Every finding on record at The Waterview Woods LLC

Based on interview and document review, the facility failed to ensure a registered nurse (RN) was scheduled for a minimum of eight hours a day. This had the potential to affect all 55 residents who resided at the facility.Findings include:Review of the facility Staffing Schedules dated 4/1/25 through 6/30/25, revealed there was no RN coverage for the following dates: 4/5/25, 4/6/25, 4/13/25, 4/20/25, 5/3/25, 5/4/25, 5/10/25, 5/11/25, 5/17/25, 5/24/25, 5/31/25, 6/1/25, 6/7/25, 6/8/25, 6/14/25, 6/15/25, 6/21/25, 6/22/25, 6/28/25 and 6/29/25.Review of the facility Condensed Employee Time Detail for the following dates identified a lack of RN coverage: 4/5/25, 4/6/25, 4/13/25, 4/20/25, 5/3/25, 5/4/25, 5/10/25, 5/11/25, 5/17/25, 5/24/25, 5/31/25, 6/1/25, 6/7/25, 6/8/25, 6/14/25, 6/15/25, 6/21/25, 6/22/25, 6/28/25 and 6/29/25.During an interview on 11/19/25 at 3:30 p.m., licensed practical nurse (LPN)-B stated she normally worked night shifts. There was usually one licensed staff with two nursing assistants in the building. There may be another nursing assistant that would float between floors to assist with rounds but that was more recent due to an increased census and increase in the number of call lights that were occurring. The facility always had a registered nurse that was reachable by phone.During an interview on 11/19/25 at 3:43 p.m., LPN care coordinator (CC)-B stated she was in her role as the second-floor unit manager at the facility for approximately 5 weeks. Because CC-B did not hold a registered nurse (RN) license, CC-B was working under the director of nursing (DON). CC-B trained with the former unit manager for a few weeks and, if CC-B had questions, she could ask the DON for guidance.During an interview on 11/20/25 at 10:06 a.m., RN-A stated she was the first-floor unit manager but helped with the second floor as well. RN-A worked Monday through Friday but was always available to nursing by phone. During an interview on 11/19/25 at 2:38 p.m., assistant administrator stated she was responsible for the facility staffing. Administration was aware the facility was lacking RN nurse coverage on the weekends. The facility had been cited previous years and there was a plan to house an agency RN in the assisted living section of the building. However, when the agency RN's contract was complete, the facility was unable to obtain further staffing. The assistant administrator stated the facility's licensed practical nursing staff were more than capable of resident care and there was a RN on-call 24/7 for the licensed staff to reach out to. During an interview on 11/20/25 at 2:21 p.m., the administrator stated, yes, administration was aware of the lack of RN coverage on the weekends, and the facility had been cited for the same concern in previous years. The facility did have a plan for an agency nurse to provide coverage, but the contract was complete, and the facility was unable to obtain further staffing. The facility had posted a RN job posting, had offered licensed practical nursing staff school cost reimbursement, and sought out agency placements but had not found a RN for weekend coverage. There were currently only two RNs staffed: the DON and the first-floor unit manager. The DON and first-floor unit manager were not expected to be in-house on weekends due to work/life balance and the facility had sought to get a staffing waiver, but this was not approved. The administrator stated she understood regulation required the facility to provide RN coverage for 8 hours per day but was unable to do so.A policy was requested but not received. The facility's Facility Assessment Tool dated 7/17/25, identified the facility staffing plan for licensed nurses providing direct care LPN, LVN with a 1:25-30 ratio Days and Evenings and 1:59 ratio Nights. The facility assessment also identified the facility planned to have a part time Infection preventionist (DON), a part time Minimum Data Set (MDS) coordinator, a full-time health unit coordinator (HUC), a full time DON and 2 full time nurse managers. However, the facility assessment failed to identify the facility need for a RN coverage 8 hours per day.

Based on observation, interview, and document review the facility failed to follow a self-administration of medication (SAM) form which indicated the resident should not self-administer medications. The facility also failed to have a provider order to self-administer medications and to keep medications at bedside. Lastly the facility failed to appropriately assess a resident with memory and decision-making concerns that was allowed to self-administer medications. This effected 2 of 3 (R25, R29) residents reviewed for self-administration of medications.Findings include R25's quarterly Minimum Data Set (MDS) dated [DATE], indicated R25 had mild cognitive impairment. Diagnoses included atrial fibrillation and sepsis. R25's care plan dated 10/21/24, identified R25 chose to self-administer oral medications left at bedside after setup by nursing. The goal was for the resident to safely administer medications set up by nursing and left at bedside per provider orders. Interventions included nursing to ensure medications were taken and assess that the resident was capable of self-administering medications left at bedside quarterly. R25's Self Administration of Medication (SAM) Evaluation form dated 1/17/25, identified R25 was able to self-administer medications due to having the manual dexterity sufficient to self-administer medications accurately and the ability to accurately report the medication use to nursing staff. The SAM form did not have knowledge of what the medication is for, ability to recognize the medications and verbalize understanding of the purpose of the medication, or knowledge of the correct times to take medications check marked, which indicated R25 could not demonstrate those steps. R25's active Order Summary Report dated 11/20/25 lacked orders R25 could self-administer medications after nursing setup or orders R25 could have medications left at bedside to take at a later time. R25's provider progress note dated 10/15/25 at 8:00 a.m., identified R25 could not make medical decisions due to cognitive impairment. The provider had discussed with the family at that time to acquire power of attorney (POA) to make R25's medical decisions for him. Diagnoses for this decision included infantile cerebral palsy, cerebellar atrophy, and cognitive impairment. Sister had obtained POA paperwork and would be completed. POA could be activated based on prior cognitive testing and below capacity evaluation performed that day. On 11/17/25 at 3:32 p.m., a plastic medication cup was observed on R25's bedside table with 5 different medications in it. There were no staff in the room at that time. On 11/17/25 at 4:52 p.m., the same plastic medication cup was still observed on R25's bedside table and there were no staff present. On 11/18/25 at 2:48 p.m. a plastic medication cup was again observed on R25's bedside table with 5 different medications in it. There were no staff present in the room, but the licensed practical nurse (LPN)-F was observed leaving R25's room five minutes prior.During an interview on 11/18/25 at 3:24 p.m., R25 could not state what any of the medications in the plastic medication cup were or what the medications were for. R25 could not state a general list of medications that he currently took on a daily basis. R25 could not report any signs of adverse reaction to medications taken or when the medications should be taken.During an interview on 11/18/25 at 3:26 p.m., LPN-F stated R25 did have some mental concerns and memory concerns. R25 did not like taking his medications in front of staff at all so we would give the afternoon medications to him after 2:30 p.m., and he would usually take them with dinner. We check back after dinner to make sure he took them. LPN-F stated R25 did have trouble remembering some of the medications he took and why the medications were important to take. The registered nurses and the nurse managers were the staff who filled out the SAM forms. LPN-F was not aware a provider order was needed to self-administer medications or leave them at bedside.R29's quarterly Minimum Data Set (MDS) dated [DATE], indicated R29 was cognitively intact. Diagnoses included heart failure, depression and anxiety. R29's care plan lacked documentation R29 could self-administer medications or have medications left at bedside. R29's active order summary report dated 5/14/25, indicated an order for Diclofenac Sodium external gel 1%, apply 4 grams (gr) to the lower back topically three times a day. On 7/16/25, an order for Diclofenac Sodium external gel 1%, apply 2 gr to shoulder was added. The active order summary report lacked provider orders R29 could self-administer medications or keep medications at bedside. R29's SAM form dated 5/14/25, indicated R29 could not self-administer medications due to cognitive related diagnoses and a recent urinary tract infection. On 11/17/25 at 4:18 p.m., a tube of Diclofenac Sodium external gel 1% was observed on R29's nightstand. There were no staff present in the room On 11/19/25 at 2:40 p.m., a tube of Diclofenac Sodium external gel 1% was again observed on R29's nightstand. Again, no staff were present in the room On 11/19/25 at 2:43 p.m., registered nurse (RN)-A entered R29's room and confirmed the Diclofenac Sodium external gel 1% had been left in R29's room on the nightstand During an interview on 11/19/25 at 2:46 p.m., RN-A stated the nurse managers did the SAM evaluations. Items such as mental capacity, ability to safely take medications, understanding the medications, and identifying medications were all looked at when the decision to self-administer medications is decided. After the evaluation was done then conversation would occur with the interdepartmental team, which also included the resident's provider. If the provider felt the resident was mentally unsafe to make medical decisions, that would more than likely keep the resident from self-administering medications or keeping them at bedside. RN-A reviewed R 25's SAM report and provider notes. RN-A stated the provider documentation would probably disqualify the resident from self-administering medication. RN-A also reviewed R29's SAM and acknowledge the SAM evaluation said R29 could not self-administer of keep medications at bedside so that should not have been going on.During an interview on 11/20/25 at 10: 18 a.m., the director of nursing (DON) expected the IDT would discuss every resident that wanted to self-administer medications. If the ability to self-administer medications safely was there, the resident should be able to but if the ability was not there then staff should follow what is documented on the SAM report and observe all medications taken. The DON did not believe mental health concerns would always disqualify a resident from self-administering medications.Facility policy Self-Administration of Medications last revised 2/24 indicated 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) would assess each resident's cognitive and physical abilities to determine whether self-administering medications was safe and clinically appropriate for the resident. 2. The IDT considered the following factors when determining whether self-administration of medications was safe and appropriate for the resident:a. The medication is appropriate for self-administration.b. The resident is able to read and understand medication labels.c. The resident can follow directions and tell time to know when to take the medication.d. The resident comprehends the medication's purpose, proper dosage, timing, signs of side effects and when to report these to the staff.e. The resident has the physical capacity to open medication bottles, remove medications from a container and to ingest and swallow (or otherwise administer) the medication; andf. The resident is able to safely and securely store the medication.

Based on interview and document review, the facility failed to provide a bed hold notice for 1 of 1 resident (R2) reviewed for hospitalization. Findings include: R2's admission Minimum Data Set (MDS) dated [DATE], identified R2 was cognitively intact and had a diagnosis of stroke with left sided hemiplegia (paralysis that affects one side of the body). R2's Face Sheet dated 11/20/25, identified R2 was admitted on [DATE] and discharged to an acute care hospital on [DATE]. R2's progress notes dated 11/9/25, identified R2 was transferred to a local hospital by Emergency Medical Services (EMS)(ambulance). The medical record lacked documentation a bed hold was given or discussed. R2's progress note dated 11/10/25, identified R2 called the facility and stated they were being transferred to a larger acute care hospital. The medical record lacked documentation a bed hold was give or discussed. During an interview on 11/20/25 at 12:12 p.m., the clinical manager (CM) stated when a resident was transferred to the hospital a bed hold was to be discussed with the resident or the resident's representative and then documented in the medical record. R2's medical record did not have any documentation regarding a bed hold for the 11/9/25 transfer. During an interview on 11/20/25 at 12:58 p.m., the director of nursing (DON) stated all residents who were transferred or went on leave were to have a bed hold done and documented. The facility's Bed-Holds and Returns policy dated May 2023, identified prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy.

Based on observation, interview and document review, the facility failed to revise resident care plans with updated interventions for 2 of 2 residents (R7, R63) reviewed for behaviors and transmission-based precautions (TBP). Findings include: R7: R7's annual Minimum Data Set (MDS) dated [DATE], identified R7 had diagnoses which included dementia and post-traumatic stress disorder. In addition, R7's MDS identified he was severely cognitively impaired and had verbal behaviors that were directed towards others. R7's care plan initiated on admission 8/25/25, did not address behaviors until 11/18/25. R7's nursing notes identified the following: 8/17/25 at 1:39 p.m., Resident came out to nurse's desk asking CNA (certified nursing assistant) for pain pill. CNA stated she will let nurse know. Resident stated you are fat you are too f****** fat to work here. CNA stated you can go wait in your room for the nurse and I will let her know you want a pain pill, have a great nite ***. He then stated f*** you and went back to his room. 8/30/25 at 1:29 p.m. resident threatening resident that shares a bathroom with him. Resident saying, I'm going to beat you're a** get the f*** out of my way. Writer did go and speak to both residents. Encouraged other resident to use either tub room or employee bathroom if he needed. On 10/22/25, time not noted R7 threw medication at staff and said he was not going to take them. This documentation was requested but not provided. 10/25/25 at 2:00 p.m. removing dressing to stump a few times. resident was sitting on the toilet in the tub room, resident put light on for staff to assist of toilet. staff member went into bathroom and resident says you dumb f****** idiot, what the hell are you doing in here On 11/17/25 at 3:54 p.m., R7 was observed wheeling himself down the hallway away from the dining room, kitchenette area, another resident (R12) was wheeling toward the dining room kitchenette area. R7 said something to R12 voice sounded angry but unable to distinguish the words, R7 then began hitting R12 with his fists. Facility staff was immediately alerted, and the incident was reported to the director of nursing (DON). Licensed practical nurse (LPN)-A stated R7 could get aggressive with staff but they were not aware of R7 being aggressive with other residents. During an interview on 11/17/25 at 4:07 p.m., the DON stated nothing like this had occurred before. During an interview on 11/19/25 at 9:42 a.m., nursing assistant (NA)-A, stated R7 had behaviors mainly toward women, including throwing pills and swearing. NA-A did recall the incident in August when he would not allow the resident who shared the bathroom to use it. She recalled R7 was moved to a different room. NA-A verified there was nothing in the care plan related to R7's behaviors. During an interview on11/20/25 at 9:47 a.m., licensed practical nurse (LPN)-A stated she knew R7 had behaviors and had had an altercation in August with a different resident and R7 was moved from the [NAME] side of the building to the East side. LPN-A verified the care plan did not address behaviors. During an interview on 11/20/25 at 12:16 p.m., LPN care coordinator (CC)-B verified R7's behaviors should have had been part of his care plan with interventions listed for staff to assist with de-escalation. LPN CC-B verified the care plan did not address behaviors until 11/18/25. During an interview on 1/20/25 at 12:31 p.m., the DON verified R7 had had a verbal altercation with a different resident in August, and the care plan should have been updated at that time to address behaviors. R63: R63's admission Minimum Data Set (MDS) dated [DATE], identified no cognitive impairment and a diagnosis of a MDRO (multidrug-resistant organism) (which are germs that resist multiple classes of antibiotics). R63's Face Sheet dated 11/20/25, identified R63 had 2 MDROs. One was Methicillin Resistant Staphylococcus Aureus (MRSA), and the other was Extended Spectrum Beta Lactamase (ESBL) resistance. Provider order dated 11/7/25, identified R63 was on contact precautions (infection control measures used to prevent the spread of pathogens through direct or indirect contact with an infected or colonized person). During observations on 11/19/25 at 9:00 a.m., R63's door had a sign that identified she was on contact precautions. R63's care plan dated 11/7/25, identified R63 had precautions with cares related to wound care and a MDRO. Interventions included staff to follow enhanced barrier precautions, and staff to enhanced barrier precautions when providing high contact cares. During an interview on 11/20/25 at 9:57 a.m., the clinical manager (CM) started the care plan was important because it was used to communicate type of care needed for the residents. If a resident was on contact precautions, it would have been important to identify that in the care plan. R63's care plan did not identify they were on precautions and should have. The CM said the information regarding the contact precautions did not populate the care plan and she did not know why. During an interview on 11/20/25 at 12:58 p.m., the director of nursing (DON) stated if a resident was on contact precautions, it would be expected the care plan would reflect that. The care plan was used for staff to reference and identify the care needed for the resident. R63's care plan should have been updated to reflect they were on contact precautions. The facility's Care Planning policy dated November 2024, identified the care plan shall be used in developing the resident's daily care routines and will be utilized by staff personnel for the purposes of providing care or services to the resident. The plan of care will be utilized to provide care to the resident. The care plan is to be modified and updated as the condition and care needs of the resident changes.

Based on observation, interview and document review, the facility failed to ensure a resident's hearing devices were in use for 1 of 1 resident (R35) reviewed for communication and hearing. In addition, the facility failed to ensure the family member was kept updated on changes of condition for 1 of 1resident (R35) reviewed for change of condition.Based on observation, interview and document review, the facility failed to ensure a resident's hearing devices were in use for 1 of 1 resident (R35) reviewed for communication and hearing. In addition, the facility failed to ensure the family member was kept updated on changes of condition for 1 of 1resident (R35) reviewed for change of condition.Findings include:R35's quarterly Minimum Data Set (MDS) dated [DATE], identified R35 had diagnoses which included moderate difficulty with hearing and had hearing aids, mild cognitive function, depression, and anxiety. In addition, R35's MDS identified he was rarely/never understood and had memory problems.R35's care plan dated 8/22/24, identified he had an alteration in communication and was hard of hearing. R35's care plan identified he had hearing devices. Interventions included to encourage resident to use hearing aids or pocket talker, if he refused have different staff reapproach if resident refuses. Staff were to offer hearing aids every morning, he had an alternate communication method listed as pocket talker. In addition, R35's care plan identified he was at risk for falls initiated on 8/22/24. Interventions included pommel wedge to prevent resident from sliding out, ensure staff were near if wheelchair was in the upright position, have tray table next to resident when in common area with fidgets and snacks in reach. Occupational therapy was to evaluate for a new wheelchair. The care plan identified R35 was assessed and provided with a tilt wheelchair to prevent sliding out on 12/11/24.R35's Order Summary Report identified Offer hearing aids every morning in the morning dated 5/2/25.R35's care conference dated 5/23/25, identified resident and guardian present. Guardian (G)-A identified the following, Resident's guardian voiced concerns of resident's Broda chair not appearing to be secure and not being updated on things such as medication changes and OT (occupational therapy) orders.R35's care conference dated 7/29/25, identified a new pocket talker had been received and was ready for use.R35's care conference dated 10/20/25, identified the following, Resident's guardianexpressed concerns of resident's hearing devices not being utilized throughout the day.During an observation on 11/18/25 at 10:36 a.m., R35 was seated in the dining area in a Broda chair, he was dressed and wearing sunglasses. Hearing aids were not in, no headphones on.During an observation on 11/18/25 at 1:22 p.m., R35 was in bed, he was awake, he was not wearing hearing aids and did not have headphones on. When spoken to, he stated, I can't hear you.During an observation on 11/19/25 at 8:42 a.m., R35 was sitting in his Broda chair in the dining area eating breakfast, he was not wearing any hearing aids or headphones.During an observation on 11/19/25 at 9:10 a.m., nursing assistant (NA)-A asked R35 a question several times, he finally responded with come back later. R35 was not wearing hearing aids or headphones.During an interview on 11/19/25 at 9:39 a.m., NA-A verified R35 did not hear very well, NA-A said he could read lips and stated he had headphones that helped him with his hearing. NA-A verified she did not use the headphones when R35 could not understand/hear her question.During an interview on 11/19/25 at 10:37 a.m., family member (FM)-A stated the staff were not using his hearing aids and did not know how to use them. FM-A stated she currently had the hearing aids for repair. She stated he had headphones that could be used while the hearing aids were being repaired but stated they were often not charged for use. FM-A stated they were not notified when R35 was moved from a wheelchair to the Broda chair.During an interview on 11/19/25 at 11:43 a.m., NA-B verified R35 was not wearing his hearing aids or headphones, she looked in his room and was not able to find them. NA-B found NA-A and asked her if she knew where they were, NA-A showed the headphones which were plugged in to charge.During an interview on 11/20/25 at 9:42 a.m., licensed practical nurse (LPN)-A stated R35 should have his hearing aids in daily, she stated they were either in his room or at the desk charging.During an interview on 11/20/25 at 12:16 p.m., care coordinator (CC)-B verified R35 was supposed to wear his hearing aids or headphones daily to help with communication.During an interview on 11/20/25 at 12:31 p.m., director of nursing (DON) verified she would expect staff to make sure his hearing aids or headphones were put in/on in the morning so he would be able to hear and communicate with staff and others. The DON stated she would expect staff to keep the devices charged. The DON stated she was unsure when R35 moved from a wheelchair to the Broda chair, said it's been quite a while. The DON verified the guardian should have been involved and notified the change. A policy on hearing and communication was requested but not provided.Notification Of Changes Policy dated 3/2024, identified the objective was to ensure the facility made appropriate notifications timely to ensure any need to alter treatments could be made.

Based observation, interview and document review, the facility failed to provide timely assistance with repositioning to prevent the worsening or development of pressure ulcers for 1 of 3 residents (R1) reviewed for pressure ulcers.Findings include:R1's quarterly Minimum Data Set (MDS) dated [DATE], identified she had diagnoses which included diabetes, morbid obesity, heart failure (a chronic condition where the heart can't pump enough oxygen rich blood to meet the body's needs), and pressure ulcer. In addition, R1's MDS identified her as cognitively intact and as having a pressure ulcer.R1's electronic medical record banner identified the following special instructions; elevation of lower extremities 4x (times) a day for 15 min (minutes) needs to be done every day.R1's care plan dated 12/20/24, identified R1 had an alteration in skin integrity to top of left foot, left heel, and buttock. Interventions included turn and reposition or reminders to offload every two to three hours and as needed.R1's Order Summary Report included the following order:10/4/25, Please encourage supine in bed at night to improve edema. She should also have her feet elevated 2-3 times throughout the day for 15-20 minutes each time, ideally above her heart level. ACE wraps for gentle compression on in the morning and off at night with sleeping. Please offload heel at all times. Every day shift.A review of R1's November progress notes did not document any refusals of care.On 11/18/25 10:39 a.m., R1was seated in her wheelchair in her room watching a television (TV) program. Left foot in a padded boot resting on the wheelchair foot pedal. Both feet dependent. Staff asked her if she planned to go to bingo in the afternoon.-11:08 a.m., no change in position, no staff in or out of her room-12:15 p.m., R1 remained seated in her wheelchair eating lunch-12:29 p.m. R1 remained in her wheelchair, talking on her phone-12:35 p.m., R1 remained in her wheelchair, both feet remained in dependent position, no staff offered to help her change her position or offload-12:40 p.m., staff entered and gave R1 her insulin injection, no offer was made to change position, offload or elevate feet. Both feet remained in a dependent position.-12:49 p.m., R1 remained in her wheelchair, no changes in position-12:52 p.m., staff entered to pick up the meal tray, no offer was made to change position-1:04 p.m., staff entered and checked on her activity plan, no offer made to change position, offload, or elevate feet-1:11 p.m., staff answered her call light and told R1 they would be right back-1:12 p.m., staff entered emptied her foley catheter and two staff straightened her in her chair as she was leaning to the right and left. R1 stated she had been sitting in her wheelchair since 7:30 a.m. R1 then left to go to bingo.R1 remained at bingo in the basement until 2:53 p.m., at which time she was brought back to her room. No offer for a position change, offloading or elevating her feet, which remained dependent on the wheelchair rests.-2:59 p.m., R1 put her call light on-3:02 p.m., R1's call light was answered, she asked staff to move items out of her recliner, which was completed, no offer was made for a position change, offloading, or elevating her feet, which remained dependent on her wheelchair rests.-3:23 p.m., R1 remained sitting her wheelchair with both of her feet dependentDuring an interview on 11/19/25 at 8:59 a.m., licensed practical nurse (LPN) care coordinator (CC)-B verified R1 had some open areas on her buttocks.During an interview on 11/19/25 at 9:46 a.m., nursing assistant (NA)-A stated she worked with two other NAs to complete repositioning for about 13 residents, R1 was not one she listed. NA-A then stated R1 should be repositioned every two hours and offers should be made to R1 to reposition her and elevate her feet.During an interview on 11/19/25 at 11:50 a.m., LPN-E stated NAs should tell her if a resident was refusing repositioning, she did not recall being told R1 refused repositioning on 11/18/25.During an interview on 11/20/25 at 8:21 a.m., R1 stated she had been up in her chair since 6:45 a.m., she stated staff did not offer to assist her with position changes unless she put on her call light and asked for a position change.During an interview on 11/20/25 at 9:40 a.m., LPN-A stated R1 should be repositioned every two hours, said she could lift her own legs. LPN-A verified they wait for R1 to ask to be repositioned and were not offering a position change, offloading, or elevating feet every two hours.During an interview on 11/20/25 at 12:16 p.m., LPN-B verified staff were not offering R1 position changes and they should have been making the offer every two hours.During an interview on 11/20/25 at 12:31 p.m., the director of nursing (DON) stated staff should be following the orders as written and offering repositioning for R1. The DON stated this was important to prevent further skin concerns and to help with healing current skin concerns.The Skin Assessment & Wound Management dated 2/2025, identified staff would review and update the care plan as needed, would educate the resident on skin problems and would include the risk and benefits of following care, and would follow ongoing treatments per provider order.

Based on observation, interview, and document review the facility failed to implement interventions to prevent falls for 1 of 3 (R44) residents reviewed for falls.Findings include: R44's quarterly Minimum Data Set (MDS) dated [DATE] indicated R44 had moderative cognitive impairment. Diagnoses included alcohol dependence and delirium. R44's care plan dated 8/14/24, identified R44 was a fall risk related to dementia and safety. Interventions included wheelchair to be kept at bedside with brakes locked and auto-locking breaks on WC. Gripper socks were to be on when out of bed. On 11/17/2025 at 4:14 p.m., R44 was observed to self-transfer from the bed to the wheelchair. The wheelchair locks were not locked and R44 was wearing regular socks with his shoes lying on the floor. R44 was unsteady during transfer, leaned forward to grab the wheelchair and the wheelchair rolled backwards. R44 was able to grab both wheelchair arms and sit down before the wheelchair rolled away from R44. On 11/19/25 at 10:26 a.m., nurse assistant (NA)-C entered R44's room. R44 was in his bed. R44's wheelchair was next to the bed, but his locks were not locked and there were no auto-locking devises on the wheelchair. Staff new which interventions the staff needed to be aware through the resident care plan.During an interview on 11/19/25 at 10:26 a.m., NA-C stated R44 had a history of frequent falls. Interventions included gripper socks on his feet when out of bed and the wheelchair needed to be right next to the bed with the wheels locked. NA-C stated the staff did a pretty good job to keep the WC by the bed and the wheels locked when R44 was in bed. NA-C was unsure if auto locking breaks needed to be on R44's wheelchair. NA-C did confirm R44's wheels were not locked when she entered the room and there were no auto locking breaks on R44's WC at that time.During an interview on 11/19/25 at 2:43 p.m., registered nurse (RN)-A stated interventions were put in place by the inter-disciplinary team (IDT) for residents with a history of falls to attempt to keep the resident safe. Interventions were placed on the care plan, so all staff were aware and to follow. Maintenance would be notified when autolocking breaks were needed on a resident wheelchair.During an interview on 11/20/25 10:18 a.m. the director of Nursing (DON) stated all staff were expected to follow the resident plan of care and implement all resident fall interventions to keep the resident safe.Facility policy Care Planning last revised 11/24, indicated the care plan would be developed the daily care routines and used for the purpose of provided cares or services to the resident.

Based on observation, interview, and document review the facility failed to monitor pain, provide non-pharmacological pain management, and consistently administer as needed pain medication to minimize pain for 1 of 1 resident (R61) who had pain. R61's admission Minimum Data Set (MDS) dated [DATE], identified R61 was cognitively aware and had diagnoses that included chronic obstructive pulmonary disease (COPD) (a progressive group of lung diseases that includes emphysema and chronic bronchitis, making it difficult to breathe due to airflow obstruction. Common symptoms are chronic cough, mucus, and shortness of breath, which worsen over time and are often exacerbated by smoking or exposure to irritants.), emphysema (a progressive group of lung diseases that includes emphysema and chronic bronchitis, making it difficult to breathe due to airflow obstruction. Common symptoms are chronic cough, mucus, and shortness of breath, which worsen over time and are often exacerbated by smoking or exposure to irritants.), acute and chronic respiratory failure with hypercapnia (Acute on chronic hypercapnic respiratory failure occurs when a patient with a pre-existing, long-term condition that causes high carbon dioxide levels experiences a sudden, acute worsening of the condition. This results in a dangerous buildup of and a drop in blood pH, which can be life-threatening. Treatment depends on the severity but can involve oxygen therapy, non-invasive ventilation, or, in severe cases, mechanical ventilation, along with addressing the underlying cause) and esophagitis (is the inflammation or irritation of the esophagus, the tube that carries food from the mouth to the stomach. Symptoms can include chest pain, heartburn, and difficulty or pain when swallowing. Causes range from acid reflux and certain medications to allergic reactions, infections, and radiation.) R61 use opioid pain medications and was receiving hospice services.R61's Pain Care Area Assessment (CAA) dated 11/17/25, identified R61 denied having any physical pain but does have discomfort with epigastric pain which is controlled with the use of Omeprazole (a medication that reduced the amount of acid produced in the stomach). However, the CAA failed to identify R61's opioid medication use.Care plan dated 11/12/25, identified R61 exhibited an alteration in comfort. Staff were directed to:- Provide nonmedicinal forms of pain relief such as positioning, rest, massage, etc.- Pain medication as ordered by physician- Document on effectiveness of pain medication- Encourage R61 to verbalize discomfort- Monitor for potential medication side effects related to pain medication usage including constipation, nausea and vomiting, sedation, lethargy, anorexia and increased confusion.R61's Physician order dated 11/11/25, identified Morphine Sulfate oral solution 10 milligram (mg)/5 milliliter (ml). Give 2.5 ml by mouth every 2 hours as needed for pain related to palliative care.R61's Physician order dated 11/13/25, identified Acetaminophen Tablet 650 mg. Give 2 tablet by mouth every 4 hours as needed for mild to moderate pain or fever related to palliative care. Limit Acetaminophen to 3250 mg in 24 hours from all sources. Okay to give per rectum if unable to swallow.R61's MHM Pain Evaluation V-4 dated 11/18/25, identified R61 took Morphine Sulfate Oral Solution 10 mg/5ml. Give 2.5 ml by mouth every 2 hours as needed 2-3 times a day for pain and inflammation. R61 stated that he had adequate pain relief and had not needed any use of as needed Acetaminophen. Staff were to continue to monitor for non-verbal/verbal cues of pain and report. R61's physician would be updated regarding changes in pain.R61's Medication Administration Record (MAR) dated November 2025, identified the following:- On 11/19/25 at 12:38 a.m., R61 was administered Morphine Sulfate 10 mg/5 ml. 2.5 ml by mouth for a pain rating of 4. The dose was identified as E for effective but did not identify time of result.- On 11/19/25 at 2:08 a.m., R61 was administered Acetaminophen 650 mg for a pain rating of 4. The dose was identified as E for effective but did not identify time of result.- On 11/19/25 at 6:20 a.m., R61 was administered Morphine Sulfate 10 mg/5 ml. 2.5 ml by mouth for a pain rating of 4. The dose was identified as E for effective but did not identify time of result.- On 11/19/25 at 10:36 a.m., R61 was administered Morphine Sulfate 10 mg/5 ml. 2.5 ml by mouth for a pain rating of 5. The dose was identified as E for effective but did not identify time of result.R61's Nursing Progress Notes dated 11/19/25 through 11/20/25, failed to identify R61's pain and/or pain interventions attempted to control R61's pain.During an observation on 11/19/25 at 10:23 a.m., R61 had turned on his call light.- At 10:30 a.m., nursing assistant (NA)-A donned a disposable gown, gloves and surgical mask. Before NA-A could enter R61's door, NA-C approached NA-A and stated, tell him the nurse is aware but is in another room and will be there as soon as she can. NA-A entered R61's room, turned off R61's call light and asked what she could help him with. R61 asked if he could get his pain medicine. I asked 40 minutes ago, and it still hasn't come. NA-A explained to R61 the nurse was in another room but R61 was next on the list. R61 was lying in bed with his head of bed (HOB) elevated approximately 30 degrees with his face grimacing and stated Why is it taking so long? Don't they want me to have it? NA-A reassured R61 that the nurse would be in, and NA-A would remind her again. NA-A exited R61's room. NA-A did not offer R61 any type of nonpharmacological pain interventions such as repositioning.- At 10:36 a.m., R61 stated he had mid chest pain and rubbed at his sternum with his right closed fist. R61 is sweating and face grimacing. R61 stated it's a 5 on a 0-10 scale. It's like heartburn and R61 again rubbed at his sternum. I cough, it just burns and it's just shitty. I had trouble getting the pain medicine last night too. They don't like giving it to me but when I was in the hospital, they said it was a small dose of morphine, and I could get as much as I want. I don't want to abuse it, but it makes it, so I don't cough and I'm not so miserable.- At 10:41 a.m., licensed practical nurse (LPN)-C donned a gown, gloves and surgical mask and entered R61's room with a medication cup with a blue colored liquid medication and another medication cup with a medication tablet. LPN-C greeted R61 and stated she had R61's liquid morphine and a muscle relaxer. LPN-C handed the medications to R61 who took them with a sip of water. R61 asked LPN-C why it took so long, and LPN-C stated she was only told R61 was asking for pain medications a few minutes prior. R61 stated he told a NA, the tall one, and was told the nurse knew an hour prior. LPN-C stated she was unsure if R61 could have had a dose of pain medication an hour earlier but came as soon as she was aware. R61 then verbalized his medication orders and stated R61 could have a dose every 2 hours and R61 kept track. R61 then stated staff would not give him medication during the night either. LPN-C stated the night nurse administered R61 a dose of morphine shortly after midnight and R61 stated, yes, that was true, but he asked for it again at approximately 4:00 a.m. LPN-C then stated the night nurse had been busy with other residents who required transfer to the emergency department and was really busy. R61 then turned to look out the window and stated, that's no excuse.During an interview on 11/19/25 at 10:56 a.m., LPN-C stated NA-A had told LPN-C that R61 was requesting pain medicine a few minutes ago. LPN-C stated she understood the nursing assistants were busy, but staff did have walkies that they could use to communicate. However, there were a lot of agency staff, and not all staff would wear/use a walkie. Additionally, there were not enough walkies for all staff. [NAME] stated [NAME] only told me a few minutes ago. I get their busy and we do have walkies. We have a lot of agency staff and not everyone will wear a walkie. LPN-C stated she did not work second floor frequently but knew R61 received pain medication pretty frequently. LPN-C was unsure what the frequency of R61's order and would have to review his chart. LPN-C then stated she expected the nursing assistants to report pain right away to help with pain control. R61 had been on hospice but R61 had wanted to start physical therapy, and hospice was discontinued earlier that day. However, R61's physician orders remained the same as previous. I can't provide pain medication without being told.During an interview on 11/19/25 at 11:00 a.m., NA-A stated she told LPN-C right away when R61 asked. NA-A stated R61 had asked NA-C prior. During an interview on 11/19/25 at 11:01 a.m., NA-C stated R61 did ask for pain medication, however, LPN-C was busy. NA-C stated she always waited until she could tell a nurse a resident request face to face because the nurses were busy. The nurses could be in another resident room or doing dressing changes. NA-C did not want to bother them if they were doing something sanitary.During an interview on 11/19/25 at 3:30 p.m., LPN-B stated she always wore a walkie for the nursing assistants to be able to tell her resident requests/concerns, especially on night shift. There was one licensed staff for both floors and a nursing assistant on each floor. However, so many walkies had gone missing there weren't enough to go around. The nursing assistants usually came to find her right away when a resident was requesting pain medicine and LPN-B expected them to do so. When a resident complains of pain, LPN-B would either say she would be able to come to the resident in a few minutes or go right away because residents in pain should not wait. A resident should never wait for pain control.During an interview on 11/20/25 at 7:56 a.m., LPN-A stated she had looked for a walkie that morning but could not find one and stated that's why she was keeping the medication cart at the nurses' desk as much as possible so LPN-A could see what was going on and be available. It was a pretty usual thing to not have a walkie. LPN-A pointed to the walkie charging station sitting on the nurse's desk. There are 6 slots and all empty. LPN-A stated nursing assistants should let her know of resident requests for pain medicine as soon as possible.During an interview on 11/20/25 at 8:00 a.m., NA-B and NA-D were sitting at the nurses' desk in front of the walkie charging station. NA-B was wearing a walkie, but NA-D was not. NA-B stated there just wasn't enough. Staff forget and take the walkies home; they get broken and sometimes they all end up on another floor. Staff just talked to each other. NA-B shrugged and stated it's been like that for a bit. Well, probably a couple months. If staff were in a room, didn't have a walkie and could not leave, staff could turn on the bathroom light and start yelling for help. Then pray that works. If a resident was asking for pain medicine and NA-B didn't have a walkie, she would look for the nurse right away and tell them face to face. During a telephone interview on 11/20/25 at 1:30 p.m., LPN-D stated she had worked with R61 the night shift of 11/18/25. LPN-D had given R61 a prn dose of morphine early in the shift and when R61 asked for it again it was 30-45 minutes too early. LPN-D administered a PRN dose of Tylenol instead. R61 did ask if he took the Tylenol if he could still have the morphine when it was time. LPN-D told R61 yes but when LPN-D peeked in his doorway R61 appeared to be asleep so LPN-D did not approach R61. LPN-D marked the dose of Tylenol as effective, and LPN-D didn't tell R61 she was going back so didn't think R61 was waiting for her. LPN-D believed R61 would turn on his call light again if he still needed it.During an interview on 11/19/25 at 3:43 p.m., LPN care coordinator (CC)-B stated R61 complaints of pain were unacceptable. A resident should never have to wait for pain medication. In R61's situation, the morphine was to help relieve R61's breathing and the cough/pressure R61 felt with that. The NA should have either found another nurse and/or CC-B to help the R61 if the NA felt she couldn't say anything over the walkie. CC-B expect residents to receive pain control timely.During an interview on 11/19/25 at 4:05 p.m., the director of nursing (DON) stated she was unaware there were not enough walkies for all staff to be able to communicate with each other and the DON expected nursing assistants to report resident requests for pain medication immediately to provide adequate pain control.The facility policy Pain Control Protocol revised 3/23/23, identified the facility was to ensure that residents with pain or at risk for pain, have an effective pain management plan in place with individualized interventions that are consistent with the resident's goals for comfort. Staff were directed to provide the following:Treatment/Management1. With input from the resident and/or resident representative, the provider and staff will establish goals of pain treatment, for example, freedom from pain with minimal medication side effects, less frequent headaches, or improved functioning, mood, and sleep.2. Nursing will evaluate for appropriate non-pharmacologic interventions to address the individual's pain.3. Provider will order appropriate medication interventions to address individuals' pain.4. The staff will evaluate and report how much and how often the resident utilizes PRN pain medication.a. Depending on severity and location of pain, the provider may start with PRN doses or supplement routine doses with PRN doses for breakthroughpain.b. If there are more than occasional PRN analgesic utilization (and depending on the success of nonpharmacological interventions), the provider may consider changing to regular administration of at least one analgesic with another medication for PRN use, increasing the routine dose of an existing analgesic or switching to another analgesic.5. Staff will provide the elements of a comforting environment and appropriatephysical and complementary interventions; for example, local heat or ice, repositioning, massage, and the opportunity to talk about chronic pain.6. Resident's plan of care will reflect pain management needs.7. For the individual who is receiving opioid analgesics, the provider may order a regimen of laxatives and other measures to prevent constipation.

