly skin assessments by a Licensed nurse every Sunday on Day shift and Braden scale (used to predict pressure sore risk) weekly times 4 weeks, one time a day every Thursday. E. Record review of the R #245's Nurses Notes dated [DATE] revealed the following: 1. Nurses Notes [DATE] at 22:40 (10:40 pm) - Note Text: Received call from facility nurse at 2050 (8:50 pm) stating he had entered the residents room and was (sic) found resident unresponsive 911 was called and CPR was initiated. EMS (Emergency Medical Service) was in facility and responded to resident they called the code at approximately 2135 (9:35 pm). Assessment of resident revealed resident did not respond to verbal tactile or painful stimulation, skin was dry pale and cool to the touch. Pupils fixed and dilated breath sounds absent. Apical (chest), carotid (neck) and radial (wrist) pulses absent, bowel sounds absent capillary refill absent. Time of death 2142 (9:42 pm). Call placed to emergency contact and to OMI (Office of Medical Investigation). Author: Director of Nursing (DON)(e-Signed) 2. Nurses Notes [DATE] at 23:22 (11:22 pm) - Note Text: The Nurse spoke with (Name of Medical Examiner from OMI), he reviewed the resident information and stated they would not pick up the case and that the body of (R #245) could be released to the funeral home of the families choice .Author: DON (e-Signed) There were no further nurses notes documented. F. On [DATE] at 2:45 pm, during an interview, the DON confirmed that there should have been an admission note in the nurses notes for R #245. She stated that she expects the nurses to chart as soon as they can on an admission, but that the nurses do have 24 hours to complete the admission paperwork. She stated that her expectations of what the nurses should chart in the admission note would include when the patient/resident arrived at the facility, if patient/resident were stable or not, if the patient/resident was comfortable or not, document some sort of an assessment, document something about their skin and falls and that the admitting orders were verified by the physician. She stated that there was no process in place to orient agency nursing staff to the floors. She stated, I believe that (Name of RN #2) took report on R #245, but was not made aware when R #245 was physically here in the room. G. On [DATE] at 10:15 am, during an interview, the DON stated that R #245 had shortly arrived from (Name of local hospital), he coded around 8:30 pm. She stated that when the hospital packets for the new admissions had arrived, that she took the paperwork to the nurses station on the Skilled Nurses Unit. She further stated that the evening shift 6:00 pm to 6:00 am nurse had told her that she did not know that R #245 was here, the ambulance must have dropped him off. H. On [DATE] at 2:45 pm, during an interview, Nurse Practitioner (NP) #1 stated that there was a day when two residents had died within 8 hours. She stated that they were full codes, and that the EMS (Emergency Medical Services) was working on the first code and then there was another code (name of R #245). She said, No one told me that he was here (in the facility), I knew that he was going to be on the Skilled Nursing Unit and that he had [MEDICAL CONDITION]. I. On [DATE] at 3:45 pm, during an interview, RN #2 (agency nurse, who was working the day shift on [DATE]) stated, No one told me he (name of R #245) was here. She said that there were 23 patients on the Skilled Nursing Unit, she was the only nurse on for the day and that it was real busy that Thursday. She stated that the hospital nurse had called her at 1:15 (pm) to give her report on R #245, but that she didn't take report because she wanted to review the hospital records that she had on R #245. She said that she called the hospital nurse back, and left her a message to call her on her cell phone, but that the hospital nurse never called her back to give her report on R #245. She said, I guess the hospital still sent the patient, even though I never got report. RN #2 said that she was still in the facility around 8:30 pm that night finishing up her paperwork (her shift ended at 6:30 pm), she said my gut told me that he was there - he was vomiting, diaphoretic (sweating heavily) and was a diabetic. She said that I know that my documentation sucked that day, and said, that was the worst day of my nursing career. J. On [DATE] at 11:20 am, during an interview, RN #2 stated that on that Thursday of (MONTH) 1st (2018), that it was her second day of working in the facility as an agency nurse. She stated that she remembered that as the day was going on, she was asking the DON for help. The Administration sent another nurse, but that this other nurse did not have computer access, so the nurse did the CBGs (capillary blood glucose levels, the level of the number is needed before a patient can receive their insulin (injection medication needed to treat high blood sugars)) on the patients that needed them. RN #2 stated that she was aware that there were three pending admissions that day, but that she could not do the admission paperwork, as she had not been trained to do that. RN #2 stated that she remembered asking the DON specifically, if she could admit the incoming patients. She said, there was no way that I could have handled all that was going on in the unit. She stated that when the next shift came on at six, they did walking rounds as I didn't know who had arrived yet from the hospital. K. On [DATE] at 2:15 pm, during an interview, Licensed Practical Nurse (LPN) #2 (staff nurse who worked the evening shift) stated that on Thursday (MONTH) 1st (2018), remembered that night there were back-to-back codes. She said that she was orienting another nurse that night and said that she was not aware that there was a patient in room [ROOM NUMBER]. She said that she did not get report on anybody in that room. She said, I remembered going down the hall and hearing a noise and thought, who is this patient. She said, I asked him if he was OK, and if he was a diabetic. I told him that I will be right back. I went back to the nurses station and called the doctor. I just didn't know who he was (meaning R #245). She said that the DON was trying to bring up his name (R #245) up in the computer and his name wasn't in there. LPN #2 stated that the next morning to told the DON and ADON that this event should not have happened. She said they brought him in and he was just left there, nobody was told. She said that RN #2 (the day nurse from the day before) who was an agency nurse, was very overwhelmed that day. She stated, That night bothered me a lot and that I had thought about calling the State. LPN #2 stated that during the codes that night, there was a key that was missing for the oxygen tank located on the emergency cart, and that the CNA's were not trained in CPR and were not helping the nurses. She said, Things should not go that way. When she was asked if she can chart in PCC? She said that she has never been trained, and that she has had a hard time charting. She said that I want to tell the Administration that I'll even come in on my own time to learn the computer and said, I'm just real uncomfortable with charting in the nursing facility. I don't even know how to put orders into the computer. L. On [DATE] at 2:55 pm, during an interview, the mother of R #245 stated that at 2:00 on [DATE], we were waiting for (name of R #245) to be transferred to the nursing home. She said that her and her other son thought that R #245 was fine and so they left the nursing home at about 5:30 that evening and that the facility was going to bring R #245 his dinner tray. She said that it was a shock when the facility called her to tell her that R #245 had died . She said we knew he was very sick while he was in the hospital, but that we were confident that he was going to be OK. M. On [DATE] at 1:30 pm, during an interview, NP #2 when asked if she saw R #245 on Thursday (MONTH) 1st (2018), stated that what she remembered of that day was that a patient had arrived from the hospital and was in the building. She said that usually she is just given a piece of paper that has orders from the hospital and that she approves the orders, without seeing the patient. She stated that after (MONTH) 1st, she requested not to go back to this nursing home, because it was not safe. She said that there were back-to-back codes and that it was a traumatic day. Findings for R #247: N. Record review of, the facility's, New Admission Meeting Form, with attached hospital notes, dated [DATE] at 2:30 pm revealed the resident's date of birth was [DATE], she was admitted to the facility on [DATE] at 2:30 pm from a local acute care facility where she had been treated starting on [DATE] for, acute [MEDICAL CONDITION] ( a condition where too little oxygen is transported from the lungs to the blood stream) with [MEDICAL CONDITION] (not enough oxygen reaching the body's cells) community acquired pneumonia,[MEDICAL CONDITION] (an infection in the blood) due to pneumonia and acute on chronic (an exacerbation of an a chronic medical problem) [MEDICAL CONDITION] ([MEDICAL CONDITION], a condition where the heart does not pump blood as efficiently as normal often resulting in excess fluid build up in the body). O. Record review of the progress note dated [DATE] at 4:00 pm, indicated, Patient was found sitting in the chair with SaO2 (oxygen saturation on red blood cells) 66% (various normal ranges are quoted, for most people the percentage should be above 90%) she stated she forgot to put her cannula (tube attached to oxygen source) back on her nose. It took between 5 to 8 minutes for oxygen to reach 90%, oxygen flow was increased to 3 liters. P. Record review of facility nursing assessment reveals the first documentation at 6:53 pm on [DATE]. It was never completed in the approximately 54.2 hours that R #247 was in the facility prior to death. Q. On [DATE] at 1:30 pm, during an interview, RN #2, shared that, when R #247 was found dead, I think it was off (the oxygen cannula was not in the residents nares (nostrils)) .(the resident had previously told him) .I don't need it. R. On [DATE] at 11:45 am, during an interview, the DON related, there is no policy for skilled nursing care that directs the assessment timing .they have to do an assessment within 24 hours and they usually have the CNAs (Certified Nursing Assistants) do vital signs for them for their daily note. Findings for R #292: S. Record review of R #292's Skin Observation form dated [DATE] indicated R #292 had reddened areas on his body which included his right buttock and left buttock. The form also noted he had an [MEDICAL CONDITION] (medical condition in which patches of skin become rough and inflamed) rash but did not specify where. T. Record review of R #292's medical record revealed he did not have any skin checks or wound measurements from [DATE] to [DATE]. U. Record review of R #292's Skin Observation form dated [DATE] indicated R #292 had an unstageable wound measuring 8 centimeters (cm) long by 3.4 cm wide on his left buttock and a wound measuring 3.7 cm long by 1.4 cm wide and a depth of 1.2 cm on his right gluteal fold (lower buttock). V. Record review of R #292's Treatment Administration Record (TAR) dated (MONTH) (YEAR) and (MONTH) (YEAR) revealed: 1. R #292's skin check on [DATE] is marked as completed but no skin observation or notes were documented. 2. R #292's skin check on [DATE] had a notation that RN #9 was not able to complete the skin check and notified the night nurse. 3. R #292's skin checks on [DATE] and [DATE] are marked as completed but no skin observation forms were completed. 4. R #292's skin check on [DATE] had a notation that the nurse was not able to complete the skin check and notified the night nurse. W. On [DATE] at 10:07 am, during interview, RN #10 stated that he used to work at the facility as an Assistant Director of Nursing from (MONTH) (YEAR) to (MONTH) (YEAR). He stated he never completed a skin check for R #292 despite signing off on the TAR that he had completed a skin check on [DATE]. He stated that either the Former Director of Nursing or the Former Wound Care Nurse told him to sign off that the skin check had been completed that day ([DATE]) even though he did not do it himself. RN #10 stated that the management routinely made him complete documentation for things he had not done himself and was not sure anyone else had done either. When asked about R #292 and whether the Certified Nursing Assistants (CNAs) were turning/repositioning him every 2 hours he stated, I can tell you they definitely were not. He stated that in order to determine whether the CNAs were turning residents, he used turning cards which are small cards that he placed underneath the resident's body and the card had instructions to return it to him. He stated that he placed turning cards on several residents and would return 4 hours later to collect them all. RN #10 also stated that the facility was severely understaffed. He stated they hired nurses who spent most of their work day in an office yet the facility included them in their PPD (Per Patient Day - a calculation used to determine how many direct care staff hours, on average, are devoted to a single resident each day). He stated that if you only included the staff who actually worked directly with resident the facility had between a 1.8 to 2.2 PPD. X. On [DATE] at 3:03 pm, during an interview with Physical Therapist #1, stated that he worked with R #292 several times doing various physical exercises/therapies. He stated that at one point he did see the resident's wounds alongside the wound care nurse but does not remember what day that was. Stated that he advocated for R #292 needing a Low Air Loss (LAL) mattress but was told by nursing staff that he had fallen out of one previously and it was too dangerous for him to have one. He stated that he responded that there are LAL mattresses that have inflated sides to prevent the resident from falling out however they did not listen to him. Y. On [DATE] at 9:45 am, during interview, the DON stated that sometimes a task is created on the Activities of Daily Living (ADL) sheets regarding turning/repositioning residents every 2 hours for the CNA's to sign off. She stated that R #292 did not have that task listed on his ADL sheet. The DON also stated that based on the documentation on the ADL sheet for (MONTH) it appeared that R #292 had a LAL mattress that was discontinued on [DATE]. The DON stated she is not entirely sure why the LAL mattress was discontinued but believes that the Former Wound Care Nurse decided it was not appropriate for R #292 and spoke with the physician about discontinuing it. The DON verified that there should be a physician's orders [REDACTED].