Every finding on record at Three Meadows Post Acute

Based on observation, staff interviews, and review of facility policy, the facility failed to ensure medications were stored in a locked compartment. This had the potential to affect all residents residing on the first and second floors, except 13 (#250, #251, #252, #253, #254, #255, #256, #257, #258, #259, #260, #261, and #262) residents identified by the facility as residing on the secured memory care unit. The facility census was 91.Findings include:1. Observation on 03/10/26 at 10:30 A.M. revealed a medication cart next to the first-floor nurses' station was unattended and unlocked.Interview on 03/10/26 at 10:31 A.M. with Licensed Practical Nurse (LPN) #130 confirmed the medication cart next to the first-floor nurses' station was left unattended and unlocked.2. Observation on 03/11/26 at 12:00 P.M. revealed a medication cart next to the second-floor nurses' station was unattended and unlocked.Interview on 03/11/26 at 12:04 P.M. with LPN #142 confirmed the medication cart next to the second-floor nurses' station was unattended and unlocked.Review of the facility policy titled, Medication Labeling and Storage, dated February 2023, revealed the facility would store all medication in locked compartments.This was an incidental finding discovered during the complaint investigation.

Based on medical record review, observations, staff interviews, and review of facility policies, the facility failed to utilize enhanced barrier precautions (EBP) and perform hand hygiene to prevent the spread of infection. This affected two (#165 and #185) of two residents observed for the use of EBP. The facility census was 91.Findings include:1. Review of the medical record for Resident #165 revealed she was admitted on [DATE] with diagnoses including stage four chronic kidney disease, osteoporosis, gastro-esophageal reflux disease (GERD), dysphagia, cognitive communication deficit, and muscle wasting.Review of the quarterly Minimum Data Set 3.0 (MDS) assessment, dated 12/05/25, revealed Resident #165 was cognitively impaired and did not display any behaviors nor refusals of care at the time of the assessment. She utilized a wheelchair and required maximal to dependent assistance with mobility, transfers, and activities of daily living (ADLs).Review of the physician orders for Resident #165 revealed an order dated 01/20/26 for EBP precautions to be used when providing high-contact care, including dressing changes. Continued review of her physician orders revealed she had an order dated 02/19/26 for wound care to the right first digit of her foot, cleanse with wound cleanser and paint with betadine every night shift.Observation on 03/10/26 at 3:50 P.M. of wound care provided by Licensed Practical Nurse (LPN) #105 revealed she began wound care for Resident #165 by removing her sock on her right foot. LPN #105 did not wear a gown. LPN #105 replaced the sock, left the room to verify wound care orders, then returned wearing a gown and gloves. LPN #105 removed Resident #165's sock then removed her gloves and applied new gloves without performing hand hygiene. LPN #105 proceeded with wound care as ordered and replaced Resident #165's sock and shoe.Interview on 03/10/26 at 3:59 P.M. with LPN #105 confirmed she began wound care for Resident #165 without wearing a gown and should have been wearing one. Continued interview with LPN #105 confirmed did not perform hand hygiene after removing her gloves and she was unsure if she should have.Review of the facility policy titled, Wound Care, dated 2010, revealed staff would perform hand hygiene during wound care after removing gloves and an old dressing.Review of the facility policy titled, Enhanced Barrier Precautions, dated December 2024, revealed staff would utilize a gown and gloves when providing high-contact care, including wound care, for residents.2. Review of the medical record for Resident #185 revealed he was admitted on [DATE] with diagnoses including traumatic subdural hemorrhage, malignant neoplasm of right kidney, hypovolemic shock, syncope, and history of falls.Review of the admission MDS assessment, dated 02/11/26, revealed Resident #185 was cognitively intact and did not display any behaviors nor refusals of care at the time of the assessment. He required moderate to maximal assistance with ADLs and required maximal assistance for transfers. Resident #185 had a urinary catheter for urinary retention, was incontinent of bowel, and was dependent for toileting hygiene and urinary catheter cleansing.Review of the physician orders for Resident #185 revealed an order dated 02/12/26 for EBP to be used when providing high-contact care, including dressing changes. Continued review of his physician orders revealed an order dated 02/10/26 for an indwelling urinary catheter and an order dated 02/10/26 for catheter care to occur every shift.Observation on 03/10/26 at 4:10 P.M. of Certified Nurse Assistant (CNA) #128 and CNA #146 providing catheter care and perineal hygiene for Resident #185 revealed both CNAs did not perform hand hygiene prior to applying gowns and gloves. Continued observation revealed CNA #128 changed her gloves while providing catheter care and did not perform hand hygiene. At the completion of care, CNA #146 did not