Based on observation, interview, and document review the facility failed to make sure all medications in a resident room had active orders and were not expired. This affected 1 of 1 (R29) resident reviewed for medication storage.Findings include R29's quarterly Minimum Data Set (MDS) dated [DATE], indicated R29 was cognitively intact. Diagnoses included heart failure, depression and anxiety. R29's care plan lacked documentation related to creams at bedside and labeling requirements. R29's active order summary report dated [DATE], indicated an order for Diclofenac Sodium external gel 1% and Clotrimazole external cream 1%. The active order summary report lacked orders for any other medicated creams or lotions. On [DATE] at 4:18 p.m., a white basket with several tubes of medicated creams was observed in R29's room on the counter next to the bathroom and R29's other care items. On [DATE] at 2:40 p.m., a white basked with several tubes of medicated creams was again observed in R29's room on the counter next to the bathroom. On [DATE] at 2:43 p.m., registered nurse (RN)-A entered R29's room and confirmed there was a white basket on R29's counter that held several tubes of medication creams and powders. Several of the tubes had labels that were worn off and unable to read most of the label. RN-A went through the basked and found the following medications with the connected expiration dates in R29's room: Ketoconazole cream, expired [DATE],Triamcinolone acetonide cream, expired [DATE]Clotrimazole and betamethasone cream, expired [DATE]rosac cream expired, [DATE]hydrocortisone 2.5% cream, expired [DATE]Santyl cream, expired [DATE],Nystatin powder, expired [DATE]During an interview on [DATE] at 2:46 p.m., RN-A stated a family member must have brought all of the medicated creams and powders in for R29. When families bring in medications, they are told to bring them to the nurses' station to make sure they are still good to use and there is a current order for the resident to use the medicated creams. RN-A stated she was not aware they were in the room but did state obviously the front-line staff knew since the creams were sitting with R29's other daily care items. The nursing staff should have been reviewing the creams to make sure there were active orders to utilize the creams and the creams were not past their expiration dates.During an interview on [DATE] at 9:18 a.m., the consultant pharmacist (CP) stated it was important for facility staff to make sure all medications a resident had and received had active orders and were not expired for the safety of the resident. When medications are not ordered or expired, they could cause adverse reactions to the resident or could cause the resident to actually receive double of the same classification of medication.During an interview on [DATE] at 10:18 a.m., the director of Nursing (DON) stated all staff were expected to track current orders and expiration dates for all medications in a resident room for resident safety.Facility policy Medications Brought to the Facility by a Resident or Responsible Party last reviewed 2025, indicated medications brought into the facility by a resident or responsible party would be used only upon written order by the resident's attending physician, after the contents are verified, and if the packaging met the facility's guidelines. Unauthorized medications would not be accepted by the facility.

Based on interview and document review, the facility failed to ensure the consultant pharmacist recommendations were addressed for 1 of 5 residents (R1) reviewed for unnecessary medications.Findings include:R1's quarterly Minimum Data Set (MDS) dated [DATE], identified she had diagnoses which included diabetes, morbid obesity, heart failure (a chronic condition where the heart can't pump enough oxygen rich blood to meet the body's needs), and pressure ulcer. In addition, R1's MDS identified her as cognitively intact and as receiving insulin injections seven days of the week and receiving anti-psychotic medication.R1's care plan dated 12/20/24, identified a potential for psychotropic adverse drug reactions related to daily use of psychotropic medication. Interventions included monitoring for adverse drug reactions, medication review by pharmacist and medical provider, and updating the medical provider of efficiency of medications. R1's Order Summary Report identified the following order: 10/24/24, quetiapine 25 milligrams (mg) give 0.5 tablet by mouth at bedtime for sleep related delirium due to know physiological condition A review of R1's monthly medication reviews identified the following:10/15/25, This resident has an order for QUETIAPINE TAB 25MG - GIVE ONE-HALF TABLET BY MOUTH EVERY NIGHT AT BEDTIME with a start date greater than 3 months without a recent documented GDR attempt. RECOMMENDATION. Unless clinically contraindicated, could we please consider a Gradual Dose Reduction (GDR) at this time. If not, due to low dose, please document the benefits of current doseThere was no documented response from the provider on the form. 9/11/25, This resident has an order for QUETIAPINE TAB 25MG - GIVE ONE-HALF TABLET BY MOUTH EVERY NIGHT AT BEDTIME with a start date greater than 3 months without a recent documented GDR attempt. RECOMMENDATION. Unless clinically contraindicated, could we please consider a Gradual Dose Reduction (GDR) at this time. If not, due to low dose, please document the benefits of current dose Prescriber's Response: To be addressed by elder care at next 60 day dated 10/17/25A review of R1's elder care visit dated 11/13/25, identified R1 as taking quetiapine 25 mg tablet take 0.5 tablet by mouth at bedtime. Indications: Delirium, trouble sleeping. The note did not address the pharmacy recommendation to consider a gradual dose reduction of the quetiapine. During an interview on 11/20/25 at 11:52 a.m., the consultant pharmacist verified she had not received a response to her request to consider a gradual dose reduction from the September or October requests. She was not aware of how the facility forwarded the requests to elder care. During an interview on 11/20/25 at 12:16 p.m., with licensed practical nurse (LPN) and care coordinator (CC)-B, CC-B stated she did not know how elder care was involved in gradual dose reductions when they were referred to them. During an interview on 11/20/25 at 12:31 p.m., the director of nursing (DON) stated the gradual dose reduction was referred to elder care and whomever was going to be completing the 60-day elder care review should have been informed of the need to address the gradual dose reduction. The DON reviewed the 60-day elder care note and was unable to see any evidence it was addressed. The Consultant Pharmacist Services Provider Requirements dated 5/2022, identified the pharmacist would conduct a monthly medication review at least monthly, incorporating federally mandated standards of care in addition to other applicable professional standards as outlined in the procedure for medication regimen review and would make recommendations to medical providers.

Based on observation, interview, and document review the facility failed to correctly label a prescribed medication for 1 of 1 resident (R29) reviewed for medication labeling.Findings include R29's quarterly Minimum Data Set (MDS) dated [DATE], indicated R29 was cognitively intact. Diagnoses included heart failure, depression and anxiety. R29's care plan lacked documentation related to creams at bedside and labeling requirements. R29's active order summary report dated 5/14/25, indicated an order for Diclofenac Sodium external gel 1%, apply 4 grams (gr) to the lower back topically three times a day. On 7/16/25, an order for Diclofenac Sodium external gel 1%, apply 2 gr to shoulder was added. On 11/17/25 at 4:18 p.m., a tube of Diclofenac Sodium external gel 1% was observed on R29's nightstand. there was no labeling on the tube to indicate the resident name, directions for use, open date of expiration date. On 11/19/25 at 2:40 p.m., a tube of Diclofenac Sodium external gel 1% was again observed on R29's nightstand. there was no labeling on the tube to indicate the resident name, directions for use, open date, or expiration date. On 11/19/25 at 2:43 p.m., registered nurse (RN)-A entered R29's room and confirmed the Diclofenac Sodium external gel 1% did not have any label on it to indicate the resident name, directions for use, open date, or expiration date During an interview on 11/19/25 at 2:43 p.m., RN-A stated any medication left at the bedside should have a label on it to indicate the right resident, right dose, right medication, right time and directions on use. There should also be an open date and an expiration date.During an interview on 11/20/25 at 9:18 a.m., the consultant pharmacist (CP) stated any medication left at bedside should have a label on it to indicate the right resident, right dose, right medication, right time and directions on use. There should also be an open date and an expiration date. Labeling is done for resident safety, so staff are aware the correct way to use.During an interview on 11/20/25 at 10:24 a.m., the director of nursing (DON) stated all medication at bedside should have a label on it to indicate the right resident, right dose, right medication, right time and directions on use. There should also be an open date and an expiration date for resident safety. The DON stated Diclofenac was a stock medication and was not aware staff could make their own label if pharmacy would not provide a label. Facility policy Medication Ordering and Receiving from Pharmacy/ Medication Labels dated 5/22, indicated a label would be affixed to the outside of the prescription container. Floor stock medications [are/may be] labeled as floor stock or house supply and kept in the original manufacturer's container (See IC8: HOUSE SUPPLIED (FLOOR STOCK) MEDICATIONS). The manufacturers or pharmacy's label should include the following:1) Medication name2) Medication strength3) Quantity4) Accessory/auxiliary instructions5) Lot number6) Expiration date7) Manufacturer and/or distributor

Based on observation, interview, and document review the facility failed to arrange dental services for a resident with broken teeth and possible cavities. This affected 1 of 2 (R44) residents reviewed for dental concerns.Findings include:R44's quarterly Minimum Data Set (MDS) dated [DATE] indicated R44 had moderative cognitive impairment. Diagnoses included alcohol dependence and delirium.R44's Oral/Dental Evaluation form dated 11/29/24, indicated there was plaque or debris in localized areas between the teeth. The form also indicated R44 had teeth broken and appears to have cavities. Halitosis (bad breath) was also present. R44's electronic medical record was reviewed from 11/29/24 to 11/19/25 and lacked documentation R44 was referred to dental for evaluation related to broken teeth and possible cavities. During an observation on 11/17/25 at 5:18 p.m., R44 was observed to have two broken teeth on the front lower tooth line. There were also areas of black and brown on various parts of his tooth to possibly could have been cavities. During an interview on 11/18/25 at 3:48 p.m. family member (FM)-D stated R44 had broken teeth since admission to the facility. FM-D was not aware R44 had possible cavities. FM-D stated the facility had not reached out to him to see if a dentist needed to see R44 related to the broken teeth or possible cavities since admission to the facility. During an interview on 11/19/25 at 10:18 a.m., health unit coordinator (HUC) stated when a resident needed dental services, staff reported it to her. At that time the HUC would send all appropriate information to the dental group to get schedule for a dental visit. No staff had ever reported R44 needed to see a dentist since admission to the facility.During an interview on 11/19/25 at 2:43 p.m., registered nurse (RN)-A stated clinical managers performed the oral/dental evaluation forms every quarter when the MDS is due. If there were broken teeth the resident or resident representative would be notified a dental referral would be made. the HUC would then be notified so the resident could be scheduled for a dental evaluation visit.During an interview on 11/20/25 at 9:56 a.m., the director of nursing (DON) stated an expectation staff would place dental referrals for any resident that had dental concerns that needed evaluation by the dentist such as broken teeth or possible cavities.The facility dental policy was requested but not provided.

Based on interview and document review the facility failed to establish a process for antibiotic review in order to determine appropriate indications and resistance for use of an antibiotic for 1 of 1 resident (R3).Findings include:R3's Quarterly Minimum Data Set (MDS) dated [DATE], identified R47 had a mild cognitive impairment and had diagnoses that included Parkinson's Disease, visual hallucinations, anxiety, and dementia.Cognitive Loss/Dementia Care Area Assessment (CAA) dated 3/5/15, identified R3 triggered for Cognitive Loss CAA on most recent assessment related to R3's BIMS score of 13. Per staff, R3 had short term memory deficits and was aware that she was in a nursing home. R3's cognitive skills for daily decision-making skills were moderately impaired. R3's diagnoses included Parkinsons Disease, atrial fibrillation (irregular heartbeat), congestive heart failure (CHF), Adult Failure to Thrive, and Hypertension (high blood pressure). R3's husband and daughter assisted with decision making. R3/family plan for long term placement; R3 was admitted to hospice services today. Social services would continue to be available to R3. Proceed to Care Plan.Care plan revised 12/3/25, identified alteration in elimination exhibited by urine and bowel incontinence, need for occasional straight catheterizations, Parkinson's Disease, adult failure to thrive, weakness and abnormalities of gait and mobility. Staff were directed to provide the following: Assist of 1 for toileting. Provide assistance with peri-cares morning, bedtime and as needed.Provide incontinence products and assist to change as needed.Monitor bowel movements as they occur. Administer bowel medications as ordered. Toileting plan: offer toileting to resident every 2-3 hours, and after meals.MHM Target Behavior Form dated 9/26/25, identified excessive call light usage. Yelling toward staff members. Staff were to provide redirection and reassurance. Talk with R3 about the Vikings football team. Offer R3 one on one time.R3's Physician order dated 11/18/25, identified Ciprofloxacin HCl Oral Tablet 500 MG (Ciprofloxacin HCl) (An antibiotic) Give 1 tablet by mouth two times a day for urinary tract infection for 3 Days.R3's Consultant Pharmacist Note dated 11/19/15 at 8:16 p.m., identified the pharmacist identified no irregularities during R3's monthly medication review. R3's Nursing Progress Notes identified the following:On 11/3/25 at 3:05 a.m., R3 was on her call light numerous times. R3 appeared to be confused at times saying staff needed to change her body instead of brief. R3 also stated to this writer R3 feared falling into the black hole that was next to her recliner. R3 also told staff R3 believed she was sitting at the edge of her bed when R3 was in her recliner. On 11/4/25 at 9:58 p.m., R3 was convinced that staff were outside of her room, talking about her and R3 did not want to put her call light on. On 11/7/25 at 1:30 a.m., R3 was awake so far that shift, yelling hello, is anyone out there? R3 was asking the same questions to different staff, what time was it, where was the remote, can you sit my head up a little? R3 had received as needed dose of Seroquel (an antipsychotic medication used to treat various mental health conditions). Will continue to monitor.On 11/14/25 at 1:47 p.m., a urinalysis (a set of tests that looks at the appearance of your pee (urine) and checks for blood cells, proteins and other substances in it. You provider might use it as a routine screening test or to look for signs of infection, kidney or liver disease, diabetes or other health conditions.) was collected. Light yellow clear urine as output. Will be taken to Lab. However, the note failed to identify R3's symptoms and/or why the urinalysis was collected. On 11/14/25 at 8:16 p.m., R3's urinalysis results were received. Clear yellow urine negative for glucose, ketones, protein, nitrates but noted a small leukocyte esterase. Also noted 30-50 white blood cells (WBCs) and few squamous epithelial cells. Will update hospice of results. However, the note failed to identify R3's symptoms. On 11/16/25 at 6:16 a.m., R3 used her call light excessively throughout night. R3 was given an as needed dose of Dilaudid (an opioid pain medication) as well as toileted and fluids offered with repositioning. However, the note failed to identify R3's symptoms.On 11/17/25 at 9:47 a.m., R3's urine culture results were received and noted 50,000- 100,000 cfu/100,000 cfu/ml Proteus mirabilis (a Gram-negative bacterium commonly associated with urinary tract infections). Will update MD and hospice accordingly.During an interview on 11/17/25 at 7:06 p.m., R3 stated she was just told yesterday she has a urinary tract infection (UTI). R3 stated she didn't have any symptoms of a UTI and denied burning, urgency or discomfort. My daughter said I had attitude changes. R3 stated an antibiotic had been started. During an interview on 11/18/25 at 1:53 p.m., licensed practical nurse (LPN)-C stated, normally, she would get a set of vitals, and try to do an assessment and nursing note when a resident complained of not feeling well or had symptoms of a UTI. LPN-C would then let the nurse manager know what she found and, more than likely, would collect a UA if it could be a UTI. The nurse manager would contact the provider. LPN-C stated R3 did not exhibit symptoms of a UTI. R3's daughter requested it and had said R3 was acting like she was getting a UTI a couple day prior. R3 had been acting normally LPN-C's shift when LPN-C collected the UA. R3 had no fever and no pain with urination. LPN-C stated, normally, she would monitor a resident with complaints of confusion and let the nurse manager know. That day, LPN-C did let the nurse manager know R3's daughter was requesting a UA and the decision to collect a UA was from the nurse manager. LPN-C stated she had only worked with R3 one shift since the UA collection, but R3 was acting her usual self then too. LPN-C did not enter a nursing note because she believed the nurse manager would do so. I can only think that because R3 really wasn't showing symptoms and it was R3's daughter's request, I didn't think it was needed. During an interview on 11/18/25 at 2:26 p.m., LPN-E stated when a resident complained of not feeling well, LPN-D would check them: what's their mental status, vitals, do they have any as needed medications, then notify the nurse manager and enter a nursing progress note. LPN-E would enter everything she did into the nursing progress note: what questions she asked the resident etc. and the follow up; even the conversation with the nurse manager. Staff had to ask the provider every time for a UA. The clinical manager completed an order on paper. LPN-E collected and labeled the urine sample, then it was taken to the lab. writes the order on paper. After that, it's taken care of by the nurse manager. I collect the UA and put the name label on it, and it gets taken to the lab. After that, the nurse manager takes care of it. R3 had a history of UTI but LPN-E stated she was unaware R3 had a UA completed nor that R3 was on an antibiotic. During an interview on 11/19/25 at 3:43 p.m., the LPN care coordinator (CC)-B stated there was an interdisciplinary team that reviewed resident conditions and CC-B was not familiar with all the residents. CC-B stated she would need to talk to the DON about R3. During a telephone interview on 11/20/25 at 9:49 a.m., the consultant pharmacist stated she did review R3's physician order for Ciprofloxacin on 11/19/25 but was pleased to see the length of treatment was 3 days versus 7 days. The consultant pharmacist stated she did see there was a UA result, and the consultant pharmacist did look for positive nitrites which would indicate an infection was brewing. R3's was negative but R3 did have a history of UTI. The consultant pharmacist did review R3's nursing notes, but staff did not always document thoroughly either. It's a small, tight knit community and the consultant pharmacist could see the providers performing a UA per the family's request. However, from an antibiotic stewardship standpoint, confusion was not an appropriate indication. Documentation was a strong factor during the monthly medication review process because it provided a full picture of what was going on with that resident and if the antibiotic was appropriate. During an interview on 11/20/25 at 10:06 a.m., registered nurse (RN)-A stated when a staff member contacts her regarding a resident, RN-A asked what the staff had experienced with the resident. What does their urine look like? Are they voiding? Any other symptom the resident was having, and RN-A updated the resident's provider either with a phone call or a fax. RN-A then completed a nursing note or she would tell the staff member to do a note. RN-A stated for R3, RN-A updated the hospice nurse that afternoon and requested a UA verbally. RN-A did not do a condition note. RN-A stated a family request for UA was not an appropriate reason. RN-A stated she was told R3 was yelling, using the call light and had been in the bathroom frequently, however, RN-A did not document this nor does R3's medical record reflect R3's symptoms. During a telephone interview on 11/20/25 at 11:29 a.m., RN-B stated the facility requested R3 have a UA because R3's daughter was complaining of R3 having increased confusion and behaviors for 3 days. R3 had a history of UTI and R3's daughter insists that R3 shows no other symptoms for UTI other than confusion. RN-B stated she had never attempted to educate R3 and/or R3's daughter regarding UTI symptoms and/or appropriate antibiotic treatment. We usually treat because that is the patient and family's wishes.During an interview on 11/20/25 at 11:54 a.m., the director of nursing (DON) stated R3's daughter had requested to have a UA done because she was noting confusion in R3. R3's daughter believes confusion was related to the UTI, however, R3 did exhibit behaviors and confusion related to her diagnoses and not necessarily to a UTI, but R3's daughter insisted it was an increase. In that situation, I would expect a resident with a history of UTI who was experiencing symptoms that the symptoms were clearly documented and obtain a UA if appropriate and ordered by the provider. Staff were expected to provide a full picture to the provider and document that as well. Regarding antibiotic stewardship, R3 did not meet the criteria for a UTI, however, the DON received a lot of resistance from providers when she questions the appropriateness of antibiotic orders. The facility was going to obtain the assistance of the medical director to override the inappropriate orders. With R3, the order was received on yesterday, 11/19/25, and I will contact the provider today, 11/20/25, to discuss the order to ensure she really needs the antibiotic. Normally, the DON would have requested an antibiotic timeout, requested more monitoring and/or push fluids to watch symptom management. Overall, more antibiotic resistance was being seen and the only way to minimize that was to have a good antibiotic stewardship program to ensure appropriateness. With R3, staff did wait for the UC result and the facility's rounding provider deferred to the hospice provider because it was comfort based. The facility's Antibiotic Stewardship Program revised 11/2024, identified prior to calling a provider to communicate a suspected infection, the nurse will obtain and have the following information available:Signs and symptoms of suspected infection (based on McGeer's criteria)History of present illnessCurrent medication listAllergiesLast INR results (if currently receiving warfarin)All pertinent lab, imaging or test resultsAppropriate indications for antibiotic use include:Criteria met for clinical definition of active infection or suspected sepsis; andPathogen susceptibility, based on culture and sensitivity, to antimicrobial (or treatment begun while culture is pending. Empirical use of an antibiotic on clinical criteria may be appropriate.

Based on observation, interview and document review, the facility failed to ensure ceiling tiles were maintained in a safe manner for 1 of 1 resident (R49) reviewed for environment.Findings include:R49's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition. Diagnoses included hypertension, hyperlipidemia and renal insufficiency. During observation on 7/24/25 at 11:08 a.m. R3's bathroom had a missing ceiling tile that was over the toilet. There was a wet towel draped across the hole and drooping down, exposing the area above the ceiling tiles. There was noted free standing water on the toilet itself. The white towel was stained with brown discoloration along with the middle areas saturated with moisture.During an interview on 7/24/25 at 11:10 a.m. R3 stated the ceiling tile has been missing and the towel in place for at least a month. He was told it was because of a leak of some kind from the room on the second floor, right above R3's room.During an interview on 7/24/25 at 12:18 p.m., housekeeper (HSK)-A stated the missing ceiling tile and towel over the tile has been that way for at least a month. There was some kind of leak in the room above this. It must still be leaking because when the room was cleaned this morning there was free standing water and the toilet paper on the back of the toilet had to be thrown away because it was soaked with water. During an interview on 7/24/25 at 1:28 p.m., the maintenance director (M)-A stated he was not sure how long the ceiling tile had been that way in R3's room. There was a leak in the toilet ion the room above R3's room and that is where the water had come from. The leak had been fixed, and the towel was there to see if the leak was still there. During an interview on 7/24/25 at 12:40 p.m., the infection preventionist (IP) stated anytime wet towels were left hanging in rooms and there was free standing water in the room there was an increased risk of infection and other illnesses to be present. During an interview on 7/24/25 at 2:06 p.m., the regional director of operations (RDO) stated water leakage, and a damaged ceiling would lead to the resident being moved, water cleaned up, and the problem fixed prior to letting any resident back in the room. A policy for environmental services water leakage was requested but not provided.

Based on interview and document review the facility failed to ensure accurate doses of buprenorphine (an opioid pain medication) were administered to 1 of 3 residents (R1) investigated for a significant medication error.Findings include:R1's face sheet dated 7/24/25 indicated diagnoses included pathological fracture in neoplastic disease of left femur (left leg upper bone), malignant neoplasm of esophagus and aftercare for joint replacement.R1's medical record indicated R2 was cognitively intact.R1's physician orders dated 7/16/25, indicated an order for buprenorphine HCL sublingual 2mg tablet. Give 1mg (half a tab) under tongue three times a day.A picture of R1's medication card dated 7/16/25, showed an individual bubble packed 30-day card with 24 whole pills, one in each bubble. There were also 6 slots with holes to indicate 6 pills had been removed. The order on the card identified buprenorphine sub. 2 milligrams (mg). Place half a tab under tongue three times a day. Pharmacy to send full 2mg tablets. Nursing to cut to administer 1mg three times a day.R1's narcotic sign-out book page not dated, indicated an order of buprenorphine 2mg give half a tablet three times a day. The page indicated on 6 different occasions R1 received a whole tablet instead of the half tablet ordered.During an interview on 7/24/25 at 1:05 p.m., licensed practical nurse (LPN)-A stated if a whole pill was signed out there would be a dot with a line under it. If there was a half a tablet removed there would be 1/2 tab document in amount given and then a note which would indicate if the other half was thrown away or saved for the next dose. LPN-A reviewed R1's narcotic medication sign out sheet and stated the documentation showed R1 received one whole tablet each time a dose was given. During an interview on 7/24/25 at 1:44 p.m. the acting director of nursing (DON) stated nursing needed to follow the five rights (right medication, patient, dose, route and time). A half tablet should be documented as 1/2 and a whole tablet given would be documented as a dot with a line under it.Facility policy Medication Administration- General Guidelines last reviewed 2025, indicated nursing would follow the five rights and would triple check those rights during the medication administration process.

Based on observation, interview and document review, the facility failed to properly assess, care plan, and ensure the correct sling was used during transfers for 1 or 1 resident (R1) reviewed for mechanical lift transfers. The resident was transferred using a ceiling lift with a reported toileting sling (a sling which does not cover the buttocks) of unknown size, fell out of the sling during the transfer, and sustained a laceration to the back of head. The deficient practice was identified as an immediate jeopardy (IJ) situation, however, the provider had implemented corrective action prior to the investigation, therefore, the deficiency was issued as past non-compliance. The IJ began on 12/22/24 at 8:10 p.m., when R1 was transferred with a ceiling lift using a reported toileting sling of unknown size. R1 slipped out of the sling during the transfer which resulted in R1's head hitting the ground and sustaining a laceration to the back of the head. The administrator and director of nursing (DON) were informed of the IJ on 12/31/24 at 4:45 p.m. The facility implemented corrective action on 12/23/24, prior to the start of the survey, therefore, was past non-compliance. Findings include: R1's incident report from 12/22/24, identified R1 was admitted to the facility on [DATE], with a primary diagnosis of chronic combined systolic and diastolic (congestive) heart failure (heart unable to pump enough blood to organs) and nonrheumatic aortic stenosis (narrowing of heart valve). R1's last brief interview for mental status (BIMS) was on 11/13/24 which showed moderate cognitive impairment. Incident report described the accident as follows: NAR was transferring resident via ceiling lift from wheelchair to bed when resident put her arms up which caused her to slide through. LPN stated she walked in, and resident was on the floor. It was noted resident had a bump that was bleeding on back of head, vitals stable, A&O, eyes equal and reactive to light, pain level 5/10, pain medication given. Pressure bandage placed on the back of head. Hospice and family notified. R1's significant change Minimum Data Set (MDS) dated [DATE], identified R1 required substantial/max assist with transfers. R1's care plan reviewed on 12/30/24, identified assist with movement in and in/out bed A2 (assist of two persons) nonmechanical lift. Use [NAME]/ceiling lift as needed if resident is unable to stand in non-mechanical stand aide. Assist with transfers requires minimum assist from elevated recliner for sit/stand into nonmechanical stand aid for transfers. R1's progress note dated 12/22/24 at 8:34 p.m., identified resident has not been standing up for lift, she can't lift herself to stand. R1's progress note dated 12/22/24 at 8:37 p.m., identified resident upgraded to ceiling lift due to not standing in the stand aid. Correct type of sling and size was used during transfer. Resident was in ceiling lift being transferred into bed from wheelchair. Resident was being lifted out of wheelchair and resident lifted arm straight up and fell to the floor. During interview on 12/30/24 at 12:38 p.m., R1 stated they dropped me. R1 explained during a recent transfer using a ceiling lift she slipped out of the sling and hit her head on the ground. R1 stated her head hurt after the fall but was unable to quantify her pain level. During interview on 12/30/24 at 1:13 p.m., nursing assistant (NA)-A confirmed being present during R1's fall on 12/22/24. This was NA-A's second day working at the facility and first time working with R1. NA-A was instructed to transfer R1 from wheelchair to bed. R1's care sheet identified R1 used a non-mechanical lift for transfers. Due to being unfamiliar with R1, NA-A confirmed R1's transfer status with another CNA and was instructed to use the ceiling lift due to R1 having weakness in the evenings. NA-A was informed R1 tends to flail during transfers with ceiling lift. NA-A placed a half sling on R1 which was in R1's room, began to raise R1 from wheelchair, R1 began to flail, and slipped out of the sling. R1's lower body remained in the sling while R1's upper body fell to the ground. R1 hit her head on the ground during the fall and NA-A reported the fall to a nurse. During interview on 12/30/24 2:28 p.m., NA-B stated all residents who use a sling for transfers have their slings in their room. If uncertain about what sling size or type to use, would consult the care sheet. During interview on 12/30/24 at 2:33 p.m., licensed practical nurse (LPN)-A stated if there was change in a resident's transfer status, she would report this to nursing management. If nursing management was not available and it was a safety issue she would upgrade the resident's lift/sling type. She would select the correct sling by consulting the sling size chart(s) at the nursing station, write a progress note, and report the change to nursing management. Each resident who uses a sling should have a sling in their room. During interview on 12/30/24 at 2:40 p.m., registered nurse (RN)-A confirmed R1's care plan and progress note from 12/22/24 did not list the type or size sling to use for transfers. RN-A was unsure if the sling type or size was listed in the medical record of any resident who used a sling. RN-A stated R1 was assessed by the director of nursing (DON) post fall and was upgraded to a full body sling. During interview on 12/30/24 at 3:11 p.m., DON stated any nursing staff can upgrade a resident from a non-mechanical to mechanical lift for safety. To select the correct sling, nursing staff are expected to use the manufacturers height and weight sling chart(s) posted at the nursing stations and should report any changes in sling/lift use to nursing management. The facility does not use a formal sling assessment form and the specific sling type and size used was not documented in the resident's medical record. The appropriate sling should always be in the resident's room and if staff are unaware what size/type of sling to use they should consult with another staff member and/or the manufactures height and weight chart(s). DON stated R1 had not been using the ceiling lift prior to the fall on 12/22/24 and the use of a sling for R1 should be signed off by a register nurse prior to its continued use. DON reported on 12/23/24 she completed a sling assessment on R1 and determined due to R1's inability to keep arms on the outside of a toileting sling, R1 required a full body sling and the assist of 2 during transfers with the ceiling lift. During interview on 12/31/24 at 8:25 a.m., trained medical aid (TMA)-A stated during an emergency all nursing staff can implement the use of a sling, but only half back slings. An assessment by an RN or physical therapy was needed for a full sling. To implement a sling, the sling charts need to be consulted to determine the correct size and this should be reported to nursing management who document the sling. Any available staff member can obtain a sling from the sling room. During interview and observation on 12/31/24 at 8:58 a.m., NA-C identified as being pool staff and stated slings were always in the resident's room and only facility staff were able to obtain slings. NA-C located the sling in R4's room and identified it was a Guldman, size medium toileting sling. While R4 was in wheelchair, NA-C proceeded to place the back of the sling across R4's back and leg straps under R4's legs. NA-C crossed the leg stapes, moved the ceiling lift towards R4, properly connected the upper and lower body sling strap loops to the ceiling lift. NA-C instructed R4 to keep arms outside of and hold on to sling. NA-C slowly raised R4 from wheelchair and transferred to bed making sure R4's body was in proper alignment prior to lowering the lift. When R4 was fully lowered onto the bed, NA-C removed the sling loops from the lift, moved the sling away from R4's lower body, and pushed the lift a safe distance away from R4 before proceeding with cares. R4 reviewed and determined to be using the proper sling size based on manufactures guidelines. During interview on 12/31/24 at 11:13 a.m., LPN-A confirmed being the nurse who responded to R1's fall on 12/22/24. Prior to the fall, LPN-A had made the determination to upgrade R1 from a non-mechanical lift to the ceiling lift due to weakness. LPN-A did not select the sling size/type and used the sling that was already in R1's room, which was described as not a full body sling of unknown size. LPN-A stated R1 has been having intermittent weakness in the evening and has been using the ceiling lift for a while. As a result of the fall, R1 sustained a laceration to the back of her head which required a pressure bandage and per hospice nurse evaluation did not require stitches. LPN-A stated when selecting what sling to use, she does not take measurements of the resident or reference any manufacturers chart(s) to determine what sling size to use. Sling was selected based on how it fits around the residents back. During follow up interview on 12/31/24 at 11:52 a.m., DON was unaware R1 was using a ceiling lift prior to 12/22/24 and would expect this change to be reported. DON stated there was no way to determine when R1 began to use the ceiling lift unless a progress note was made as expected, but this does not always happen. In response to the fall, the DON stated on 12/23/24, the DON and administration re-assessed all residents who use a sling to ensure the correct size and type was being used. Aside from R1, no change in sling type/size was needed. All direct care staff were required to complete mechanical stands competency prior to the start of next shift. During observation on 12/31/24 from 8:43 a.m. to 11:01 a.m., residents rooms who were required lifts were audited for correct sling size based on size chart at nurses station. The slings in resident rooms were correct based on manufacture chart guidelines. During document review on 12/31/24, signed copies of direct care staff mechanical stands competencies dated 12/23/24 to 12/31/24, outlined how to utilize mechanical stands, including how to apply slings, per manufacturer guidelines and facility policy and procedure. During interview on 12/31/24 at 4:40 p.m., the administrator expected all residents who require a sling for transfers are using the appropriate slings to ensure the safety of the residents and staff. Using an improper sling could result in anything from pinching and being uncomfortable to falls and injury. A policy for mechanical lift and sling use was requested, but not provided. Facility identified they do not have a specific policy but follow manufacturers guidelines. The facility implemented corrective action to prevent recurrence by 12/23/24, when the facility implemented a systemic plan that included the following actions: On 12/23/24 DON completed a sling assessment on R1 and determined a full body sling with the assist of 2 was required during ceiling lift transfers. On 12/23/24, all residents who use mechanical lifts were re-assessed for the correct sling size and type. Starting on 12/23/24 all direct care staff were required to complete a mechanical stand use competency prior to the start of their next shift.