#292 does not have one in his medical record. Z. Record review of R #292's ADL Sheet for (MONTH) (YEAR) revealed an entry for Check LAL mattress for proper functioning up until [DATE]. AA. Record review of R #292's care plan dated [DATE] stated he had the potential for impaired skin integrity and one of the interventions listed was to reposition at least Q (every) 2 hours as tolerated. Another intervention listed was skin checks on shower days. BB. On [DATE] at 2:40 pm, during interview, the NP #1 stated that the nursing staff failed to communicate R #292's wound progression to her. She stated she knew that R #292 had [MEDICAL CONDITION] rashes in several places on his body including his buttocks and coccyx area but that it wasn't until around [DATE] when the staff let her know that the resident had 2 unstageable pressure ulcers to his left buttocks and right gluteal fold. She stated that the resident did have conditions that put him at risk for pressure ulcers including his lack of mobility but stated that his two pressure ulcers were avoidable. She stated that if the nursing staff was turning the resident every 2 hours, providing timely incontinence care and providing appropriate preventative skin care the resident should not have developed such severe pressure ulcers in a relatively short period. CC. On [DATE] at 10:08 am, during interview, the Medical Director (MD) stated that she saw R #292 on [DATE] and noted the two pressure wounds on the sacrum and right ischial and noted he had lost 34 pounds. She stated she had not seen him prior to [DATE] as NP #1 was seeing him. She stated that NP #1 saw him on [DATE] and the resident most likely had the wounds at that time but they were not communicated to her. The MD verified that the ulcers were avoidable considering R #292's [DIAGNOSES REDACTED]. Findings related to injuries of unknown origin resulting in serious bodily harm to residents were not reported to the State Licensing Authority within 2 hours: Findings for R #85: DD. Record review of incident report dated [DATE] at 9:56 pm, stated that the Certified Nursing Assistant reported to the nurse that R #85 was lying on his left hip in the bathroom complaining of pain. The nursing description stated that R #85's left hip was one and a half times the size of his right hip. It also stated the resident was not moved and 911 was called. EE. Record review of the facility's 5-day follow up investigation (not dated) stated that R #85 obtained a pelvic fracture as a result of the fall on [DATE]. FF. Record review of the facility's initial report of the incident to the State Licensing Authority revealed it was reported on [DATE] at 7:47 am. Findings for R #248: GG. Record review of the facility's 5-day follow up investigation dated [DATE] indicated that R #248 was found sitting on the floor in her room at 6:00 am on [DATE]. It indicated that R #248 sustained a laceration to the back of her head and had complaints of pain to her right hip. It also revealed that at the emergency room (ER) they discovered she had a [MEDICAL CONDITION]. HH. Record review of the facility's initial report of the incident to the State Licensing Authority revealed it was reported on [DATE] at 12:31pm. II. On [DATE] at 12:30 pm, during interview, the Administrator verified that R #248's incident should have been reported within 2 hours and it was not. The Administrator stated that R #85's incident was not reported within 2 hours because the staff was not aware he had sustained a fracture until he was evaluated at the hospital. Findings related to the Administration failing to thoroughly investigate allegations of neglect and report the results of those investigations to the State Licensing Authority within 5 days: Findings for R #59: JJ. Record review of Family Member (FM) #1's grievance dated [DATE] revealed there were many concerns listed which included lack of staff, not getting R #59 the help she needs to get in and out of her bed/wheelchair, not getting R #59 the help she needs to eat, R #59's medications not being administered, medications being changed without notifying family, multiple urinary tract infections and incontinence care not being done timely. The grievance included an allegation of neglect by indicating, The worst part about this is that my mom was soiled and needed changing. It was more than an hour before my mom was tended to for this. KK. On [DATE] at 12:30 pm, during interview, the Administrator stated that FM #1's grievance dated [DATE] was never forwarded to her as it should have been. The Administrator verified that the allegations of neglect involving R #59 was never reported to the State Licensing Authority and the facility never conducted a thorough investigation. Findings related to treating and providing services to prevent and heal pressure ulcers: Findings for R #292: LL. Record review of R #292's Skin Observation form dated [DATE] indicated R #292 had reddened areas on his body which included his right buttock and left buttock. The form also noted he had an [MEDICAL CONDITION] (medical condition in which patches of skin become rough and inflamed) rash but did not specify where. MM. Record review of R #292's medical record revealed he did not have any skin checks or wound measurements from [DATE] to [DATE]. NN. Record review of hospital record dated [DATE] at 9:24 pm indicated R #292 was admitted with two stage 4 pressure ulcers: one on his right ischial (lower hip bone) measuring 3.0 cm long by 3.0 cm wide with a depth of 3.0 cm where bone was palpated (examined by touch) and one on his sacral/coccyx (tail bone) measuring 6.0 cm long by 3.0 cm wide. The records stated the wounds had been present for an unknown time frame. Record review of hospital record H&P (History & Physical) dated [DATE] completed by a nurse practitioner stated .Brought in by ambulance from (Name of Nursing Home) on [DATE] for fever and penile bleeding following a failed attempt at Foley catheter (A flexible plastic tube inserted into the bladder to provide continuous urinary drainage) insertion. Workup revealed acute UTI with concern [MEDICAL CONDITION]. admitted for further evaluation and treatment. On [DATE] (Name of R #292) developed septic shock (an infection in the blood stream) requiring pressors (a substance that elevates arterial blood pressure) and transfer to the ICU (Intensive Care Unit). He did stabilize and was transferred out of ICU on [DATE]. On [DATE] (Name of R #292) respiratory status declined again requiring Bi PAP (Bilevel Positive Airway Pressure - a non-invasive ventilation machine) The records indicated he died on [DATE] with the cause of death as acute hypoxic [MEDICAL CONDITION], septic shock and urinary tract infection. OO. On [DATE] at 10:54 am, during an interview with the Director of Nursing (DON), she stated she started working at the facility after R #292 had already been discharged . The DON verified that the nurses failed to complete any skin checks between [DATE] and [DATE]. The DON acknowledged that R #292's [MEDICAL CONDITION] did not turn into unstageable pressure ulcers overnight and that the resident most likely had pressure wounds prior to the first documentation of them on [DATE]. The DON verified that R #292 did not receive any wound care prior to [DATE]. PP. On [DATE] at 10:07 am, during an interview RN #10, stated that he used to work at the facility as an Assistant Director of Nursing from (MONTH) (YEAR) to (MONTH) (YEAR). He stated he never completed a skin check for R #292 despite signing off on the TAR that he had completed a skin check on [DATE]. He stated that either the Former Director of Nursing or the Former Wound Care Nurse told him to sign off that the skin check had been completed that day ([DATE]) even though he did not do it himself. RN #10 stated that the management routinely made him complete documentation for things he had not done himself and was not sure anyone else had done either. Findings related to providing adequate and competent nursing staff to ensure that residents were receiving the assistance that they required: QQ. On [DATE] at 9:15 am, during interview, RN #3 (an agency nurse) stated that when she came on that morning at 6:00 am, she did not receive any orientation to the units. She stated, I know how to get into the computer, but I don't know how to enter notes yet .there are two CMA's to pass meds, no other nurses here (on the long term care side) but me. RR. On [DATE] at 2:55 pm, during a requested interview, R #33's family member stated that she visits her husband daily. She stated, Last few months, since new administration, things have been hot and cold .I'm here every day with my husband .weekends really hard .under staffing .earlier this week .(at the evening meal) there were no CNAs and no nurses to help (residents that needed help to eat) .just Restorative Aide (RA) #1 .I told them at the desk .it took 45 minutes to get a couple of CNAs in. Two or three weeks ago we had some agency nurses and no one could understand them .we had a situation where one nurse was banned .(Name of Administrator) has encouraged us to come to her .the nurse (RN #12, an agency nurse) .did not flush my husband's catheter and she told me, that will just drive the bacteria up the tube, what do you want me to do and once there was one med tech doing all three halls (on the long term care unit). SS. On [DATE] at 3:30 pm, during a requested interview, R #58's daughter stated that she comes almost daily and spends the morning with her dad, then leaves for a couple of hours and comes to spend a few hours in the afternoon with him. If she can't be there, her sister comes in. They (she and her sister) do most of all the care for her dad. She said, I think, perhaps I have a different perspective .we have no confidence in the care here .since the new administration came .there have been so many CNAs that left .and nurses .a lot of them were good .They were be-littled, treated rudely, mis-treated .some were targeted .My biggest complaint, Agency staff, that is a big problem, they don't care as much, make medication errors .if I wasn't sitting in the dad's room he would get the wrong dose .I asked one for his medication that was late and she said she had given it to him but I told her, I am sitting here and you didn't .some of the agency CNAs just are on their phones .the administration is not friendly .I went to tell them about an agency nurse (RN #12) .I went home about 2 pm and when I came back about quarter to 6, I couldn't wake my dad .it was on Saturday .I told her (RN #12), 'I can't wake my dad, I need your help,' she just sat there, when she came she took his blood pressure .she turns to me and just cold as can be said, he's dying, call your family .two CNAs who know him took his vital signs and he was okay .weekends are very very bad .one CNA for the whole hall .My dad has two specific complaints, he gets up super early because he was a farmer .he gets a shower every day .then he goes back to bed and sleeps .they bring his breakfast and leave it but don't wake him up .his is upset because then it is cold and he wants them to wake him up .He takes his medication at 6:30 pm .[MEDICATION NAME] (a sedative to treat anxiety) .he goes to sleep but he wakes up later and needs his [MEDICATION NAME] (sedative and antidepressant) .he puts on his light between 9:30 pm and midnight .he is a clock watcher .no one comes .it is not once in a while it is almost every night .I went through the steps .I went to them (nurse and administration) first, then the Ombudsman .on the morning of [DATE] from 6:00 am to 8:00 am, there were no CNAs. TT. On [DATE] at 5:30 am, during interview, Licensed Practical Nurse (LPN) #3 stated, When that agency nurse comes on duty (referring to the day of [DATE], the nurse having 70 residents by herself) they know what they are signing up for. UU. Record review of the facility's staffing calculation worksheet for PPD hours from [DATE] to [DATE] revealed a range of 2.4 to 4.1 with many of the lower