Based on observation, interview and document review, the facility failed to develop a comprehensive person-centered care plan based on the resident assessment which identified the type and size of sling required during transfers for 3 of 3 residents (R1, R3, R4) reviewed for mechanical lift use. Findings include: R1's fall incident report from 12/22/24 identified R1 was admitted to the facility on [DATE] with a primary diagnosis of chronic combined systolic and diastolic (congestive) heart failure (heart unable to pump enough blood to organs) and nonrheumatic aortic stenosis (narrowing of heart valve). R1's last brief interview for mental status (BIMS) was on 11/13/24 which showed moderate cognitive impairment. Incident report identified nursing assistant (NA)-A was transferring resident via ceiling lift from wheelchair to bed when R1 put her arms up which caused R1's upper body to slide through the sling. Licensed practical nurse (LPN)-B found R1 on the floor who was noted to have a bump that was bleeding on back of head. R1 was assessed by hospice nurse and did not require stitches. At the time of the fall, R1 was upgraded to a ceiling lift due to not standing in the stand aide and the correct sling and size were used during the transfer. Specific size and type of sling was not noted. Post fall, the director of nursing (DON) attempted education with the resident on proper body placement when in a sling. Staff was to now use a full body sling and will have 2 staff members presents during transfers. R1's progress note dated 12/22/24 at 8:37 p.m., identified resident upgraded to ceiling lift due to not standing in the stand aid. Correct type of sling and size was used during transfer. Resident was in ceiling lift being transferred into bed from wheelchair. Resident was being lifted out of wheelchair and resident lifted arm straight up and fell to the floor. R1's significant change Minimum Data Set (MDS) dated [DATE], identified R1 required Substantial/max assist with transfers. R1's care plan reviewed on 12/30/24, identified assist with movement in and in/out bed A2 (assist of two persons) nonmechanical lift. Use hoyer/ceiling lift as needed if resident is unable to stand in non-mechanical stand aide. Assist with transfers requires minimum assist from elevated recliner for sit/stand into nonmechanical stand aid for transfers. Care plan failed to identify the type and size of sling to be used with transfers. R3's admission MDS dated [DATE], identified diagnoses of chronic gout, coronary artery disease, hypertension, and arthritis. R3 was identified as dependent on staff for transfers. R3's care plan reviewed on 12/30/24, identified R3 required a ceiling / hoyer lift for transfers. Care plan failed to identify the sling type or size used during transfers. R4's quarterly MDS dated [DATE], identified diagnoses of seizures and arthritis. R4 was identified as dependent on staff for transfers. R4's care plan reviewed on 12/31/24, identified R4 required a ceiling / hoyer lift for transfers. Care plan failed to identify the sling type or size used during transfers. During interview on 12/30/24 at 1:13 p.m., nursing assistant (NA)-A confirmed being present during R1's fall on 12/22/24. NA-A was instructed to transfer R1 from wheelchair to bed. R1's care sheet identified R1 used a non-mechanical lift for transfers. Due to being unfamiliar with R1, NA-A confirmed R1's transfer status with another CNA and was instructed to use the ceiling lift due to R1 having weakness in the evenings. NA-A placed a half sling on R1 which was in R1's room, began to raise R1 from wheelchair, R1 began to flail, and slipped out of the sling. R1's lower body remained in the sling while R1's upper body fell to the ground. R1 hit her head on the ground during the fall and NA-A reported the fall to a nurse. During interview on 12/30/24 2:28 p.m., NA-B stated all residents who use a sling for transfers have their slings in their room. If uncertain about what sling size or type to use, would consult the care sheet. NA-B reviewed R1's care sheet and confirmed it listed the lift type but not sling size or type. During interview on 12/30/24 at 2:33 p.m., licensed practical nurse (LPN)-A stated if there was change in a resident's transfer status or if she upgraded the residents transfer status in an emergency, she would report this to nursing management and write a progress note. LPN-A would use the height / weight charts to select the correct sling. Each resident who uses a sling should have a sling in their room and the sling type should be listed on their care plan. During interview on 12/30/24 at 2:40 p.m., registered nurse (RN)-A confirmed R1's care plan and progress note from 12/22/24 did not list the type or size sling to use for transfers. RN-A was unsure if the sling type or size was listed in the medical record of any resident who used a sling. RN-A stated R1 was assessed by the DON post fall and was upgraded to a full body sling. During interview on 12/30/24 at 3:11 p.m., DON stated any nursing staff can upgrade a resident from a non-mechanical to mechanical lift for safety. To select the correct sling, nursing staff are expected to use the manufacturers height and weight sling chart(s) posted at the nursing stations and should report any changes in sling/lift use to nursing management. The facility does not use a formal sling assessment form and the specific sling type and size used was not documented in the resident's care plan. The care plan includes lift type but not sling type. During observation on 12/31/24 from 8:43 a.m. to 11:01 a.m., resident's rooms who required lifts were audited for correct sling size based on size chart at nurse's station. The slings in resident rooms were correct based on manufacture chart guidelines. During interview on 12/31/24 at 4:40 p.m., the administrator expected all residents who require a sling for transfers are using the appropriate slings to ensure the safety of the residents and staff. Using an improper sling could result in anything from pinching and being uncomfortable to falls and injury. During interview on 12/31/24 at 4:41 p.m., DON indicated a comprehensive care plan was important as it directs resident care and plans to update the care plan(s) to include sling type and size for residents who use mechanical lifts.

Based on interview and document review, the facility failed to ensure a resident with an allergy to shellfish was not served shellfish for 1 of 1 resident (R209) reviewed for food allergies. The resident was fed a dinner containing shellfish, had an allergic reaction, and was sent to the emergency department (ED) for treatment. The deficient practice was identified as an immediate jeopardy (IJ) situation, however, the provider had implemented corrective action prior to the investigation, therefore, the deficiency is issued as past non-compliance. The IJ began on 10/13/24 at 5:15 p.m. when R209 was served, and consumed, shrimp. R209 complained of numbness of the tongue and lips and was sent to the ED for treatment of allergic reaction. The administrator and director of nursing (DON) were informed of the IJ on 10/24/24 at 11:13 a.m. The facility implemented corrective action on 10/14/24, prior to the start of the survey, therefore, was past non-compliance. Findings include: R209's undated face sheet identified he was admitted to the facility on [DATE]. R209's admission note dated 10/9/24, identified he had an allergy to shellfish. R209's care plan dated 10/9/24, identified he had an allergy to shellfish. Progress note dated 10/13/24 at 10:26 p.m., identified R209 had been sent to the emergency room for an allergic reaction to shellfish. Note also identified kitchen staff were notified of the shellfish allergy. Progress note dated 10/14/24, from the culinary director (CD), identified R209's meal ticket was now updated to show allergy to shellfish. R209's shellfish allergy was not on his meal ticket prior to this date. On 10/21/24 at 2:52 p.m., R209 stated he was served shellfish while at the facility, which he was allergic to. On 10/23/24 at 1:02 p.m., R209 stated he had suffered an anaphylactic reaction (severe, life-threatening allergic reaction) after eating shellfish when he was younger that required him to receive epinephrine to counteract his allergic reaction. On 10/23/24 at 10:57 a.m., nursing aide (NA)-A stated resident food allergies should be listed on the resident's meal ticket and in the electronic medical record (EMR) banner. On 10/23/24 at 11:03 a.m., registered nurse (RN)-A described the process for communicating food allergies for new admissions. Health unit coordinator (HUC) receives admission information for new residents and enters allergies into the EMR. The nurse managers verify allergy information in EMR. HUC then completes a dietary sheet and gives to kitchen staff. On 10/23/24 at 11:37 a.m., cook (C)-A stated kitchen staff learn about resident food allergies from the dietary sheet. Kitchen staff then log the resident food allergy in a communication book. Resident food allergies are printed on the resident's meal ticket. On 10/23/24 at 12:00 p.m., CD described how resident food allergies are entered into dietary system. HUC brings dietary sheet to the kitchen staff and kitchen staff note the food allergy in communication book. CD noted staff are expected to review communication book every shift. CD verifies resident food allergies in dietary system, which then produces meal tickets with listed resident food allergies. CD stated she is the only staff that can log in to dietary system and verify/add food allergies. On 10/23/24 at 1:03 p.m., culinary aide (CA)-A stated that floor staff brought the dietary forms down and gave them to culinary staff. The culinary staff would then enter the information into the dietary communication book, so all culinary staff were aware of new residents and their dietary restrictions/allergies. The slip would then go into a bucket for the CD to enter the information into the dietary program. The only person in the kitchen who had access to the dietary program is the CD. On 10/23/24 at 1:04 p.m., NA-B stated resident food allergies are listed on meal tickets and in the resident's care plan. NA-B further stated if the food allergy was not on the meal ticket she would not know about the food allergy unless she looked at the care plan. She further stated she doesn't always check the care plan when passing out meal trays. On 10/23/24 at 1:11 p.m., licensed practical nurse (LPN)-A stated a resident's food allergy would be on the meal ticket and also on EMR banner. On 10/23/24 at 1:12 p.m., RN-B stated resident food allergies should be on meal ticket and in the resident care plan. RN-B further stated she can not log into dietary system to add food allergies to the meal tickets. On 10/23/24 at 1:14 p.m., NA-C stated resident food allergies are typically listed and highlighted on meal tickets. During interview on 10/24/24 at 8:59 a.m., nurse practitioner (NP) stated allergic reactions to food can range from an upset stomach to anaphylaxis. NP also stated if a resident has a history of anaphylaxis to a food allergy, the resident could have the same severe reaction if exposed to that same food allergen. On 10/23/24 at 3:58 p.m., the director of nursing (DON) stated the nurse working the evening of 10/13/24 called her first and then she called the administrator, all around 5:40 p.m. The administrator and DON confirmed R209's anaphylactic allergy, learned he had a scratchy throat, his tongue was numb, and he was sent to ED. The administrator and DON called the dietary director that evening and an investigation ensued. Event was reported to the state agency within two-hour time frame. All residents with food allergies were reviewed for accuracy. The corporate regional dietary director and nursing consultant were involved in a meeting with the leadership team to determine a root cause. The root cause was identified as a dietary sheet that was lacking a place for allergies, therefore was not communicated to the kitchen staff upon R209's admission and lead to the resident being served shrimp. Facility policies were reviewed and did require revisions. The DON had completed an audit on the only admission they have had since this incident. Facility document Waterview Woods Fall/Winter 2024-2025, identified the evening meal on 10/13/24 was seafood pasta alfredo, buttered peas, apricots. The alternative meal for 10/13/24 was garden vegetable soup or hamburger on a bun. The facility implemented corrective action to prevent recurrence by 10/14/24, when the facility implemented a systemic plan that included the following actions: On 10/13/24, all residents were audited for current food allergies. On 10/14/24, the new admission form was modified to add an area specifically to address resident food allergies, dietary policy related to meal tickets was reviewed, resident allergy documentation was reviewed, and staff were educated on the meal ticket handling policy and what to do with new admissions form. Audits did not result in further discrepancies. This was verified through observation, interview, and document review.

Based on interview and document review the facility failed to have 8 hours of continuous registered nursing coverage on a daily basis. This had the potential to affect all residents residing in the facility. Findings include: The Centers for Medicare and Medicaid Services' (CMS) Payroll Based Journal (PBJ) Staffing Data Report, identified during the third quarter of 2024 (4/1/24 - 6/30/24) the facility failed to have 8 hours of registered nurse (RN) coverage on the following dates: 4/6, 4/7, 4/20, 4/21, 4/27, 4/28, 5/19, 5/25, 5/26, 6/1, 6/2, 6/8, 6/9, and 6/22. During an interview on 10/24/24, at 2:28 p.m., the administrator confirmed the facility did not have 8 hours of continuous RN coverage on the dates identified on the PB&J report. The administrator stated it was important to have an onsite RN for 8 continuous hours every day for safety of the residents. The facility's scheduling policy and RN coverage policy was requested but not provided.

Based on interview and document review, the facility failed to offer and provide a substantive snack after dinner and before bedtime, when there were 15 hours between the evening and morning meals. This had the potential to affect all residents in the facility. Findings include: During interview on 10/23/24 at 11:45 a.m., cook (C)-A stated dietary staff bring snacks to the unit and restock fridges. C-A further stated nursing staff were responsible for giving snacks to the residents. R8's quarterly Minimum Data Set (MDS) dated [DATE] identified intact cognition and diagnoses of Parkinson's disease and type II diabetes mellitus. During a resident council meeting on 10/24/24 at 1:23 p.m., R8 stated there was no evening snack pass and further stated the kitchen closed at 7 p.m. each evening. R8 confirmed there was not a snack cart, and residents have to request a snack to get one. The unit fridges always have sandwiches but they are locked at night and they cannot get a snack without asking staff. During interview on 10/24/24 at 1:40 p.m., licensed practical nurse (LPN)-B identified she worked both day and evening shifts. LPN-B stated the kitchen sends snack to the unit. LPN-B further stated there was no evening snack cart and staff did not offer snacks to residents. During interview on 10/24/24 at 1:43 p.m., LPN-C stated she worked both day and evening shifts. LPN-C stated there were many options for snacks on the unit. LPN-C further stated residents have to ask for a snack, and staff do not have a snack cart anymore. LPN-C stated she did not know why the snack cart was stopped. The Waterview Woods LLC Mealtimes document identified breakfast as being served at 8:00 a.m. and dinner at 5:15 p.m. Taking into consideration there may not be more than 14 hours between meal services unless a substantial bedtime snack is offered, all residents will have available to them, a bedtime snack. Adequacy of the snack would be determined by individuals in the group and evaluation of the overall nutritional status of those in the facility.

Based on observation, interview and document review, the facility failed to notify the provider, monitor, determine root cause and revise interventions to address pressure ulcers for 1 of 2 residents (R21) reviewed who was at risk for pressure ulcer development/deterioration. The facility's failure resulted in harm when R21 developed 2 pressure ulcers, one that deteriated to a stage 3 and another to a stage 4. In addition, R1 had documented redness and skin breakdown to the buttocks area and a right heel wound that both deteriorated to unstageable pressure ulcers. Findings include: The National Pressure Ulcer Advisory Panel (NPUAP) definition of a stage 3 pressure ulcer included: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. The NPUAP definition of a Stage 4 pressure ulcer included: Full thickness, skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and or eschar may be visible on some part of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the wound bed, it is an unstageable pressure ulcer. Suspected deep tissue injury are identified as persistent non-blanchable deep red, maroon or purple discoloration intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. The NPUAP definition of Unstageable Pressure Injury included: obscured full-thickness skin and tissue loss: full-thickness skin and tissue loss in which the extent of tissue damage within is ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a stage 3 or stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. R21's significant change Minimum Data Set (MDS) dated [DATE], identified R21 was cognitively intact. R21's diagnoses included cancer, hypertension, cerebrovascular accident, hemiplegia(weakness/lack of use to one side of the body) and seizure disorder. The MDS did not identify R21 had a pressure ulcer. The Care Area assessment dated [DATE], indicated pressure ulcers was a specialized area of concern that needed to be addressed in the care plan. R21's care plan dated 10/3/22, indicated alteration in with a goal of skin breakdown would be resolved by next review. Interventions of monitor skin integrity daily during cares, weekly skin inspections, pressure redistribution mattress to bed, pressure redistribution cushion to wheelchair, and monitor for skin breakdown/notify provider were added on 10/3/22. On 10/20/22, turn and reposition or reminders to offload every 2-3 hours was added as an intervention. No other interventions had been added until 2/2/24, staff had to document on skin conditions and keep health care provider informed. On 2/4/24 at 5: 36 p.m., a large dressing was observed on R21's left posterior buttocks and medial coccyx. R21 stated at that time he had two large sores underneath the bandages. He rated the pain at that time a 6 out of 10 but stated staff were giving him pain medication. R21 refused to allow the surveyor to look at the wounds at that time. The undated facility standing orders identified the wound care nurse would be notified to conduct a root cause analysis (RCA) to determine wound type and recommended dressings and well as MD/NP notification. The following Weekly Skin Inspection forms were reviewed from 10/30/23 to 12/11/23, as followed: -On 10/30/23 at 1:56 p.m., R21 had self-inflicted scratches to legs. All other skin ok. -On 11/6/23 at 1:32 p.m., R21 had redness and breakdown on buttocks. -On 11/20/23 at 1:46 p.m., R 21 had redness and breakdown to buttocks. -On 12/11/23 at 10:23 a.m., R21's wound on coccyx is getting worse. All of the weekly skin inspection forms above lacked documentation of notification of the health care provider or new interventions to prevent worsening of the pressure ulcers. The forms also lacked any documentation of an RCA related to the wounds. Skin & Wound Evaluation form dated 10/30/23 at 3:01 p.m., identified R21 had an abrasion on the front right lateral lower leg. No other skin concerns noted. Skin & Wound Evaluation form dated 11/21/23 at 2:50 p.m., identified R21 had a new in house acquired Moisture Associated Skin Damage (MASD) to the Sacrum (Bone at the top of the Buttocks region) which measured 3.5 centimeters (cm) long (L) by 2.3 cm Wide(W). The wound had 20% Epithelial, 20% granulation and 60% slough. There was a light amount of serosanguinous (pinkish clear colored) drainage. There was a photo attached to the file that showed a stage 3 pressure ulcer with 60% slough noted. A copy of the picture was requested but not provided. Skin and Wound Evaluation form dated 12/1/23 at 3:04 p.m., identified R21 had a deteriorating MASD to the sacrum that measured 4.3 cm L by 2.3 cm W. The form lacked any other documentation of the wound and lacked documentation the provider was notified. On 12/12/23, Integrated Wound Care (IWC) saw R21 for the first time and documented R21 had a stage 4 pressure ulcer to the medial coccyx with exposed bone and tunneling. A stage 3 pressure ulcer to the left posterior buttocks was also documented. The visit documentation from 12/12/23, to 1/10/24, was requested but not provided. On 1/16/24, IWC documentation indicated an ulcer to the medial coccyx that measured 5cm L by 6cm W by 1cm deep (D) that had bone exposed and undermining that was 1-4 cm deep. The documentation also indicated an ulcer to the left posterior buttocks that measured 3 cm L by 1.5 cm W x 0.1 cm D. There was moderate serosanguinous drainage and 100% slough. Healthcare provider visit notes from 11/10/23 to 11/29/23 were reviewed and lacked documentation of provider awareness of the pressure ulcers and/or treatment plans for the pressure ulcers. The documentation indicated the skin was warm and dry at each visit. Review of nursing documentation from 11/1/23 to 12/12/23, indicated the following: -On 11/7/23 at 6:04 p.m., the nurse practitioner (NP) reviewed the labs and ordered new labs. -On 11/7/23 at 9:11 p.m., purplish area on coccyx. Reminded resident to shift frequently in bed. There was no documentation of provider notification. -On 11/22/23 at 3:46 p.m., the NP again saw R21 but the documentation only addressed vital signs and med changes related to the vital signs. It lacked any documentation the NP was aware of the wound and treatment plan orders for the wound. -On 11/29/23 at 12:07 p.m., medical provider on rounds. No new orders at this time. -On 12/1/23 at 3:35 p.m., .wound needs orders. Orders requested from hospice. Review of all health care provider orders from 11/1/23 to 12/12/23, lacked any orders related to wound care treatment for the pressure ulcers on the buttocks or coccyx. On 12/12/23, the first orders from IWC were written. On 2/7/24 at 9:28 a.m., a message was left with IWC, but no return call was received. During an interview on 2/6/24 at 10:14 a.m., licensed practical nurse (LPN)-A stated if a resident acquired a new wound of any kind they would notify the nurse manager of the wound right away and also notify the provider of the wound. After notifying each person a note would be made in the progress notes to indicate they were notified. LPN-A stated R21 had a stage 4 pressure ulcer to the coccyx and a stage 3 pressure ulcer to the buttocks that had been treated for at least two months. The notes from 11/6/23 to current date were reviewed and LPN-A acknowledged all documentation was about the same wound. She became aware of the wound the first time on 11/7/23 and did not report anything to the NP because she assumed it was already reported since that was protocol. During an interview on 2/7/24 at 9:08 a.m., registered nurse (RN)-B stated the picture attached to the 11/21/23, Skin and Wound Evaluation form had been taken during the skin and wound evaluation on 11/21/23. She confirmed the picture was a stage 3 pressure ulcer and did not know why the form called it moisture associated skin damage. RN-B stated when a new wound was reported to the nurse managers, the wound would be evaluated right away and then the provider would be notified for orders to treat. A skin analysis was also done to see what caused the new wound to form. After everything was completed, documentation would be placed in the chart as a progress note by the nurse. RN-A reviewed R21's medical records and acknowledged there was no notification to provider or skin analysis documented, and based on the lack of findings confirmed it more than likely was not performed. During an interview on 2/7/24 at 11:03 a.m., the Director of Nursing (DON) stated any new wounds should be reported to the nurse manager right away, but no later than the next morning so they could be evaluated. Part of the evaluation process was to analyze what caused the wound and what additional interventions where required to prevent worsening of the wounds. The provider would be notified right away to get order to treat the wounds and assist in monitoring of the wounds. During an interview on 2/8/24 at 11:23 a.m., the primary care provider (PCP) stated she had been on medical leave in November 2023 and the NP was covering during the leave. She was made aware of the pressure ulcers after returning on 12/1/23 by hospice. On 2/8/24 at 11: 42 a.m., a message was left for the NP to return a call. No return call was received. Facility policy Skin Assessment & Wound Management last revised 11/17/23, stated when a new pressure ulcer was identified the provider would be notified for treatment orders, an initial Skin and Wound Evaluation form would be completed, the nurse manager/wound nurse would be notified. Lastly the care plan would be reviewed and updated with interventions and risks for skin breakdown. 47263 R1: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was severely cognitively impaired. Section M-Skin Conditions identified R1 was at risk to develop pressure ulcers. M0300.-Current number of unhealed Pressure Ulcers at Each Stage: identified R1 had two unstageable pressure ulcers that were not present at the time of admit. R1's facesheet dated 2/7/24, indicated R1 was admitted the facility on 9/21/23. The following diagnoses were included: dementia, Alzheimer's disease, urinary retention, adult failure to thrive, non-pressure chronic ulcer of unspecified part of right lower leg with fat layer exposed, and chronic kidney disease. R1's care plan identified the focus area of alteration in skin integrity for venous ulcer right calf, pressure ulcer right heel, and pressure ulcer coccyx with the goal of skin breakdown resolved by 5/31/24. Interventions initiated on 9/21/23 included: -Monitor skin during cares and weekly skin inspection by nurse. -Treatment to open areas per order. -Pressure redistribution mattress on bed and wheelchair. -Encourage dietary supplements. -Weekly measurement and assessment of wound. -Monitor for skin break down for signs/symptoms of infection. Report signs/symptoms to provider. -Document on skin condition and keep MD or PA-C informed of changes. -Followed by wound care. Intervention initiated on 2/7/24: Heel protectors on at all times. R1's record included the following weekly skin checks: -9/28/23, No new changes to skin. Res has a wound dressing to right LE, and breakdown on coccyx buttocks area. Calmospetine ointment being applied with cares. -10/19/23, breakdown on buttocks, using calmoseptine. Wound to right shin, wound care done as ordered. -11/2/23, redness/breakdown on buttocks, using calmospetine cream. Wound on right shin and right heal, wound care done as ordered. -12/7/23, Skin is warm and dry. Lotion applied to dry legs, arms, and face. Bruise noted to right shin, small fading bruises on bilateral arms. Ongoing wound care completed to right heel and shin and buttocks. The admission MHM Skin Evaluation and Skin Risk Factors completed on 9/21/23, by RN-A identified R1 had a vascular stasis ulcer to the right lower extremity. The document indicated the coccyx/sacral area was not assessed during the admit skin assessment. The MHM Skin Evaluation and Skin Risk Factors assessment completed by RN-A on 11/30/23, indicated R1 had an unstageable ulcer on left buttock, and an unstageable right heel would, and a previously identified vascular ulcer on the right lower extremity. R1's IWC progress notes indicated they were consulted on 10/10/23, for evaluation and treatment for chronic venous ulcer and first encounter of pressure ulcer to right heel. The right heel was unstageable measuring 4x4 centimeters without exudate and 100% Eschar. R1's IWC progress note dated 11/14/23, indicated in addition to the venous ulcer and unstageable heel pressure ulcer, they were being consulted for first encounter for a pressure ulcer to the coccyx. The coccyx pressure ulcer measured 4 x 3 cm with no exudate and was 100% Eschar. Blue boots were recommended for heels. R1's regulatory provider encounter notes from a 9/29/23, indicated R1 had a chronic lower extremity non-pressure wound. Note did not address coccyx/buttock redness or breakdown. Provider encounter on 10/6/23, did not address R1's heel or coccyx/buttock redness or breakdown. Provider encounter on 10/27/23, indicated R1 was also being evaluated for an unspecified staged right heel blister. The provider advised to continue orders from wound care: wound cleaner, bordered foam, no shoes, and float heels. The note did not address coccyx/buttock redness or breakdown. Provider encounter on 11/1/23, did not address R1's heel or coccyx/buttock redness or breakdown. Provider encounter on 11/29/23, addressed R1's heel and sacral ulcer and included: The heel was covered with dry eschar. There was a soft boggy eschar overlying the right sacrum draining purulent drainage. The pressure ulcer measured 6 x 6 cm. The wound was debrided down to healthy granular tissue with no visible bone or tendon. Twice a day wound packing and low air mattress recommended. During an observation on 2/6/24 9:00 a.m., R1 was dressed with slipper socks on. During an observation on 2/7/24 at 7:40 a.m., R1 was seated in their wheelchair by the bird area. R1 was dressed with slipper socks on. During an observation on 2/7/24 9:43 a.m., R1 was seated in sitting area by nurse station in wheelchair. No heel protectors on. During an observation on 2/7/24 at 11:42 a.m., R1 entered the elevator with a staff, R1 did not have heel protectors on. During an observation on 2/7/24 at 1:04 p.m., R1 was in bed with covers on, could not determine if heel protectors were on. During an observation on 2/7/24 at 2:30 p.m., R1 was in the day room with slipper socks on wheeling self around. During an observation on 2/8/24 at 9:04 a.m., NA-C brought R1 into the shower room, transferred R1 to the shower chair and proceeded to bathe R1. R1's pressure ulcer dressing, and sacral dressing were on the resident after the shower. At 9:15 a.m. NA-C dressed R1 with new brief, pants, and a sweater and then transferred R1 back to their wheelchair. NA-C stated the nurse would check R1's wounds later. R1 was brought to their room. During an interaction on 2/8/24 at 12:10 p.m., licensed practical nurse (LPN-A) stated they would not be doing R1's dressing changes until after lunch. During an interview on 2/7/24 at 11:46 a.m., NA-A stated when they did a resident shower they did a skin sheet, they clipped fingernails as needed if the resident wasn't diabetic, and if they found something suspicious with the resident's skin they would usually try and get the nurse to look at the resident's skin in the shower. During an interview on 2/7/24 12:35 p.m., RN-A stated the nurses should be checking resident skin on bath days. RN-A confirmed the NA completed a skin sheet for each resident on their bath/shower day, however, it was still the nurse's responsibility to do an eyes on assessment of the skin. RN-A stated they looked at the treatment record to ensure skin assessments were being completed. Nurses are still required to complete a skin assessment, not just sign it off in the TAR. RN-A indicated moving forward, they would need to check the assessments, not the TAR to ensure an assessment was done and issues were communicated. For pressure ulcer care, even with a pressure reducing mattress, R1 should be repositioned in bed and off loaded when in their chair every 2 to 3 hours. R1 should also have heel protectors on at all times. These items should be part of the resident's plan of care. During an interview on 2/7/24 at 1:17 p.m., the director of nursing stated it was an expectation that the nurse always completed the skin assessment. The DON confirmed the NA did complete the skin assessment form, but not as an assessment. The NA form was used as information to pass onto the nurse, so the nurse could assess the skin. The DON stated they had the NAs complete the form because they were the most hands on with the residents. If something did get identified as skin break down by one of the nurses, the nurse manager should be notified so they can immediately follow-up on that. When there is skin breakdown identified, it should either be staged or called moisture associated. The nurse should follow-up on care and treatment. Usually, wound care is initiated through integrated wound care or Essentia wound care if we note any kind of skin break down. Even if it is something like break down form incontinence, we would consult wound care. During an interview on 2/8/24 at 12:20 p.m., RN-A pulled up R1's medical record and stated R1 was admitted with the non-pressure leg wound. R1 was also admitted with an order for barrier cream for their buttocks as a preventative measure for incontinence. RN-A confirmed R1's sacral/buttocks area was not assessed when R1 was admitted to the facility on [DATE]. RN-A indicated on 10/10/23, the heel ulcer was noticed, and wound care was asked to evaluate R1's heel pressure ulcer that day. RN-A stated they had not been notified R1 had any skin break down in the coccyx/buttocks area until right before they had the wound care nurses consulted on 11/14/23. RN-A confirmed weekly skin check documentation starting on 9/29/23, indicated R1 had redness and skin breakdown in the buttocks/sacral area. RN-A indicated they had not been notified of skin break down, but should have been notified immediately, when redness was identified in the buttock and coccyx area. RN-A did not find documented provider notification of R1's heel or coccyx pressure ulcers, but indicated they would have done that around the time they consulted wound care. The facility policy Skin Assessment & Wound Management dated 11/17/23, included a weekly skin inspection by licensed staff, notification of nurse manager for any changes, and routine daily skin inspection with care. In addition, the policy directed the following actions for new non-pressure wound/altered skin and for new pressure ulcers: notify the provider/obtain treatment orders, notify resident representative, complete education with resident, initiate wound skin and wound evaluation, notify nurse manager, review and update care plan, consult nutrition and appropriate therapies.