This is a repeat deficiency from a complaint survey completed on 02/01/18. Based on record review and interview, the Facility Assessment failed to identify and describe what nursing resources were necessary to provide competent care for residents during day-to-day operations, where overall staffing was indicated as insufficient to meet each resident's needs for all 92 residents identified on the alphabetical resident census list provided by the Administrator on 03/29/18. These deficient practices resulted in three (3) immediate jeopardy (IJ) situations that were identified as resident neglect, Substandard quality of care issues and insufficient staffing with competent nursing concerns that negatively impacted the residents in this facility. The findings are: A. Record review of the Facility assessment dated (MONTH) (YEAR), revealed the following considerations to the following question: Describe how you arrived at the determination of sufficiency indicated in the sufficiency analysis for Overall Staffing, Staff Competencies, and Services Provided? The facility indicated the following considerations: 1. Staffing and scheduling systems: (Name of facility) operates 12-hour nursing shifts for RN (Registered Nurse)/LPN (Licensed Practical Nurse), CMA (Certified Medication Aide), and CNA (Certified Nursing Assistant) staff 24/7 (24 hours a day/7 days a week). We have 10-hour RNA (Restorative Nursing Aide) staffing .The schedules are prepared and posted to the staff on the 15th day of every month reflecting a 30-day period. 2. Staff training and competency program: (Name of facility) conducts a 2-day new hire orientation which covers an introduction to all facility related systems. Each new hire received 1 on 1 training in their respective departments for their job descriptions for a minimum of 3-days . In response to the above question, the facility indicated what system they were utilizing, which did not describe how the facility determined the overall staffing level. B. Record review of the Facility's assessment dated ,[DATE] revealed the following: under Section II. Staffing, Training, Services, & Personnel - A. Function, Mobility, & Physical Disabilities - Sufficiency Analysis Categories - Activities of Daily Living (ADL), which includes: Bed Mobility, Transfer, Toilet Use, Eating, Bathing, Dressing and Hygiene/Grooming)- indicated Overall Staffing: Insufficient - Staff Competencies: Sufficient - Services: Sufficient and Action/Plan in Place - No; and Mobility, which includes: Ambulation, In Chair All or Most of Time and With Contractures (a condition of shortening and hardening of muscles, tendons or other tissue) - indicated Overall Staffing: Insufficient - Staff Competencies: Sufficient. Further review of the Facility's Assessment it does not describe how the facility arrived at the determinations of sufficiency indicated in the sufficiency analysis for the Overall Staffing, Staff Competencies, and Services Provided. C. On 03/29/18 at 3:00 pm, during interview, the Administrator stated that when they are short staffed We do and we don't admit residents. They have put a hold on admissions due to staffing .if a resident is discharged we fill those beds of course .we don't admit otherwise unless we have enough agency staff to cover a new admission .we make sure the agency will be able to staff our facility to cover a 7-day period .we have to look that far out . D. Record review of the facility's CMS 672 Resident Census and Conditions of Residents dated 03/29/18, indicated the following for the 92 total residents residing in the facility: 1. Bathing - indicated 54 residents need assist of one or two staff, 38 residents are dependent (on staff); 2. Dressing - indicated 88 residents need assist of one or two staff (members), 2 residents are dependent (on staff); 3. Transferring - indicated 87 residents need assist of one or two staff (members), 3 residents are dependent (on staff); 4. Toilet Use - indicated 85 residents need assist of one or two staff (members), 6 residents are dependent (on staff); 5. Eating - indicated 9 residents need assist of one or two staff (members), and 5 residents are dependent (on staff) . 6. Incontinence- 52 residents are indicated as 'Occasionally or frequently incontinent of bladder,' and 42 residents are indicated as 'Occasionally or frequently incontinent of bowel'

This is a repeat deficiency from a recertification survey completed on [DATE]. Based on record review, interview and observation, the facility failed to provide care and services to residents that meet professional standards of care to assist residents in reaching their highest well being for 11 residents (R #39, 53, 60, 82, 93, 192, 244, 245, 247, 249 and 343) of 12 (R #39, 53, 60, 82, 93, 192, 244, 245, 246, 247, 249 and 343) looked at for quality of care. This deficient practice has the potential . 1. The facility failed to obtain a needed dermatologist consult for a resident with a [MEDICAL CONDITION] suspicious [MEDICAL CONDITION], first identified 7 months previously for R #39. 2. The facility failed to follow through with a physician order [REDACTED]. 3. The facility failed to provide timely and adequate initial and ongoing assessment and supervision for residents. 4. The facility caused harm to residents by not ensuring adequate assessment and implementation of interventions to meet resident's care needs were completed and acted upon in a timely manner as is expected when providing professional care. The findings are: Findings related to R #245: A. Record review of R #245's Discharge Summary dated [DATE] from an acute care hospital revealed the following: (Name of R #245) is a [AGE] year-old gentleman with past medical history significant for [MEDICAL CONDITION] and other comorbid conditions admitted for [MEDICAL TREATMENT] [MEDICATION NAME] syndrome (DDS) (symptoms include nausea, headache, vomiting and restlessness, more serious symptoms can result in [MEDICAL CONDITION] and coma. which could be attributed to cerebral [MEDICAL CONDITION] (swelling in the brain) during or following shortly after [MEDICAL TREATMENT] (a medical procedure to remove fluid and waste products from the blood, when the kidneys do not work properly)). The patient was not able to tolerate [MEDICAL TREATMENT] secondary to [MEDICAL CONDITION] (low blood pressure) related from poor oral intake and was also found to have possible [MEDICAL CONDITIONS] (in which there is a slow, progressive obstruction of airflow into or out of the lungs), significant dysphasia (difficulty speaking) that was hard to manage and patient was made npo (nothing by mouth) for liquids. He was cleared for nectar thick liquids (a thickened liquid to help prevent choking and stop fluid from entering the lungs) but his dysphasia still persisted to some degree. At this point since the patient is able to tolerate [MEDICAL TREATMENT] and oral intake he was more stable and discharged to rehab . B. Record review of the admitting orders from the acute care hospital dated [DATE], included: Oxygen at 5 L (liters), Renal diet, Pureed texture, Nectar consistency, Therapy: PT (Physical Therapy), OT (Occupational Therapy) and ST (Speech Therapy) evaluate and treat if indicated, Weekly skin assessments by a Licensed nurse every Sunday on Day shift and Braden scale (used to predict pressure sore risk) weekly times 4 weeks, one time a day every Thursday. C. On [DATE] at 2:45 pm, during interview, the DON (Director of Nurses) confirmed that there should have been an admission note in the nurses notes for R #245. She stated that she expects the nurses to chart as soon as they can on an admission, but that the nurses do have 24 hours to complete the admission paperwork. She stated that her expectations of what the nurses should chart in the admission note would include when the patient/resident arrived at the facility, if patient/resident were stable or not, if the patient/resident was comfortable or not, document some sort of an assessment, document something about their skin and falls and that the admitting orders were verified by the physician. She stated that there was no process in place to orient agency nursing staff to the floors. She stated, I believe that (Name of RN (Registered Nurse) #2) took report on R #245, but was not made aware when R #245 was physically here in the room. D. On [DATE] at 1:40 pm, during interview, the daughter of R #245 stated that on Thursday (MONTH) 1st (2018), at around 2:30 pm that afternoon, they being her grandmother and uncle were waiting for her dad (R #245) to be transferred to the nursing facility. She said that her dad was in good spirits that day, as he had been in the hospital for a long time, he was joking and making faces at her. She said that it was about 3:00 pm when they arrived at the nursing home, we were unloading R #245's belongings. (The Visitor's Sign-In Sheet indicates that family signed in at 3:15 pm.) She said that there was a random nurse, in black scrubs, that told the family that his nurse will be in the room shortly. She said that there was a nurse, in blue scrubs, who brought in a pitcher of water into the room, and she told the nurse that her dad needed a thickener to be put into the water or else he could choke on the water. She said that she even had a packet of thicker that the nurse from the hospital had given her, which she offered to the staff member but that the staff member didn't take it. She said that her dad had said that he wasn't thirsty at that time. She said that she had set up her dad's room for him and left the nursing facility around 6:30 pm or 6:45 pm that evening. She said that she called her dad at around 7:30 pm that night and told him good night and that she loved him. She stated that around 10:30 pm that night, that she got the call that her dad was dead. She stated that on her dad's Death Certificate indicated that the time of her dad's death was at 9:46 am in the morning, and that she was confused about that. When she was asked if she remembers if her dad had received a dinner tray that evening? She stated that he did not and that the last time that he had eaten was at the hospital. E. On [DATE] at 3:45 pm, during interview, RN #2 (agency nurse, who was working the day shift on [DATE]) stated, No one told me he (name of R #245) was here. She said that there were 23 patients on the Skilled Nursing Unit, she was the only nurse on for the day and that it was real busy that day. She stated that the hospital nurse had called her at 1:15 pm to give her report on R #245, but that she didn't take report because she wanted to review the hospital records that she had on R #245. She said that she called the hospital nurse back, and left her a message to call her on her cell phone, but that the hospital nurse never called her back to give her report on R #245. She said, I guess the hospital still sent the patient, even though I never got report. RN #2 said that she was still in the facility around 8:30 pm that night finishing up her paperwork (her shift ended at 6:30 pm), she said my gut told me that he was there - he was vomiting, diaphoretic (sweating heavily) and was a diabetic. She said that I know that my documentation sucked that day, and said, that was the worst day of my nursing career. F. On [DATE] at 11:20 am, during interview, RN #2 stated that on that Thursday of (MONTH) 1st, that it was her second day of working in the facility as an agency nurse. She stated that she remembered that as the day was going on, she was asking the DON for help. The Administration sent another nurse, but that this other nurse did not have computer access, so the nurse did the CBGs (capillary blood glucose levels, the level of the number is needed before a patient can receive their insulin (injection medication needed to treat high blood sugars)) on the patients that needed them. RN #2 stated that she was aware that there were three pending admissions that day, but that she could not do the admission paperwork, as she had not been trained to do that. RN #2 stated that she remembered asking the DON specifically, if she could admit the incoming patients. She said, there was no way that I could have handled all that was going on in the unit. She stated that when the next shift came on at six, they did walking rounds as I didn't know who had arrived yet from the hospital. G. On [DATE] at 2:15 pm, during interview, Licensed Practical Nurse (LPN) #2 (staff nurse who worked the evening shift) stated that on Thursday (MONTH) 1st (2018), remembered that night there were back-to-back codes. She said that she was orienting another nurse that night and said that she was not aware that there was a patient in room [ROOM NUMBER]. She said that she did not get report on anybody in that room. She said, I remembered going down the hall and hearing a noise and thought, who is this patient. She said, I asked him if he was OK, and if he was a diabetic. I told him that I will