Based on observation, interview, and document review, the facility failed to promptly obtain opioid medication and failed to notify the physican to prevent opioid withdrawal for 1 or 1 residents (R13) reviewed for pain management. This practice resulted in a significant medication error and actual harm when R13 did not receive opioid medication for 7 consecutive days resulting in R13 being sent to the emergency room to receive care for acute opioid withdrawal. Findings include: R13's quarterly Minimum Data Set (MDS) dated [DATE], identified R13 was cognitively intact and reported almost constant pain, which limited ability to sleep and complete day to day activities. MDS diagnoses included neurofibromatosis type 2 (growth of noncancerous tumors in the nervous system), long term (current) use of opiate analgesic, and paraplegia. R13's elder care visit summary dated 1/2/2024, identified R13 was prescribed 4 milligrams (MG) of oral hydromorphone (opioid medication) every 4 hours as needed for pain. R13 was not being tapered from this medication. Review of R13's medication administration record (MAR) from 12/1/23 to 1/1/24, identified hydromorphone was administered 3 to 6 times daily with a minimum of 3 administrations per day. On 1/2/24, hydromorphone was administered once. From 1/3/24 to 1/9/24 hydromorphone was not administered. R13's progress notes from 1/3/24 to 1/7/24 gave no indication R13 was out of hydromorphone or R13's provider was contacted. Progress notes failed to identify any attempt to get R13 hydromorphone or any other type of opioid pain medication. R13's progress note dated 1/8/24 at 9:05 p.m., stated, resident says I need my pain meds. R13's progress note dated 1/9/24 at 4:45 p.m., stated received order to substitute 2 MG hydromorphone tablets for 4 MG tablet. R13's progress note dated 1/9/24 at 9:02 p.m., stated resident was sent to the emergency department due to having severe high blood pressure (172/102 and 197/100) and vomiting. Has not been feeling well all day. Had diarrhea and vomiting in the morning. By the afternoon estimated has vomited 10 times throughout the day. R13's emergency department after visit summary dated 1/9/24, identified a visit diagnosis of acute opioid withdrawal. Instructions state if hydromorphone is unavailable give oxycodone every 4 hours. Included information identified opioid withdrawal occurs when a person has used opioids daily for at least 3 weeks. R13 was discharged at 11:45 p.m., 3 doses of hydromorphone had been administered and blood pressure was 136/75. During interview on 2/5/24 at 3:51 p.m., R13 stated the facility has failed to consistently provide opioid medications on at least 3 occasions. R13 has gone at least 3 days without opioid medications, and this most recently occurred a few weeks ago. R13 was unsure when the other 2 occasions occurred. During interview on 2/7/24 at 12:57 p.m., licensed practical nurse (LPN)-A states all floor nurses can request a refill on a controlled mediations if the medication has a refill. If a medication needs a refill, was not delivered, or if a resident was out of a medication, a registered nurse would be notified. LPN-A acknowledged difficulty obtaining R13's hydromorphone and stated the facility received a slip from the pharmacy notifying of hydromorphone national shortage. LPN-A was unsure of when the facility received this notification. On 2/8/2224 at 9:15 a.m., registered nurse (RN)-B stated they were not notified R13 was out of hydromorphone because RN-B was out of the facility from 1/3/24 to 1/10/24. Upon return, RN-B was having difficulty obtaining refill of hydromorphone due to the national shortage and needed to contact the provider to obtain a prescription for a new opioid medication. RN-B stated was unaware if provider was contacted during absence but explained phone contacts made to the provider are documented in excellent professionals individualized care (EPIC) (an electronic health record). RN-B reviewed EPIC and confirmed no phone contacts were made to the provider from 1/3/24 to 1/8/24. RN-B's stated during absence, first-floor clinical manager and director of nursing (DON) were managing nursing duties. During interview on 2/8/2024 at 1:31 p.m., director of nursing (DON) confirmed was in part managing RN-B's nursing duties during absence. DON stated having the expectation of being notified if a resident was out of a medication and a progress note was made. DON stated was not notified R13 was out of hydromorphone. DON expects opioid medications are obtained the same day the medication was needed and if it cannot be obtained the resident should be sent to the emergency department to obtain the medication. The Food and Drug Administration (FDA) Drug Safety Communication dated 4/9/19, identified serious harm has been reported when patients who are physically dependent on opioid medications suddenly have these medicines discontinued. Requested copy of EPIC provider contact documentation. Documentation was not provided.

Based on observation, interview and document review, the facility failed to ensure documentation of each resident's advance directive/code status was consistent throughout their records to ensure the code status reflected resident current resuscitation preferences and physician orders. The facility's failure resulted in an immediate jeopardy, risk of serious harm, injury, or impairment for 1 of 25 residents (R21) reviewed for advance directives. The immediate jeopardy began on [DATE], when it was identified R21 had changed her preference from requesting cardiopulmonary resuscitation (CPR) to do not attempt resuscitation (DNR). R21's electronic medical record (EMR) and POLST listed discrepancies in R21's most current code status and the facility lacked a system to ensure changes were reflected in the residents current record. The associate administrator and the director of nursing (DON) were notified of the IJ on [DATE], at 3:26 p.m. The IJ was removed at 10:48 a.m. on [DATE], but noncompliance remained at the lower scope and severity of D-pattern, with no actual harm but potential for more than minimal harm. Findings include: R21's Admission Report printed on [DATE], indicated R21's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R21's admission Minimum Data Set (MDS) dated [DATE], indicated R21 had moderate cognitive impairment. On [DATE], at 7:20 p.m. R21's EMR was reviewed which revealed the following: -R21's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -R21's code status located in the EMR banner indicated R21's code status was CPR (cardiopulmonary resuscitation). -R21's POLST was found in the EMR under the miscellaneous tab. The POLST indicated R21's code status was do not resuscitate (DNR). The POLST was signed by R21 and social services (SS)-A on [DATE], and signed by the provider/nurse practitioner on [DATE]. On [DATE], at 8:21 a.m., licensed practical nurse (LPN)-A stated she would look in the EMR banner to see if a resident wanted CPR or DNR. On [DATE], at 8:22 a.m. the director of nursing (DON) verified the resident's code status would be found in the EMR banner, in the resident's orders, and the POLST would be found in the scanned documents. On [DATE], at 9:47 a.m. R21 stated when she first came to the facility she wanted to be a full code (CPR), but then changed her mind to be DNR. R21 verified her current wishes were for DNR. On [DATE], at 9:53 a.m. registered nurse (RN)-A reported code status was identified in the EMR banner and staff checked this for area for a resident's code status. RN-A stated orders for code status were entered by the admitting nurse. R21's code order had been entered on [DATE], by RN-B as CPR. RN-A verified R21's code status in the EMR was incorrectly listed as CPR on the banner and in the orders, based on R21's current POLST. On [DATE], at 11:27 a.m. during follow up interview, the DON stated resident code status was reviewed quarterly at each resident's care conference, annually and anytime a resident would request a change to their POLST. The DON verified the order for R21's code status did not reflect R21's current wishes. On [DATE], at 11:47 a.m. RN-B stated the POLST was part of the admission packet and was reviewed on admission with the admitting nurse helping the resident to fill the POLST out. Once the admitting nurse knew the resident's choice for code status the order was added, and this step generated the code status in the EMR banner. RN-B stated she thought another nurse would check to ensure the order was entered correctly. RN-B recalled during R21's admission process, R21 wanted to talk with her daughter about code status. RN-B stated she then deferred the matter to the clinical manager (RN-A) and didn't remember entering R21's code status order. On [DATE], at 12:10 p.m. social service (SS)-A stated POLST's were generally filled out by nursing, and she would make the code status entry in the care plan. Although R21's POLST was signed by SS-A, she could not recall any details about why she helped R21 fill out the form. SS-A stated the order for code status was put in by health information staff. On [DATE], at 12:13 p.m. during a group interview with DON and RN-A, DON stated the POLST order was to be completed by the admitting nurse. The DON stated there should have been a double check of the order by another nurse. RN-A stated she could not say that orders were always checked by another nurse 100% of the time. Both the DON and RN-A stated there was no system in place to verify a double check was completed after entering a POLST order. On [DATE], at 9:51 a.m. R21's medical doctor (MD)-A verified she would have expected the facility to have processes in place to ensure resident's resuscitation status was accurate and reflected the resident's current wishes. The facility policy titled POLST Documentation dated [DATE], indicated code status would be discussed with the resident and/or resident representative upon admission and would be entered into the individualized plan of care/electronic medical record and communicated throughout the facility, so staff would know what actions to take in an emergency. The facility policy did not address how changes would be made should the resident wish to change their code status. The IJ was removed on [DATE], at 10:48 a.m. when it was verified the facility had reviewed all the residents records to ensure the banner and order reflected the resident's most current POLST. In addition, the facility reviewed the policy titled POLST Documentation dated [DATE]. A process for completing a POLST and obtaining a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The process was to be completed by the DON, the nurse manager, the LPN care coordinator, medical records, or admission nurse. In addition, the the process included a step that required a check by a second staff person (from the staff already listed) for accuracy. The second staff person would initial the original POLST when they verified the order was accurately entered. In addition, social services would no longer be completing a POLST. The staff involved with the POLST process were educated on [DATE]. This information was verified with the DON, SS-A and three licensed staff on [DATE], between 9:38 a.m. and 10:30 a.m.

Based on interview and document review, the facility failed to ensure residents were free from alleged abuse for 1 of 7 residents (R1) reviewed for abuse. This resulted in an immediate jeopardy (IJ) for R1, who felt he had been sexually abused. The IJ began on 3/12/21, when R1 alleged nursing assistant (NA)-A forcibly removed his clothing during the night, and R1 felt he had been sexually abused. The IJ was identified on 3/18/21, and nurse consultants (NC)-A and NC-B were notified of the IJ at 3:52 p.m. on 3/18/21. The IJ was removed on 3/19/21, at 9:46 a.m., however, noncompliance remained at the lower scope and severity level of D (isolated, with no actual harm with potential for more than minimal harm). Findings include: R1's Transfer/Discharge Report printed 3/22/21, indicated R1's [DIAGNOSES REDACTED]. R1's admission Minimum Data Set ((MDS) dated [DATE], identified R1 was cognitively intact, had clear speech, was able to understand others and be understood. R1's MDS further indicated he required extensive assistance of one with transfers, walking, dressing, toilet use, and personal hygiene. R1's MDS further indicated he was always continent of bladder. R1's care plan initiated on 3/2/21, indicated R1 had a self-care deficit, and would be dressed, groomed, and bathed per his preferences. On 3/17/21, at 1:22 p.m. R1 was interviewed. R1 stated during the night on 3/12/21, he had applied lotion to his legs, then asked staff to help him pull up his pants. R1 stated nursing assistant (NA)-A came in, removed his pants and underwear, and said she was going to change his clothing. R1 stated he told her to stop, but she continued to forcibly take off his clothes, and put other clothes on him. R1 said he was not wet, he never wet his pants, and he did not wear an incontinent brief. R1 said he felt violated, and said he knows how women must feel when they are raped, and someone does not stop when they are told to. R1 stated he reported this incident to many staff. R1's Electronic Medical Record (EMR) progress notes from 3/11/21, through 3/19/21 lacked indication of R1's allegation of abuse. On 3/17/21, at 2:14 p.m. NA-A was interviewed. NA-A stated she did not know resident names, only room numbers. NA-A stated her care guide worksheet did not indicate who was continent or incontinent. NA-A stated when she answered call lights, she checked to see if the residents were wet. NA-A stated that night she was making rounds, and R1's light went on. NA-A stated she was having trouble understanding R1, so she checked to see if he was wet, he was not, so she covered him with a blanket and left the room. -at 2:30 p.m NA-B was interviewed. NA-B stated she was familiar with R1, and was aware that he was continent of bladder. NA-B stated R1 did not wear an incontinent brief, and always wore boxers. -at 2:38 p.m. NA-C was interviewed. NA-C stated she was familiar with R1. NA-C stated R1 never wore an incontinent brief, he always wore boxers, and was continent of bladder. NA-C stated, After they have been here awhile, you get to know who is continent all the time. -at 3:20 p.m. NA-D was interviewed. NA-D stated he usually looked at the care plan on the computer to know how to care for residents. NA-D was familiar with R1, and stated R1 wore underwear. -at 3:38 p.m. NA-E was interviewed. NA-E stated R1 always wears underwear. On 3/18/21, at 9:07 a.m. social worker (SW)-A was interviewed. SW-A stated the director of nursing (DON) came to her on 3/12/21, and told her R1 had some concerns. SW-A stated she spoke to R1, who told her what occurred. SW-A stated R1 told her he knew how a woman must feel when raped by a man when she tells him no. SW-A stated she thought NA-A had been removed from the schedule for the night of 3/12/21, through 3/13/21, pending investigation, but the administrator designee was unable to get in touch with NA-A, and so did not remove her from the schedule, and let her continue to work. Individual Employee Time Card provided by the facility, NA-A was not removed from the schedule pending the investigation of the incident, and worked the night of 3/13/21, punching in at 10:37 p.m. and punching out at 6:56 a.m. on 3/14/21. -at 9:21 a.m. the DON was interviewed. The DON stated the morning of 3/12/21, a staff person reported to her that R1 was upset, and said a night staff person forcibly removed his clothes. The DON said she reported this to the SW and the nurse consultant (NC). The DON said she did not think about removing NA-A from the schedule that day pending investigation, and she was not aware when NA-A worked again. The DON stated she did talk to R1 at a later date, and he told her he knew how a woman must feel when raped by a man when she tells him no. On 3/19/21, at 10:54 a.m. the DON was interviewed. The DON stated when there was an allegation of abuse, the first step was to ensure the safety of the resident, and if an employee was the alleged perpetrator, they would be removed from the facility pending an investigation. The DON stated the administrator would need to be notified, and the report to the State Agency (SA) would need to be made within two hours. -11:03 a.m. SW-A was interviewed. SW-A stated staff need to report allegations of abuse immediately, and need to report abuse to the DON and the administrator. -at 11:25 a.m. the administrator was interviewed. The administrator stated staff need to report allegations of abuse immediately to their immediate supervisor. The facility policy Abuse Prohibition/Vulnerable Adult Plan dated 7/5/19, directed all staff are responsible for reporting any situation that is considered abuse or neglect along with injuries of unknown origin. The policy further identified the immediate supervisor will be notified immediately. The policy directs if the abuse is staff to resident alleged or suspected abuse, the staff person will be immediately suspended until the investigation is completed. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The IJ that began on 3/12/21, was removed on 3/19/21, when the facility implemented corrective actions which included the following: The facility interviewed all residents and none had concerns regarding abuse, and all staff were educated on the abuse policy and abuse reporting.

Based on interview and document review, the facility failed to ensure medications were administered to the correct resident for 1 of 3 residents (R3) reviewed for medication administration. This failure resulted in a significant medication error and actual harm to R3, who received medications belonging to R4, and subsequently had a decreased blood pressure, and was transferred to the emergency department for medical treatment. Findings include: R3's Admission Record printed 1/12/21, indicated R3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's quarterly Minimum Data Set, dated dated dated [DATE], indicated R3 had a severe cognitive impairment. R3's Order Summary Report printed 1/12/21, indicated R3 was to receive the following medications in the morning: aspirin 81 milligrams (mg), [MEDICATION(S)] sodium (stool softener), 100 mg leveothyroxine (thyroid medication) 50 micrograms (mcg), [MEDICATION(S)] (lowers blood pressure) 2 mg, and [MEDICATION(S)] (lowers blood glucose) 500 mg. R4's Order Summary Report printed 1/12/21, indicated R4 was ordered to receive the following oral medications in the morning: tylenol 650 mg, [MEDICATION(S)] (lowers heart rate and blood pressure) 6.25 mg, [MEDICATION(S)] (blood thinner) 75 mg, [MEDICATION(S)] extended release (lowers blood pressure) 30 mg, [MEDICATION(S)] (reduces fluid volume in the body, which can lower blood pressure) 20 mg, [MEDICATION(S)] (reduces fluid volume in the body, which can lower blood pressure) 25 mg. Additionally, R4 was ordered [MEDICATION(S)] (pain medication) 50 mg every six hours, as needed, for pain. A document titled Teachable Moment dated 12/10/20, indicated, Resident received another resident's medication which required ER [emergency room ] visit. The document further indicated staff was to remember the five rights of medication administration and to take time to ensure the correct resident was receiving the correct medication when interrupted. The document was signed by registered nurse (RN)-A and RN-C on 12/10/20. On 12/10/21, an emergency department (ED) physician note indicated R3 was mistakenly administered another resident's medications which included: [MEDICATION(S)] 6.25 mg, [MEDICATION(S)] 20 mg, [MEDICATION(S)] extended release (ER) 30 mg, [MEDICATION(S)] 75 mg, [MEDICATION(S)] 50 mg, and [MEDICATION(S)] 12.5 mg. R3 reported feeling funny. The ED note further indicated R3 generally had a systolic blood pressure (pressure produced when the heart contracts) of 90 millimeters of mercury (mm/Hg). Upon admission to the ED, R3's systolic blood pressure was between 70-75 mm/Hg. R3 was monitored for six hours, received two liters of intravenous (IV) fluids, and was subsequently discharged when her vital signs normalized to her range. On 12/10/20, at 1:35 p.m. a progress note indicated R3 was at the ED and doing well. The note indicated R3's systolic blood pressure was initially 60 mm/Hg, and she was administered two liters of fluids. On 12/10/20, at 4:05 p.m. a progress note indicated R3 returned from the ED. R3 was to have her vital signs checked every four hours for the next 24 hours. R3 appeared at her baseline. On 1/12/21, at 12:33 p.m. an interview was conducted with RN-A. RN-A stated on 12/10/20, herself and licensed practical nurse (LPN)-A worked day shift together. RN-A stated herself and LPN-A were passing medications and shared the same medication cart. RN-A stated she was working on the side of the medication cart near the narcotics lockbox, and LPN-A worked on the opposite side of the medication cart. RN-A stated she had prepared R3's medications, and LPN-A had prepared R4's medications. RN-A stated at that time, she was notified of a resident fall. RN-A stated herself and LPN-A had prioritized the fall, and R3 and R4's medications were left on the medication cart. RN-A stated she then returned to the medication cart and grabbed a medication cup which was located on the side near the narcotics lockbox. RN-A stated she administered the medications to R3, and R3 had difficulty swallowing the medications. RN-A stated she quickly realized R3 received the incorrect medications, and she instructed R3 to spit the medications out. RN-A stated R3 was unable to spit the medications out and had swallowed them. RN-A stated R3's medications were still on the medication cart on the side near the narcotics lockbox. RN-A stated she learned she mistakenly grabbed R4's medication cup as LPN-A had began working on the side of the medication cart near the narcotics lockbox. RN-A stated she did not realize LPN-A placed R4's medication cup near R3's medication cup. RN-A confirmed R3 received R4's morning medications. RN-A stated she notified facility administration as R4 was ordered blood pressure medications, and R3's blood pressure normally ran low. RN-A stated she also notified R3's physician and was instructed to transfer R3 to the emergency department. RN-A stated R3 was at her baseline upon transfer to the emergency department. RN-A stated she called the hospital and was told R3 was receiving IV treatment. RN-A stated herself and LPN-A had been working crazy hours. RN-A stated the facility reminded herself and LPN-A of the six rights of medication administration. On 1/12/21, at 1:13 p.m. an interview was conducted with RN-B. RN-B stated she was on vacation when the medication error occurred. RN-B stated she overhead a nurse was called away from a medication cart, and subsequently returned to the medication cart and administered incorrect medications to R3. RN-B reviewed R3's medical record and stated R3 was sent to the hospital and had a low systolic blood pressure. RN-B stated she was not aware of any changes at the facility since the incident occurred. RN-B stated she would had written resident initials on a medication cup if she were called away. On 1/12/21, at 1:49 p.m., an interview was conducted with the facility nurse consultant, RN-C. RN-C stated the director of nursing (DON) was not at the facility during the incident, so she handled it. RN-C stated LPN-A and RN-A were preparing medications and a resident had a fall. RN-C stated LPN-A and RN-A put the prepared medication cups down and attended to the fall. RN-C stated RN-A returned to the medication cart, grabbed a medication cup, and administered R4's medications to R3. RN-C stated staff called her regarding the incident, and she instructed them to call the doctor right away. RN-C stated the resident was transferred to the emergency department and administered IV fluids. RN-C stated R3 remained in the emergency department until medication peek times (highest level of a drug in the bloodstream) were achieved. RN-C stated she conducted immediate education with RN-A. RN-C stated no other staff were educated as no other medication errors of this type occurred before. RN-C stated R3's blood pressure normally ran low. A medication error incident report was requested, but not received. The facility policy Medication Error Procedure reviewed 1/20, directed Medication errors will be rectified according to standard of practice and the facilities pharmacy policy for preventing and detecting adverse consequences and medication errors.

Based on interview and document review, the facility failed to ensure staff who were exhibiting signs and symptoms of COVID-19 were restricted from entering the facility and working. This resulted in an immediate jeopardy (IJ) situation which had the potential to affect 22 of the 35 residents who resided in the facility who were not currently infected with COVID-19 and had not had a previous COVID-19 diagnosis. The IJ started on 9/13/20, when it was determined the facility was allowing staff who were exhibiting signs and symptoms of COVID-19 to work. The administrator and the director of nursing (DON) were notified of the IJ at 5:58 p.m. on 10/13/20. The IJ was removed on 10/14/20, at 4:02 p.m., but noncompliance remained at the lower scope and severity level of E, pattern which indicated no actual harm with potential for more than minimal harm that is not IJ. Findings include: On 10/12/20, at 1:20 p.m. the administrator stated the facility had their first resident and staff case of COVID-19 diagnosed on [DATE]. On 10/12/20, at 11:23 a.m. licensed practical nurse (LPN)-B was interviewed. LPN-B stated she was told she needed to work when she had symptoms of COVID-19 that included body aches and a cough, but no fever. LPN-B was unable to provide a date of this occurrence. -1:01 p.m. therapeutic recreation aide (A)-A was interviewed. A-A stated on her arrival to work, she answered the COVID-19 screening questions herself, filling out the screening sheet. A-A stated another staff checked her temperature. A-A stated there was not a review of her COVID-19 answers prior to her starting work. -2:24 p.m. registered nurse (RN)-B was interviewed. RN-B stated the administrative staff had been telling staff they needed to work, with even if they had symptoms of COVID-19. RN-B stated on 10/10/20, LPN-A had worked a double shift, days to evenings, and when LPN-A got home she realized she could not taste or smell. RN-B stated LPN-A called on 10/11/20, and talked to RN-A asking if she should work on 10/12/20. RN-A stated LPN-A was told to work unless she had a fever. On 10/13/20, at 8:45 a.m. nursing assistant (NA)-B was interviewed. NA-B stated she had previously tested positive for COVID-19. NA-B stated after she was cleared to return to work, she developed trouble breathing, and was told to come in to work by the DON, and again by RN-A. NA-B's COVID-19 Screening Tool dated 9/26/20, indicated yes to the following questions: -Do you have Shortness of Breath? -Do you have Muscle Pain? NA-B's COVID-19 Screening Tools dated 9/30/20, 10/9/20, and 10/10/20, indicated yes to the following questions: -Do you have New loss of taste or smell? -at 10:44 a.m. LPN-B stated the education staff received on the employee screening tool was if staff answered yes to any questions to put the screening form in the DON's box unless the staff member had a fever. Staff were instructed to call the administrator or the DON if they had a fever. LPN-B verified LPN-A worked the morning of 10/12/20, passing medication to residents. LPN-B thought LPN-A left her shift due to feeling ill around 8:40 a.m. -at 12:00 p.m. NA-C was interviewed. NA-C stated on 10/8/20, she was told to work despite having cold, and possible COVID-19 symptoms. -at 1:30 p.m. the facility's staff COVID-19 Screening Tool sheets were reviewed. There were 28 staff with a Yes answer to symptom questions. Seven of the 28 staff later tested positive for COVID-19. NA-E's COVID-19 Screening Tool dated 10/3/20, indicated yes to the following questions: -Do you have a Sore Throat? -Do you have Muscle Pain? -Do you have a Headache? -Do you have Nausea, Vomiting, or Diarrhea? Time sheets provided by the facility on 10/14/20, indicated NA-E worked on the following date: 10/3/20, in at 5:15 p.m. out on 10/4/20, at 4:53 a.m. LPN-D's COVID-19 Screening Tool dated 9/13/20, indicated yes to the following questions: -Do you have a New or Change in Cough? -Do you have a Sore Throat? LPN-D's COVID-19 Screening Tool dated 9/14/20, indicated yes to the following questions: -Do you have a New or Change in Cough? -Do you have a Sore Throat? -Do you have Muscle Pain? -Do you have a Headache? LPN-D's COVID-19 Screening Tool dated 10/10/20, indicated yes to the following questions: -Do you have a New or Change in Cough? -Do you have a Sore Throat? -Do you have Muscle Pain? -Do you have a Headache? -Do you have a New loss of taste or smell? Time sheets provided by the facility on 10/14/20, indicated LPN-D worked on the following dates: 9/13/20, in at 10:26 p.m. out on 9/14/20, at 10:48 a.m. 9/14/20, in at 10:25 p.m. out on 9/15/20, at 6:22 a.m. 10/10/20, in at 10:17 p.m. out on 10/11/20, at 6:16 a.m. LPN-C's COVID-19 Screening Tool dated 9/23/20, indicated yes to the following questions: -Do you have Muscle Pain? -Do you have a Headache? -Do you have a New loss of taste or smell? LPN-C's COVID-19 Screening Tool dated 9/29/20, indicated yes to the following questions: -Do you have chills? -Do you have Muscle Pain? -Do you have a Headache? -Do you have New loss of taste and smell? LPN-C's COVID-19 Screening Tool dated 10/05/20, indicated yes to the following questions: -Do you have a Sore Throat? -Do you have a Headache? -Do you have New loss of taste and smell? Time sheets provided by the facility on 10/14/20, indicated LPN-C worked on the following dates: 9/23/20, in at 10:10 p.m. out on 9/24/20, at 6:30 a.m. 9/29/20, in at 10:11 p.m. out on 9/30/20, at 10:36 a.m. 10/5/20, in at 10:11 p.m. out on 10/6/20, at 6:18 a.m. -at 1:51 p.m. NA-A was interviewed. NA-A stated, Oh those sheets, do your own temperature, the thermometer was just on the desk, co-worker signs it. NA-A stated on 9/14/20, and 9/15/20, she had experienced shortness of breath, muscle pain, and headache. NA-A had screened herself, reported to work, but did not report her symptoms. On 9/19/20, during the day NA-A had told the administrator in charge (A)-D she was experiencing increased symptoms of COVID-19, and requested a COVID-19 test. The (A)-D told her to go to the COVID-19 testing center, which was in a nearby town. The A-D did not tell NA-A to stay home from work. NA-A was scheduled to work night shift on 9/19/20. NA-A's COVID-19 Screening Tool dated 9/19/20, indicated yes to the following questions: -Do you have chills? -Do you have Shortness of Breath? -Do you have a New or Change in Cough? -Do you have a Sore Throat? -Do you have Muscle Pain? -Do you have a Headache? -Do you have Nausea, Vomiting, or Diarrhea? Time sheets provided by the facility on 10/14/20, indicated NA-A worked: 9/14/20, from 10:25 p.m. to 9/15/20, at 7:01 a.m. 9/15/20, from 10:25 p.m. to 9/16/20, at 7:04 a.m. 9/19/20, from 10:25 p.m. to 9/20/20, at 1:10 a.m. -at 2:48 p.m. LPN-A was interviewed. LPN-A stated on 10/7/20, she answered yes to symptom questions. She stated she was told by RN-A that she needed to stay (she was scheduled for the day and evening shifts) and was told they were trying to replace her. The facility was unable to locate this screening form. LPN-A stated the administrator let her go out and sit on the steps as she wasn't feeling well and needed air. LPN-A stated she was not screened prior to the start to the evening shift, which would have been a double shift. LPN-A stated she talked to RN-A on 10/11/20, from work, stating she had no taste or smell but otherwise felt fine. LPN-A stated she was told by RN-A she could continue to work, unless she felt worse or developed a fever. LPN-A stated she was also told by RN-A that they would do a rapid COVID-19 test on 10/12/20. On 10/12/20, LPN-A did not think she should be at work, but her co-worker asked her to, Please stay and pass meds, which she did, and then she went home. LPN-A's COVID-19 Screening Tool dated 10/11/20, indicated yes to the following questions: -Do you have Muscle Pain? -Do you have New loss of taste or smell? LPN-A's COVID-19 Screening Tool dated 10/12/20, indicated yes to the following questions: -Do you have a New of Change in Cough? -Do you have Muscle Pain? -Do you have New loss of taste or smell? -Do you have Nausea, Vomiting, or Diarrhea? (Diarrhea was circled). Time sheets provided by the facility on 10/14/20, indicated LPN-A worked on: 10/11/20, from 6:03 a.m. to 2:30 p.m. 10/12/20, from 6:06 a.m. to 8:40 a.m On 10/13/20, at 10:07 a.m. the administrator and RN-A were interviewed. Both verified LPN-A had reported loss of taste and smell. RN-A verified LPN-A had called her on 10/11/20, to report the new loss of taste and smell. RN-A verified she told LPN-A she could work on 10/12/20, as long as she had no other symptoms. Initially both the administrator and RN-A stated they did not know if LPN-A worked from 6:00 a.m. to the time of her rapid COVID-19 positive test result. RN-A stated the reason LPN-A was given a rapid COVID-19 test was decided by the testers. The administrator and RN-A verified LPN-A should not have been working with symptoms despite not having a fever. -at 10:36 a.m. business office manager (BO)-C was interviewed. BO-C verified LPN-A worked at 6:06 a.m. and was done at 8:40 a.m. on 10/12/20. On 10/14/20, at 8:59 a.m. RN-C was interviewed. RN-C stated she worked on 10/12/20, on the unit until her COVID-19 test result came back as positive. RN-C's COVID-19 Screening Tool dated 10/8/20, indicated yes to the following questions: -Do you have a New or Change in Cough? -Do you have a Headache? Time sheets provided by the facility on 10/14/20, indicated RN-C worked on the following date: On 10/8/20, in at 5:58 a.m. out at 6:52 a.m. -at 9:11 a.m. NA-D was interviewed. NA-D stated she was called to come to the facility on [DATE], at 3:30 p.m. for an absentee discipline meeting with the administrator. NA-D stated the administrator looked at her screening sheet and said she should not even be in the building. However, they had the meeting in the day room with social distancing with her union steward present. NA-D stated the screening process was for staff to fill out their own screening form and have another staff check their temperature. NA-D stated the screening forms then go into a stack. NA-D stated she never had anyone come and ask her about her yes answers to symptoms, and she never went to the DON to talk about the yes answers to her symptoms. NA-D stated the practice was that you worked unless you had a fever. -at 9:48 a.m. the facility's medical director (MD)-A was interviewed. MD-A stated staff who answered yes to any COVID-19 screening questions should have been excluded from working. MD-A further stated staff who had previously had a COVID-19 positive result and developed new symptoms, should be excluded from work and further investigation should be completed. -at approximately 2:45 p.m. the facility provided the results they had received from the testing of residents. R4 was tested for COVID-19 on 10/12/20. On 10/13/20, R4's results indicated she was positive. This was communicated as a critical result to the medical director. R5 was tested for COVID-19 on 10/12/20. On 10/13/20, R5's results indicated she was positive. This was communicated as a critical result to the medical director. -at approximately 2:45 p.m. the facility reported three additional staff tested positive for COVID-19 from the 10/12/20, testing. Monarch Healthcare Management Policy titled Coronavirus (COVID-19) revision date 10/8/20, indicated the following: Facility staff will be advised to check for any signs of illness prior to reporting to work and notify the designated personnel if they are symptomatic of COVID-19 (Fever, Chills, Shortness of Breath, New or Change in Cough, Sore Throat, Muscle Pain, Headache, New Loss of Taste or Smell, Nausea, Vomiting, or Diarrhea), or a respiratory infection, should not report to work. The facility should screen at the beginning of each shift for fever and/or other symptoms of COVID-19 such as Chills, Shortness of Breath, New or Change in Cough, Sore Throat, Muscle Pain, Headache, New Loss of Taste or Smell, Nausea, Vomiting, or Diarrhea. Actively take their temperature and document the absence of shortness of breath, new or change in cough, sore throat and other symptoms of COVID-19. If they are ill, please have them leave the workplace. The Monarch Healthcare Management COVID-19 Screening Tool undated, indicated the following: Anyone who have symptoms of a respiratory infection should be restricted from entering the facility. The IJ that began on 10/13/20, at 5:58 p.m. was removed on 10/14/20, at 4:02 p.m. when the facility implemented corrective actions which included the following: The COVID-19 screening tool process was reviewed and staff were educated in person or via telephone on reporting signs and symptoms, active screening by nurse on duty and assessing reported symptoms consistent with COVID-19. COVID-19 competency training requires screener to notify nurse if any questions are answered yes on the COVID-19 screening tool. Employee will not be allowed in the building if the employee answers yes. Screening forms are to be reviewed daily by Director of Nursing, or designee. Policies and procedures for COVID-19, emerging infectious diseases and emergency preparedness relating to testing and staffing is implemented according to CDC and MDH guidelines. DON or designee will review and track infections daily. All staff will be educated prior to their next scheduled shift via telephone or in person on COVID-19 Screening Tool and signs and symptoms consistent with COVID-19. Training of all staff began on 10/14/20. DON or designee will continue providing training. Mass communication alert sent to staff to inform them that training must be completed prior to the start of their next scheduled shift. Signs are posted at the time clock and on the employee/visitor screening area to alert staff of this requirement. The following describes the ongoing measures to sustain improvement needed to prevent further infection. DON or designee will audit screening tool daily. The results of the audits will be shared with the facility QAPI Committee for input on the need to increase, decrease or discontinue the regular audits. DON will maintain the infection control log.