be right back. I went back to the nurses station and called the doctor. I just didn't know who he was (meaning R #245). She said that the DON was trying to bring up his name (R #245) up in the computer and his name wasn't in there. LPN #2 stated that the next morning to told the DON and ADON that this event should not have happened. She said they brought him in and he was just left there, nobody was told. She said that RN #2 (the day nurse from the day before) who was an agency nurse, was very overwhelmed that day. She stated, That night bothered me a lot and that I had thought about calling the State (Licensing Authority). LPN #2 stated that during the codes that night, there was a key that was missing for the oxygen tank located on the emergency cart, and that the CNA's were not trained in CPR and were not helping the nurses. She said, Things should not go that way. When she was asked if she can chart in PCC (Point Click Care) She said that she has never been trained, and that she has had a hard time charting. She said that I want to tell the Administration that I'll even come in on my own time to learn the computer and said, I'm just real uncomfortable with charting in the nursing facility. I don't even know how to put orders into the computer. H. On [DATE] at 2:55 pm, during interview, the mother of R #245 stated that at 2:00 pm on [DATE], we were waiting for (name of R #245) to be transferred to the nursing home. She said that her and her other son thought that R #245 was fine and so they left the nursing home at about 5:30 that evening and that the facility was going to bring R #245 his dinner tray. She said that it was a shock when the facility called her to tell her that R #245 had died . She said we knew he was very sick while he was in the hospital, but that we were confident that he was going to be OK. She stated that her granddaughter was alarmed when the staff member brought in a water pitcher, when we knew he needed that thickener put into the water before he drank it. I. On [DATE] at 1:30 pm, during interview, NP (Nurse Practitioner) #2 when asked if she saw R #245 on Thursday (MONTH) 1st, stated that what she remembered of that day was that a patient had arrived from the hospital and was in the building. She said that usually she is just given a piece of paper that has orders from the hospital and that she approves the orders, without seeing the patient. She stated that after (MONTH) 1st, she requested not to go back to this nursing home, because it was not safe. She said that there were back-to-back codes and that it was a traumatic day. Findings related to R #39: J. Record review of physician's orders [REDACTED]. 1. An order dated [DATE] indicated, Please arrange dermatology appt (appointment) ASAP (as soon as possible) for neck lesion - suspicious for [MEDICAL CONDITION]. 2. An order dated [DATE] indicated, Dermatology evaluation for neck growth. 3. An order dated [DATE] indicated, General surgery - lesion removal on neck - been growing since (September (YEAR)). Awaiting c/b (call back) from (local medical center.) 4. An order dated [DATE] indicated, Growth to left neck monitor drainage or change in appearance notify MD (physician) for any changes daily. 5. An order dated [DATE] indicated, Wound care: left neck wound: Cleanse with normal saline bullet or wound cleanser, apply skin protectant to peri wound (area around the wound) skin, apply two layers of (gauze and ointment product) to wound beds, cover with 4x4s (gauze squares) secure with rolled gauze and tape. (Dressing) changes every MWF (Monday, Wednesday and Friday) and PRN (as needed). K. Record review of NP progress notes for R #39 revealed that assessments of the lesion size were not sufficient to track the growth of the lesion over time: 1. Note dated [DATE], did not mention a lesion on the resident's neck. 2. Note dated [DATE], indicated that the resident had a neck lesion measuring 5 cm (centimeters) by 0.25 cm in size. 3. Note dated [DATE], indicated that the resident had a neck lesion measuring 6 mm (millimeters) round. 4. Progress notes dated [DATE] through [DATE], indicated that the lesion was large grape-sized. L. Record review of nurses' notes dated [DATE], indicated, Nurse spoke w/ (with) Transportation dept. (department) about making resident's Derm. appt (Dermatology appointment). Transportation states that only a select few of the dermatologists around, accept this resident's insurance (R #39). The one they did get a hold of, stated to call back on [DATE], and see if they could get her in as a new patient. M. On [DATE] at 12:29 pm, during observation of a dressing change by RN #11, R #39's neck lesion was viewed. It was noted to be approximately 2.5 cm by 4 cm in size, and to protrude from the surrounding skin by approximately 1.5 cm. It had a moist, pink appearance, and dried matter around the lesion indicated some drainage. The resident reported pain when the old dressing was removed or the lesion was touched. N. On [DATE] at 2:50 pm, during interview, NP #1 stated that about 5 (staff) people have been trying to make (consultation) appointments (for R #39), because they (the staff) keep leaving. She indicated that, due to months of failed attempts to secure a dermatology appointment, she decided to bypass dermatology and have the lesion removed by General Surgery. So far, however, no General Surgery appointment had been successfully made. O. On [DATE] at 9:50 am, during interview, the Case Manager/Transportation Staff stated that she had been attempting to make a General Surgery appointment for R #39 for 4 weeks, but that she had not yet secured an appointment. She stated that the original paperwork had been misplaced, so she faxed it to the General Surgery office a second time that week. P. On [DATE] at 12:29 pm, during interview, the DON confirmed that the original dermatology consult order was not successfully acted on. She had reviewed R #39's progress notes and found the note dated [DATE] indicating that the facility should call the dermatology office on [DATE] to secure an appointment. She had not found any progress notes between [DATE] and [DATE], indicating that attempts to secure the appointment had been made. R. On [DATE] at 3:50 pm, during interview, the DON stated that she was unable to find additional documentation of the size of lesion over time. She stated that the facility had no documentation to indicate whether the lesion was growing. Q. On [DATE] at 2:00 pm, during interview, NP #1 indicated that she didn't feel that R #39's lesion had grown considerably since she first saw it in (MONTH) (YEAR). She stated that it was originally scabbed, but that the scab came off and the lesion was bleeding and oozing. The amount of protrusion from the surrounding skin would appear to fluctuate. She indicated that she couldn't be sure of the type [MEDICAL CONDITION] without a biopsy, but that she did not feel that it was melanoma (a serious form of [MEDICAL CONDITION]). It was more likely a [DIAGNOSES REDACTED] or a squamous cell lesion (types of [MEDICAL CONDITION]), which could be invasive (spread to other tissues). She stated, they don't usually bleed if they're benign (non-cancerous), but that the resident's lymph nodes (small glands all around your body that are part of your immune system) were not inflamed (which might indicate progression of [MEDICAL CONDITION]). She stated that the proximity of the lesion to major blood vessels in the neck made her unwilling to deal with it here. She stated, I could probably have done a punch biopsy (a means of obtaining a specimen) if I'd had the tools, but I don't know who we'd even send it to for cytology (laboratory analysis of tumor cell type.) She indicated that she had considered sending the resident to an emergency room just to get it looked at and get her into the (health care) system, but that the resident's daughter had declined that option. Findings related to R #192: R. Record review of Complaint Intake found that a complainant described as a family member had reported that, prior to his discharge to a local hospital on [DATE], the family had overheard a nurse and medication aide discussing R #192, and stating that he had not received his oral [MEDICAL CONDITION] (a type of treatment that includes a medication or combination of medications to [MEDICAL CONDITION]) (chemo) medication for over a month. S. Record review of a hospital Emergency Department (ED) note for R #192, dated [DATE], found a statement indicating (R #192) is a 66 y.o. (year old) male with a history of metastatic [DIAGNOSES REDACTED] (cancer of the blood and bone marrow) and prostate (a gland surrounding the neck of the bladder in males) cancer. Last chemo treatment yesterday Presents to the ED with worsening of his chronic right hip pain. Complains of decreased appetite secondary to pain. A physical examination section stated Neurological: He is alert and oriented to person, place and time. An Assessment and Plan section stated Pt (patient) presents for evaluation of intractable (unrelieved) right hip pain in setting of known bony mets (metastases) from [DIAGNOSES REDACTED] to the same area. He states that because of the worsening pain he does not have an appetite and has not been taking PO (food and fluids by mouth) very well over the last week. It does appear that he is currently on a cycle of oral chemo. T. Record review of a hospital Admission History and Physical document for R #192, dated [DATE], indicated, Admit for supportive care, hydration, pain control will include the use of IV (intravenous) narcotics . see if this will improve his status with pain. (MONTH) need to consider palliative care (specialized medical care for people with serious illness) consult. MM ([DIAGNOSES REDACTED]) advanced, consider ONC (oncology) to see too; [DATE] office note reviewed. Anorexia - hopefully will improve with pain control and hydration, consider nutritional consult. U. Record review of the facility's medical record for R #192 found that he was noted to have a code status of full code, and [DIAGNOSES REDACTED]. Census information indicated that he was originally admitted to the facility on [DATE], on hospital leave beginning [DATE], and with a notation to stop billing on [DATE]. V. Record review of a Nurse Practitioner Progress Note for R #192, dated [DATE], indicated Patient seen today for follow-up after starting [MEDICAL CONDITION] for his [DIAGNOSES REDACTED]. History of Present Illness: [AGE] year-old male, admitted [DATE] from (previous long-term care facility). Patient initially admitted to previous facility for chronic severe pain due to [DIAGNOSES REDACTED] with metastasis to his lower back. He was unable to ambulate well or perform his own ADLs (Activities of Daily Living, such as hygiene, dressing and eating.) He was placed on high-dose opiates (narcotic pain medications) to help with his pain control which did have some efficacy (positive effect) and patient was able to have enhanced mobility and underwent physical therapy. Patient now undergoing [MEDICAL CONDITION] with Revlimid ([MEDICAL CONDITION] medication) for his [DIAGNOSES REDACTED]. He is being followed by (name of hospital oncologist) at (name of [MEDICAL CONDITION] center). Patient states his pain has been will controlled on the current regimen. His only complaint is he is experiencing generalized anasarca (widespread swelling of the skin) as a side effect. (Name of hospital oncologist) did order and place him on [MEDICATION NAME] (a medication to reduce fluid overload) 20 mg (milligrams) daily. He has no complaints of shortness of breath, chest pain, fever, chills, weakness, malaise, unusual fatigue or bleeding. A medication list in the note includes Revlimid 25 mg 21 days on and 7 days off per schedule. W. Record review of a Nurse Practitioner Progress Note for R #192, dated [DATE], found that Revlimid 25 mg (milligrams) p.o. (by mouth) per schedule remained in the medication list. X. Record review of a hospital oncology appointment After Visit Summary document for R #192, dated [DATE], found a section stating Complete list of medications you should be taking, which included lenalidomide (Revlimid) 25 mg capsule. 25 mg PO (by mouth) start on Day 1 of each new [MEDICAL CONDITION] cycle for 21 consecutive days (3 weeks on, one week off). Y. Record review of an Order Summary Report for R #192, dated [DATE] and signed by the Medical Director on [DATE] as a monthly review / renewal of orders, found that Revlimid capsule 25 mg (lenalidomide.) Give 25 mg by mouth one time a day 21 days on and 7 days off [MEDICAL CONDITION]. Use gloves when handling medication - swallow whole. Ordered by (name of hospital oncologist) remained among active orders. Z. Record review of physician's orders [REDACTED]. The dosing schedule on the order indicated the 21-days-on, 7-days-off dosing scheme. AA. Record review of completed Medication Administration Records (MARs) for R #192 found that he missed 51 scheduled doses of Revlimid between (MONTH) (YEAR) and (MONTH) (YEAR). Documentation indicated that: 1. (MONTH) (YEAR), he did not receive Revlimid on 6 of 21 scheduled days. 2. (MONTH) (YEAR), he did not receive Revlimid on 5 of 21 scheduled days. 3. (MONTH) (YEAR), he did not receive Revlimid on 4 of 22 scheduled days. 4. (MONTH) (YEAR), he did not receive Revlimid on 8 of 24 scheduled days. 5. (MONTH) (YEAR), he did not receive Revlimid on 2 of 23 scheduled days. 6. (MONTH) (YEAR), he did not receive Revlimid on 2 of 24 scheduled days. 7. (MONTH) (YEAR), he did not receive Revlimid on 4 of 24 scheduled days. 8. (MONTH) (YEAR), he did not receive Revlimid on 20 of 21 scheduled days. 9. a key to administration codes indicated that Medication not available / ordered from pharmacy and Other / See Nurse Notes were the primary reasons given on the non-administration days. BB. Record review of administration notes related to R #192's Revlimid dosing found that notes were not written on a majority of the days. For the days on which an explanation of the non-administration was given: 1. On [DATE], Didn't receive from Px (pharmacy) was noted. 