Based on interview and document review, the facility failed to monitor a surgical wound and provide treatment for [REDACTED]. R1 subsequently required hospitalization , surgical debridement of the ankle, and removal of the ankle hardware from the previous surgery, intravenous antibiotic treatment, and possible amputation. The deficient practice was identified as an immediate jeopardy (IJ) situation. The IJ began on 7/24/20, when R1 was admitted to the facility with physician orders [REDACTED]. R1's surgical incision was not monitored nor was the dressing changed until 8/3/20. As a result, R1 was hospitalized and underwent surgery for [REDACTED]. The administrator and director of nursing (DON) were informed of the IJ on 8/17/20, at 2:47 p.m. and corrective action was immediately implemented. The IJ was removed on 8/18/20, at 1:01 p.m., but non-compliance remained at the lower scope and severity of a G, (actual harm that is not immediate jeopardy). Findings include: R1's Admission Record printed 8/18/20, indicated R1's [DIAGNOSES REDACTED]. R1's admission paperwork to the facility from the hospital dated 7/24/20, indicated R1 had left ankle surgical wound dressings, and directed nursing staff were to change the dressings as needed. The orders also included R1's left leg boot/cast was to be in place at all times, and R1 was non-weight bearing. The paperwork indicated R1 was to have a follow-up appointment scheduled in 5 days. R1's admission Minimum Data Set ((MDS) dated [DATE], incorrectly indicated R1 had no surgical wounds. The MDS also indicated R1 required extensive assistance with activities of daily living (ADLs), and had intact cognition. R1's care plan initiated 7/24/20, lacked surgical /wound monitoring for R1's left ankle fracture. R1's treatment administration record (TAR) and Medication Administration Record [REDACTED]. On 7/24/20, at 7:11 p.m. a progress note indicated R1 had been admitted to the facility from hospital after left ankle fracture requiring surgery on 7/23/20. R1 was non-weight bearing in his left leg, and required assistance of two staff for all transfers. R1's right lower extremity had an abrasion from a fall resulting in the left ankle fracture. The left ankle had a boot. On 7/31/20, at 2:34 p.m. a progress note indicated R1 was seen by the rounding physician via video conference. The progress note indicated R1 complained of pain at the fracture site and at the surgical incision. The rounding physician made no changes to R1's orders or cares at that time. On 8/3/20, at 9:40 a.m. a progress note indicated nursing had seen R1. The note indicated R1's incision was observed, and there was no drainage at the surgical site. However, slight warmth was noted to the inner aspect of the left lower ankle. R1 had scratches on both lower legs that were noted to have been bleeding due to his scratching. R1 had requested his surgical incision be seen by his physician. The facility rounding physician was called, and the facility was instructed to take pictures of R1's surgical wound and his legs, and send them to her. The rounding physician ordered [MEDICATION NAME] ([MEDICATION NAME]) applied to R1's legs to help with the itching, and the rounding physician indicated she would show pictures to R1's surgeon. The pictures were taken and sent to the rounding physician. R1's boot was placed back on, and the facility waited for a reply from the physician. The notes lacked indication R1's dressing been changed, or that the physician had been notified. On 8/4/20, at 1:03 p.m. a progress note indicated on 8/3/20, nursing staff looked at R1's surgical wounds that were located on the inner and outer aspect of his ankle. Staples were noted to both surgical wounds. No drainage was noted. There was a scabbed area to the inner aspect of the ankle from the boot rubbing. An order had been received from the rounding physician allowing R1's left boot to be loosened some when in bed. The surgical incisions were noted to have slight warmth. No signs or symptoms of infection were noted. There were scratches on both of R1's legs. The notes lacked indication R1's dressing been changed, or that the physician had been notified. On 8/7/20, at 5:22 p.m. a progress note indicated R1's ankle surgical incision had two open areas measuring 3 inches by 2 inches. Slough (dead cells) was noted to the rest of the incision with drainage. The surgical incision area was cleansed with normal saline, and foam dressings were applied to incision. R1's surgeon (MD)-A was called, and a message was left. No additional attempts were made to contact MD-A. On 8/10/20, at 8:04 a.m. a progress note indicated MD-A had come to the facility to see R1's surgical wounds. MD-A ordered R1 to be transfer to hospital on [DATE], in the morning, for surgery scheduled for noon. On 8/17/20, at 10:25 a.m. nursing assistant (NA)-A was interviewed and stated it was the responsibility of licensed nursing staff to provide cares for surgical incisions. NA-A stated she would notify a licensed nurse if a dressing came off, or if a resident had concerns with their wound. NA-A stated she personally never looked at R1's actual surgical site due to his wearing of the boot when she provided cares. On 8/17/20, at 10:25 a.m. licensed practical nurse (LPN)-A stated if a resident had a surgical incision, and it was to be monitored, it would be scheduled on the TAR or MAR. LPN-A stated licensed staff should also document in the progress notes. LPN-A stated she would notify the registered nurse (RN) on duty if there was a change in a resident's condition. LPN-A stated R1 had removed his boot back in early August, said his surgical incision was infected, and stated he wanted to see a physician. LPN-A stated she had informed RN-A, who then contacted R1's physician. LPN-A stated that was the last time she had worked with R1. LPN-A stated the only time she recalled seeing R1's surgical incision was the day R1 had removed his boot, and she immediately reported it RN-A. LPN-A stated she did not do a dressing change at that time or inspect the incision. On 8/17/20, at 11:08 a.m. MD-A was interviewed. MD-A stated on 8/7/20, he had received a note to call the facility. MD-A stated he did call the facility, but there was no answer. MD-A stated the note had no details related to changes in R1's surgical incision. MD-A stated he went to the facility on [DATE], to look at R1's surgical site and remove R1's staples. MD-A stated R1 appeared to have a change in cognition, and appeared somewhat delirious. MD-A stated R1 was lying in his bed picking at his surgical incision, which was uncovered. MD-A stated R1's boot was lying in the corner, and there was obvious drainage and infection to the incision site. MD-A stated additionally, there were a few flies around the incision, and he knew then R1 would require a surgical debridement, so that was arranged for the following day. MD-A stated R1 required the hardware from his previous surgery to be removed, and he had doubts this would ever heal properly. MD-A stated R1 could be looking at possible amputation of his left lower leg due to the infection. MD-A stated R1 would remain hospitalized , and would continue to receive intravenous (IV) antibiotics for the next several days. On 8/17/20, at 2:47 p.m. RN-A was interviewed and stated nursing staff should be inspecting surgical incisions at a minimum of once a day, to check for signs and symptoms of infection, and to monitor for any changes to the incision. RN-A stated monitoring directions for nursing staff are generally located on the TAR. RN-A stated treatments and monitoring were to be put in place at the time of admission. RN-A stated nursing had not monitored R1's surgical incision daily for infection, and directions were not in place for nursing to do so. RN-A also stated R1's orders for dressing changes were not transcribed and implemented as ordered. RN-A stated she was not the nurse who completed R1's admission, and stated she was not able to do it all herself. RN-A stated monitoring R1's surgical incision had been missed, and it should not have been. RN-A verified R1 was to have an appointment with MD-A within five days of admission, however, this was missed and had not been scheduled. RN-A stated R1 was seen by the rounding physician via videoconference on 7/31/20, however, the surgical incision site was not looked at during that visit. RN-A stated she was made aware of R1 taking his boot off sometime around 8/3/20, and the rounding physician was updated at that time. RN-A stated the rounding physician had ordered [MEDICATION NAME], and to allow for the boot to be loosened at night. RN-A verified MD-A was not contacted and updated with changes on 8/3/20, when R1 had changes to surgical site and requested to see physician. RN-A verified MD-A was not contacted and updated with changes on 8/4/20, when R1's surgical incisions were noted to have slight warmth. RN-A stated it was not until 8/7/20, when she looked at R1's surgical incision, she noted the incision appeared infected. RN-A stated she had called the clinic and left a message for MD-A to call the facility back. RN-A verified MD-A had not called the facility back, nor had nursing tried to contact him or another surgeon that day regarding the change in R1's surgical incision. On 8/17/20, at 2:10 p.m. the director of nursing (DON) stated nursing staff should have been removing R1's boot each shift to inspect R1's surgical incision and to properly monitor for infection. The DON stated failure to properly monitor a surgical site or wound site could cause an infection to spread or worsen if not immediately identified through monitoring. The DON stated wound monitoring should have been on R1's TAR upon admission to ensure nursing staff was monitoring for infection. The DON verified monitoring the surgical incision and dressing changes were not in place for R1, and this prevented early detection of infection. The DON stated nursing staff should have contacted R1's surgeon numerous times if needed, to properly update him with R1's change in condition on 8/7/20, to ensure proper treatment was provided. The facility implemented corrective action to prevent recurrence by 8/18/20. The facility revised all resident's Face Sheets to include if a resident had any areas with skin conditions. In addition, all licensed nursing staff were trained to include monitoring surgical incisions for signs and symptoms of infection, and the procedure for notifying the physician in the event of a change in condition. The corrective actions were verified by interviews with staff and document review. The facility policy Admission Criteria revised 3/19, directed admission to the facility included only those resident whose needs can be met. Examples of nursing/medical needs that can be met included post-operative care needs. The facility policy Resident Examination and Assessment revised 4/14, directed, The purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan. The facility policy Skin Assessment and Wound Management dated 7/18, directed, Wound care will be provided per nursing or provider order. Procedure will be performed utilizing safe and sanitary methods in effort to prevent contamination or the spread of infection. The facility policy Skin Assessment and Wound Management dated 7/18, directed, Wound care will be provided per nursing or provider order. Procedure will be performed utilizing safe and sanitary methods in effort to prevent contamination or the spread of infection.

Based on observation, interview, and document review, the facility failed to notify the physician regarding high and low blood glucose results for 2 of 3 residents (R1, R3) reviewed for blood glucose and [MED] administration. This resulted in actual harm for R1, who was hospitalized for [REDACTED]. Findings include: R1's Admission Record dated [DATE], indicated R1's [DIAGNOSES REDACTED]. R1's annual Minimum Data Set ((MDS) dated [DATE], identified R1 was cognitively intact, and he had no behaviors or rejection of care. The MDS also identified R1 was unable to walk, and required extensive assistance with bed mobility, transfers, and dressing. The MDS indicated R1 received [MED] injections and [MEDICAL TREATMENT] services. R1's Active Orders dated [DATE], indicated R1 was ordered the following: [MEDICAL TREATMENT] every Monday, Wednesday, and Friday. Notify physician if blood sugar (blood glucose) less than [AGE] or greater than 450 (initiated 1/7/20). [MED] [MEDICATION NAME] ([MEDICATION NAME], a long acting [MED]) 100 units/milliliter (mL) inject 14 units daily. The order lacked parameters for when to hold the medication. [MED] [MEDICATION NAME] ([MEDICATION NAME], a short acting [MED]) 100 units/mL injected as per sliding scale three times daily at 8:00 a.m., 12:00 p.m., and 5:00 p.m.: 151 - 199 = 3 units 200 - 249 = 4 units 250 - 299 = 5 units 300 - 349 = 9 units 350 - 399 = 13 units 400 - 449 = 15 units 450 - 499 = 20 units Ensure resident eats at least 50% of meals and [MED] to be administered after meals. [MEDICATION NAME]100 units/mL injected as per sliding scale daily at 8:00 p.m.: 350 - 399 = 3 units 400 - 449 = 5 units 450 - 499 = 6 units Greater than 499 = 7 units Recheck in 45 minutes, if still above 499 notify RN. R1's care plan initiated [DATE], indicated R1 had the potential for alteration in blood sugar related to diabetes. Interventions included notify provider if blood sugars were less than [AGE] or greater than 450, administer [MED] as ordered, encourage resident to take [MED] as ordered, document refusals, and notify provider of refusals. A Refusal of Care/Interventions Risk and Benefits document dated 8/29/19, indicated R1 refused a diabetic/renal diet, medications, and cares. The document further indicated R1's risks included failure to maintain normal blood sugars, increased [MEDICAL CONDITION], vascular (blood vessels) damage, kidney damage, and infections. The document did not identify alternative treatment. The document was signed by R1's designee on 8/29/19. R1's October 2019 Medication Administration Record [REDACTED] -[MEDICATION NAME] was administered 29 of 31 opportunities, refused once, and held once. -[MEDICATION NAME]was administered 78 of 124 opportunities, sliding scale parameters were not met 21 times, refused 14 times, held due to intake once, absent from the facility ([MEDICAL TREATMENT]) three times, see nurses' notes once, and the MAR indicated [REDACTED]. R1's medical record lacked indication a physican was notified [MED] was held due to intake or refusals. R1's November 2019 MAR indicated [REDACTED] -[MEDICATION NAME] was administered 28 of 30 opportunities and refused twice. -[MEDICATION NAME]was administered [AGE] of 120 opportunities, sliding scale parameters were not met 24 times, refused 12 times, no associated documentation three times, absent from the facility ([MEDICAL TREATMENT]) twice, sleeping once, and see nurses' notes once (R1's medical record lacked any associated documentation). R1's medical record lacked indication a physican was notified of his refusals. R1's December 2019 MAR indicated [REDACTED] -[MEDICATION NAME] was administered 23 of 31 opportunities, refused three times, not given due to being in the hospital three times, and held twice. -[MEDICATION NAME]was administered 68 of 124 opportunities, sliding scale parameters were not met 27 times, refused 11 times, absent from the facility ([MEDICAL TREATMENT]) four times, not given due to being in the hospital nine times, directed to reference nursing notes three times, and sleeping twice. Additionally, R1 was administered [MEDICATION NAME]seven times with less than 50% documented intake, and had no documented intake for 51 occurrences. R1's medical record lacked indication a physican was notified [MED] was held due to intake or refusals. R1's January 2019 MAR indicated [REDACTED] -[MEDICATION NAME] was administered 23 of 27 opportunities, held three times, and refused twice. -[MEDICATION NAME]was administered of 69 of 106 opportunities, sliding scale parameters were not met 23 times, refused 12 times, and directed to see nurses' notes twice. R1 was administered [MEDICATION NAME]with less than 50% intake six times and there was no documented intake for 56 occurrences. R1's medical record lacked indication a physican was notified [MED] was held due to intake or refusals. -Beginning 1/7/20, the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Review of R1's October 2019 Weights and Vitals Summary dated 1/29/20, indicated the following blood sugar results: -100 - 199: 21 occurrences -200 - 299: 22 occurrences -300 - 399: 21 occurrences -400 - 499: 6 occurrences -500 - 599: 20 occurrences -[AGE]0 - 699: 4 occurrences R1's medical record lacked indication a physican was notified of blood sugar results greater than 500. Review of R1's November 2019 Weights and Vitals Summary dated 1/29/20, indicated the following blood sugar results: -100 - 199: 18 occurrences -200 - 299: 19 occurrences -300 - 399: 29 occurrences -400 - 499: 17 occurrences -500 - 599: 9 occurrences -[AGE]0 - 699: 4 occurrences R1's physican was notified of an elevated blood sugar result on 11/5/19. R1's medical record lacked indication a physican was notified of any further blood sugar results greater than 500. Review of R1's December 2019 Weights and Vitals Summary dated 1/29/20, indicated the following blood sugar results: -100 - 199: 14 occurrences -200 - 299: 20 occurrences -300 - 399: 29 occurrences -400 - 499: 15 occurrences -500 - 599: 9 occurrences -[AGE]0 - 699: 1 occurrence R1 was noted to have a blood sugar of 57 on [DATE], and 45 on 12/13/19. R1's medical record lacked indication a physican was notified of blood sugar results greater than 500 or less than [AGE]. Review of R1's January 2020 Weights and Vitals Summary dated 1/29/20, indicated the following blood sugar results: -100 - 199: 26 occurrences -200 - 299: 16 occurrences -300 - 399: 21 occurrences -400 - 499: 12 occurrences -500 - 599: 10 occurrences [AGE]0 - 699: 2 occurrences R1's medical record lacked indication a physican was notified of blood sugar results greater than 500. A progress note dated 10/2/19, at 1:21 p.m. indicated R1's 12:00 p.m. medications were not administered as he was at [MEDICAL TREATMENT]. A progress note dated [DATE], at 10:18 p.m. indicated R1 refused supper as staff were not getting to him fast enough. The progress note further indicated R1's blood sugar was high at 9:00 p.m. A progress note dated 10/26/19, at 8:09 p.m. indicated R1 refused [MED] due to not eating dinner. A progress note dated [DATE], at 10:06 p.m. indicated R1 declined dinner as he did not like how it tasted. The progress note further indicated R1 was given half of what his sliding scale called for to prevent a blood sugar crisis. There were no corresponding physician's orders [REDACTED]. A progress note dated 11/23/19, at 1:33 p.m. indicated R1's [MEDICATION NAME]was held as he did not eat. A progress note dated 11/23/19, at 3:25 p.m. indicated R1 stated he did not feel very well, and his morning blood sugar was 507 and his lunchtime blood sugar was 5[AGE]. The progress note further indicated R1 was not administered a noon dose of [MED] due to not eating. A progress note dated 11/24/19, at 1:58 p.m. indicated R1's [MEDICATION NAME]was held due to not eating. A progress note dated 11/25/19, at 5:13 p.m. indicated R1's [MEDICATION NAME]was held due to refusing dinner. A progress note dated 11/25/19, at 8:03 p.m. indicated R1 refused all medications and blood sugar check at bedtime as the nurse was late. The progress note further indicated R1's 5:00 p.m. [MED] was held due to refusing dinner. A progress note dated 11/30/19, at 12:08 a.m. indicated R1 was very irritable and apathetic when staff checked his blood sugar. The progress note further indicated R1 stated it was pointless as I just ate. A progress note dated 12/6/19, at 6:21 p.m. indicated R1's [MEDICATION NAME]was held as he refused to eat. A progress note dated 12/7/19, at 12:10 a.m. indicated R1 refused his afternoon medications and meal. The progress note further indicated R1 requested staff retrieve food items and pop from a vending machine however, staff was unavailable. R1 was asleep during bedtime medication pass and blood glucose check at 9:00 p.m. A physician note dated [DATE], indicated R1 was often non-compliant with a diabetic diet and medications. A progress note dated 12/21/19, at 5:22 p.m. indicated R1's [MEDICATION NAME]was held due to nausea, vomiting, and the resident was not eating. A progress note dated 12/22/19, at 8:15 a.m. indicated R1 was experiencing frequent vomiting, diarrhea, and reported severe chest pain. R1 was given [MEDICATION NAME] (dilates blood vessels to reduce chest pain) and stated it was ineffective. R1 was sent to the hospital via ambulance. A progress note dated [DATE], at 4:49 a.m. indicated R1 was transferred from emergency department to another hospital with a [DIAGNOSES REDACTED]. A progress note dated 12/24/19, at 4:44 p.m. indicated R1 returned to the facility. A hospital discharge summary dated 12/24/19, R1 was admitted to the hospital with [REDACTED]. A progress note dated 12/24/19, at 5:11 p.m. indicated R1's blood sugar was 571 before supper. The progress note further indicated R1 drank a bottle of Mountain Dew and would be covered with [MED] after he ate. A progress note dated 12/29/19, at 1:13 a.m. indicated R1's [MED] was held due to poor intake. A progress note dated 12/30/19, at 11:52 a.m. indicated R1's 12:00 p.m. medications were not given as he was at [MEDICAL TREATMENT]. A [MEDICAL TREATMENT] communication tool dated 1/6/20, indicated the facility communicated R1 had low blood sugar ([AGE]) to the [MEDICAL TREATMENT] center. The [MEDICAL TREATMENT] center responded R1's blood sugar was 32 upon arrival and was given intravenous [MEDICATION NAME]. The [MEDICAL TREATMENT] communication tool further indicated, Please ensure pt. (patient) is stable before sending to [MEDICAL TREATMENT]. A progress note dated 1/16/20, at 11:35 a.m. indicated a registered dietician reviewed R1's blood sugars, which ranged from 70 - 561, and noted a couple of higher blood sugars. The dietician was to update the nurse manager. The progress note further indicated R1's intakes were great. A progress note dated [DATE], at 2:56 p.m. indicated R1 was hospitalized [DATE], through 12/24/19 for chest pain and mild diabetic ketoacidosis. On 1/24/20, at 10:50 a.m. an interview was conducted with R1. R1 stated he was diabetic for [AGE] years, his blood sugars were all over the place, and the facility did not listen to him in regards to [MED] administration. R1 stated he was hypoglycemic at a recent [MEDICAL TREATMENT] appointment however, he was unable to recall specific details of the event. R1 also stated the facility does send him to [MEDICAL TREATMENT] with a bag lunch however, he does not like 90% of the food that was provided. R1 also stated he was able to eat independently however, required assistance, at times. On 1/24/20, at 11:13 a.m. R1 was observed wearing a jacket and seated in a wheelchair near the doorway to his room. At 11:18 a.m. licensed practical nurse (LPN)-A brought a medication cup and water to R1, who took the medications without further assistance. On 1/24/20, at 11:26 a.m. LPN-A was interviewed. LPN-A stated she hadn't checked R1's blood sugars yet, and stated she would do this before lunch, and administer [MED] after residents ate. LPN-A stated R1's 8:00 a.m. blood sugar was 110. On 1/24/20, at 11:42 a.m. staff wheeled R1 out of his room and towards a medical transportation driver. The medical transportation driver wheeled R1 near the facility entrance. The surveyor requested the driver to stop. LPN-A was interviewed and confirmed she had not taken R1's 12:00 p.m. blood sugar, and stated she did not have time. LPN-A also stated R1's 12:00 p.m. blood sugar was to be taken prior to being transported to his [MEDICAL TREATMENT] appointment. LPN-A then took R1's blood sugar, and the result was 437. The transportation driver asked if the resident may leave the facility and LPN-A stated yep. LPN-A was asked if R1 needed [MED] coverage for a blood sugar of 437. LPN-A confirmed R1 needed [MED] coverage however, stated she was unable to administer [MED] unless she knew how much a resident ate. LPN-A again directed the transportation driver to transport R1 to [MEDICAL TREATMENT]. The transportation driver then exited the facility with R1. On 1/24/20, at 3:13 p.m. an interview was conducted with nursing assistant (NA)-A. NA-A stated NAs were responsible to document how much residents ate. NA-A also stated staff were to document 0 and notify the nurse if a resident did not eat. On 1/24/20, at 3:24 p.m. an interview was conducted with NA-B. NA-B stated NAs were responsible to document resident intake. NA-B also stated there was a range of 0-25% to document if a resident did not eat. NA-B stated NAs were to notify a nurse if a resident did not eat. On 1/24/20, at 3:31 p.m. an interview was conducted with LPN-A. LPN-A stated she would probably still administer [MED] if a resident's blood sugar was high however, she would need to notify the doctor if [MED] was held. LPN-A also stated she relied upon word of mouth from nursing assistants relating the amount of a meal a resident ate, as she was unable to see how much a resident ate on the electronic medical record. LPN-A stated R1 drank a lot of pop, and did eat well. LPN-A also stated staff had previously given R1 [MED] in his sleep because his blood sugar was high. LPN-A was unable to state parameters of when a physician needed to be called in regards to high or low blood sugar readings. On 1/24/20, at 3:35 p.m. an interview was conducted with registered nurse (RN)-C. RN-C stated she generally asked residents how much they ate prior to administering [MED] however, she would ask NAs if a resident's cognition was low. RN-C also stated she would not administer [MED] unless a resident ate 50% of their meal however, if [MED] was held staff were to notify the physician to see if a dose should still be administered. RN-C stated a doctor needed to be notified if a residents blood sugar was less than [AGE], or greater than 450. On [DATE], at 10:17 a.m. an interview was conducted with RN-A. RN-A stated R1 was noncompliant with his diet, medication, cares, and drank a lot of Mountain Dew. RN-A also stated R1 usually did not take [MED], and sometimes did not allow staff to take his blood sugar. RN-A stated R1's refusals were dependent upon his mood, he liked to sleep after [MEDICAL TREATMENT], and the facility had tried everything. RN-A confirmed R1 was hospitalized in December 2019, for chest pain that was not relieved with [MEDICATION NAME]. RN-A stated the facility always kept R1's physician up-to-date in regards to blood sugar levels. RN-A also stated R1's primary care provider was on a medical leave since January, and an emergency department physician or other medical provider was to be notified of blood sugar levels in the interim. RN-A was unable to recall if she was notified of R1's low blood sugar level at [MEDICAL TREATMENT] on 1/6/20, and stated she would have ensured the resident ate and rechecked R1's blood sugar level prior to leaving the facility. RN-A stated blood sugar parameters were individualized for each resident, and physicians were to be notified if a resident's blood sugar level was less than [AGE] greater than 450, or a resident ate less than 50% of their meal. RN-A stated the facility was working to get LPNs who were new to the facility, up to speed as several nurses were hired in November 2019. RN-A also stated if LPN's were not comfortable calling the doctor, they could consult with an RN to do so. RN-A confirmed the physician needed to be notified when LPN-A held R1's [MED] on 1/24/20. RN-A also stated she was unable to locate documentation R1's physician was notified of high blood sugar readings of after 1/7/20 (date which the facility diabetic protocol was initiated): -540 on [DATE], at 9:08 a.m. -571 on [DATE], at 11:33 a.m. -4[AGE] on 1/11/20, at 1:05 p.m. -4[AGE] on 1/14/20, at 9:08 a.m. -512 on 1/16/20, at 6:07 p.m. -549 on 1/16/20, at 8:50 p.m. On [DATE], at 11:33 a.m. an interview was conducted with a [MEDICAL TREATMENT] staff person (DS)-A. DS-A stated on 1/6/20, R1 arrived to their facility with a package of graham crackers on his lap, was not making any sense, and was really sweaty. The DS-A stated R1's blood sugar was checked, and was noted to be in the 30's. The DS-A stated R1's condition did not allow staff to administer anything by mouth, and intravenous [MEDICATION NAME] needed to be administered, and he was hospitalized from the [MEDICAL TREATMENT] center. The DS-A also stated a communication sheet was sent to the [MEDICAL TREATMENT] center indicating R1 had low blood sugar. The DS-A also stated the facility sometimes forgot to send lunch with R1 to his [MEDICAL TREATMENT] appointments. On [DATE], at 12:09 p.m. an interview was conducted with the director of nursing (DON). The DON stated R1 was very non-compliant, refused everything, and drank a lot of Mountain Dew. The DON also stated that R1's moods were always better in the morning. The DON stated R1 was admitted to the hospital with [REDACTED]. The DON also stated she did not know if the lack of diabetic protocols contributed to R1's hospitalization as she was not the DON at that time of the hospitalization . The DON stated the facility had been without a DON for quite some time. The DON stated she was made aware of incident involving R1's low blood sugar afterwards, and RN-A was notified right away. The DON also stated she spoke to LPN-A regarding the incident, and she instructed her residents were not to be sent out of the facility with a low blood sugar. The DON stated she also notified the facility medical director about the incident, and a blood sugar protocol was initiated, on 1/7/20, as the facility lacked blood sugar protocols. When asked about R1's subsequent high blood glucose readings after 1/7/20, she responded saying the facility had a documentation problem. The DON stated the facility probably called the physician [AGE]% of the time regarding resident blood sugar levels which were outside of the established parameters. The DON also stated R1's MAR indicated [REDACTED]. The DON confirmed documentation on the MAR indicated [REDACTED]. The DON then stated the facility expectation was for nursing to write a progress note when the physician was notified so that information was captured. The DON stated staff needed to administer R1's 12:00 [MED] on 1/24/20, and should had sent the resident with a snack. The DON also stated it was their policy to complete blood sugar checks prior to meals, and administer [MED] after meals, as residents have had a lot of lows and drops. The DON confirmed a physician was to be notified if [MED] was held. The DON again stated the facility had a documentation problem, and she had spoken facility nursing quite a bit regarding the issue. The DON also stated that she had placed reminders around the facility regarding documentation, and had told nurses if it was not documented it was not done. The DON stated going nurse-to-nurse regarding this information was not working. The DON also stated the facility would implement stand-up and stand-down meetings beginning on 1/28/20, and nurses would not be permitted to go off-duty until their documentation was completed. R3's Admission Record printed [DATE], indicated R3 had a [DIAGNOSES REDACTED]. R3's admission MDS dated [DATE], indicated R3 was cognitively intact. R3's MDS further indicated R3 received [MED] injections, and required supervision for dressing, grooming, personal hygiene, transfers, bed mobility, and toileting. R3's care plan initiated 10/29/19, indicated R3 had an alteration in blood sugar related to [DIAGNOSES REDACTED]. R3's interventions directed staff to encourage a bed time snack, monitor R3 for signs and symptoms of low and high blood sugar levels, monitor blood sugar as ordered, and to administer scheduled and sliding scale [MED] as ordered. R3's Order Summary Report dated [DATE], indicated R3 had active orders for [MEDICAL TREATMENT] Tuesday, Thursday, and Saturday, [MEDICATION NAME] Solution Pen (long acting [MED]) 15 units (u) in the morning, [MEDICATION NAME] (glucose) injection 1 milligram (mg) into the muscle one time as needed for low blood sugar. In addition, R2's active orders included [MEDICATION NAME] (fast acting [MED]) was to be given per sliding scale for blood sugar readings as followed: 0-16= no [MED] 161-190-2u 2191-200-4u 221-250-6u 251-2[AGE]-8u 281-310-10u 311-340-12u 341-370-14u 371-400-16u 401-430-18u 431-4[AGE]-20u 461-490-22u 491-520-24u 521-550-26u 551-5[AGE]-28u 581-610-30u 611+-32u R3's Order Summary Report further instructed [MED] to be given after meals, and if blood sugars were elevated and R3 failed to eat greater than 50% of meal, contact provider for direction and not to hold [MEDICATION NAME] without direct instructions. R3's MAR printed [DATE], indicated the following blood sugar parameters effective 1/6/20: Notify physician if outside of parameters of blood sugar less than [AGE] or greater than 450, or if residents eats less than 50 percent of meal, and blood sugar is less than 140 every shift. In the month of December 2019, R3 had 19 blood sugar readings over 450 that were documented in R3's progress notes and/or on R3's Weekly Weights and Vitals Summary. R3's progress notes indicated R3's physician was notified 1 out of the 19 times R3's blood sugar levels were over 450 which was on 12/29/19. R3's progress notes lacked evidence the physician was notified of R3's blood sugar level above 450 the remaining times. In the month of December 2019, R3 had 9 blood sugar readings below [AGE] that were documented in R3's progress notes, and/or on R23's Weekly Weights and Vitals Summary. R3's progress notes lacked evidence the physician was notified for any of R3's blood sugar readings below [AGE]. In the month of January 2020, R3 had 16 blood sugar readings over 450 that were documented in R3's progress notes and/or on R3's Weekly Weights and Vitals Summary. R3's progress notes indicated R3's physician was notified 5 out of the 16 times that R3's blood sugar levels were over 450 which were on 1/8/20, 1/14/20, [DATE], 1/24/20, and [DATE]. R3's medical record lacked evidence the physician was notified of R2's blood sugar levels above 450 for the remaining times. In the month of January 2020, R3 had 6 blood sugar readings below [AGE] that were documented in R3's progress notes, and/or on R3's Weekly Weights and Vitals Summary. R3's progress notes indicated R3's physician was notified 1 out of the 6 low blood sugar readings which was on 1.15.20. R3's Medication Administration Record [REDACTED]. In addition, R3's progress notes indicated R3 received additional [MEDICATION NAME] 1 mg injection on 1/14, and 1/15 for low blood sugar. R3's medical record lacked evidence R3's physician was notified of R2's blood sugar readings below [AGE] as directed. R3's progress note dated 12/7/19, indicated R3's was found unresponsive, cold, clammy, and shaking. R23's blood sugar was 23 at 4:35 p.m., and [MEDICATION NAME] injection was administered intramuscularly (injection into the muscle, IM). Resident ate only 30% of dinner and refused bedtime [MEDICATION NAME]. R3's progress notes lacked evidence R3's physician was notified. R3's progress note dated 12/8/19, indicated R3 refused [MEDICATION NAME] [MED]. Progress note lacked evidence the physician was notified of R3's refusal of [MED]. R3's progress note dated 12/12/19, indicated R3 refused [MED] after meal intake. Progress note lacked evidence physician was notified of R3's refusal of [MED]. R3's progress note dated 12/13/19, indicated R3 refused all [MED] fearing her blood sugar would drop too low. Progress note lacked evidence physician was notified of R3's refusal of [MED]. R3's progress note dated 12/15/19, indicated R3 refused [MED] after dinner. Progress note lacked evidence physician was notified of R3's refusal of [MED]. R3's progress note dated 12/29/19, indicated at 6:44 p.m. R3's blood sugar was 4[AGE] and agreed to take half the dose of her [MEDICATION NAME] sliding scale [MED], fearing blood sugar would drop. Progress note further indicated at 10:15 p.m. R3's blood sugar was 502 and [MEDICATION NAME] was administered. R3's progress note lacked evidence R2's physician was notified and updated. R3's progress note dated 12/24/19, indicated R3 refused [MEDICATION NAME]after eating supper and expressed her concern of her blood sugar dropping too fast. Progress note further indicated R3 reported to staff at 11:30 p.m. she felt sweaty, and requested her blood sugar to be checked. R3's blood sugar was 41 so R3 ate toast, strawberries, and drank 3 cups of juice. Progress note lacked evidence R3's physician was notified of R3's refusal of [MEDICATION NAME]and blood sugar of 41. R3's progress note dated 12/31/19, indicated R3 refused [MEDICATION NAME]because R3 thought her blood sugar level was to low and preferred to wait to see what her blood sugar reading would be later. Progress note lacked evidence R3's physician was notified and updated of R3's refusal of [MEDICATION NAME] [MED]. R3's progress note dated [DATE], indicated R3 was found unresponsive and sweaty around 4:30 p.m. R3's blood sugar was 38 and was administered [MEDICATION NAME] 10mg. R3's progress noted lacked evidence R3's physician was notified. R3's progress note dated 1/15/20, indicated R3 was found unresponsive in her room. R3's blood sugar was 40 and R3 was administered [MEDICATION NAME] injection. R3's blood sugar was rechecked after ten minutes and was still 40. R3 was sent to the emergency room . R3's Interagency Referral Form dated 1/20/20, indicated R3 was admitted to the hospital on [DATE], with altered mental status, and was given [MED] drip to treat [DIAGNOSES REDACTED] (low blood sugar). On [DATE], at 11:38 a.m. RN-A stated staff would notify the physician if a resident's blood sugar was below 40 or higher than 450, and the physician was notified by either fax or by phone, depending on the physician's preference. RN-A stated R3's physican liked to be called 24/7. RN-A stated if a physician was called about a resident's blood sugar, there should be documentation in the resident's progress notes. RN-A stated R3's blood sugar levels were all over the place, and R3 would often times fall below [AGE] or rise above 450. RN-A stated R3 was sent to the emergency room [DATE], for a low blood sugar of 40 that did not rise after [MEDICATION NAME] injection was administered. RN-A verified R3's progress notes lacked documentation of staff contacting R3's physician regarding several blood sugar readings under [AGE] and over 450. RN-A stated, If was not documented, then it didn't happen. RN-A stated she texted R3's physician that day because R3 had a blood glucose over 450. RN-A stated R3 would refuse to take her [MED], or only take half of the prescribed dose because R3 would be afraid of her blood sugar dropping too low. On [DATE], at 11:50 a.m. RN-B stated R3 was compliant with staff checking her blood glucose, and sometimes R3 would request to have her blood glucose checked because R3 felt her blood sugar was running low. RN-B stated if a resident's blood sugar was out of the parameters of below [AGE] and above 450, nursing would notify the physician. RN-B stated when a physician was called, nursing should be documenting in the residents progress notes. RN-B was unable to find any documentation in R3's progress notes of R3's recorded blood sugars over 450 on 1/24/19, or 1/26/19 or indication the physician was notified. On [DATE], at 12:09 p.m. the DON stated R3's progress notes lacked documentation, or indication the physician was notified on several blood glucose reading that were below [AGE] or over 450. DON stated staff were either calling the physician and not documenting, or not contacting the physician as instructed. DON stated one of the first things that was learned in nursing school was that if it was not documented, it didn't happen. The facility policy Diabetes - Clinical Protocol revised 9/17, directed, The physician will follow up on any acute episodes associated with a significant sustained change in blood sugars or significant deterioration of previous glucose control and document resident status at subsequent visits until the acute situation is resolved. The policy lacked indication of when staff was expected to notify the physician of abnormal blood glucose results. The facility policy Change in Resident Condition dated 6/19, directed, The facility shall notify the resident/representative and physician/healthcare provider of changes in the resident's condition and/or status.