2. On [DATE], Still waiting for arrival from Px was noted. 3. On [DATE], Medication (med) not available was noted. 4. On [DATE], Still waiting on arrival from Px was noted. 5. On [DATE], PHARMACIST STATED THAT THEY NEED NEW RX (prescription) AND FAMILY NEEDS TO PROVIDE THE MEDICATION was noted. 6. On [DATE], On order was noted. 7. On [DATE], Med not in stock; pt (patient) not taking currently was noted. 8. On [DATE], Medication not available order states the patient should be on medication one time a day 21 days on and 7 days off [MEDICAL CONDITION]. It was started on ,[DATE], needs verification was noted. 9. On [DATE], Medication has not been available to give notified nurse (name) on [DATE] also again today needs to be ordered from other pharmacy was noted. 10. On [DATE], Patient off of this medication for 7 days 1 of 7 (unclear) was noted. 11. On [DATE], Medication is not available will call pharmacy and notified nurse was noted. 12. On [DATE], Medication unavailable, called pharmacy to order medication, they said they need a hard script from the doctor so they can send the referral to the specialty pharmacy, notified charge nurse (name) was noted. 13. On [DATE], Called and was told by rep (representative) that answered, that the request is with the MA (medical assistant) and the DR (physician), to be filled. Rep stated that we would receive a call when it was filled and ready to be picked up at whichever facility. Staff will contact the specific pharmacy and see if it can be delivered was noted. CC. Record review of R #192's physician's progress notes indicated last physician's note was dated [DATE], and indicated that the resident was continuing with his 21-day-on, 7-day-off dosing of Revlimid. No notation of gaps in the delivery of the drug were found. DD. Record review of R #192's physician's orders [REDACTED]. of hospital oncologist). EE. On [DATE] at 10:50 am, during interview with the DON confirmed that R #192 did not receive his [MEDICAL CONDITION] drug at all during February. She had not been the DON at the facility prior to that month, and had no direct knowledge of any lapses prior to February. She stated that there was some confusion about how the medication was to be supplied. She confirmed that [MEDICAL CONDITION] agents work by [MEDICAL CONDITION] cells in order to reduce the size of the tumor or slow its growth. She confirmed that failure to receive the medication could result in [MEDICAL CONDITION] cells continuing to multiply, or failing to reduce in number. She confirmed that R #192 did decline in late February, and was sent out to a hospital, where he died . FF. On [DATE] at 11:30 am, during interview with the DON stated that she had reviewed the MARs for R #192 during the previous months when he had been at the facility, and agreed that the documentation indicated that he had not received [MEDICAL CONDITION] on all 51 of the dates identified. She confirmed that the [MEDICAL CONDITION] was a crucial part of the plan of care for residents [MEDICAL CONDITION], and that failure to deliver the medication as ordered represented a medication error and a significant lapse in care. She stated that she had spoken with the facility's Medical Director about the resident's [MEDICAL CONDITION], but that it could not be determined whether failure to get his Revlimid had contributed to R #192's decline and death. GG. On [DATE] at 11:50 am, during telephone interview with the Hospital Oncologist, who was R #192's primary Oncologist, he indicated that he had not been aware that R #192 was not receiving his Revlimid as ordered. He stated that the facility was not sending the usual recap of medications taken with R #192 when he had his appointments, so that he (the oncologist) could not be sure what he was taking. The oncologist stated that it is impossible to know if failure to receive his Revlimid had contributed to R #192's decline and death, but that it is possible. HH. On [DATE] at 3:33 pm, during interview with former facility Nurse Practitioner #2, she indicated that she had overseen R #192's care at the facility from (MONTH) (YEAR) until his discharge in (MONTH) (YEAR). She stated that she was never advised by the facility that he hadn't been receiving his ordered Revlimid. The only indication that she had that there was a problem with the Revlimid was in late February, when the facility had called her to ask that she write a new prescription for it. She had been unable to do so, as [MEDICAL CONDITION] is a specialty drug which must be ordered by an oncologist. She stated that, even then, she wasn't told that he hadn't received it for a month at that point. II. On [DATE] at 4:30 pm, during interview with the Director of Clinical Quality Management, she indicated that the problem with R #192's [MEDICAL CONDITION] is that it was not supplied by the facility's usual pharmacy. She did not provide an explanation of why the doctors and nurse practitioners responsible for R #192's care were never notified of the interruptions in his [MEDICAL CONDITION] dosing. Findings for R #53: JJ. Record review of R #53's (MONTH) (YEAR) MAR found that it indicated that he had missed ordered doses of [MEDICATION NAME] (an antipsychotic medication) on three occasions on [DATE], [DATE] and [DATE]. Findings for R #60: KK. Record review of R #60's (MONTH) (YEAR) MAR found that it indicated that she had not received ordered doses of [MEDICATION NAME] (an antifungal powder) on three occasions, on [DATE], 2 doses and [DATE]. Findings for R #82: LL. Record review of R #82's (MONTH) (YEAR) MAR found that it indicated that he had not received ordered doses of [MEDICATION NAME] (a drug to combat muscle spasms) on two occasions, on [DATE] and [DATE] MM. On [DATE] at 10:10 am, during interview, the DON confirmed that R #'s 53, 60 and 82 had not received their doses of medication on the identified dates. She indicated that the rationale for the missed doses was sometimes absent, but that some indicated that the medication had run out. She could find no indication that the appropriate physician or nurse practitioner had been notified of the missed doses. She also stated that she had been unaware of R #192's missed [MEDICAL CONDITION] doses until right before he left. Findings related to R #93: NN. Record review of the admission record indicated that R #93 was admitted on [DATE]. She was admitted with pressure ulcers of the sacral region stage 4 (a very deep ulcer, reaching into muscle and bone) and pressure ulcer of left hip unstageable (an ulcer that has a covering of dead tissue), muscle weakness, lack of coordination, [MEDICAL CONDITION] (a paralysis that results in the partial or total loss of all four limbs), contracture (a condition of shortening and hardening of muscles, tendons, or other tissue) of the right hand and other acute osteo[DIAGNOSES REDACTED] (infection of the bone) of right femur (thigh bone). OO. Record review of the History and Physical (H & P) dated [DATE] indicated that Patient with suprapubic cath (a tube inserted in the abdomen, above the bladder that drains urine), she states over the last couple of days she has had some bladder spasms, nausea, and felt feverish; which she states occurs when she has an infection. The H & P also indicated in the Plan Section: Dysuria (difficulty urinating): Patient with chronic catheter, having symptoms suggestive UTI (Urinary Tract Infection) will obtain UA (urinalysis) and C & S (culture and sensitivity); . PP. Record review of the physician's orders [REDACTED]. QQ. Record review of the lab section in the medical chart indicated that there was no lab work for a UA and C & S on or after [DATE]. RR. Record review of the physician's orders [REDACTED]. SS. On [DATE] at 12:14 pm, during interview, the DON stated that she did not see a physician order [REDACTED]. The DON did see that an order written [REDACTED]. The DON stated that it must not have ever been entered into the system. She stated that usually a physician will write an order and the order is given to the nurse and the nurse will enter it into the system and if it is for a lab, the lab will be ordered and the lab slip will be put into the book. TT. Record review of the nursing progress notes indicated that on [DATE], R #93 was sent to ( (TRUNCATED)

Based on record review and interviews the facility failed to provide necessary discharge planning services for 1 (R #249) of 1 (R #249) resident reviewed for discharge planning. This deficient practice resulted in the resident being discharged prematurely and requiring readmission to the facility to restart another round of antibiotic therapy via a PICC (peripherally inserted central catheter a form of intravenous access that can be used for a prolonged period of time) line to ensure a successful round of antibiotic use. The findings are: A. Record review of R #249's, New Admission Meeting Form dated 12/28/17, revealed, the resident was admitted from a local acute rehabilitation hospital to the facility on [DATE] with a [DIAGNOSES REDACTED]. He was receiving Intravenous (IV) (in a vein) antibiotic therapy through a PICC that was placed on 12/15/17 for that purpose. The IV antibiotic therapy orders were being managed by a local acute care hospital's outpatient [MEDICATION NAME] antimicrobial therapy (OPAT) clinic. In the attached paperwork there is a report from the OPAT Nurse Practitioner, (Nurse Practitioner #3) that stated, EOT (end of treatment) 1/26 (2018) however pt (patient) will need head CT (computerized tomography, a type of radiological imaging procedure) prior to stopping abx (antibiotics). B. Record review of R #249's, Discharge Instructions For Care with a social service discharge summary dated 01/26/18 and signed by the Social Services Assistant stated, Resident will d/c (discharge) on 1/27/18. Will go home alone. No DME (Durable Medical Equipment such as a wheelchair) needed. No HHC (Home Health Care) needed. No other documentation was found in the residents medical record regarding the plan for discharge from the facility. C. On 04/09/18 at 10:15 am, during an interview, with the Medical Director, she reported, saw that his antibiotic was completed and took the PICC out and discharged him .not knowing the OPAT clinic had sent an order. D. Record review of R #249's orders revealed that on 01/25/18 a verbal order was given by the Medical Director and confirmed by the Social Services Manager, D/C home with meds (medications) on 1/27/18. E. Record review of complaint allegations from Nurse Practitioner #3 dated as faxed 02/05/18 revealed, I .faxed orders to (the facility on 01/24/18) not to discharge the pt (patient) .Pt came to clinic on 1/30 (2018) .& told me the (facility) DC (discharged ) him on Sat (01/27/18) case manager called (the facility) and spoke with the assistant DON (Assistant Director of Nursing (ADON)) .who found the order that I faxed on 1/24 (2018). F. On 03/29/18 at 9:45 am, during an interview, with the Social Services Manager and Social Services Assistant they could not find any documentation related to the discharge planning on R #249. G. On 03/29/18 at 12:00 pm, during an interview with the Administrator she stated, the Social services Manager had not been, involved (in the discharge planning for R #249) the Assistant Director of Nursing, (ADON) talked to the resident and the resident had insisted on leaving the facility . no documentation (of that discussion). The Administrator was asked to have the ADON write up what discharge planning had occurred. The ADON note indicated, On 02/05/18, I was caring for (Name of resident) and was speaking with him about his previous discharge. Patient stated, Lord works in mysterious ways because I needed to get my apartment cleaned out so it was okay. Stated that he took an extra couple of days before going in (to (OPAT) Clinic) due to him having to take care of this. H. On 03/30/18 at 12:10 pm, during a phone interview, with R #249 he stated, for whatever reason they sent me out early .it wasn't my idea. I. On 04/06/18 at 7:55 am, during an interview, with Nurse Practitioner #3 she stated that, R #249 still had a brain abscess and had to be readmitted for continued IV antibiotics, first went to (name of a local acute care hospital) and then back to (name of the facility) . another PICC was placed. R #249 was discharged home with meds on 01/27/18. He was readmitted to the facility on [DATE].

This is a repeat deficiency from a complaint survey completed on [DATE]. The facility failed to ensure that the residents' medical records reflected the resident's medical status when any positive or negative condition change occurs and the services that were provided thus to ensure that the information would be available to facilitate communication among the professional team members. This deficient practice resulted in an Immediate Jeopardy (IJ) at a scope and severity of J being identified on [DATE]. The facility was notified on [DATE] at 11:35 am. The facility took corrective action by providing an acceptable Plan of Removal on [DATE] at 5:42 pm. This resulted in the scope and severity being reduced from level K to level G. Based on the Plan of Removal, interventions included: 1. Licensed Nurses will be oriented by the DON (Director of Nursing)/Designee on how to document in PCC (Point Click Care, software used to document) and assessments that should be completed prior to end of shift. 2. The DON/Designee will validate their training by providing a quiz at the completion of their orientation. DON/Designee will contact nurses every shift to validate completion of documentation prior to end of shift. A log will be kept for ongoing monitoring. 3. Any areas found to be out of compliance will be corrected immediately. Results of logs will be brought to the monthly QAPI (Quality Assurance and Performance Improvement) meeting for review and recommendations. Based on record review and interview, the facility failed to ensure that medical records were complete, and accurate ensuring that the information would be available to facilitate communication among the physicians and other team members for 13 (R #44, 53, 60, 64, 66, 70, 82, 192, 244, 245, 249, 292 and 347) of 13 (R #'s 44, 53, 60, 64, 66, 70, 82, 192, 244, 245, 249, 292 and 347) residents' whose medical records were reviewed. This deficient practice negatively impacted the treatment of [REDACTED]. The findings are: Findings related to R #192: A. Record review of a hospital Emergency Department (ED) note for R #192, dated [DATE], found a statement indicating (R #192) is a 66 y.o. (year old) male with a history of metastatic [DIAGNOSES REDACTED] (cancer of the blood and bone marrow) and [MEDICAL CONDITION]. Last chemo ([MEDICAL CONDITION]-treatment that includes a medication or combination of medications to [MEDICAL CONDITION]) treatment yesterday Presents to the ED with worsening of his chronic right hip pain. Complains of decreased appetite secondary to pain. A physical examination section stated Neurological: He is alert and oriented to person, place and time. An Assessment and Plan section stated Pt (patient) presents for evaluation of intractable (unrelieved) right hip pain in setting of known bony mets (metastases) from [DIAGNOSES REDACTED] to the same area. He states that because of the worsening pain he does not have an appetite and has not been taking PO (food and fluids by mouth) very well over the last week. It does appear that he is currently on a cycle of oral chemo. B. Record review of a Nurse Practitioner Progress Note for R #192, dated [DATE], found that Revlimid ([MEDICAL CONDITION] medication) 25 mg (milligrams) p.o. (by mouth) per schedule remained in the medication list. C. Record review of an Order Summary Report for R #192, dated [DATE] and signed by the Medical Director on [DATE] as a monthly review/renewal of orders, found that Revlimid capsule 25 mg (lenalidomide.) Give 25 mg by mouth one time a day 21 days on and 7 days off [MEDICAL CONDITION]. Use gloves when handling medication - swallow whole. Ordered by (name of hospital oncologist) remained among active orders. D. Record review of completed Medication Administration Records (MARs) for R #192 found that he missed 51 scheduled doses of Revlimid between (MONTH) (YEAR) and (MONTH) (YEAR). Documentation indicated that: 1. (MONTH) (YEAR), he did not receive Revlimid on 6 of 21 scheduled days. 2. (MONTH) (YEAR), he did not receive Revlimid on 5 of 21 scheduled days. 3. (MONTH) (YEAR), he did not receive Revlimid on 4 of 22 scheduled days. 4. (MONTH) (YEAR), he did not receive Revlimid on 8 of 24 scheduled days. 5. (MONTH) (YEAR), he did not receive Revlimid on 2 of 23 scheduled days. 6. (MONTH) (YEAR), he did not receive Revlimid on 2 of 24 scheduled days. 7. (MONTH) (YEAR), he did not receive Revlimid on 4 of 24 scheduled days. 8. (MONTH) (YEAR), he did not receive Revlimid on 20 of 21 scheduled days. 9. a key to administration codes indicated that Medication not available / ordered from pharmacy and Other / See Nurse Notes were the primary reasons given on the non-administration days. E. Record review of administration notes related to R #192's Revlimid dosing found that notes were not written on a majority of the days. For the days on which an explanation of the non-administration was given: 1. On [DATE], Didn't receive from Px (pharmacy) was noted. 2. On [DATE], Still waiting for arrival from Px was noted. 3. On [DATE], Medication not available was noted. 4. On [DATE], Still waiting on arrival from Px was noted. 5. On [DATE], PHARMACIST STATED THAT THEY NEED NEW RX (prescription) AND FAMILY NEEDS TO PROVIDE THE MEDICATION was noted. 6. On [DATE], On order was noted. 7. On [DATE], Med not in stock; pt (patient) not taking currently was noted. 8. On [DATE], Medication not available order states the patient should be on medication one time a day 21 days on and 7 days off [MEDICAL CONDITION]. It was started on ,[DATE], needs verification was noted. 9. On [DATE], Medication has not been available to give notified nurse (name) on [DATE] also again today needs to be ordered from other pharmacy was noted. 10. On [DATE], Patient off of this medication for 7 days 1 of 7 (unclear) was noted. 11. On [DATE], Medication is not available will call pharmacy and notified nurse was noted. 12. On [DATE], Medication unavailable, called pharmacy to order medication, they said they need a hard script from the doctor so they can send the referral to the specialty pharmacy, notified charge nurse (name) was noted. 13. On [DATE], Called and was told by rep (representative) that answered, that the request is with the MA (medical assistant) and the DR (physician), to be filled. Rep stated that we would receive a call when it was filled and ready to be picked up at whichever facility. Staff will contact the specific pharmacy and see if it can be delivered was noted. F. Record review of R #192's physician's orders [REDACTED]. of hospital oncologist). G. On [DATE] at 9:15 am, during a telephone interview with a Hospital Social Worker, who was another complainant, she reiterated that R #192 was unkempt when arriving from the facility for his oncology appointments, often with soiled clothing and an odor of urine. She had not been made aware that there were lapses in the facility's delivery of the [MEDICAL CONDITION] agent, Revlimid, to the resident. H. On [DATE] at 10:50 am, during interview with the facility DON, she confirmed that R #192 did not receive his [MEDICAL CONDITION] drug at all during (MONTH) (2018). She had not been Director of Nursing at the facility prior to that month, and had no direct knowledge of any lapses prior to February. She stated that there was some confusion about how the medication was to be supplied. She confirmed that [MEDICAL CONDITION] agents work by [MEDICAL CONDITION] cells in order to reduce the size of the tumor or slow its growth. She confirmed that failure to receive the medication could result in [MEDICAL CONDITION] cells continuing to multiply, or failing to reduce in number. She confirmed that R #192 did decline in late February, and was sent out to a hospital, where he died . I. On [DATE] at 11:30 am, during interview with the facility DON, she stated that she had reviewed the MARs for R #192 during the previous months when he had been at the facility, and agreed that the documentation showed that he had not received [MEDICAL CONDITION] on all 51 of the dates identified. She confirmed that [MEDICAL CONDITION] was a crucial part of the plan of care for residents [MEDICAL CONDITION], and that failure to deliver the medication as ordered represented a medication error and a significant lapse in care. She stated that she had spoken with the facility's Medical Director about the resident's [MEDICAL CONDITION], but that it could not be determined whether failure to get his Revlimid had contributed to R #192's decline and death. J. On [DATE] at 11:50 am, during telephone interview with the Hospital Oncologist, who was R #192's primary Oncologist, he indicated that he had not been aware that R #192 was not receiving his Revlimid as ordered. He stated that the facility was not sending the usual recap of medications taken with R #192 when he had his appointments, so that he (the oncologist) could not be sure what he was taking. The oncologist stated that it is impossible to know if failure to receive his Revlimid had contributed to R #192's decline and death, but that it is possible. K. On [DATE] at 2:00 pm, during interview with the Hospital Social Worker, she indicated that she had discussed R #192's case with the Hospital Oncologist, and had confirmed that the oncology center had not been receiving medication lists from the facility when R #192 had his appointments, despite having requested them many times. She reiterated that no one at [MEDICAL CONDITION] center had not been aware that R #192 had not been receiving his Revlimid as ordered. L. On [DATE] at 2:40 pm, during interview with facility Nurse Practitioner #1, she stated that she oversaw R #192's care until (MONTH) (YEAR), when she temporarily relocated to another facility. She stated that the facility had never advised her about any missing Revlimid doses until (MONTH) (YEAR), shortly before she left. M. On [DATE] at 3:33 pm, during interview with former facility Nurse Practitioner #2, she indicated that she had overseen R #192's care at the facility from (MONTH) (YEAR) until his discharge in (MONTH) (YEAR). She stated that she was never advised by the facility that he hadn't been receiving his ordered Revlimid. The only indication that she had that there was a problem with the Revlimid was in late February, when the facility had called her to ask that she write a new prescription for it. She had been unable to do so, as [MEDICAL CONDITION] is a specialty drug which must be ordered by an oncologist. She stated that, even then, she wasn't told that he hadn't received it for a month at that point. N. On [DATE] at 4:30 pm, during interview with the Director of Clinical Quality Management, she indicated that the problem with R #192's [MEDICAL CONDITION] is that it was not supplied by the facility's usual pharmacy. She did not provide an explanation of why the doctors and nurse practitioners responsible for R #192's care were never notified of the interruptions in his [MEDICAL CONDITION] dosing. Findings related to R #53: O. Record review of R #53's (MONTH) (YEAR) MAR found hat it indicated that he had missed ordered doses of [MEDICATION NAME] (an antipsychotic medication) on three occasions, on [DATE], [DATE] and [DATE]. Findings related to R #60: P. Record review of R #60's (MONTH) (YEAR) MAR found that it indicated that she had not received ordered doses of [MEDICATION NAME] (an antifungal powder) on three occasions, on [DATE] (twice) and [DATE]. Findings related to R #82: Q. Record review of R #82's (MONTH) (YEAR) MAR found that it indicated that he had not received ordered doses of [MEDICATION NAME] (a drug to combat muscle spasms) on two occasions, on [DATE] and [DATE]. R. On [DATE] at 10:10 am, during interview with the DON, she confirmed that R #'s 53, 60 and 82 had not received their doses of medication on the identified dates. She indicated that the rationale for the missed doses was sometimes absent, but that some indicated that the medication had run out. She could find no indication that the appropriate physician or nurse practitioner had been notified of the missed doses. She also stated that she had been unaware of R #192's missed [MEDICAL CONDITION] doses until right before he left. Findings related to R #245: S. On [DATE] at 2:45 pm, during interview, the DON confirmed that there should have been an admission note in the nurses notes for R #245. She stated that she expects the nurses to chart as soon as they can on an admission, but that the nurses do have 24 hours to complete the admission paperwork. She stated that her expectations of what the nurses should chart in the admission note would include when the patient/resident arrived at the facility, if patient/resident were stable or not, if the patient/resident was comfortable or not, document some sort of an assessment, document something about their skin and falls and that the admitting orders were verified by the physician. She stated that there was no process in place to orient agency nursing staff to the floors. She stated, I believe that (Name of RN #2) took report on R #245, but was not made aware when R #245 was physically here in the room. Findings related to R #s 347, 44, 60, 64, 66 and 70: T. On [DATE] at 11:00 am, during an interview, Licensed Practical Nurse (LPN) #1 stated all the directives are in the MOST (New Mexico Medical Orders For Scope of Treatment), book here (he indicates at the nurses desk) if we need to know anything. U. Record Review of the MOST book noted that 3 residents out of the first 16 (18.75%) in the MOST book did not have completed MOST forms. V. On [DATE] the following was revealed on medical record review: 1. R #347, admitted to the facility on [DATE], no code status was found in the Electronic Health Record (EHR), no doctors orders regarding code status were found, no discussions of advanced directive education or planning were found to be documented in the nursing progress notes or on the (MOST) document. 2. R #44, admitted to the facility on [DATE], resident was designated, Full Code (this directed potential rescuers to do all indicated resuscitative measures if the resident's heart stops or breathing ceases). The MOST form was not signed by the resident. 3. For R #60, admitted to the facility on [DATE], resident was designated, DNR (this directed potential rescuers not to initiate life support measures if the residents heart stops or breathing ceases). The MOST form was dated [DATE] and had not been updated. 4. For R #64, admitted to the facility on [DATE], resident was designated, Full Code. The MOST form was dated [DATE] and had not been updated. 5. For R #66, admitted to the facility on [DATE], resident was designated, Full Code. The MOST form was not signed or dated, there was no documentation of any discussion of advanced directives found. 6. For R #70, admitted to the facility on [DATE], resident was designated, DNR. The MOST form was not signed or dated, there was no documentation of discussion of advanced directives found. W. On [DATE] at 3:45 pm, during interview, the DON reported, I cannot find any documentation that any of these have been updated (documentation for advanced directive planning for, R #s 44, 60, 64, 66, 70 and 347). Findings related to R #292: X. On [DATE] at 10:54 am, during an interview with the DON, she stated that R #292 was being treated for [REDACTED].) The DON verified that the nurses failed to complete any skin checks between [DATE] and [DATE]. The DON acknowledged that R #292's [MEDICAL CONDITION] did not turn into unstageable pressure ulcers overnight and that the resident most likely had pressure wounds prior to the first documentation of them on [DATE]. Y. On [DATE] at 10:58 am, during an interview with the Minimum Data Set (MDS) Coordinator, she stated that she was not employed by the facility at the time R #292 was a resident. She verified that R #292 did lose a significant amount of weight as of [DATE] and continued to lose weight. She stated that if R #292 had also developed a pressure ulcer at least 14 days prior to his discharge on [DATE], then a significant change MDS Assessment should have been completed. Z. Record review of R #292's Treatment Administration Record (TAR) dated (MONTH) (YEAR) and (MONTH) (YEAR) revealed: 1. R #292's skin check on [DATE] is marked as completed but no skin observation or notes were documented. 