Based on interview and document review, the facility failed to complete a comprehensive skin assessment, provide ongoing monitoring and develop interventions to promote healing and prevent further worsening for 1 of 1 resident (R1) who developed multiple pressure ulcers in the facility. This deficient practice resulted in actual harm for R1 who acquired three pressure ulcers (coccyx, gluteal fold and heel) and [MEDICAL CONDITION] after the coccyx pressure ulcer became infected, was subsequently hospitalized and died . Findings include: Unstageable pressure ulcer (observed full thickness skin and tissue loss in which the extent of the damage cannot be confirmed due to the wound bed obscured with slough or eschar) Stage 3 pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muschle not exposed. Slough may be presnet but doe not obscure the depth of tissue loss. (MONTH) include undermining and tunneling) Stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough, may also present as an intact or open/ruptured blister) R1's admission Minimum Data Set ((MDS) dated [DATE], indicated R1 had [DIAGNOSES REDACTED]. The MDS identified R1 had severe cognitive impairment and required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers, dressing, toileting, personal hygiene, bathing and set up assistance with eating. The MDS further identified R1 was at risk for developing pressure ulcers and had no current pressure ulcers identified. The MDS revealed the following interventions were in place; pressure reducing device for R1's chair and bed. The MDS identified R1 had no weight loss and received a therapeutic diet for meals. The MDS further identified R1 was frequently incontinent of bladder and bowel. R1's annual Care Area Assessment (CAA) dated [DATE], indicated R1 required extensive assistance with ADL's due to weakness, poor balance and severe cognitive impairment. The CAA identified R1 was at risk for developing pressure ulcers due to she required staff assistance with relieving pressure, was confined to a bed or chair most of the time, required a special mattress or seat cushion to reduce or relieve pressure and moisture associated skin damage. The CAA further indicated R1 was at nutritional risk due to dementia, arthritis, contractures, functional limitation with range of motion and inability to perform ADL's without significant physical assistance. The CAA identified R1 had frequent bladder and bowel incontinence due to limited mobility, pain and frequent urinary tract infections. R1's care plan, revised [DATE], indicated R1 was at risk for pressure ulcers and had an alteration in skin integrity. R1's care plan listed various interventions which included pressure relieving mattress in bed, pressure relief cushion in wheelchair, lift do not slide, assistance from staff to transfer, toilet and bed mobility. Further R1's care plan directed to observe skin with cares and report any changes to the licensed nurse, and complete weekly skin audits/evaluations by nurse on bath days, turn and reposition or reminders to offload every 2 hours and as needed, weekly measurements and assessment of wound, report and monitor for skin breakdown for signs/symptoms of infection and report any changes to MD. R1's Skin Assessment with Braden Scale forms from [DATE] to [DATE] revealed the following: - Skin Risk Assessment with Braden Scale (tool used to determine risk for pressure ulcer development) dated [DATE], indicated R1 had no pressure ulcers, was at risk for developing pressure ulcers due to acute condition, cognitive impairment, diabetes and requiring extensive assistance with bed mobility and occasional bowel incontinence. The assessment identified R1 had redness to her buttocks which was blanchable (area returns to normal skin color when pressure was applied and removed). - Skin Risk Assessment with Braden Scale form dated [DATE], indicated R1 continued to be at risk for developing pressure ulcers and no current pressure ulcers were identified. The assessment identified R1 had moisture associated skin damage due to incontinence and continued to have [MEDICAL CONDITION] to her lower extremities. The assessment indicated R1 continued to have redness to her buttocks that was blanchable. -Skin Risk Assessment with Braden Scale form dated [DATE], indicated R1 continued to be at risk for developing pressure ulcers and no current pressure ulcers were identified. The assessment identified R1 had moisture associated skin damage due to incontinence and [MEDICAL CONDITION] to her lower extremities. The assessment indicated R1 continued to have redness to her buttocks that was blanchable. The assessment indicated staff were to apply barrier cream after incontinence episodes, use of mechanical left for transfers, lift do not slide with repositioning, assist with transfers, toileting and bed mobility as needed and elevate l/e ( lower extremities) throughout the day. The medical record lacked any further skin assessments completed after [DATE]. Review of R1's progress notes from [DATE] to [DATE] revealed the following: -[DATE], redness to buttocks which was blanchable. -[DATE], redness to buttocks which was blanchable. -[DATE], redness to buttocks and barrier cream was being applied. -[DATE], continued to have redness to buttocks that was blanchable and staff were applying barrier cream. -[DATE], skin was clear and intact and did not address R1's skin on the buttocks. -[DATE], skin was clear and intact. -[DATE], yellow bruising to R1's left upper arm and the note lacked any further assessment of the rest of R1's skin. -[DATE], weekly skin inspection completed by licensed nurse however had no results of the inspection documented. -[DATE], staff applied a dressing to R1's bottom and administered pain medicaiton to R1 due to complaints of pain to her bottom. A later note indicated again staff placed a patch on R1's buttocks wound. The progress note lacked any description, measurement or staging of the pressure ulcer. R1's record lacked evidence of a comprehensive skin assessment completed including identifying causitive factors, contributing factors, nutrition, resident clinical condition and risk factors to develop approprate interventions to promote healing and prevent further pressure ulcers. -[DATE], changed dressing to coccyx pressure ulcer. The progress note lacked any description, measurement or staging of the pressure ulcer. -[DATE], coccyx pressure ulcer measured 4 cm. by 2.7 cm. with a depth of 0.4 cm. and classified as unstageable. The note identified the dark spot present on R1's pressure ulcer extended from R1's coccyx to the right buttocks and measured 3 cm. by 3 cm. The note indicated R1's right buttocks had pink, macerated and fragile skin that measured 2 cm. by 2.6 cm. related to urinary incontinence. The note further indicated R1 had four small open areas present on the right buttock which measured 1.6 cm. by 0.4, 0.6 cm x 0.8 cm., 1 cm x 0.6 cm and 0.2 cm x 0.2 cm. -[DATE], late entry [DATE], unstageable pressure ulcer on coccyx with 30% slough and 70% eschar, periwound skin dark pink does blanch. Stage 2 pressure ulcer in right gluteal fold with [MEDICATION NAME] tissue. Developed a skin tear when bandage covering pressure ulcer removed. Area cleansed with soap and water, periwound skin treated with no sting barrier and sacral dressing applied. -[DATE], wound on coccyx changed, area cleansed with normal saline, dried and no sting barrier spray applied, new dressing applied. Later, a note indicated the dressing was changed due to saturation. -[DATE], dressing changed on bottom, area cleansed and no sting applied and new dressing placed. No indication if changing change was done to the coccyx or gluteal fold pressure ulcer. -[DATE], resident seen by MD for sacral wound, new order for Bactrim DS(antibiotic) BID x 12 days, foley catheter due to [MEDICAL CONDITION] and grade 3 sacral wound infected, ,[DATE] strength Dakins(antiseptic solution) wet to dry twice a day (BID) and as needed(PRN) covered with ABD(thick absorbent gauze dressing) pad. The note did not address treatment for [REDACTED]. -[DATE], dressing change done, area cleanses, new Dakins wet to dry, covered with ABD pad. Yelling throughout help me, pain medication given prior to dressing change -[DATE], coccyx wound changed this shift, cleansed, new Dakins wet to dry, no sting and ABD pad applied. Foul odor from wound, starting to tunnel to right side. The note did not address measurements of the new tunnelling, current size of the pressure ulcer and did not address the right gluteal fold pressure ulcer. -[DATE], while turning resident noted a deep tissue injury (blister) on heel of right foot, measures 3.5 cm x 3.5 cm. noted resident pushing on bed with her heels. Implemented foam heel dressing and blue boots on at all times. A note later that day indicated dressing changed on coccyx, area cleansed, new Dakins wet to dry, ABD applied. Later that day, shaking and screaming help during wound care and for 1.5 hours after. Nurse sat with her for 20 minutes to provide reassurance, no interventions effective. Given pain medication which was ineffective. Also has new skin breakdown on the left hip/buttocks area. The notes did not address dressing change for the rght gluteal fold pressuer ulcer and did not include measurements, characterics, any possible drainage and treatment for [REDACTED]. -[DATE], daughter here and very concerned. Was here til 11:00 pm last evening and R1 moaning, appeared in pain, moving around a lot. She also reported R1 had a new open area on buttocks, family wanted her sent to the emergency room . The notes indicated R1 had been transferred to the emergency room approximately one hour later Review of facility form titled Weekly Pressure Wound Evaluation from [DATE] to [DATE] revealed the following: - [DATE], new unstageable pressure ulcer identified that measured 4 centimeters (cm.) in length, 2.7 cm. in width and 0.4 cm. in depth. The evaluation further indicated R1 had a dark spot extending from the coccyx to the right buttock that measured 3 cm. by 3 cm. Additionally, the right buttocks had pink macerated fragile skin that measured 2 cm. by 2.6 cm. and had four small open areas that measured 1.6 cm. by 0.4 cm., 0.6 cm. by 0.8 cm., 1 cm. by 0.6 cm. and 0.2 cm. by 0.2 cm. The evaluation identified R1's skin as fragile and macerated due to incontinence. The area was cleansed with wound cleanser and patted dry with a gauze dressing. A [MEDICATION NAME] (an absorbent foam dressing) dressing was applied to R1's coccyx as well as barrier cream. -[DATE], unstagable pressure ulcer to coccyx measured 5 cm. by 3.2 cm. with no depth noted. The wound had 30% slough and 70% eschar. Additionally, a pressure ulcer was noted to R1's right gluteal fold that measured 1.5 cm. by 1 cm. with 0.1 cm. of depth and classified as a stage two pressure ulcer. A scant amount of serosanguinous drainage was noted and an odor was present. The wound evaluation identified R1 spent the majority of her day sitting in her wheelchair or recliner and refused to stand due to fear of falling. An order was obtained for a sacral dressing to be changed every three days and as needed and staff were instructed to reposition or off load every two hours. The medical record lacked any further Weekly Pressure Wound Evaluation forms completed after [DATE]. R1' clinical record lacked documentation the facilty conducted weekly monitoring of R1's multiple pressure ulcers which included location, size, depth, color, drainage, odor and staging of the pressure ulcers. On [DATE], at 3:30 p.m. family member (FM)-A stated R1 did not have a pressure ulcer present upon admission to the facility. She indicated she had never seen the facility use special mattresses or cushions to aid in pressure ulcer prevention. FM-A stated the first two weeks of R1's stay went well and things deteriorated once R1 transferred to the second floor of the facility. She indicated she had been present on [DATE], during the medical doctor (MD)-A visit, MD-A had indicated they would be starting a treatment which consisted of a wash and staff would reposition R1 every two hours. She indicated R1's room had a foul odor lingering in the room, which she felt was from the infected pressure ulcer. FM-A indicated the night before R1 was transferred to the hospital, she had been informed the facility would be placing R1 on an air mattress. FM-A stated she had been very upset to learn the facility had an air mattress and had not started using it prior to that time. FM-A stated on the morning of [DATE], she asked the staff to transfer R1 to the hospital to be evaluated. FM-A stated the surgeon on duty (MD-B) informed her the pressure ulcer had started from the inside out and R1 may have had the wound for a long time. MD-B informed her a debridement of the wound was to be done that day due to the fact the pressure ulcer was infected. On [DATE], at 8:35 a.m. during a telephone interview, MD-B verified he had been called for a surgical consult for R1 due to an infected pressure ulcer. MD-B stated he evaluated R1 when she was in the intensive care unit (ICU) and R1 was quite sick with low blood pressure and septic shock (potentially fatal condition in [MEDICAL CONDITION] leads to dangerously low blood pressure and abnormalities in cellular metabolism). MD-B stated he had a discussion with R1's family members present and explained R1 was in critical condition and R1 had a severe large foul smelling wound which had rotting slough and debris present. MD-B confirmed this type of wound was most commonly related to pressure at the site of the wound. MD-B estimated the size of the pressure ulcer upon his first evaluation to measure 10 cm. by 10 cm. with the surrounding skin necrotic and the center of the pressure ulcer black and foul smelling. MD-B verified R1's pressure ulcer was the major contributor of the development [MEDICAL CONDITION]. MD-B stated a significant amount of foul-smelling dead tissue had been debrided, the pressure ulcer had progressed to the bone and involved the bone. MD-B indicated after a second debridement, R1 had been placed on palliative care and subsequently passed away. On [DATE], at 9:59 a.m. RN-A indicated R1 had been at risk for developing pressure ulcers and verified R1 did not have a pressure ulcer upon admission. RN-A stated R1 had not developed a pressure ulcer to her coccyx until after R1 moved from the first floor to the second floor. RN-A was not able to recall when R1 developed the pressure ulcer to her coccyx nor what stage the pressure ulcer was at when identified. RN-A indicated skin inspections were to be completed weekly on bath days. RN-A stated the process for skin inspections was for (nursing assistant) NA's to complete the skin inspection, document it on the facility Body Observation Sheet, give the sheet to the licensed nurse and the licensed nurse would then document in the medical record the results under the progress notes which were titled weekly skin inspection. RN-A reviewed the medical record and verified weekly skin inspections had not been completed on R1 in the month of June. Further, RN-A stated the pressure ulcer had been identified on [DATE] and had been classified as an unstageable pressure ulcer. RN-A reviewed the weekly facility Body Observation Sheets and verified on [DATE], the sheet indicated R1 had a bleeding sore. Further, RN-A verified the medical record lacked documentation of the wound developing on [DATE]. Review of R1's Body Observation Sheets completed by nursing assistants (NA) on resident bath days from-[DATE] to [DATE] revealed the following: -[DATE], redness to buttocks and coccyx. -[DATE], intact skin with no redness to buttocks or coccyx. -[DATE], intact skin with no redness to buttocks or coccyx. -[DATE], redness to coccyx. -[DATE], intact skin with no redness to buttocks or coccyx. -[DATE],bleeding sore to coccyx. -[DATE], pressure ulcer to coccyx. -[DATE], pressure ulcer to coccyx. R1's Weekly Skin Inspection,completed on [DATE] by licensed nursing staff, indicated R1 had an open area on her coccyx and new treatment orders were in place. Additionally, R1 had received a new cushion for her wheelchair and recliner. The inspection form indicated R1 would be turned and repositioned every two hours and as needed as resident allowed. R1's medical record lacked any further Weekly Skin Inspection forms completed by licensed nursing staff, even though R1 had a pressure ulcer on her coccyx and gluteal fold. On [DATE], 10:22 a.m. NA-A stated the process for skin inspections consisted of the NA's completing the forms on bath days and the inspections were given to the licensed nurse to enter into the medical record. In addition, NA-A stated he would inform the licensed nurse if he had noted any abnormalities during the inspection. NA-A stated he was not certain of the timing of when R1's pressure ulcer developed and stated the wound was large and had an odor to it. NA-A stated R1 would at times call out and say her bottom hurt. On [DATE], 10:32 a.m. NA-F stated nursing assistants completed the body observations on bath days weekly and provided the sheet to the licensed nurse to analyze it. NA-F stated if she had noticed anything abnormal she would have informed the licensed nurse. NA-F stated she was not sure when R1's pressure ulcer developed and indicated R1's pressure ulcer was pretty big and had an odor to it. On [DATE], at 11:43 a.m. NA-C stated R1's skin concerns developed after her move to second floor. NA-C stated she noticed R1's pressure ulcer to her coccyx around three weeks prior to R1 being hospitalized and further stated she had reported it to a licensed nurse. NA-C stated around two weeks before R1 was transferred to the hospital, the pressure ulcer had deteriorated to a hole and the skin surrounding R1's pressure ulcer was starting to die. NA-C further stated R1's pressure ulcer had an odor to it. On [DATE], at 11:51 a.m. licensed pratical nurse (LPN)-A stated on [DATE], she noted R1 had a dressing to her coccyx area. LPN-A stated she had completed the dressing change once and R1's pressure ulcer had black tissue present. On [DATE], at 12:05 p.m. director of nursing (DON) indicated she expected staff to complete weekly skin inspections on every resident. DON reviewed R1's medical record and confirmed R1's pressure ulcer had been identified on [DATE]. DON reviewed R1's Body Observation Sheets and confirmed the presence of a bleeding sore on [DATE]. DON confirmed he was not aware of the presence of a bleeding sore on R1 identified [DATE], and was not sure why it had been missed. After review of R1's medical record, DON confirmed weekly skin inspections, wound evaluations had not been completed for R1. He confirmed the last skin assessment had been done in May. DON stated R1 had been admitted to the hospital on [DATE], due to symptoms of shaking, whimpering and very diaphoretic. Further, DON stated the hospital informed the facility R1 [MEDICAL CONDITION], dehydration and shock and expired on [DATE]. On [DATE], at 2:19 p.m. NA-E indicated R1's pressure ulcer developed a couple of weeks before R1 was hospitalized . NA-E stated R1's pressure ulcer started out as a tiny spot and within a week R1's pressure ulcer grew larger and started to develop black tissue. NA-E further stated R1's pressure ulcer within the next week or so became larger and developed even more black tissue to it. On [DATE], at 2:33 p.m. during a follow-up interview, DON indicated the facility conducted an ad-hoc meeting that was similar to a root cause analysis after he had been notified of R1's hospitalization and death. DON confirmed no training had been provided to the staff regarding pressure ulcer identification and care since this incident. DON confirmed improvement in processes needed to occur to ensure residents were properly assessed and treated for [REDACTED]. Additionally, DON confirmed no auditing of cares had been completed and confirmed no changes to the facilty's process for pressure ulcer care had been completed at that time. Review of physician's progress notes from [DATE] to [DATE] revealed the following: -[DATE], admitted to the facility from home with worsening dementia and significant generalized weakness and had a reluctance to walk due to low back pain which was new. Orders for physical therapy, occupational therapy and to continue previous cares. The note had no indication of R1 having any skin concerns at that time. -[DATE], physician note indicated the plan was to continue current orders. R1 had no skin issues identified at this visit. -[DATE], multiple family members were present for physician visit and had questions about R1's sacral wound as well as her continued urinary issues and dementia. The note indicated the sacral pressure ulcer developed and had progressively worsened due R1 refused to stand or walk or be turned. The plan in the note identified primary physician advised against sending R1 to the hospital for debridement due to outpatient care should be attempted first and indicators of a more systemic issue were not present at the time. New orders were received for nursing staff to insert a urinary catheter due to [MEDICAL CONDITION] and a significant sacral pressure ulcer. Additionally, new orders were received for R1 to start on antibiotics. The note indicated R1's pressure ulcer was classified as a stage three (full thickness skin loss potentially extending into the subcutaneous tissue) pressure ulcer. Plan was to follow-up in four weeks or sooner if needed. On [DATE], at 9:20 a.m. during a telephone interview, MD-A stated R1's initial discharge plan was to participate in therapy to improve strength and function with the goal of returning home. MD-A stated R1 had dementia and had a fear of standing and falling and as a result was not getting up. MD-A stated during his last visit, R1 was seated in her recliner and appeared very uncomfortable. MD-A stated R1's pressure ulcer was pretty big and had a large amount of eschar present. MD-A stated he advised the family they would treat R1's pressure ulcer conservatively. MD-A stated the conservative approach had been attempted for about three days and then the family made the decision to transfer R1 to the hospital. Review of faciltiy policy titled Skin Assessment and Wound Management dated [DATE], indicated the staff would complete a Braden scale assessment upon admission, weekly times three and when a significant change occurs. The policy instructed staff to notify licensed staff when skin changes were identified. The policy further instructed licensed staff to complete weekly skin inspections. Additionally, the policy instructed staff to notify the physician, family representative when a pressure ulcer was identified. The policy indicated staff were to initiate the weekly pressure ulcer wound evaluation weekly until healed. The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated ,[DATE], identified Section M: Skin Conditions to be completed to identify the risk, presence, appearance and change of pressure ulcers/injures. The manual defines a pressure ulcer/injury as a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of intense and/or prolonged pressure in combination of shear. The pressure ulcer/injury can present as intact skin or an open ulcer and may be painful. The manual further identified it was imperative to determine the etiology of all wounds and [MEDICAL CONDITION] as that would determine and direct the proper treatment and management of the wound. - The manual defines an unstageable pressure ulcer/injury as Known but not stageable due to coverage of wound bed by slough or eschar.

Based on observation, interview, and document review, the facility failed to ensure safe transfer techniques when transferring residents utilizing ceiling lift transfers, resulting in actual harm for 1 of 11 residents (R5) who was transferred using a ceiling lift and Guldman brand sling. This resulted in serious injury to R5 who fell from the lift during a transfer, was sent to the emergency room , and sustained pain, abrasions, and a fractured humerus. In addition to R5, the facility failed to ensure safe transfers for 3 additional residents (R3, R16, R59) who were also transferred improperly with ceiling lifts and slings. The facility failed to ensure direct care staff were utilizing manufacturer recommended sling placement technique during transfers, which resulted in an immediate jeopardy (IJ) situation for (R5, R3, R16, and R59). All of these residents were listed as totally dependent upon staff for transfers. The immediate jeopardy began on 10/21/17, when R5 fell from a ceiling lift sling during a transfer from the wheelchair to the bed, was sent to the emergency room and was diagnosed with [REDACTED]. This incident was identified on 10/23/17. The administrator and director of nursing were notified of the immediate jeopardy on 10/23/17, at 6:42 p.m. The immediate jeopardy was removed on 10/24/17, at 4:40 p.m. but noncompliance remained at the lower scope and severity level of an G, which indicated actual harm that was not immediate jeopardy. In addition, interventions to reduce injuries related to falls were not provided consistently for R74, and a a decline in ability to transfer safely leading to shoulder pain and decreased range of motion was not comprehensively assessed, and interventions were not initiated to prevent further injury for R74. In addition, comprehensive toileting and fall assessments, and root cause analyses of falls was not completed to identify appropriate interventions to prevent falls for R2. This resulted in actual harm for R2 who sustained a cervical (neck) fracture. Findings include: R5 sustained a broken humerus due to a fall from a Guldman sling attached to a ceiling lift in the facility. Staff failed to use the proper sling placement according to manufacturer recommendations for the transfer. In addition to the broken humerus, R5 complained of neck pain, a headache, had several abrasions on her face and red areas on her neck. R5's Face Sheet printed 10/23/17, identified [DIAGNOSES REDACTED]. R5's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R5 was cognitively intact, and was totally dependent upon staff for activities of daily living (ADLs), including transfers. The MDS also identified R5 had no falls since the last assessment. R5's Falls Care Area Assessment (CAA) dated 12/26/16, identified R5 was at risk of falls due to being unable to maintain balance without assistance. The CAA indicated R5 was alert and oriented, and able to make her needs known. The CAA also indicated R5 received total assistance with ADLs due to [DIAGNOSES REDACTED]. The CAA further indicated R5 was not able to maintain balance without staff assistance due to her diagnoses, and had not had any falls in the assessment look back period and no falls in the last year. R5's care plan dated 9/25/17, indicated R5 was at risk for falls, with the goal to not be seriously injured due to a fall. The care plan also indicated R5 required total assist of staff and ceiling track lift for transfers. The care plan identified the following interventions: keep the call light within reach when in room, anticipate needs, provide toileting assistance as soon as possible at resident's request, redirect if resident observed attempting to stand or walk independently (even though the resident was quadriplegic and was unable to attempt to stand or walk independently). The care plan directed to refer to Kardex/behavior tool for resident specific plan of care. R5's Kardex dated 10/17/17, directed staff to use a ceiling track lift with a full sling to transfer R5. R5's care plan and Kardex lacked direction of sling placement. A progress note dated 10/21/17, at 7:53 p.m. indicated R5 fell while being transferred from her wheelchair into bed. The note indicated after the fall, R5 complained of pain to the right side of her forehead and right neck/clavicle area. The note further indicated R5 sustained two pinpoint abrasions above her right eyebrow, and a red area on the right side of her neck. The note also indicated R5 fell to the floor and was laying on her left side/back with her legs slightly bent at the knees and tucked under the bed, with her right arm behind her body, and her head leaning to the left and left arm folded at her side. The note indicated R5 stated she bumped her head and had a headache, nursing assessment indicated R5's pupils were 5+ (high side of normal) and sluggish (abnormal slow response). The note concluded that R5 was sent to the emergency room for further evaluation. A progress note dated 10/21/17, at 9:43 p.m. indicated the emergency room called and informed the facility R5 had sustained a fractured right humerus (upper arm). The note also indicated the hospital was waiting on a few more scans, and would call the facility with further updates. A progress note dated 10/22/17, at 2:16 a.m. indicated R5 returned to the facility. A progress note dated 10/22/17, at 11:41 a.m. indicated R5 was tired and felt nauseated. Family reported concerns as resident was not finishing sentences with their conversations. According to the note, R5's vital signs were taken and her oxygen saturation was at 85% on room air (normal is 95%). Supplemental oxygen was then used, per standing orders, and R5's oxygen saturation then went up to 90%. Neurological checks were then implemented hourly for 3 hours and then every 4 hours for 24 hours. The facility assured family they would follow up with any changes in condition, and they contacted the nurse practitioner. A progress note dated 10/22/17, at 6:21 p.m. indicated R5 was mumbling and hard to rouse. R5's blood pressure was 53/41 (low), her pupils were dilated, but not symmetrically, and her oxygen saturation was 90% on 1.5 liters per minute of supplemental oxygen. R5 was sent to the emergency room again, and from there transferred to a medical intensive care unit at a larger tertiary hospital with septic shock and a urinary tract infection. On 10/23/17, at 9:56 a.m. the director of nursing (DON) was interviewed and stated R5 fell while one nursing assistant (NA) was transferring R5 from the wheelchair to bed with a Guldman ceiling lift and basic high mesh sling. After the fall, a licensed practical nurse (LPN) completed an initial assessment and assisted R5 back to bed. The DON stated she was called to R5's room and upon arrival, R5 was lucid and able to answer her questions. R5 told the DON she had neck pain and a headache, moderate shoulder pain and the DON noted two small abrasions on her forehead. The DON stated she began some passive range of motion (ROM) on R5's arms, but R5 grimaced when her arm was moved so she stopped. The DON indicated R5's pupils were large and pupil response time was slow. The DON stated she was concerned, and had the LPN call for an ambulance immediately. The DON further stated facility policy allowed staff to transfer residents with only an assist of one staff when using the ceiling lifts. The DON stated that when the LPN entered R5's room on 10/21/17, the sling was still hooked at all four points. The DON stated R5 and the NA performing the transfer recalled the fall differently: R5 told the DON she fell out head first, and the NA told the DON it all happened so fast she doesn't know how R5 fell out of the sling, but thought R5 slipped through the hole created by the straps crossing under R5's bottom and upper legs. The DON confirmed that R5 was sent to the hospital and sustained a humerus fracture. On 10/23/17, at 1:10 p.m. the DON stated the facility hosts an annual safety training day in which all direct care staff are required to demonstrate competency in transferring with a ceiling lift and hoyer lift. The DON stated for the 2017 training day, she was role playing a resident, and staff had to transfer her from bed to wheelchair and back again. The DON stated she trained all staff to position the sling according to manufacturer instructions which included having the sling straps cross up between the legs (not crossed underneath the resident) and up through the strap loops. The DON stated after R5's fall from the lift and sling, she had the LPN review sling use and safety with nursing assistants in report, but she did not implement any house-wide interventions for sling use as they did not yet know the root cause of the fall, and did not know which direction to focus interventions. The DON stated she did re-educate the NA who was transferring R5 and ensured a note was read at report that indicated, Always make sure you are using the right size, right style, and the right set up when transferring residents with a lift. On 10/23/17, at 1:30 p.m. the DON read from her fall incident investigation notes that the NA indicated she placed the sling on R5 in the cradle position (indicating the straps cross under the legs and then remain on the outside of resident's legs, not between the legs and up through the loop, crossing in front of the resident. This cradle position was not recommended by the manufacturer and left open the possibility of a resident pitching forward out of the sling without any barrier to falling. The DON further read the incident report, which indicated the full body net sling was placed on R5 so that the top was aligned mid-ear and cradled legs and arms inside sling, R5's catheter bag was held in left hand (of NA) and lift remote in the right hand (of NA). The DON stated the NA believed R5 fell through the hole created by crossing the sling straps under the legs. According to the DON, R5 felt she crashed out, with her upper body hitting the floor first and her bottom after. R5 told the DON that the transfer felt the same as always prior to the fall, with no jerking and her catheter did not pull. Again, the DON stated that R5 felt she slide out of the sling head first, while the NA thought R5 fell through the hole in the sling. On 10/23/17, at 1:46 p.m., the facility report board was reviewed and the note that read, Always make sure you are using the right size, right style and the right set up, was noted to be there. On 10/23/17, at 2:53 p.m. the DON and registered nurse (RN)-A demonstrated the cradle method of sling use to show how R5 was transferred on 10/21/17. The DON stated this was not how she taught staff to apply the sling and straps, nor could she find it in the manufacturer's instructions as a method to use stating, It's not the typical hook up. On 10/23/17, at 1:35 p.m. RN-A stated there were 11 residents residing in the facilty who were transferred using ceiling lifts and 2 who were transferred with a hoyer lift. On 10/23/17, at 1:48 p.m. NA-O stated she has had training on use of the ceiling lifts and slings, and was told in the last two days (after R5's fall) to ensure that she was using the correct slings. On 10/23/17, at 1:58 p.m. NA- B stated she has had previous training on proper use of ceiling lifts and slings, but has not been reminded recently of proper sling use. On 10/23/17, at 4:06 p.m. the DON stated she did not know that staff were using the cradle method rather than the manufacturer's recommended method to transfer R5. The DON stated she had trained staff on transferring residents, but had not observed staff transferring residents. The DON stated she had not performed audits on ceiling lift transfers nor had she watched actual transfers and how the staff were setting up the sling and straps. On 10/23/17, at 4:07 p.m. RN-A stated she did not know that staff were using the cradle method to transfer R5, she had not observed staff transfer R5. On 10/23/17, at 5:02 p.m. NA- E stated she had used the cradle method to transfer R5 since June 2017, when someone trained her to set up the sling that way for R5. NA-E also stated she used the cradle method for sling placement when transferring R3, R16, and a couple of other residents whose names she could not think of at the time. On 10/23/17, at 5:10 p.m. NA-P stated R5 was the only resident that she has transferred using the cradle method. NA-P stated she has transferred R5 that way since January 2017, and did not know why that method was used. On 10/23/17, at 5:13 p.m. NA-K stated she has used the cradle method to transfer R5 for over a year. NA-K stated she did not know why that method was used, but indicated she had been trained by other NAs on transfer techniques. On 10/24/17, at 12:48 p.m. the DON stated they had conducted a number of training and provided reminders on correct transfer technique which included: - A NA training on 6/5/17, on selecting the proper sling type and size. - Individual competency and skills demonstrations throughout the summer of 2017, that included demonstration of proper lift sling transfers from bed to wheelchair and wheelchair to bed under the supervision of the DON or assistant director of nursing (ADON). - 7/11/17, staff education that included using the correct sling size and style for the lift and individual resident - Various emails and pay day updates: - 10/20/17 email: The slings MUST be used according to manufacturer's guidelines in order to stay in compliance and increase safety . - 7/21/17 pay day update: Safety belts used in slings for transfers to the toilet must be used at all times! No exceptions. The manufacturer's recommendations must be followed. The DON stated they had focused on slings and lifts due to concerns at other area facilities, and the fact that the slings being used in the facility did not always match with the lift available or the correct size for a specific resident. The DON stated they now have correct size and style of sling for each resident being transferred, and had done competency training on correct transfer style. However, neither the DON nor other licensed nursing staff had observed any transfers of actual residents; nor had they audited correct transfer technique. The DON stated no staff had indicated they were using a cradle method of sling placement on some residents. The DON stated NAs were getting training on the floor by other NAs and believed this process lead to the unsafe cradle method being consistently used on some facility residents. On 10/24/17, at 8:28 a.m. the administrator stated they identified all residents being transferred with the cradle method (R3, R16, R59), and believed the practice originated from a NA who had used it at another facility, and then transferred the practice to this facility and in training other NAs as they were oriented. The administrator stated there are no lifts in the facility in which the cradle method should be used. When staff were using the incorrect cradle method in transfers, they should have been immediately re-educated. R3's Face Sheet printed on 10/23/17, identified [DIAGNOSES REDACTED]. R3's significant change MDS dated [DATE], indicated R3 was totally dependent upon staff for transfers and had not walked in the assessment period. R3's care plan printed on 10/23/17, indicated R3 had limited functional abilities due to physical deficits and terminal health conditions. R3's care plan referred staff to the Kardex for resident specific plan of care and functional capabilities. R3's Kardex indicated R3 required an assist of one staff with transfers, and was to be transferred with a ceiling track lift and Guldman sling. R5's care plan and Kardex lacked direction of sling placement. R3's 7/30/17, 8/4/17, and 10/20/17, Observation Detail List Reports indicated R3 was unable to stand on his own due to the [DIAGNOSES REDACTED]. On 10/23/17, at 5:02 p.m. NA- E stated she used the cradle method for sling placement when transferring R3. R3 was at risk of potential harm if he fell while being transferred with the incorrect cradle method, as was facility practice. R16's Face Sheet printed on 10/24/17, identified [DIAGNOSES REDACTED]. R16's quarterly MDS dated [DATE], indicated R16 was totally dependent upon staff for transfers, and had not walked during the assessment period. R16's care plan dated 9/24/17, identified R16 at risk of falls due to a [DIAGNOSES REDACTED]. R16's care plan did not specify how staff were to transfer R16, but directed staff to the Kardex for the specific plan of care. R16's Kardex indicated she was non-weight bearing and was to be transferred with a ceiling track lift and full body mesh sling. R16's care plan and Kardex lacked direction on sling placement. R16's Fall Risk assessment dated [DATE], indicated R16 required a hoyer lift for transfers and relied on staff assistance for mobility, transfers and daily activities. R16's 10/21/17 Observation Detail List Report indicated she was dependent upon staff for all ADLs including transfers and mobility. On 10/23/17, at 5:02 p.m. NA- E stated she used the cradle method for sling placement when transferring R3. R16 was at risk of potential harm if she fell while being transferred with the incorrect cradle method, as was facility practice. R59's Face Sheet printed on 10/24/17, identified [DIAGNOSES REDACTED]. R59's annual MDS dated [DATE], indicated R59 was totally dependent upon staff for transfers. R59's care plan dated 9/11/17, indicated he had limited functional abilities and ADLs due to physical and sensory deficits. The care plan referred staff to the Kardex for residents specific plan of care and functional abilities. R59's Kardex indicated R59 required a hoyer lift with an assist of one staff, there was a ceiling track lift in R59's room, and to use a large Guldman toileting sling. R5's care plan and Kardex lacked direction of sling placement. R59 was at risk of potential harm if he fell while being transferred with the incorrect cradle method, as was facility practice. On 10/23/17, at 5:02 p.m. NA- E stated she used the cradle method for sling placement when transferring R59. The immediate jeopardy that began on 10/21/17, was removed on 10/24/17, at 4:40 p.m. when the facility updated their policy, trained staff, identified residents who had been transferred incorrectly, and placed measures to ensure staff knew to never use the cradle method for any transfers in the facility. However, the noncompliance remained at the lower scope and severity level of G (isolated scope and severity level), which indicated actual harm that was not immediate jeopardy. R74 sustained multiple falls, some with injury, and the facility failed to comprehensively assess risk factors related to the continued falls. In addition, interventions to prevent falls were not consistently implemented. R74's Face Sheet printed 10/19/17, indicated R74 had [DIAGNOSES REDACTED]. R74's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R74 had significantly impaired cognition and moderately impaired vision (can see objects, but not read newsprint). The MDS also indicated R74 required supervision with bed mobility, toileting, and ambulation, and required limited assistance with transfer and extensive assistance with dressing. The MDS further indicated R74 was continent of bladder and bowel, and had two or more falls since the last assessment, and two or more falls with minor injury. R74's Falls Care Area Assessment (CAA) dated 2/22/17, identified R74 had been admitted to the facility due to severe cognitive impairment, inability to care for self, and frequent falls in his assisted living facility (some with injuries). The CAA indicated R74 appeared to understand others at times, and staff needed to anticipate R74's needs. The CAA also indicated R74 required cues, prompting and daily supervision. The CAA further identified R74 was not always steady with transfers and walking, but was able to maintain balance without staff assistance, and he readily accepted help for cares. R74's medical record lacked any further comprehensive fall assessments. R74's care plan dated 9/11/17, identified a goal that R74 would not be seriously injured due to a fall. The care plan identified the following interventions: call light within reach when resident is in room, anticipate needs, provide toileting assistance as soon as possible at resident's request, speak directly to R74 and allow ample time for him to respond, and refer to Kardex for resident's specific plan of care. R74's Kardex dated 10/17/17, indicated R74 was independent with wheelchair, recliner and bed repositioning, used a front wheeled walker, and was independent with ambulation. The Kardex directed R74 required an assist of one with dressing, was independent to an assist of one with undressing, and was independent to lay down after meals. The Kardex further directed staff to keep the bed close to the bathroom, have a sign posted to call for help, and a sign in the bathroom to pull up pants when done. Review of R74's Falls Event Reports indicated the following: -3/15/17, at 5:15 a.m. R74 was found on his bottom on the bathroom floor in front of his sink. R74 stated he hit his head and it hurt. The immediate intervention was to remind R74 to use his call light. The interdisciplinary team (IDT) intervention was to keep a urinal accessible at bedside. On 10/19/17, at 10:38 a.m. the DON stated the urinal was not an effective intervention as he did not use it. -5/8/17, at 3:19 p.m. R74 was standing in his bathroom with blood on his head. R74's pants were lying on the floor of his bedroom and his walker was tipped over. R74 sustained an abrasion above his left eye, a small skin tear on his left upper cheek, a small abrasion on his left elbow, and a scratch was noted on left side of rib cage. The immediate intervention was to remind R74 to ask for assistance with cares. The IDT intervention was to have staff follow R74 to his room as he allowed. -6/24/17, at 5:45 a.m. R74 fell while independently getting into bed. The immediate and IDT intervention was to demonstrate proper hand and foot placement when getting into and out of bed. -7/7/17, at 1:19 p.m. R74 fell when standing up from his chair in the dayroom. The new intervention was to order and place an adaptive height cushion for R74's dining room table chair. -7/8/17, at 3:00 p.m. R74 fell in the shower room, with staff present. The immediate intervention was to increase assistance with transfers during that shift. The IDT intervention was to encourage the resident to rise slowly. -7/18/17, at 6:00 p.m. R74 was found on the floor in his bedroom in front of the dresser. The top dresser drawer was broken and on the floor. R74 sustained a small abrasion on his left mid-shoulder blade and a scratch on his mid-left back, an an abrasion on his left elbow. The IDT intervention was a repeat of the 5/8/17, intervention to watch for R74 as he left the dining area after supper, and to follow him as he allowed and assist him with undressing before he lay down. -7/28/17, at 4:00 p.m. R74 was found on the floor leaning up against the wall in the day room. Prior to the fall he had been having coffee and a snack. R74 hit his head and had a red area on the back left side of his head and a red mark on his mid/left side of his back. The IDT intervention was to anticipate needs after dining and assist with chair as needed. -8/15/17, at 6:30 p.m. R74 fell in his room. R74 was not wearing socks or shoes and indicated he had mild pain in his buttocks after the fall. The immediate intervention was to put grippy socks on R74's feet, and have staff check more frequently through the night. The IDT intervention was to assess R74's environment and place his bed closer to the bathroom as R74 has a habit of undressing or partially undressing in the bathroom and walking across his room to his bed to lay down. The new arrangement reduced the amount of ambulation needed and allowed for more privacy. -8/31/17, at 5:00 p.m. R74 slid while attempting to sit down for dinner. R74 did not have his walker with him. R74 hit the back of his head against the wall. The immediate and IDT intervention was to place a sign on the walker reminding R74 to use his walker. -9/1/17, at 12:47 p.m. R74 was found on the floor in front of his bed with his pants down around his ankles. Resident was walking from bathroom to bed with his pants around his ankles and tripped. The immediate intervention was to remind R74 to pull up his pants before walking. The IDT intervention was to place a sign in the bathroom to remind R74 to pull up his pants before leaving the bathroom. -9/10/17, at 1:53 p.m. R74 was found on the floor by his closet. The immediate and IDT intervention was to encourage R74 to wear shoes. -10/11/17, at 8:22 a.m. R74 was found on his stomach on the floor next to his bed. The housekeeper had just been in R74's room, and R74 had been lying in bed. The housekeeper had told R74 that it was time for breakfast. R74 sustained a 1 centimeter (cm) skin tear above his left eyebrow, which was cleansed and a steri strip applied. The IDT intervention was to implement orthostatic blood pressure monitoring to determine if that was a contributing factor to his falls as R74's blood pressure was lower than usual. R74's fall pattern in 2017 prior to survey: 12 2 at 5 a.m. 1 at 8 a.m. 9 in the afternoon/very early evening Location of R74's falls: 1 in shower 3 in dayroom 8 in bed/bathroom On 10/19/17, at 10:27 a.m. the above pattern and location of R74's falls was reviewed with the DON. The DON stated she was not surprised by the times, locations or frequency of R74's falls, but she had not done a summary before. During survey, after surveyor investigation had begun, the following fall occurred: -10/22/17, at 6:43 p.m. R74 was found on the floor in his room next to his bed. R74 was sent to the hospital for a contusion. The IDT intervention was to refer R74 to therapy for an evaluation and treatment of [REDACTED]. On 10/18/17, at 7:16 a.m. R74 was observed standing with his walker in his bedroom doorway in his underwear and with bare feet. R74 left the doorway and using his walker, returned to his bed and laid down. A housekeeper entered his room at 7:19 a.m At 7:21 a.m. LPN-B entered R74's room to take R74's blood pressure and left at 7:25 a.m., at which point R74, still barefoot, returned to the doorway of his bedroom. At 7:30 a.m. LPN-B got R74 some clothes to wear and left, shutting the door as she left. At 7:52 a.m. R74 left his room in a t-shirt, sweatpants and what appeared to be slippers, but were actually black tennis shoes in which R74 had slid his feet into, stepping down the back under his heels. R74 walked independently with his walker to the dining room, ate, stood from the table with assistance from NA-D, and left the dining room independently with his walker; R74 continued to wear his shoes with the backs stepped down. On 10/19/17, at 8:55 a.m. a height cushion was observed to be in the chair that R74 used for meals, according to care plan and Kardex. A sign was present in R74's bathroom reminding him to pull up his pants or take them off before he left the bathroom. There was no sign on his walker, but there was a sign in R74's bedroom reminding him to take his walker with him. On 10/19/17, at 8:57 a.m. R74 was observed standing up from his bed independently with white socks on his feet. R74 walked to his bathroom independently with his walker. R74 left his bathroom at 9:10 a.m. with his walker, his sweatpants were pulled up. On 10/19/17, at 9:05 a.m. NA-B stated fall interventions for R74 included to keep his room free from clutter, check on him, and there were signs in his bathroom. NA-B also stated they make sure the table is out of his way when he stands up after meals. NA-B stated there were care plan change sheets that get read at report, but NA-B did not think there had been any care plan changes on R74. On 10/19/17, at 9:09 a.m. LPN-C stated the care plan update sheets get shredded after a week. On 10/19/17, at 9:12 a.m. NA-D stated staff make sure R74's door was open, his shoes were on, his pants were up and that he had his walker. On 10/19/17, at 9:19 a.m. NA-C stated they try to supervise R74 when walking to the dining room; keep grippy socks on him; make sure he has his walker and his floor is clear of clutter (he likes to pick things up). On 10/19/17, at 9:22 a.m. the LPN-A stated they have rearranged R74's room so his bed is closer to the bathroom and they make sure he has his walker with him and his shoes on. LPN-A stated he has grip strips on his bathroom floor and regular white athletic socks available. LPN-A stated she did not know if family had been asked to not provide white socks or not. On 10/19/17, at 9:28 a.m. certified occupational therapist assistant (COTA)-A stated R74 used to fall frequently when living in assisted living. COTA-A stated R74 was strong but impulsive and had issues with coordination of movement and safety. Physical therapist assistant (PTA)-A stated R74 had not received physical therapy while a resident of the facility, only an evaluation upon admission. On 10/19/17, at 10:27 a.m. the DON stated when a resident falls, the supervising nurse initiates an immediate intervention to keep a resident from falling again. After the immediate intervention, the IDT team meets once to discuss the fall, including contributing factors of the environment, medications, behaviors, and patterns. The DON stated the facility completes a root cause analysis after each fall. The DON stated they have a fall investigation tool, dated 4/17, that they sometimes used in their IDT meetings, but it was not part of the medical record. The DON stated they did not use it each time, only if they need to reference it as a guide. The DON stated R74 liked to take off his clothes and scatter them on the floor. The DON stated R74 will get dressed or undressed before or after meals, and be in and out of his bathroom. The DON stated they try to have staff anticipate R74's needs. R74 was somewhat receptive to interventions, and staff try to follow R74 out of the dining room after meals, but that was not always possible. The DON stated they communicate care plan changes in several ways: verbally in report, sometimes in emails and sometimes on the care plan or Kardex. The DON stated they are not going to prevent R74's falls, they just want to make R74 safe. The DON stated they have moved items out of R74's way, moved the bed closer to the bathroom, and applied non-slip strips to the bathroom floor. The DON stated they cannot use a low bed, as R74 is tall, and a low bed would be a restraint and fall mats would be at tripping hazard. The DON stated R74 has not worked with therapy. The DON stated current interventions should be listed on the Kardex. On 10/19/17, at 11:24 a.m. the DON stated they were not going to prevent R74 from falling, but wanted to make him safe. The DON reviewed the Kardex and confirmed it did not include all the interventions for fall prevention for R74, as the facility was about to begin a review and updating of all Kardex's. The facility's Falls policy, dated 8/16, indicated the purpose of the policy was to address