2. R #292's skin check on [DATE] had a notation that RN #9 was not able to complete the skin check and notified the night nurse. 3. R #292's skin checks on [DATE] and [DATE] are marked as completed but no skin observation forms were completed. 4. R #292's skin check on [DATE] had a notation that the nurse was not able to complete the skin check and notified the night nurse. AA. Record review of R #292's medical record revealed he did not have any skin checks or wound measurements from [DATE] to [DATE]. BB. On [DATE] at 10:07 am, during an interview with RN #10, stated that he used to work at the facility as an Assistant Director of Nursing from (MONTH) (YEAR) to (MONTH) (YEAR). He stated he never completed a skin check for R #292 despite signing off on the TAR that he had completed a skin check on [DATE]. He stated that either the Former DON or the Former Wound Care Nurse told him to sign off that the skin check had been completed that day ([DATE]) even though he did not do it himself. RN #10 stated that the management routinely made him complete documentation for things he had not done himself and was not sure anyone else had done either. RN #10 stated he quit after his 90-day orientation because he was scared that he would get some kind of negative action taken against his license if he kept documenting as he was. CC. On [DATE] at 9:45 am, during an interview with the DON, she stated that sometimes a task is created on the Activities of Daily Living (ADL) sheets regarding turning/repositioning residents every 2 hours for the CNA's to sign off. She stated that R #292 did not have that task listed on his ADL sheet. Findings related to R #244: DD. Record review of the physician's orders [REDACTED].#244 was on [MEDICATION NAME] (a blood thinning medication) starting on admit [DATE] to the day she left on [DATE]. EE. On [DATE] at 3:47 pm, during an interview with Nurse Practitioner (NP) #1, she stated that when she saw R #244 on [DATE], she was pale, had a lot of bruising on her and was short of breath and had a nose bleed early that morning. NP #1 stated that R #244's PT/INR had not been checked since [DATE], and she was on an antibiotic, which means that the PT/INR needed to be monitored more frequently. NP #1 also stated that when it was checked on [DATE] the INR was very high at 10. R #244 was sent out to the emergency room due to shortness of breath and a INR being in the supra therapeutic (means above the therapeutic level) range. NP #1 also stated that this R #244 passed away at the hospital a day or two later. FF. Record review of the Lab Results Report collected on [DATE] and reported on [DATE], indicated that R #244 had a BUN (blood urea nitrogen test, which is used to evaluate kidney function and diagnose disease) of 101 which is in the critically high range. The reference range is ,[DATE]. GG. On [DATE] at 4:06 pm during an interview with Nurse Practitioner #2, she stated that if you see a BUN significantly out of line with the Creatinine level that would make me want to order a Guaiac (blood stool testing). NP #2 also stated that getting results on critical labs or even non critical labs had been an issue at that facility. NP #2 also stated that she had never received the results of, or any information on R #244's Guaiac test. She also stated that normally when she monitored any residents PT and INR it would be done per week if the resident was on an antibiotic and once per week if the resident was not. She did not know that the PT/INR that she had ordered on [DATE] did not get done. HH. Record review of the physician's orders [REDACTED]. On [DATE] the physician ordered a Guaiac test one time a day for screening starting on [DATE]. II. Record review of the MAR (Medication Administration Record) indicated that the Guaiac test ordered on the [DATE] was not done. The MAR indicated [REDACTED]. The MAR for (MONTH) (YEAR) indicated: 1. [DATE] indicated that the test was not done. 2. [DATE] it is marked with a 13 indicating to see nurses note. 3. [DATE] indicated that the test was done-no results could be found. 4. [DATE] indicated that the test was done-no results could be found. 5. [DATE] was marked that R #244 was out of facility. JJ. On [DATE] at 10:35 am, during an interview with DON, she stated that the Guaiac test could be done here at the facility. This is not something that is sent out of the facility. She also stated that the results of the test would be found in the nursing notes. During a follow up interview with DON, she stated that for the Guaiac test ordered on [DATE] it was not done. On [DATE] she stated that the MAR indicated [REDACTED]. On ,[DATE] there was no stool to check, on ,[DATE] and ,[DATE] the DON stated that if it was done, she did not see where the results were documented in the nursing notes. She did not see any documentation of the physician being notified, or any other documentation of new orders. KK. Record review of R #249's Medication Administration Record [REDACTED]. LL. On [DATE] at 12:30 pm, during an interview, the DON stated that she could not confirm that the antibiotic doses were given.

This is a repeat deficiency from the survey conducted on 03/03/16. Based on observation, interview and record review, the facility failed to provide timely and effective pain relief for 1 resident (R #290) of 4 residents (R #18, 62, 129, and 290) reviewed for pain during a recertification and complaint survey. The resident reported significant pain and distress, and stated that he had been waiting nearly 2 hours for [MEDICATION NAME] (pain-relieving) medication since advising staff that he needed it. Unrelieved pain diminished the resident's quality-of-life, causing anger and frustration, and had the potential to result in depression, delayed healing, and an increased likelihood of pressure ulcers. The findings are: A. On 01/10/17 at 2:19 pm, during interview with R #290, he stated that he had pain in his femur (leg) and lower back. He stated that his pain was severe, and spoke at length about what he felt was a lack of responsiveness of his assigned nurse. He stated that he originally advised an unidentified CNA (Certified Nurse Aide) that he needed pain medication at 12:30, and that the CNA had told him that his nurse was on her lunch break and that he would have to wait until she returned. R #290 spoke of being very frustrated that his pain was routinely not taken seriously at the facility. Throughout the interview, the resident exhibited signs of pain, such as grimacing and changing position in bed numerous times in an effort to get comfortable. B. On 01/10/17 at 2:28 pm, LPN (Licensed Practical Nurse) #1 (R #290's assigned nurse) was observed bringing the resident [MEDICATION NAME] for his pain. She stated that she had only been informed of the resident's pain about 15 minutes earlier. C. On 01/10/17 at 2:36 pm, during interview with LPN #1, she stated that she had followed-up with the CNA, and had conducted a teachable moment with him, advising him that there is always someone available to give pain medication to a resident in need. She stated that she felt the incident was a case of poor communication, and confirmed that it was especially important to hear about R #290's pain as, due to the nature of his injuries, it was often severe. D. On 01/17/17 at 3:48 pm, during interview with the Director of Nursing, she stated that there should be no occasion when pain medication is not available to a patient in need. She stated that when a nurse is at lunch, the unit's other nurse or a certified medication aide should be available to retrieve the prescribed [MEDICATION NAME] (pain reliever). She confirmed that a CNA should never be telling a patient that he had to wait for his nurse to come back from lunch to have his pain addressed. E. Record review of R #290's care plan, dated 01/05/17, found a focus area stating (Resident's name) has pain r/t (related to) multiple fractures s/p (following) MVA (motor vehicle accident). Listed interventions included Anticipate (resident's name)'s need for pain relief and respond immediately to any complaint of pain.

This is a repeat deficiency from the survey conducted on [DATE]. Based on record review and interview, the facility failed to provide treatment for [REDACTED].#149) of 5 (R #s 78, 94, 145, 149 and 293) residents investigated for pressure ulcers. This deficient practice likely resulted in a failure to heal the original ulcer, and the development of additional ulcers, during the 9 days between the first ulcer's discovery and the resident's transfer to a hospital emergency room . The findings are: A. Record review of R #149's hospital medical record found that he was admitted on [DATE], transitioned to hospice care on [DATE], and that he died on [DATE]. 1. The principal problem for his hospital admission was listed as fell early morning. Nursing asking for med review. Other active problems were [MEDICAL CONDITION] (a chronic illness of nerve impairment), acute (sudden onset) [MEDICAL CONDITION] (brain impairment), recurrent urinary tract infections (UTIs), dysphagia (difficulty swallowing), [MEDICAL CONDITION] (elevated blood sodium levels), acute renal (kidney) failure, bacterial infection and decubitus ulcers (pressure sores). It was noted that none of these active problems were resolved prior to his death. 2. The Progress Note included a Dermatologic (skin) section stating Stage 2 (partial thickness) L (left) hip, Stage 2 sacral (lower back) decub (pressure ulcer), blister ball of big toe. 3. The Progress Note assessment and plan section includes Decubitus ulcers. He has a quarter-size ulcer on his left hip and also sacrum (lower back) and he has a blister on the ball of big toe. I ordered wound care evaluation and treatment. 4. A hospice consult note dated [DATE] stating . In the ED (Emergency Department), he was found to have acute [MEDICAL CONDITION], acute [MEDICAL CONDITION], urinary tract infection, and several new decubitus ulcers 5. Wound nurse consult notes (undated) indicated that the resident's skin issues included: a. A left hip unstageable (unable to determine depth) pressure ulcer 11.1 x 8.1 x 0 cm (centimeters) with necrotic (dead) tissue, slough (dead wound debris), and serosanguinous (clear and bloody) drainage. b. An upper sacral unstageable pressure ulcer 3.9 x 3.5 x 0 cm, with necrotic tissue and slough, and serosanguinous (means containing or relating to both blood and the liquid part of blood (serum)) drainage. c. A left foot Stage 2 pressure ulcer, 3.3 x 2.7 x 0 cm, presenting as an intact blister without drainage. d. Three Stage 1 (closed) pressure ulcers to the back. e. A penile (penis) erosion wound. 6. Black and white photographs of the resident's skin problems, including: a. An open crater of the skin, labeled Left hip. b. An open ulcer with surrounding discoloration, labeled Sacrum. c. A blister on the side of a foot, labeled Left medial foot. d. 3 discolored or bruised sections of skin, labeled Left back. e. An inflamed section of tissue, labeled Dorsal (rear of) penis. B. Record review of R #149's facility medical record dated [DATE] found that his [DIAGNOSES REDACTED]. He was noted to have a gastrostomy (feeding tube inserted through the abdominal wall into the stomach) and cystostomy (a tube for draining urine). C. Record review of R #149's Braden Scales for Predicting Pressure Ulcer Risk found that: 1. On [DATE], he was assessed as being at low risk of developing pressure ulcers. 1. On [DATE], he was assessed as being of high risk of developing pressure ulcers. 2. On [DATE] (his discharge date ), he was assessed as being of low risk of developing pressure ulcers. D. Record review of a nurse practitioner's History and Physical document for R #149, dated [DATE], found that the only skin condition noted was, He has [MEDICAL CONDITION]/[MEDICAL CONDITION] (flaky skin) to sides of nose, upper lip and chin. It is flaky with a pink base. The past medical history section states penile erosion (skin breakdown). The physical exam section states Skin: No rashes or ulcers. E. Record review of a nurse practioner's progress note for R #149 dated [DATE] found the statement, He was found to have a coccyx (lower spine area) wound [DATE] in the History of Present Illness section. The Physical Exam and Assessment and Plan sections did not discuss the wound or specify its treatment. F. Record review of IDT (Interdisciplinary Team) progress notes for R #149 found: 1. A nurse's note dated [DATE] stating Res (resident) found on the floor next to bed, no apparent injury. Neuro checks (assessments of neurological status after an injury) initiated and WNL (within normal limits), res (resident)cleaned up and assisted back to bed. During assessment a 3.2 x 1.8 cm open area to coccyx was noted, area cleansed with ns (normal saline), tao (a dressing) applied and covered. 2. A skin/wound note dated [DATE] stating Site: both right and left hip open wounds. Redness noted around the opened area on the left hip and the skin is very moist and fragile. Type: cleanse the area with normal saline and applied [MEDICATION NAME] (is a foam dressing suitable for a wide range of wounds like venous leg ulcers, pressure ulcers or diabetic ulcers) dressing. G. Record of Skin Assessment documentation for R #149 found: 1. No skin issues documented on [DATE]. 2. No skin issues documented on [DATE]. 3. A finding of mild excoriation (a scrape) to right buttock on [DATE]. 4. A open coccyx wound measuring 3.2 x 1.8 cm on [DATE]. H. Record review of dietary notes for R #149 found no notes after the discovery of his sacral pressure ulcer to indicate that the nutritionist or dietary manager was aware of the wound, or had assessed the resident for increased nutritional needs to promote wound healing. I. Record review of R #149's care plan dated [DATE], found focus areas stating Potential for impaired skin integrity r/t (related to) immobility and (Resident's name) has potential for pressure ulcer development r/t ADL (Activities of Daily Living) and cognitive (mental) deficits, incontinence, catheter (a tube for evacuation of urine) tubing. An undated update stated Alteration in skin integrity noted. Resident has: skin tears (fragile, ripped skin) to L & R (left and right) hips. J. Record review of R #149's physician's orders [REDACTED]. The only current skin-related orders were Barrier cream to buttocks and Weekly skin checks by licensed nurse q (enter day here.) K. Record review of the Treatment Administration Record for [DATE] for R #194 found no indication of pressure ulcer dressing changes taking place. L. Record review of the facility's current (2005) policy and procedure document titled Pressure Ulcers/Skin Breakdown - Clinical Protocol, provided by the Administrator, found statements indicating: 1. The physician will authorize pertinent orders related to wound treatments, including wound cleansing and debridement (removal of dead tissue) approaches, dressings (occlusive, absorptive, etc.) and application of topical agents if indicated for type of skin alteration. 2. The physician will help identify medical interventions related to wound management, for example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing comorbid medical conditions, managing pain related to the wound or to wound treatment, etc. 3. The physician will help the staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. M. On [DATE] at 1:54 pm, during interview with the Administrator and Director of Nursing, they jointly answered questions about R #149's care at the facility. They stated, After he discharged we did a chart review and realized that there had been no follow-up (on his pressure ulcer) from [DATE] to when he discharged on [DATE]. We identified that there was no documentation, so we did an action plan. We had inservices with the nurses and did a skin check of everyone in the building, and all new admits. We didn't find an order (for R #149's wound care), and didn't find any documentation that dressing changes were being done.

Based on record review and interview, the facility failed to provide the necessary care to effectively manage pain for 1 (R #115) of 1 (R #115) resident reviewed for pain. This deficient practice resulted in a resident experiencing a prolonged period of pain without sufficient relief. The findings are: A. Record review of R #115's physician's orders [REDACTED]. B. Record review of Assistant Director of Nursing (ADON) #2's progress note dated 02/14/16 at 1:58 pm stated, Resident (R #115) lethargic and grimacing. Resident unable to verbalize pain, but showing nonverbal signs of grimacing, and tense body positioning. Resident is not as responsive as usual and not easily aroused by stimuli. Resident will nod in response. C. Record review of ADON #2's progress note dated 02/14/16 at 6:41 pm stated, Resident (R #115) still non-verbally responsive, grimacing, symptoms of agitation. Hospice notified of resident status, (Name of Pharmacy) notified of need for medication delivery of pain meds and/or authorization code to pull from omnicell (an emergency kit of various medications). Message left again at 1845 (6:45 pm), meds still not received. D. On 02/26/16 at 3:34 pm, during an interview with ADON #2, she stated she observed R #115 grimacing and tensing her body several times throughout her shift on 02/14/16. ADON #2 stated that R #115's [MEDICATION NAME] was not available to administer so she called the pharmacy. She left a voice mail with the pharmacy explaining that she needed the medication delivered that day and she also requested the code to access the omnicell. ADON #2 stated she let ADON #1 know about needing access to the omnicell however even with the help of the ADON #1 they were not able to access it. ADON #2 stated that she attempted non-pharmacological interventions by adjusting the room temperature and repositioning but the resident still had non-verbal signs of pain. ADON #2 stated that the [MEDICATION NAME] had still not arrived by the end of her shift that day (7:00 pm) and she let the nurse on the next shift know about R #115's non-verbal signs of pain. When asked whether she thought about giving R#115 her prescribed Tylenol or [MEDICATION NAME] for the pain, ADON #2 stated that she could not remember whether those medications were available but remembers thinking that the resident really needed [MEDICATION NAME]. E. On 02/29/16 at 11:20 am, during an interview with the Administrator, she explained the time frame in obtaining medications for newly admitted residents. She stated all of the resident's prescribed medications, whether they are scheduled or PRN, should arrive at the facility the same day or the next day depending on what time of day the resident is admitted . The Administrator verified that since R #115 was readmitted to the facility on [DATE], her medications should have been received by 02/12/16 at the very latest. F. Record review of shipment paperwork from the pharmacy dated 2/14/16 indicated that R #115's [MEDICATION NAME] arrived at the facility on 02/14/16 at 7:17 pm. G. Record review of R #115's Medication Administration Record [REDACTED].

Based on interview and record review, the facility failed to provide monitoring and treatment to promote healing and prevent worsening of a pressure ulcer, for 1 (R #175) of 6 (R #s 12, 64, 79, 115, 175 and 276) residents reviewed for pressure ulcers. A resident discharged to a hospital due to rectal bleeding and mental status changes was found there to have a pressure ulcer larger in size and more advanced than the facility had been aware of. This deficient practice likely contributed to the resident's acute illness, through infection, pain, possible bone involvement of the wound, and affected mental status. The findings are: A. On 02/23/16 at 10:45 am, during interview with family members of R #175, they stated that she had been discharged the previous day (02/22/16) to a local hospital, due to mental status changes and rectal bleeding. They showed cell phone photographs of a large coccyx (lower spine area) wound which they stated had been discovered on R #175 at the hospital. They stated that the rectal bleeding that had caused the facility to send the resident to the hospital was, in fact, bleeding from the wound. They stated that bone scans were currently being performed at the hospital to determine whether the wound had reached the bones of the spine (a Stage IV wound). They related that a care conference had been held on 02/19/16 to develop a plan for the resident's discharge home, which was set for 02/23/16, but that there had been no mention of a pressure ulcer during the conference, and the family was not aware of it. B. On 02/23/16 at 11:51 am, during interview with Assistant Director of Nursing (ADON) #1, she stated that she had observed R #175's wound on 02/16/16. She stated that, at that point, it had been a Stage II (partial thickness) wound and had been limited to the right buttock. She stated that the plan had been for the wound to be cleaned and an [MEDICATION NAME] (a type of dressing) applied daily. She stated that nurses conduct a formal assessment of wounds weekly, but that the wound is observed daily by nurses during the dressing changes. ADON #1 stated that there was no documented assessment of the wound done prior to the resident's discharge, so she didn't know how it had changed between 02/16/16 and the resident's transfer to the hospital on [DATE]. C. On 02/23/16 at 11:51 am, during interview with the Social Services Director, she stated that the care conference had been held on 02/19/16, and that the family members of R #175 had been present. She stated that there was no discussion of pressure ulcers during the meeting. She stated that the determination during the meeting was that R #175 would be discharged on [DATE] to her family members' home, with the support of a home health service. D. On 02/23/16 at 2:38 pm, during interview with ADON #2, she stated that she had not observed R #175's wound since the dressing change done with ADON #1 on 02/16/16. She described the wound as limited to the right buttock, and somewhat more than quarter-sized. E. Record review of a 02/16/16 physician's orders [REDACTED]. Apply [MEDICATION NAME] to wound. Monitor QD (daily) for changes, every shift for pressure sore. F. Record review of a Weekly Pressure Ulcer Assessment tool for R #175, dated 02/16/16, indicated that the right buttock wound was new and had not been present on admission. Assessment stated Stage II, 1.5 x 1 x 0.2 centimeters (cm). Red/pink wound base, normal peri-wound skin. Clean with NS (saline solution) cover with [MEDICATION NAME]. Monitor daily. G. Record review of an Interdisciplinary Team Note dated 02/19/16 indicated . R (right) buttock Stage 2 measures 1.5 x 1 x 0.2 cm. Wound bed clean . H. Record review of a Social Services note pertaining to R #175's discharge planning meeting on 02/19/16 found the statement Reviewed: family concerned about hip, x-ray came back and everything negative. Resident is okay. Personal care service authorizations are in. Family wants patient to discharge on (02/23/16). No mention of a pressure ulcer was found. I. On 02/23/16 at 2:54 pm, during interview with ADON #1, she stated that when nurses mark a task completed in the electronic Treatment Administration Record, it shows they looked at (a wound). She stated that the nurses would do a progress note or a new pressure ulcer form if they had seen any changes, but that otherwise they would not measure or describe the wound. She stated that the facility did not use a wound book that would show descriptions of the wound in a side-by-side format. She stated that no one had spoken to her about the wound between the dressing change on 02/16/16 and the patient's discharge on 02/22/16. She was unable to state how 7 different assigned nurses over 9 shifts could assess changes without documentation of what each nurse was seeing. J. On 02/24/16 at 8:57 am, during interview with LPN #3, she stated that she had cared for R # 175 during the overnight shift on 02/18/16. She stated that she had observed R #175's wound during the night, and that it had been a right buttocks partial-thickness wound, approximately 5 cm by 2 cm in size, and had not been covered by a dressing. She stated that she had not been advised, during report from the previous nurse, that the resident had had a pressure ulcer. She reported that a CNA (Certified Nurse Aide) had told her that the dressing had come off in the resident's brief. LPN #3 stated that she had not documented the wound, as she believed the order had stated only to monitor for the presence of the dressing. K. Record review of the hospital record of R #175, as of 02/23/16, found: 1. A physical exam note, dated 02/22/16, stating . large coccyx ulceration with foul smell. Stage III-IV . 2. A History and Physical document, dated 02/22/16, stating . The patient has apparently not been doing well at nursing home. She has developed a large wound on her coccyx which is looking quite acute. The patient, again, has dementia at baseline and the reason for transfer is apparent worsening overall status. In the emergency room , the patient does respond to verbal, though very sluggishly. She does not appear to be septic (having a systemic infection) though is extremely frail with wasting of limbs and a large advanced-age wound on her coccyx . 3. A wound consult note dated 02/22/16 stating Sacrum/coccyx - picture taken after cleaning liquid black stool. 9 cm x 5 cm appears as stable eschar (dark tissue) and slough (dead tissue) which is softening. 4. A physician's orders [REDACTED]. Rule out osteo (bone involvement). 5. A physician's orders [REDACTED]. 6. A nurse practitioner's note dated 02/22/16 stating .Psychosocial: I spent a long time hearing appropriate anger that (family) had no idea the patient had severe pressure ulcers. They were under the impression she was doing fine and would be coming home with them tomorrow. Right now, the (family) are in shock about her condition and can't focus on the possibility of her doing poorly . L. On 03/02/16 at 10:23 am, during interview with ADON #2, she stated that the resident had health issues, but that she (ADON #2) could not point to a disease process that could explain the rapid progression of the wound to what was found when she arrived at the hospital. M. On 03/02/16 at 10:23 am, during interview with the Administrator, she stated that continuity of care is difficult in the facility, because they use a lot of traveling and agency nurses and CNAs. She stated that nurses should get a hand-off (report) from the previous shift's nurse about the needs of each resident, and that they can also go into the electronic medical record to see what assistance the resident needs. She stated that she had spoken with nurses who had seen R #175's wound on 02/19/16 and 02/20/16 and that it had only been about this big (she made a hand motion to indicate quarter-sized). The Administrator stated The documentation just isn't there to indicate the appearance of the wound on 02/21/16 or 02/22/16.