Based on observation, interview, and document review, the facility failed to assess, identify and implement interventions to prevent the development and/or worsening of pressure ulcers for 2 of 4 residents (R3, R68) reviewed for pressure ulcers. This resulted in actual harm for R3 who developed pressure ulcers that worsened. Findings include: Pressure Ulcer stages defined by the National Pressure Ulcer Advisory Panel (NPUAP): Stage 2 Pressure Ulcer: Partial thickness dermis loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptures serum-filled blister. Stage 3 Pressure Ulcer: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Ulcer. Stage 4 Pressure Ulcer: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Ulcer. Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. R3's medical record lacked a comprehensive skin assessment, weekly skin monitoring, and R3 was not repositioned in a timely manner. R3's Face Sheet printed 10/23/17, identified [DIAGNOSES REDACTED]. R3's annual Minimum Data Set ((MDS) dated [DATE], indicated R3 was at risk for pressure ulcers, and had a Stage 4 pressure ulcer present that had not been present at a lesser stage on the prior assessment. R3's 7/31/17, quarterly MDS dated [DATE], indicated R3 had one Stage 2 pressure ulcer that was not present upon admission or re-entry. The pressure ulcer was first observed on 6/14/17. The MDS also identified one Stage 4 pressure ulcer that had been previously noted. R3's significant change MDS dated [DATE], indicated R3 had a Stage 4 pressure ulcer. The MDS further indicated R3 had no rejection of cares, required extensive assistance with bed mobility, dressing, and personal hygiene, and was totally dependent upon staff for transfer and toileting. The MDS further indicated R3 had pressure ulcers on the prior assessment of 7/31/17, but one Stage 2 and one Stage 4 pressure ulcer were now present, and they were not present at a lesser stage on the prior assessment. R3's Care Area Assessment (CAA) dated 8/8/17, indicated R3 had one Stage 2 pressure ulcer and one Stage 4 pressure ulcer, and he was at risk of developing pressure ulcers. The CAA indicated R3 was to be turned and repositioned or offloaded (a process in which pressure to an area of the body is relieved)according to his care plan and Kardex. The CAA further indicated R3 had a pressure reduction mattress on his bed, and a cushion in his wheelchair to aid in healing and prevention of future pressure ulcers. R3's care plan for skin started 8/2/11, and discontinued on 9/25/17, indicated R3 had pressure ulcers on his right heel, left inner ankle and left gluteal crease. The goal was for the pressure ulcers to heal without complication. Staff approaches were listed as: turn and reposition every one hour and as needed while in bed, have resident lay on his side or stomach, and noted that R3 had a history of [REDACTED]. R3's care plan for skin updated 9/25/17, indicated R3 had an alteration in skin integrity related to a [DIAGNOSES REDACTED]. R3's goals were the wound would remain free from infection, and would not impair his lifestyle or activities. Interventions included to refer to the Kardex for resident specific plan of care. R3's Kardex dated 10/17/17, directed staff to apply lotion, moisturize skin as needed, float heels (keep the heels off of any surface), use blue boots (to relieve pressure), apply barrier cream as needed, use a Roho/gel cushion in his wheelchair (for pressure relief), and an alternating air pressure mattress in bed. The Kardex further directed staff to reposition R3 every hour when in his wheelchair, recliner and bed, and to use a gel insert under his wheelchair cushion to reduce shearing. On 10/18/17, at 9:17 a.m. R3's pressure ulcer was observed with NA-D and NA-B. The pressure ulcer was observed to be an uncovered open area on the left buttock/ischial tuberosity, approximately 1.5 cm by 2.5 cm by 1.0 cm in depth with surrounding blanchable redness and irregular edges. R3 had an alternating air pressure mattress on his bed, per his care plan. In addition, a think foam cushion (approximately 3-4 inches) and below that, a thick gel cushion were on R3's wheelchair. R3's medical record indicated the following on information documented on his pressure ulcers: On 6/9/17, a progress note referred to R3 returning from the wound clinic with new orders for a left ischial (sitting bone) ulcer. On 6/14/17, a progress note indicated R3 had a black area on his bottom that was identified as a deep tissue injury on the left buttocks. This was not the same pressure ulcer as noted in the 6/9/17, note. The note directed staff to reposition R3 hourly. The physician and family were updated. On 6/14/17, a facility Skin Integrity Event Report indicated R3 had a 2 centimeter (cm) by 1 cm deep tissue injury on his left buttock. The report indicated a treatment to apply foam dressing to this deep tissue injury on the left buttock, change every seven days and as needed. On 6/15/17, a progress note indicated the nurse practitioner (NP) assessed the open area on R3's left buttock, and ordered a foam dressing to the deep tissue injury on the left buttock to be changed every seven days and as needed, to continue using an air mattress on R3's bed, to provide frequent repositioning (every 2 hours) and use a wheelchair cushion. On 6/15/17, a progress note indicated nursing had changed the dressing to R3's buttocks pressure ulcer, and had noted redness to the area, but no drainage or odor. On 6/20/17, a progress note indicated R3's air flow mattress was not holding air pressure, a regular mattress was placed on R3's bed, and the manufacturer contacted. This note was a late entry for 6/15/17. The note further indicated a second mattress did not hold air and had to again be replaced. There was no documentation as to how long prior to 6/14/17, or after 6/15/17, R3 was without a pressure relieving mattress. A 6/27/17, a Body Observation sheet indicated sores on R3's coccyx area. The sheet lacked any further description or measurements of the area. On 6/27/17, a Weekly Skin note indicated R3 had two sores on the right side of his buttocks. The note indicated a dressing change had been done. The note also indicted R3 also had an open sore on his right heel. The note further indicated there were no other skin issues at that time. The sheet lacked any further description or measurements of the areas. On 6/29/17, a nurse practitioner (NP) progress note indicated R3 had a wound on his left buttock and right heel, and indicated R3 had poor wound healing. The note directed staff to apply a foam dressing every seven days and as needed, and to provide pressure relief. The note lacked any further description or measurements of the area. A 7/4/17, Body Observation sheet indicated open and 3 Xs: one on R3's left buttock, one on R3's left ischial area, and one on R3's right buttock. The sheet lacked any further description or measurements of the areas. On 7/4/17, a Weekly Skin note indicated R3 had an open area on his right heel, and two small open areas on the left side of his groin. The note lacked any documentation of the pressure ulcers on R3's ischial area. The note also lacked any further description or measurements of the areas. A 7/11/17, Body Observation sheet had no areas indicated on R3's buttocks area. A 7/18/17, Body Observation sheet indicated R3 had an open area indicated on the outer, upper left buttock area. On 7/18/17, a Weekly Skin note indicated R3 had an open area on his left buttocks that was still present but small. On 7/27/17, a NP progress note indicated R3 had a pressure ulcer on his left buttock: 1.0 cm by 1.0 cm by 0.9 cm, with a small amount of bloody drainage, pink granulation tissue in the wound bed, no odor, and the surrounding skin was intact. The NP directed staff to continue current wound care: saline moist to dry twice daily (BID) with follow up at the wound clinic. Staff were reminded to be mindful to minimize pressure. On 7/31/17, a quarterly Skin Assessment indicated R3 scored a 14 on the Braden scale, which indicated he was at risk for skin breakdown. The assessment indicated R3 had a Stage 2 pressure ulcer on his left buttock/sacral area measuring 3.0 cm by 1.8 cm, another area described as 1.0 cm by 1.0 cm area on his coccyx, and a 3.0 cm by 1.3 cm area on his right heel; the last 3 areas did not have staging indicated. The assessment indicated R3 was a maximum to total assist with mobility and the plan of care had been reviewed and remained appropriate. Review of physician orders [REDACTED]. An 8/1/17, Body Observation sheet lacked documentation of any of R3's pressure ulcers. On 8/1/17, a progress note indicated R3 was admitted to the hospital with [REDACTED]. Another 8/1/17, progress note indicated R3 would return to the facility on hospice cares. On 8/8/17, a Significant Change skin assessment note indicated R2 scored a 12 on the Braden scale which put him at risk for skin breakdown. The note further indicated R3 had a Stage 2 pressure ulcer on his left buttock/sacral area measuring 3.0 cm x 1.8 cm; an area on his coccyx measuring 1.0 cm by 1.0 cm and an area on his right heel measuring 3.0 cm by 1.3 cm. The coccyx and right heel pressure ulcers were not staged. Potential risk factors for impaired skin integrity included severely impaired mobility, and use of wheelchair for primary means of locomotion due to [DIAGNOSES REDACTED]. An 8/8/17, Body Observation sheet indicated R3 had a pressure ulcer on his right inner buttock. No other details were provided on the pressure ulcer. On 8/8/17, a Weekly Skin note indicated R3 had a red perineal area, the pressure ulcer on his buttocks was still present, and R3 had two red areas noted on right upper abdomen. No other details were provided on the pressure ulcers. An 8/15/17, Body Observation sheet indicated R3 had an ulcer on his left lower, inner buttock. No further details were documented R3's medical record lacked a comprehensive assessment following the development of the pressure ulcer to R3's left buttock. On 8/15/17, a Weekly Skin note indicated R3 continued to have pressure areas on his right heel and left ischial. No other details were provided on these pressure ulcers. On 8/22/17, a Weekly Skin note indicated R3 continued to have a pressure ulcer on his left ischial. No other details were provided on this pressure ulcer. An 8/29/17, Body Observation sheet lacked indication of pressure ulcers on R3's buttocks. On 8/31/17, a progress note indicated a fax was received from the hospital with new orders for R3's ischial pressure ulcer. The new order was to cleanse the ischial pressure ulcer with normal saline and apply ADB pad (a sterile, highly absorbent dressing with a moisture resistant barrier), and to change the dressing daily and as needed. A 9/5/17, Body Observation sheet indicated R3 had a pressure ulcer on his left buttock. No other details were provided on this pressure ulcer. On 9/5/17, a progress note indicated R3 had a Stage 3 pressure ulcer on his left buttocks measuring 1.0 cm by 0.7 cm with a depth of 0.2 cm, no drainage or odor were noted. The note indicated the wound bed had 100% granulation (healing) tissue, and the skin surrounding the wound was pink and intact, there was no undermining or tunneling; the wound was noted to be improving. R3's medical record lacked further documentation of the pressure ulcers on R3's right buttocks or right heel. On 9/11/17, a Weekly Skin note indicated R3 still had a pressure ulcer on his left buttock. No other details were provided on this pressure ulcer. A 9/12/17, Body Observation sheet indicated R3 had a pressure ulcer on his left buttock. No other details were provided on this pressure ulcer. On 9/12/17, a progress note indicated R3 had a Stage 3 pressure ulcer on his left buttock measuring 0.9 cm by 0.5 cm and a depth of 0.1 cm, with no odor or drainage noted. The wound bed was described as having 100% granulation tissue with intact wound edges, and the surrounding tissue was pink and intact with no undermining or tunneling noted. The pressure ulcer was described as improving. A 9/18/17, Body Observation sheet lacked documentation of the pressure ulcers on R3's buttocks. On 9/19/17, a progress note indicated R3 had a Stage 3 pressure ulcer on his left buttocks, measuring 1.0 cm by 1.5 cm with no odor or drainage. The wound bed was described as having 100% granulation tissues, with edged macerated (softened, often from prolonged exposure to moisture), with a 2.4 cm by 0.3 cm laceration noted at the bottom of the pressure ulcer; no undermining or tunneling was noted. On 9/26/17, a progress note indicated R3 had a Stage 3 pressure ulcer to his left gluteal area, measuring 1.0 cm by 0.9 cm and a depth of 0.3 cm, with no odor or drainage noted. The wound bed was described at 100% granulation tissue, with macerated edges and irregular, surrounding tissue was pink and intact with no undermining or tunneling noted. On 10/3/17, a Weekly Wound Assessment indicated R3 had a Stage 3 pressure ulcer to his left gluteal area, measuring 1.0 cm by 0.5 cm and a depth of 0.3 cm with no odor or drainage noted. The wound bed was described as 100% granulation tissue with wound edges macerated and irregular, surrounding tissue intact and no undermining or tunneling noted. A 10/9/17, Body Observation sheet lacked documentation of the pressure ulcers on R3's buttocks. On 10/10/17, a Weekly Wound Assessment indicated R3 had a Stage 3 pressure ulcer on his left gluteal area, measuring 1.0 cm by 0.5 cm with no odor or drainage noted. The wound bed was described as 100% granulation tissue, the wound edged were macerated and irregular and the surrounding tissue pink and intact with no undermining or tunneling noted. On 10/17/17, a Weekly Wound Assessment indicated R3 had a Stage 3 pressure ulcer to his left gluteal area, measuring 1.0 cm by 0.5 cm and a depth of 0.3 cm with no odor present, but a light amount of serosanguineous drainage was noted. The wound bed was described as having 100% granulation tissue with the surrounding tissue pink and intact with no undermining or tunneling noted. On 10/19/17, after surveyor intervention, a progress note was written directing staff to continue on an hourly repositioning schedule while R3 was in his wheelchair. The note further indicated that tilting R3 in his wheelchair was to be used to offload pressure from R3's bony prominences. Documentation of R3's refusals to reposition was requested but not received from the facility. Repositioning sheets for June 2017, immediately after the development of the left ischial/buttock pressure ulcer developed, were requested but not received. Licensed practical nurse (LPN)-C stated they are shredded after 3 months. The sheets lack information in the repositioning times column, but LPN-C stated the toileting times are the times they repositioned residents. LPN-C confirmed that there were many sheets that lacked complete information including the shift worked, and not all columns were completed. Review of R3's repositioning sheets from 7/1/17, to 7/12/17, revealed: -7/1/17 day shift, 10:50 a.m. (up) to 12:35 p.m. (down): 1 hour, 45 minutes -7/1/17 afternoon shift, 6:30 p.m. to 10:06 p.m.: 3 hours, 36 minutes -7/2/17 day shift, 8:30 a.m. (down) to 11:30 (up): 3 hours -7/2/17 afternoon shift, 6:30 p.m. to 10:05 p.m.: 3 hours, 35 minutes -7/4/17 afternoon shift, 3:40 p.m. (up) to 6:30 p.m.: 2 hours, 50 minutes -7/5/17 afternoon shift, 4:05 p.m. to 7:00 p.m. to 10:20 p.m.: 2 hours, 55 minutes and 3 hours, 20 minutes -7/7/17 afternoon shift, 6:30 p.m. to 10:17 p.m.: 3 hours, 47 minutes -7/8/17 afternoon shift, 3:51 p.m. to 6:15 p.m. to 10:05 p.m.: 2 hours, 24 minutes and 3 hours 50 minutes -7/10/17 afternoon shift, 6:15 p.m. to 10:00 p.m.: 3 hours, 45 minutes -7/11/17 afternoon shift, 6:45 p.m. until 10:20 p.m.: 3 hours, 25 minutes -7/12/17 afternoon shift, 6:20 p.m. until 10:20 p.m.: 4 hours. Repositioning sheets near to the survey time were also reviewed and provided the following data: -10/3/17 day shift, 7:00 a.m., 9:00 a.m., 11:00 a.m., 12:30 p.m.: 2 hours, 3 times; 1 hour, 30 minutes -10/8/17 afternoon shift, 4:15 p.m. to 6:45 p.m. to 10:04 p.m.: 2 hours, 30 minutes; 3 hours, 19 minutes -10/9/17 day shift, 6:40 a.m. to 9:20 a.m. to 11:00 a.m. to 1:10 p.m.: 2 hours, 40 minutes; 1 hour, 40 minutes; 2 hours, 10 minutes -10/9/17 afternoon shift, 6:40 p.m. to 8:49 p.m. to 10:15 p.m.: 2 hours, 10 minutes; 1 hour, 26 minutes -10/10/17 day shift, 11:05 a.m. to 1:00 p.m.: 1 hour, 55 minutes -10/10/17 afternoon shift, 3:30 p.m. to 6:30 p.m. to 10:18 p.m.: 3 hours; 3 hours, 48 minutes -10/11/17 afternoon shift, 6:38 p.m. to 10:07 p.m.: 3 hours, 29 minutes -10/13/17 afternoon shift, 3:45 p.m. to 6:30 p.m. to 10:00 p.m.: 2 hours, 45 minutes, 3 hours, 30 minutes -10/17/17 day shift, 8:05 a.m. to 11:05 a.m.: 3 hours -10/17/17 evening shift, 3:45 p.m. to 6:40 p.m.: 2 hours, 55 minutes On 10/18/17, R3 was continuously observed from 7:04 a.m. until 9:17 a.m. At 7:04 a.m. R3 was observed up in the wheelchair in his room. At 8:07 a.m. nursing assistant (NA)-D wheeled R3 to the dining room for breakfast. At 8:48 a.m. R3's wheelchair was repositioned so he was seated at a 45 degree angle, with his back and upper legs angled up. R3 remained in that position, on his back in his wheelchair until 9:17 a.m. when NA-D wheeled R3 back to his room to lay down. The total time was two hours and thirteen minutes. NA-D was interviewed at this time and stated he had gotten R3 up right before breakfast. NA-D stated R3 was to be repositioned every hour. On 10/18/17, at 9:24 a.m. NA-B stated she did not know how often R3 was to be repositioned, but she supposed it was every 2 hours. On 10/18/17, at 10:24 a.m. LPN-C stated R3 had a small, chronic pressure ulcer on his buttock that just wouldn't heal. LPN-C stated R3 was to be repositioned every hour when in his wheelchair, and that repositioning schedule had probably been in place since June. On 10/18/17, at 10:40 a.m. LPN-C confirmed that R3's wheelchair pad was a thick (approximately 3-4 inches) foam pad, with a gel pad underneath that pad, which she did not know what good that would do. LPN-C confirmed the facility had not completed an assessment of R3's tissue perfusion (to determine how long he could put pressure on bony prominences), within the last year, and the last one found in R3's medical record had been completed in 2014. On 10/18/17, at 1:30 p.m. RN-A stated the references to R3's left buttock and ischial pressure ulcers referred to the same wound, although different terminology was used. RN-A stated R3 got up for meals, and then lay back down. RN-A did not know if R3 was to be repositioned hourly or every two hours. RN-A verified 2 hours and 15 minutes was too long for R3 to be sitting in his wheelchair. On 10/19/17, at 9:31 a.m. certified occupational therapist assistant (COTA)-A stated R3 had not received occupational therapy (OT) services since March 2016. R3's medical record lacked therapy notes regarding use of a gel cushion or a thick foam pad in his wheelchair. Physical therapist assistant (PTA)-A stated physical therapy (PT) had not seen R3 since 2/17/17, and that was only an evaluation for range of motion. On 10/19/17, at 9:56 a.m. the director of nursing (DON) was interviewed and stated she expected the care plan would be followed. The DON stated R3 was to be repositioned every hour when in his wheelchair, and an alternating air pressure mattress was to be on his bed. The DON confirmed the facility had identified its pressure ulcer documentation as an area for improvement; indicating there have been different and incomplete ways of documenting pressure ulcer stages and descriptions. The DON further stated since 9/5/17, there had been one RN performing all pressure ulcer rounds and documentation; prior to that there were multiple nurses performing this task and the documentation was inconsistent. The DON confirmed there was not consistent references to R3's pressure ulcer locations and staging. The DON would not confirm if R3 had one or several pressure ulcers, nor would she indicate the correct staging of the pressure ulcers, including the pressure ulcer that was currently open. The DON also stated she had talked to the NAs about putting pre-existing pressure ulcers on the skin sheets that are completed with weekly baths; she was aware that this was incomplete documentation. The DON further stated she did not think R3's repositioning refusals had been documented, and she stated she did not look at these daily sheets completed by the NAs. The DON stated the LPNs were responsible to monitor these, and to address any concerns. The DON stated R3 should have had one cushion in his wheelchair, and he was to be repositioned every one hour. The facility's Skin Risk Observations policy dated 1/31/14, directed a tissue tolerance assessment was to be completed when there was new development of a pressure ulcer. The policy further directed licensed staff to develop an individualized turning and repositioning schedule based on daily skin inspection by NA's, and weekly skin inspections completed by licensed staff, with further direction to complete tissue tolerance tests to determine appropriate interventions that were updated on the care plan. The facility's Skin Integrity, Pressure Sores policy dated 2/11, directed the pressure ulcer assessment was to be completed weekly to include: location, stage, depth/tunneling, measurement (in centimeters), description of exudate/drainage, tissue description, site infection evidence, condition of skin surrounding the ulcer, appropriate care and treatment, resident condition and response to treatment. The policy further directed to specify physician orders. The policy also directed that each pressure ulcer was to be documented separately, with its own skin assessment form. R68's medical record lacked a comprehensive assessment following the development of a pressure ulcer, and the facility did not complete treatment for [REDACTED]. R68's Face Sheet printed 10/18/17, indicated R68 had [DIAGNOSES REDACTED]. R68's admission MDS dated [DATE], indicated R68 had moderately impaired cognition. The MDS also indicated R68 required extensive assistance of two staff for all transfers and bed mobility. The MDS indicated R68 did not have pressure ulcers on admission, and was at risk for pressure ulcer development. R68's care plan initiated 9/13/17, indicated R68 was at risk for alteration in skin integrity due to general muscle weakness, left side [MEDICAL CONDITION] ([MEDICAL CONDITION], commonly known as stroke) with right sided weakness, back pain, chronic pain, [MEDICAL CONDITION] and spinal stenosis. The goal was to keep the wound free of infection and not impair R68's lifestyle or activities. Interventions started on 9/13/17, included to treat wound as ordered, staff were directed to reference the Medication Administration Record [REDACTED]. Staff were directed to document wound conditions with dressing changes, to refer to nutrition problem statement and interventions in the care plan, and consult the physician as needed. The facility was unable to provide a care plan prior to 9/13/17. R68's Kardex dated 10/11/17, directed staff to lotion R68's skin, float heels at all times, apply barrier cream, and reposition R68 every 2 hours and as needed. R68 was to have a pressure reducing mattress on her bed and in her wheelchair, and staff was to reposition R68 in the wheelchair every 2 hours. Staff were directed to use pillows on R68 to protect her bony prominences. The care plan and Kardex lacked directions to staff to use a pressure reducing boot on her right heel. R68's pressure ulcer CAA dated 8/17/17, indicated R68 showed moderate cognitive impairment and required assistance from staff with all activities of daily living (ADL) due to right side weakness. The CAA indicated R68 was at risk for development of pressure ulcers, and her skin was intact at time of assessment. R68 was provided a pressure redistribution mattress on her bed and a cushion to her wheelchair. Staff were directed to assist R68 with toileting needs, incontinence care, turning, repositioning and off loading per care plan. On 10/18/17, at 11:28 a.m. R68's pressure ulcer was observed. Registered nurse (RN)-B and RN-A removed R68's dressing. RN-A verified the dressing she removed was not the dressing that was currently ordered. RN-B measured R68's pressure ulcer as 2.6 cm by 1.9 cm, with 85% of the wound described as slough. R68's wound had 10% eschar and 5% of granulated tissue. At 11:36 a.m. RN-B provided the ordered treatment of [REDACTED]. R68's Seven Day Skin Risk assessment dated [DATE], indicated R68 did not have a pressure ulcer, and she was totally dependent on staff for bed mobility. R68's Braden Scale (done to assess a resident's risk for pressure ulcer development) dated 8/20/17, was 15, which identified R68 as being at risk for pressure ulcer development. R68's Fourteen Day Skin Risk assessment dated [DATE], indicated R68 did not have a pressure ulcer, and she was totally dependent on staff for bed mobility. R68's Braden Scale Score dated 8/25/17, was 15, which identified R68 as being at risk for pressure ulcer development. R68's Twenty-One Day Skin Risk assessment dated [DATE], indicated R68 did not have a pressure ulcer, and she was dependent on staff for bed mobility. R68's Braden Scale Score dated 9/317, was 15, which identified R68 at risk for pressure ulcer development. R68's Physician order [REDACTED]. The Physician order [REDACTED]. R68's medical record indicated the following pressure ulcer: On 9/9/17, a progress note indicated R68 had a large open red sore on her inner right ankle. The area was cleansed, dressed and staff was directed to monitor it. The progress note lacked documentation of the size or the staging of the pressure ulcer. On 9/10/17, a progress note indicated R68 had a Stage 2 pressure ulcer on her right heel that measured 4.8 centimeters (cm) wide and 3.5 cm long. A dressing was applied, a blue boot was placed on R68's right heel (for pressure relief) and the care plan was updated to float her right heel at all times. On 9/12/17, a progress note indicated R68 had a Stage 3 pressure ulcer to the right heel that measured 4.5 cm by 4.0 cm without depth. Moderate drainage was noted without odor. The wound bed was described to have 90% granulation tissue (new tissue) with 10% slough (dead tissue) on the upper part of wound. Macerated (moist) edges surrounding tissue were pink and intact with no tunneling. R68's Certified Nurse Practitioner (CNP) was updated. A physician fax communication form was sent to CNP with a condition change update that indicated R68 had developed a Stage 3 pressure ulcer to her right heel with 90% granulated with 10% eschar. The CNP was informed that R68's heels would be floated, an air pressure relief mattress was in place, and the facility was requesting orders for a dressing treatment for [REDACTED]. On 9/13/17, the CNP assessed R68's pressure ulcer and ordered [MEDICATION NAME] border dressing to the right heel pressure ulcer every three days. The CNP documented R68 was seen on that day and that nursing initially noted a Stage 2 pressure ulcer to the right heel 3 days ago, with this being the first report to the CNP. The CNP indicated staff placed an undetermined dressing R68's right heel and a blue boot to relieve pressure. The CNP indicated the pressure ulcer measured 4.8 cm by 4 cm and a pink base of granulation tissue was noted with a central area of darker tissue. The CNP's assessment and plan for R68's pressure ulcer directed staff to apply Mepiplex dressing to right heel and change every 3 days. Staff were directed to float R68's heels and keep pressure off the heels at all times. On 9/18/17, the CNP documented a follow up visit for R68, and indicated R68's pressure ulcer was covered with tan slough, and central area remained dark colored. The pressure ulcer had no odor or bogginess, and a small amount of tan colored drainage was on the foam heel dressing. The CNP ordered Mepiplex AG to R68's pressure ulcer to right heel, change every 3 days. Staff were ordered to to cleanse the pressure ulcer with wound cleanser every dressing, and wrap and secure with Kerlix. On 9/19/17, a progress note indicated R68 had a Stage 3 pressure ulcer to her right heel that measured 4.8 cm by 4.3 cm with depth less than 0.2 cm. The pressure ulcers was described as 100% granulation tissue with a dark center. On 9/22/17, a physician progress notes [REDACTED].

Based on interview and document review, the facility failed to assess and treat a significant change of condition resulting in death for 1 of 4 residents (R84) reviewed with death records. Findings include: R84 was admitted on [DATE], for rehabilitation and aftercare following surgery for [REDACTED]. The progress notes dated [DATE], at 8:39 p.m. indicated R84's admission at 7:40 p.m. and noted the primary [DIAGNOSES REDACTED]. The hospital discharge summary dated [DATE], also listed discharge [DIAGNOSES REDACTED]. The discharge summary indicated R84 underwent the surgery without any complications, continued to have confusion and impulsivity, though controlled with [MEDICATION NAME] (antipsychotic medication), with hypertension controlled with medications, including [MEDICATION NAME], and [MEDICATION NAME]. The hospital interagency referral form dated [DATE], indicated that, at the time of discharge, R84 was alert and followed commands, speech was clear, and she was oriented to place, and person. The interagency referral form further indicated R84 had some memory and judgement problems, was able to express her needs and desires, and she was calm and cooperative. The interagency referral discharge instructions also directed to contact the physician if R84 developed worsening symptoms of headache, nausea, vomiting, weakness, dizziness, memory or speech difficulty, or numbness or tingling. During an interview on [DATE], at 3:01 p.m. the director of nursing (DON) verified this monitoring had not occurred. The admission clinical documentation for observation dated [DATE], to [DATE], appeared to be an undated late entry and indicated R84 had already expired. The documentation indicated R84 had clear speech, was able to make concrete requests, and responded to simple, direct communication only. The clinical documentation further noted R84's pupils to be equal in size, but the left pupil reacted sluggishly and the right pupil reacted briskly. R84 was unable to describe pain and expressed pain by moaning, vocal complaints of pain, facial expressions and protective body movements. Direct care staff were to monitor for pain and communicate to the licensed nurse if pain was noted. The clinical documentation indicated R84 was alert and able to state she hurt at the time of the assessment. An informed consent for CPR, was signed by R84's power of attorney (POA) and family representative on [DATE]. R84 was considered to be a full code (full resuscitation efforts). The undated temporary care plan indicated R84 was alert to self, had a wander guard and audible alarms on bed and wheelchair, and addressed the assistance needed by R84 for activities of daily living, risk for falls, and risk of skin breakdown. The temporary care plan also directed staff to monitor for pain every shift, use [MEDICATION NAME] (pain medications) every shift and to monitor incisions daily. The pain assessment of [DATE], at 2:06 p.m. indicated R84 was able to say, "Ow, Ow, Ow" and point to an area, but was unable to rate or describe her pain. The documentation indicated R84 appeared to have left sided abdominal pain when touched in area of a yellowing bruise. R84 also said "Ow" when moving legs, but did not appear in any distress during the pain assessment. R84's admission vital signs (temperature, pulse, respirations, and blood pressure) were monitored from [DATE] through [DATE], and were documented as stable. The final set of vital signs recorded in R84's medical record was on [DATE], at 4:08 p.m. with blood pressure, pulse, respirations, and temperature remained stable at that time. There were no documented neurological checks after the physician assessment which occurred on [DATE]. The progress notes dated [DATE], at 12:45 p.m. indicated R84 had been yelling off and on, but no signs or symptoms of pain were noted. R84 was disrobing, very confused, and was difficult to redirect at that time. Lungs were clear and respirations were even and nonlabored, and the head incision was clean, dry, and scabbed over. The physician's visit referral form dated [DATE], indicated a chief complaint of [DIAGNOSES REDACTED] with a poor quality and incapacitating severity. The physician also documented that R84 was having some back pain as far as could be told, vitals were stable, pupils were equal and reactive to light, and the neurological status for R84 was stable, but poor. The progress notes dated [DATE], at 10:07 a.m. indicated R84 was yelling out most of the morning and lying with her head on the table. The nurse attempted to give resident her medications and a pain pill four times, but R84 did not take them. R84 would strike out, lay her head on the table and refuse to open her eyes or mouth. R84 did the same at breakfast. At the time of the documentation, R84 was lying down and sleeping. The progress notes dated [DATE], at 1:21 p.m. indicated R84 refused all other medications during the day and had been quiet since lying down, but would not open eyes or mouth. The documentation indicated staff were unable to tell if earlier yelling was due to pain or anxiety. Head incisions were noted to be clean, dry, and scabbing over. R84 was oriented to self. Lungs were clear, respirations were even and nonlabored, according to documentation. The progress notes dated [DATE], at 8:59 p.m. indicated R84 could not be aroused with three unsuccessful attempts to administer medications. R84 was in bed sleeping at the time of the documentation. The progress notes dated [DATE], at 4:07 a.m. indicated, "Staff observe resident (R84) to be unresponsive, went to get charge nurse, call to 911 as (R84) is full code. Presently with (R84) at this time." The progress notes dated [DATE], at 4:25 a.m., indicated the family was called, "To inform of (R84) passing away and ambulance staff calling the code." The documentation was unclear as to when the resident stopped breathing, when resuscitation measures were initiated, and by whom (facility or ambulance staff). The progress note on [DATE], at 4:34 a.m., indicated, "The ambulance staff called the code at 4:19 a.m., left the facility at 4:25 a.m.." R84's medical record lacked documentation of vital signs, neurological assessments, assessments of change in condition, or notification of the physician on [DATE]. During an interview on [DATE], at 2:06 p.m., registered nurse (RN)-B stated that neurological assessments should have been completed at the same time as vital signs upon admission, every hour for four hours, then every fours hours for a total of 24 hours. RN-B verified the lack of documented vital signs on ,[DATE] or [DATE], or neurological status after admission. RN-B stated that assessments should have been provided and the physician/family notified. During an interview on [DATE], at 2:26 p.m., the director of nursing (DON) stated she was not working at the facility in January and was not aware of R84's death or circumstances. She was unable to determine if any resuscitation attempts were made before the ambulance arrived. The DON verified neurological assessments and vital signs should have been done for R84, and the physician should have been notified and asked if the physician would have wanted her sent in to the hospital, with the change in condition. The DON verified that monitoring of signs and symptoms of complications, as directed in the interagency referral had not occurred for R84. The policy and procedure for change in condition dated [DATE], directed the facility to notify the resident's physician, and the resident's legal representative or interested family member of a significant change in the resident's physical, mental, or psychosocial status, a need to alter treatment significantly, or a decision to transfer or discharge the resident from the facility. A significant change means a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications. The procedure directs licensed nursing staff to assess any changes noted through direct observation or through assigned staff, obtain a complete set of vital signs at the onset of the change and at 4-hour intervals, or more often as appropriate, obtain any other data necessary for a complete assessment (accucheck, neurocheck, etc.) Notify the physician of the change. Notify family. The facility policy and procedure for neurological assessment dated [DATE], indicated licensed nursing staff will perform, monitor resident neurological functioning and changes in neurological functioning will be reported to the physician immediately. The policy provided the specific procedure in performing the neurological assessment and directs staff to document result of neurological assessment and notify changes immediately to the physician.

Based on interview and document review the facility did not ensure a comprehensive pain management program was developed and effectively implemented for 1 of 3 residents reviewed (R79) with pain. Findings include: R79 was admitted on [DATE], following a total left hip arthroplasty. Other [DIAGNOSES REDACTED]. Social service notes on 7/8/14 revealed R79 to be alert and oriented. R79's pain assessment completed 7/6/14 revealed the worst pain was rated 8 out of 10 and medications help to manage the pain as did elevating the left leg, rest and ice. Staff was to observe for verbal and non-verbal signs of pain and report to the nurse. The nurse was to provide pain medications and utilize non-pharmacological interventions. The 7/19/14 pain assessment identified pain ranging from a 6-9 depending on activity level and time of day with no additional changes. R79's current pain medications included Tylenol 325 mg 2 tablets four times a day; [MEDICATION NAME] 5% patch 1 patch on in am and off at night; and [MEDICATION NAME] 5-325 mg 1-2 tablets every 4-6 hours as needed for pain. Review of nursing progress notes from 7/4-22/14 revealed R79 continued to have pain on a daily basis. Progress notes on 7/15/14, indicated scheduled narcotic pain medications were more effective. R79 was, "Having a better time doing adl's (activities of daily living), etc. for herself." Nursing notes on 7/16/14 indicated R79 had "Less pain with the (pain) meds now being scheduled." Physician orders [REDACTED]. Progress notes on 7/17/14, indicated R79 was upset over the lack of scheduled narcotic medications. R79 stated she had "Less pain and more flexibility" with routine narcotic pain medications. There was no plan to taper the narcotics while still effectively managing pain. Interview with R79 on 7/21/14 at 4:20 pm revealed ongoing problems with pain management. R79 stated the pain was still horrible. R79 had long standing issues with pain and as a result had utilized "marriage" of [MEDICATION NAME] and [MEDICATION NAME] that she took twice a day for a long time to get moving in the morning and to sleep at night along with Tylenol during the day. R79 stated,"It was the only thing that worked." R79 stated that [MEDICATION NAME] scheduled was much more helpful but the pain currently, "runs a 7-9 most of the time." R79 stated physical therapy provided several non-pharmacological interventions which were very effective. When asked about non-pharmacological interventions provided by nursing staff, there were none. R79 stated she asked for an ice pack one evening and was told they didn't have access to those kinds of things. The nurse then came back with a baggy of ice cubes which R79 stated was "Not helpful." Interview with the director of nursing (DON) on 7/21/14 at 3:45 pm verified there was no specific plan in place to manage R79's pain. The DON asked, "Isn't it enough that she can ask" for what she needs? The DON further clarified the physician ordered the taper of R79's narcotic pain medications and they were required to do so.

Based on observation, interview and document review, the facility failed to ensure interventions were implemented and monitored to decrease the risk of elopement resulting in findings of immediate jeopardy (IJ) for 3 of 18 residents (R25, R80, R85). In addition, code alert alarms were not monitored for function for 5 of 18 residents (R63, R92, R82, R84, R68) reviewed for elopment risk. Safety assessments and interventions were not provided for 1 of 18 residents (R28) reviewed for use of wheeled walkers. The immediate jeopardy began on [DATE], when the facility failed to implement and monitor interventions established to decrease the risk of elopement after R25 was found outside the building during the night. The IJ situation was identified on [DATE], and the administrator was notified of the IJ at 10:45 p.m. on [DATE]. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of a pattern scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: Review of facility event reports indicated multiple residents with attempted and successful elopements from the secure unit and/or the building since [DATE]. The secure unit included the entire second floor of the facility. The unit was not locked but the doors were alarmed to alert staff when residents at risk of elopment approached the exits. There was no evidence of increased monitoring of resident code alert alarms (ankle bracelets that triggered door alarms upon exit) or door alarms until [DATE]. On [DATE], elopement prevention interventions were identified as checking all doors with alarms before and at the end of every shift and the resident code alert alarm checks were supposed to be added to the individual electronic Treatment Administration History (TAH) to remind staff to complete daily checks to ensure the function of resident code alerts. There was no evidence to indicate staff was informed of the plan to increase monitoring of door alarms and resident code alert alarms and no evidence of monitoring to ensure the alarms were checked. The Resident Elopement policy dated February 2011, indicated if a missing resident was not with the family and could not be found, the supervisor would notify the appropriate law enforcement authorities. The policy lacked specific direction for searching the building or immediate notification of administrative staff and law enforcement R25 was at high risk for elopement and resided on the second floor secure unit. R25 was found outside the building in the early morning hours of [DATE]. Facility documentation was inconsistent regarding how long R25 was missing and regarding the system failure that allowed him to exit the building without staff being aware. The facility identified specific interventions to reduce the risk of further elopements; however, the interventions were not implemented or monitored. The lack of interventions to reduce the risk of elopement constituted IJ for R25. The Event Report at 5:11 a.m. on [DATE], indicated R25 was last seen sitting in a chair on the west side of the second floor (secure unit) at 3:30 a.m. A search of the building was completed but law enforcement and administrative staff was not contacted. A dietary personnel observed R25 across the street with a walker trying to direct traffic (time not indicated). R25 was assisted back into the building and back to the second floor. A progress note at 4:57 a.m. on [DATE], indicated R25 was last seen sitting in a chair on the east side and dietary personnel observed R25 outside across the street with a walker talking to a street sweeper. No alarms sounded and interventions included "Will monitor closely and every ,[DATE] hour." A progress note at 9:11 a.m. on [DATE], (greater than four hours later) indicated the administrator was notified and the interdisciplinary team (IDT) met to review the elopement. Staff could not locate R25 at 3:30 a.m. after R25 had been sitting on the west side of the second floor. Staff noted the door alarms were not functioning properly "possibly due to a power surge at the time of the event." R25 would be placed on ,[DATE] hour checks and a report would be made to the external agencies. The Incident Report submitted to the state agency on [DATE], (no time documented) indicated R25 was last seen in a chair on the second floor west side prior to 3:30 a.m. and was unable to be located after that. The record indicated the second floor had alarms that locked the doors if residents came too close to the doors/elevator. Dietary personnel noticed R25 across the street. Night staff reported there was a power surge during the night and the second floor alarms were not sounding, but the doors did lock. The Investigative Report Submission dated [DATE], (no time) indicated R25 was placed on ,[DATE] hour checks and maintenance checked all alarmed doors and the alarms were working. R25's code alert alarm was tested and was not functioning and was replaced. Interventions included all doors with alarms would be checked before and at the end of every shift. The elevator did not lock up, it should alarm if a resident goes near it. The report indicated R25 was found by dietary personnel at 4:45 a.m. (one hour and 15 minutes after prior observation). Staff was educated on procedures for a power outage and elopement protocol at the request of the administrator. The report indicated that the licensed practical nurse charge (LPN)-H stated that R25 had last been seen at 3:00 a.m. in a chair on two west. During ,[DATE] hour checks at 4:00 a.m. (one hour later) R25 was not located. The documentation was contradictory and indicated R25 was missing anywhere from one hour and 15 minutes, to one hour and 45 minutes. In addition, there was no evidence that law enforcement was notified when R25 was missing in the early morning hours. R25's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE], indicated R25 had severe cognitive impairment; required supervision of staff with ambulation; and had no behaviors. The Elopement Risk Assessment reviewed [DATE], indicated R25 was at high risk for elopement due to past attempts and threats both successful and unsuccessful. The assessment identified R25 had a code alert bracelet and a bracelet through the Alzheimer's association with the safe return program. The elopement care plan revised [DATE], indicated R25 was at risk for elopement due to wandering and past successful and unsuccessful elopement attempts. Interventions included to ensure the code alert bracelet was working properly and ,[DATE] hour checks for safety. At 4:06 p.m. on [DATE], a nursing assistant (NA)-C was interviewed and did not identify R25 was on ,[DATE] hour checks. NA-C stated on the day shift R25 was usually lying on the couch in the lobby 90% of the time. NA-C stated R25 occasionally went by the elevator and was redirected. R25 was observed at that time in his bedroom sleeping with a code alert bracelet on the left ankle. The registered nurse manager (RNM)-A, interviewed at 4:11 p.m. on [DATE], stated R25's code alert was replaced after the elopement on [DATE]. R25 was seen sitting in the lobby at 3:30 a.m. and on 4:00 rounds the staff noticed R25 missing. A search was started. RNM-A stated R25 was not on ,[DATE] checks prior to the elopement and had no actual elopement for greater than a year prior to the [DATE], event. R25 was on ,[DATE] hour checks "about a year ago" due to wandering and opening the door to the stairwell. Review of R25's electronic Treatment Administration History (TAH) records for [DATE], indicated there was no documentation of code alert alarm checks for R25 until [DATE], (four days after the elopement), and the facility could provide no evidence ,[DATE] hour checks were being completed. At 6:01 p.m. on [DATE], the administrator stated law enforcement was not notified when R25 was missing because R25 was found. The DON confirmed there was no documentation of the ,[DATE] hour checks for R25. At 6:26 pm on [DATE], the maintenance supervisor (MS)-A stated the morning R25 eloped ([DATE]), the door alarms were tested and were working. MS-A added, it was R25's code alert alarm that was not working. R80 was identified at IJ following an elopement from the second floor secure unit on [DATE]. There was no evidence to indicate an investigation was completed to determine how R80 left the unit without staff being aware and no evidence of interventions implemented to prevent recurrence. R80, identified at risk for elopement, eloped from the second floor secure unit to the first floor on [DATE]. The facility failed to investigate the incident to determine if the alarm system on the second floor unit was functioning correctly or if staff had turned off the alarm without checking to see if a resident set off the alarm. At 8:10 p.m. on [DATE], RNM-A stated that, when R80 was found on the first floor with the alarm sounding "it was likely staff silenced the second floor alarm and didn't check if a resident went downstairs." The Facility Event Summary Report indicated that, at 9:40 a.m. on [DATE], R80 was found sitting by the front entrance on the first floor. The Event Details at 9:40 a.m. on [DATE], indicated activity staff found R80 sitting in his wheelchair near the front door entrance. Nursing staff was notified and R80 was escorted back up to the second floor secure unit. The report noted R80's code alert alarm was functioning properly. R80 remained on ,[DATE] hour checks. Review of R80's TAH for [DATE], indicated daily checks for function of the code alert alarm were not being completed. In addition, there was no evidence of an investigation to determine if the alarm on the second floor sounded when R80 eloped from the unit, or why the second floor staff did not respond to the alarm. R80's [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE], indicated R80 had moderate cognitive impairment; required supervision with locomotion on the unit; required extensive assistance of staff with ambulation; had no behaviors; and used a walker and a wheelchair for mobility. The Elopement assessment dated [DATE], indicated R80 was at high risk for elopement due to an attempt. R80 stated he wanted to be at home. The assessment indicated R80 had alarms, personal alarms, was invited to activities, received visits from staff/family, and was moved to another room per his request on [DATE]. The wandering care plan dated [DATE], indicated R80 wandered and made attempts to leave the facility to go home. Interventions included ,[DATE] hour checks. The care plan did not address R80 had a code alert alarm or monitoring of the alarm. At 8:10 p.m. on [DATE], RNM-A stated that, when R80 was found on the first floor with the alarm sounding, "it was likely staff silenced the second floor alarm and didn't check if a resident had went downstairs." RNM-A stated it wasn't in the policy, but staff should be trained on that in orientation. RNM-A confirmed an investigation of the elopement was not completed and staff was not re-educated. At 10:00 a.m. on [DATE], the DON confirmed thorough investigations were not completed regarding the elopements for R80 and the incidents were not added to the event log for review and should have been. R85's closed record review indicated multiple elopements outside the facility. R85 expired on [DATE]. R85 eloped outside the facility at 8:47 p.m. on [DATE]. The medical records indicated R85 had a code alert alarm after a previous elopement on [DATE]. The facility did not investigate the incident on [DATE], to determine if the code alert alarm was sounding/functioning. An Event Report at 3:19 a.m. on [DATE], indicated R85 resided on the first floor and had crawled up the East hall door stairway to the second floor. Interventions included ,[DATE] hour checks and a code alert bracelet. The ,[DATE] hour checks were discontinued on [DATE]. An Event Report at 8:47 p.m. on [DATE], indicated R85 was seen walking down the sidewalk in front of the building. Interventions included to initiate ,[DATE] hour checks which were discontinued the next day (no time). The report did not indicate if R85 had a code alert alarm nor if it was sounding. No further investigation or interventions were noted. No further monitoring for functional alarm systems was completed until [DATE]. An Event Report at 12:29 a.m. on [DATE], indicated R85 was found outside the northeast corner door. The alarm sounded when R85 left out the door. R85 stated he was walking home. The code alert bracelet was in place and functioning properly and R85 was started on ,[DATE] hour checks. An Evaluation Note (not dated) on the report indicated R85 was transferred to the second floor and had no further elopements. R85's [DIAGNOSES REDACTED]. The significant change Minimum Data Set ((MDS) dated [DATE], indicated R85 had severe cognitive impairment; required the extensive assistance of staff with ambulation/locomotion; and used a walker and a wheelchair. The quarterly Elopement Risk Assessment from [DATE], to [DATE], indicated R85 changed from low risk of elopement to moderate risk on [DATE], due to increased confusion/dementia like behaviors; however, none of the assessments ([DATE], [DATE], [DATE], ,[DATE]) addressed R85's history of previous attempts at elopement (successful and unsuccessful). The care plan edited [DATE], indicated R85 had a code alert on the right ankle and was on ,[DATE] hour checks. The care plan revised [DATE], indicated R85 had a decline in condition and the code alert alarm and ,[DATE] hour checks were discontinued. R85 expired on [DATE]. At 10:00 a.m. on [DATE], the DON confirmed thorough investigations were not completed regarding the elopements for R85, and the incidents were not added to the event log for review and should have been. At 4:11 p.m. on [DATE], RNM-A stated an audit was completed on all residents with code alert alarms and the alarms were functioning. The code alert alarm checks were added to the residents' electronic Treatment Administration History (TAH) records for staff to check the function of code alerts daily. RNM-A confirmed the audit of all residents with code alert alarms was not documented. RNM-A stated the door alarms were checked for function daily at the beginning of the night shift, and provided a Code Alert Monitoring of Doors sheet for [DATE]. The record directed staff to check function of each stairwell door on the second floor every shift; however, documentation indicated only the night shift had been checking the function of the alarmed doors and on four occasions since [DATE], there were no checks documented on any shift. RNM-A verified the alarmed doors were not being checked before and after every shift. At 6:01 pm on [DATE], the DON stated there was no further monitoring of the door alarm checks. Review of a list of residents provided by the facility at 6:36 p.m. on [DATE], indicated there were 18 residents in the facility (one on the first floor, and 17 on the second floor) who had code alert alarms. From [DATE], to [DATE], five of the 18 residents (R63, R68, R82, R84, R92) were not included in monitoring code alert alarms. R63's [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], indicated R63 had severe cognitive impairment; was non-ambulatory; used a wheelchair for mobility; and had no behaviors. The quarterly Elopement risk assessment dated [DATE], indicated R63 was at high risk of elopement on admission due to a history of getting up in the night at home and being a new admit. R63 had not tried to leave the facility so was assessed at moderate risk for elopement. The assessment noted R63 lived in a secure unit and had a code alert alarm. R63's care plan did not address elopement risk or monitoring of the code alert alarm. R68's [DIAGNOSES REDACTED]. The annual MDS dated [DATE], indicated R68 had severe cognitive impairment; required limited assist of staff with ambulation; used a walker and wheelchair for mobility; and had no behaviors. The annual Elopement assessment dated [DATE], indicated R68 was at high risk for elopement and continued to wear a code alert bracelet. R68 had a history of [REDACTED]. R68's care plan did not address elopement risk or monitoring of the code alert alarm. R82's [DIAGNOSES REDACTED]. The significant change MDS dated [DATE], indicated R68 had moderate cognitive impairment; required supervision of staff with ambulation; used no assistive devices for mobility; and had behaviors of refusing cares. The admission Elopement assessment dated [DATE], indicated R82 was at moderate risk of elopement due to ETOH abuse, and verbalizations about getting out. R82 stated wanting to leave right after admission to the facility. R82's care plan did not address elopement risk or monitoring of the code alert alarm. R84's [DIAGNOSES REDACTED]. The admission Elopement assessment dated [DATE], indicated R84 was at low risk of elopement, had a fractured tibia, and had not expressed nor attempted to leave the facility. The Care plan did not address elopement risk or why a code alert alarm was required. R92's [DIAGNOSES REDACTED]. The quarterly Elopement assessment dated [DATE], indicated R92 was at low risk for elopement and had not tried to elope or talk about leaving. The assessment indicated R92 had a code alert alarm on for his protection. The mood care plan edited [DATE], indicated R92 exhibited the desire to leave the facility at times, wears a code alert alarm (wanderguard), and was on the floor which had alarms. The care plan was not revised to address monitoring of the code alert alarm. At 8:10 p.m. on [DATE], RNM-A confirmed R63, R68, R82, R84, R92 were not included with the list of residents requiring code alert alarm checks. RNM-A stated that, after the elopement assessment was completed, code alert use was determined by if a resident makes statements or attempts to elope, not necessarily by their risk level. The medical records lacked evidence the interventions placed on [DATE], were operationalized and being monitored for effectiveness to decrease the risk of further elopements from the facility. At 6:01 p.m. on [DATE], the DON reported there was no documentation related to staff training/education regarding how to identify residents at risk for elopement and how to check for function of the code alert alarms. At 6:26 p.m. on [DATE], the maintenance supervisor (MS)-A stated there was no preventative maintenance (PM) program for the code alert system and was not aware if there were manufacturer's instructions. At 7:07 p.m. on [DATE], the administrator provided an instruction manual for the code alert alarms. The (company name) manual for the code alert alarms dated [DATE], recommended system maintenance and testing of nine different zones in the system should be completed on a monthly basis (at the minimum). The manual further indicated "Periodic testing of these critical performance functions could help prevent undetected security system failures." At 7:45 p.m. licensed practical nurse (LPN)-A stated she was trained on how to check the code alert alarms, and there were extra code alert alarms in the maintenance supervisors office to use if an alarm was dysfunctional. NA-G, NA-C, and NA-I were interviewed. NA-G and NA-C were unaware of how to determine if a resident was at risk for elopement. NA-C stated it would be the residents that attempt to get on the elevator. NA-I stated residents at risk of elopement were more independent, wore ankle bracelets, and were on the clip board for ,[DATE] hour checks. At 7:50 p.m. on [DATE], LPN-D stated she was trained how to check the code alert alarms in new employee orientation. LPN-D stated she had checked the alarms in the past, but the checks were usually done on the day shift. At 7:53 p.m. on [DATE], NA-J stated there were currently no residents residing on the second floor who were at risk for elopement. LPN-B stated the device used to check the code alert alarms was in the med room and she learned about it at orientation. LPN-B demonstrated the TAD device in the med room for checking code alert alarms on residents and there was another device for checking the door alarms. LPN-B stated the residents on the second floor were generally wander risks and at risk for elopement. At 10:45 p.m. on [DATE], the administrator was notified of an immediate jeopardy at F323 at a J level related to failure to ensure safeguards were in place to prevent resident elopements. Review of R63, R68, R82, R84, R92's TAH indicated the facility had added the code alert alarm checks to the records; however, there was no documentation to indicate the alarms had been checked on [DATE], (after the lack of monitoring was brought to the facility's attention). At 10:52 p.m. on [DATE], the surveyors requested LPN-F verify R63, R68, R82, R84, R92's code alert alarms were checked and functioning. At 11:15 p.m. on [DATE], LPN-F stated she would have to get the residents out of bed and bring them by the elevator or stairwell door to check their code alert alarms. LPN-F then stated she could check the function with an accutech device and obtained the device used to check the door alarms. LPN-F stated the device was used to check the alarms and stated "oh there is another device?" after the surveyor instructed that was not the device used to test the alarms earlier in the evening (LPN-B took one testing device to check the door alarm and then took the "TAD" device to check the code alert alarms). At 11:17 p.m. LPN-F was unable to get the TAD device to work and was unsure how to use the device. At 11:27 p.m. LPN-F was observed to check the code alert alarms for R63, R68, R82, R84, and R92 and confirmed the code alert alarms were functioning properly. At 3:00 p.m. on [DATE], the administrator provided an IJ plan of removal. The plan included staff education, monitoring of all residents with code alerts every shift until Monday ([DATE]), when the Accutech alarm system could be checked by a representative. The system would be placed on a preventative maintenance program. The maintenance supervisor would monitor the programs. A form was developed for door alarm monitoring every shift until [DATE]. Staff would read and sign the policy for ,[DATE] hour checks, elopement, and code alert alarms. After [DATE], all residents with code bracelets would be monitored at least daily for functioning and replaced as needed. Residents identified at risk on the first floor would be moved to the 2nd floor for safety. Review of the current elopement policy would be completed with staff starting [DATE]. Would reiterate staff to call the police if related to missing persons and the policy would be evaluated/updated and would be left for staff to read and sign. All doors in the facility were checked and functioned properly. The removal plan was verified and, at 5:18 p.m. on [DATE], the administrator was notified regarding acceptance of the plan of removal and the IJ was removed. R28 was not assessed for safety when using a seated wheeled walker for transportation. R28's [DIAGNOSES REDACTED]. On [DATE], at 6:45 p.m. R28 was observed sitting on the seat of a wheeled walker in the lobby by the bird aviary. R28 propelled the walker backwards using both feet and looking over the right shoulder. R28 propelled the walker out of the lobby and around the corner very quickly. A licensed practical nurse (LPN)-D observed R28 propel the walker backwards and did not say anything to R28. When the surveyor turned the corner R28 was already in the room ambulating independently into the bathroom (without the walker). On [DATE], at 7:15 p.m. R28 was interviewed regarding propelling backwards in the seated wheeled walker. R28 stated "I always do it" and "I can watch behind me with my good eye." When asked if the facility staff had ever said anything about it, R28 stated "yes, they say be careful." Once interviewed, R28 quickly sat on the walker and using both feet propelled backwards out of the room, down the hall, and around the corner to the lobby. On [DATE], at 11:10 a.m. R28 exited the room and propelled backwards in the walker using both feet down the hall to the lobby. At 11:13 a.m. R28 returned through the lobby propelling backwards in the walker. Nursing assistant (NA)-O, physical therapy assistant (PTA)-I , and NA-P observed as R28 propelled past and no one said anything to R28. Review of an OT plan of care dated [DATE], to [DATE], indicated R28 received wheelchair training due to weakness. By [DATE], the goal was met and R28 was appropriate to self propel the wheelchair. The quarterly Minimum Data Set ((MDS) dated [DATE], indicated R28 had moderate cognitive impairment and was independent with ambulation. The MDS identified R28 had steady balance at all times; had no falls since the previous assessment; and had no mood indicators for depression or behaviors. The quarterly Fall Risk assessment dated [DATE], indicated R28 was at risk for falls due to history of falls, arthritis pain, and antihypertensive, cathartic, and narcotic analgesic medication use. The assessment indicated R28 continued to be independent with transferring and ambulation with the use of a walker, and used a wheelchair when fatigued. Staff would continue to assist as needed and intervene immediately if unsafe transfers/ambulation were noted. The mobility care plan revised [DATE], indicated R28 was independent with walking, wheelchair mobility, bed mobility, and transfers. R28 used a rolling walker and used a wheelchair for long distances per her request. The care plan did not address R28's unsafe use of the walker. At 2:40 p.m. on [DATE], LPN-C confirmed she had observed R28 propel on the unit in the walker. LPN-C stated "she does that once in a while. She shouldn't do that. We're supposed to remind her to use the wheelchair when that happens." At 3:20 p.m. on [DATE], the registered nurse (RN)-A confirmed R28 propels the walker in the hallways, and stated "she really shouldn't but she does. Staff re-direct her and she'll still do it. That's why she was given a wheelchair by therapy." At 4:00 p.m. on [DATE], the physical therapist (PT)-E confirmed staff had reported R28 propels backwards seated in the walker. PT-E stated R28 could ambulate just fine, but sometimes her leg gets painful. "R28 should use the wheelchair when that happens." PT-E verified the walker should not be used as a wheelchair for safety reasons; however, had continued to propel in the walker even after provided a wheelchair. PT-E stated she could provide no documentation to indicate R28 was educated regarding the risks of using the walker for transportation. R28, was interviewed regarding her understanding of the risks related to propelling herself backwards in the walker at 11:43 a.m. on [DATE]. When asked if staff explained the risks, R28 stated, "oh, I'm sure they have." R28 was unable to identify what the risks included. Review of Safety Events indicated R28 had no falls/incidents related to use of the wheeled walker within the past year. A Safety Event at 4:54 p.m. on [DATE], indicated R28 had one fall since the last survey; however, the fall was actually related to not using the walker. At 12:45 p.m. on [DATE], the occupational therapist (OT)-G confirmed R28 was evaluated for a wheelchair in [DATE], because she was "scooting" backwards in the walker and using it as a wheelchair. OT-G stated she was not sure if staff had reported R28 was still using it the walker as a wheelchair because she was "just filling in this week for the regular OT." OT-G confirmed the walker was not meant to be used as a wheelchair and stated "I'm sure the manufacturer's directions would say that." OT-G was unsure if the facility had the manufacturer's instructions and stated sometimes residents bring their walkers from home and don't have the instructions. The manufacturer's instructions dated 2012, indicated "Important Safety Notice - This is a walking aid only and is not to be used as a transportation device."