perform hand hygiene after removing her gown and gloves then left Resident #185's room.Interview on 03/10/26 at 4:30 P.M. with CNA #128 and CNA #146 confirmed the above observation and verified they did not perform hand hygiene prior to, during, and after providing catheter care for Resident #185.Review of facility policy dated October 2023 and titled Handwashing/Hand Hygiene revealed staff would perform hand hygiene immediately after removing gloves.Review of facility policy dated August 2022 and titled Catheter Care, Urinary revealed staff would wash and dry their hands prior to and after providing perineal hygiene.Review of the facility policy titled, Handwashing/Hand Hygiene, dated October 2023, revealed staff would perform hand hygiene immediately after removing gloves.This deficiency represents non-compliance investigated under Complaint Number 2786839.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure protected health information (PHI) remained secure. This affected one (#155) of one resident observed for PHI. The facility census was 91.Findings include:Review of the medical record for Resident #155 revealed he was admitted on [DATE] with diagnoses including respiratory failure, heart disease, atrial fibrillation, pulmonary hypertension, peripheral venous insufficiency, a history of falling, and transient ischemic attacks.Review of the quarterly Minimum Data Set 3.0 (MDS) assessment, dated 02/13/26, revealed Resident #155 was cognitively intact and did not display any behaviors nor refusal of care at the time of the assessment. He utilized a wheelchair and required maximal to dependent levels of assistance with activities of daily living (ADLs).Observation on 03/11/26 at 12:00 P.M. revealed a medication cart at the second-floor nurses' station with a laptop open, displaying the landing page for Resident #155. The medication cart and laptop were unattended. Viewable PHI for Resident #155, visible to anyone passing by, included his photo, name, gender, room number, date of birth , code status, allergies, and most recent vital signs.Interview on 03/11/26 at 12:04 P.M. with Licensed Practical Nurse (LPN) #142 confirmed the above observed unattended laptop was open and displayed PHI for Resident #155 and was visible to anyone passing by.Review of an undated facility policy titled, Protected Health Information (PHI), Management and Protection of, revealed it was the responsibility of facility personnel to prevent the unauthorized disclosure of protected health information.This was an incidental finding discovered during the complaint investigation.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure medication was available as prescribed. This affected one (#94) of two residents reviewed for medication administration. The facility census was 101.Findings Included:Review of the medical record for Resident #94 revealed an admission date of 02/17/22. Diagnoses included acute respiratory failure with hypercapnia, acute and chronic respiratory failure with hypoxia, Chronic Obstructive Pulmonary Disease (COPD), acute on chronic diastolic congestive heart failure, chronic kidney disease stage three, and dysphagia.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was dependent on staff for Activities of Daily Living (ADLs) and eating. Resident #94 required the use of a motorized wheelchair for mobility and was dependent on staff for transferring using a mechanical lift. Resident #94 was frequently incontinent of bowel and bladder.Review of the plan of care dated 12/01/25 revealed Resident #94 required the use of continuous oxygen related to acute respiratory failure, COPD, pneumonia, and shortness of breath while lying flat. Interventions included administering oxygen at two Liters/Minute (L/M), educating the resident on the importance of keeping oxygen on and at the prescribed setting, maintaining the head of bed elevated, and reporting signs of hypoxia.Review of the physician's orders for February 2026 revealed Resident #94 had an order on 02/05/26 for Fluticasone Furoate-Vilanterol Inhalation Aerosol Powder Breath Activated 100-25 micrograms (mcg) per actuation (act), one puff inhale orally one time a day for COPD.Observation on 02/17/26 at 9:41 A.M. of medication administration revealed the facility did not have Resident #94's Fluticasone Furoate-Vilanterol Inhalation Aerosol Powder Breath Activated 100-25 mcg/act inhaler.Interview with Licensed Practical Nurse (LPN) #302 verified the facility did not have Resident #94's Fluticasone Furoate-Vilanterol Inhalation Aerosol Powder Breath Activated 100-25 mcg/act inhaler.Review of the facility policy titled Administering Medications dated 04/2019, revealed medications are administered in accordance with prescriber orders, including any required time frame.This deficiency represents non-compliance investigated under Complaint Number 2724907.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure physicians orders were followed for oxygen therapy and the use of a Continuous Positive Airway Pressure (CPAP). This affected one (#94) of three residents reviewed for assistive breathing devices. The census was 101.Findings Included:Review of the medical record for Resident #94 revealed an admission date of 02/17/22. Diagnoses included acute respiratory failure with hypercapnia, acute and chronic respiratory failure with hypoxia, Chronic Obstructive Pulmonary Disease (COPD), acute on chronic diastolic congestive heart failure, chronic kidney disease stage three, and dysphagia.Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/03/25, revealed the resident had intact cognition. The resident was dependent on staff for Activities of Daily Living (ADL) and eating. Resident #94 required the use of a motorized wheelchair for mobility and was dependent on staff for transferring using a mechanical lift. Resident #94 was frequently incontinent of bowel and bladder.Review of the plan of care dated 12/01/25 revealed Resident #94 required the use of continuous oxygen related to acute respiratory failure, COPD, pneumonia, and shortness of breath while lying flat. Interventions included administering oxygen at two liters per minute (L/M), educating the resident on the importance of keeping oxygen on and at the prescribed setting, maintaining the head of bed elevated, and reporting signs of hypoxia.Review of the after-visit summary from Resident #94's pulmonology appointment on 11/18/25 revealed Resident #94 had Obstructive Sleep Apnea (OSA) and was to resume the CPAP 15 centimeters of water column (cm of H2O) when the CPAP was available. Further review of the after-visit summary revealed Resident #94 had been getting more short of breath at night at the facility while he was not on oxygen and does not want to depend on oxygen. Resident #94's CPAP malfunctioned and the facility ordered a new machine months ago. Resident #94 was not using his CPAP at 15 cm of H2O. Resident #94 has insomnia and sleeps with the Head of Bed (HOB) elevated. Resident #94 stated he did not use the CPAP machine because the mask was broken but he now has a new mask.Review of the physician's orders dated 11/28/25 revealed oxygen two L/M via nasal cannula, for shortness of breath related to pneumonia.Review of the physician's orders dated from November 2025 through February 2026 revealed no orders for the CPAP 15 cm of H2O.Review of the Nurse Practitioner (NP) progress notes on 12/19/25 revealed Resident #94 was seen at the request of the nursing staff reporting Resident #94 had been wearing oxygen at four L/M. Resident #94 had a history of COPD, OSA, and does not wear a CPAP at night. Oxygen was reading at 98 percent (%) on 2 L/M, with oxygen off reading 93% to 94%. The NP educated the resident on the use of the CPAP with naps and at night. Resident #94 was to wear his CPAP at nighttime and with naps, staff was to monitor oxygen levels and administer oxygen at two liters as needed to keep oxygen above 90%.Review of the physicians' orders for December 2025 revealed an order for continuous oxygen at two L/M via nasal cannula. Further review of the physicians' orders revealed no order for as needed oxygen at two liters to maintain oxygen above 90%.Review of the Nurse Practitioner (NP) progress notes on 01/06/26 revealed Resident #94 was seen due to not feeling well and shortness of breath. The diagnoses and plan revealed Resident #94 was educated on wearing the CPAP at night and with naps. Staff was to monitor oxygen levels, and supplement with oxygen at two liters as needed to keep oxygen above 90%. Resident #94 had a sleep study appointment on 01/07/26. Resident #94 had oxygen on with new orders for a Complete Blood Count (CBC), Basic Metabolic Panel (BMP) once, start prednisone (a steroid medication) 10 milligrams (mg) one tablet daily for four days.Review of the NP #338 progress note on 01/29/26 revealed Resident #94 was seen due to cough and congestion. NP #338 stated Resident #94 was wearing his oxygen to help with shortness of breath. Under the section titled Physical Exam revealed for respiratory no increased work of breathing at rest on oxygen.Review of the physician orders dated for January 2026 and February 2026 revealed no orders for as needed oxygen at two liters to maintain oxygen above 90%.Interview with the Director of Nursing (DON) on 02/10/26 at 11:30 A.M. verified the NP #338 had an order for Resident #94 to receive as needed oxygen at two liters to maintain an oxygen level above 90%, and there was no order on 12/19/25 written. The DON further stated she was unsure where the order for continuous oxygen at two liters on 11/28/25 came from. The DON stated Resident #94 had a CPAP machine but the face mask was broken and was being replaced. The DON stated Resident #94 frequently refused, however there was no documentation supporting refusals.Interview on 02/10/26 at 1:03 P.M. with NP #338 revealed Resident #94 should not been on continuous oxygen. NP #338 stated Resident #94 at times requested oxygen for comfort, but it was not recommended and NP #338 had educated Resident #94 on this. NP #338 stated staff at the facility at times would approach her and ask if Resident #94 could have oxygen and she would give a verbal order for Resident #94 to have an as needed order for oxygen at two L/M via nasal cannula for shortness of breath or oxygen levels falling below 90%. NP #338 further verified on 12/19/25 the oxygen orders should have been as needed to maintain an oxygen level above 90% and not continuous. NP #338 further said Resident #94 should have had an order for the CPAP, though he was not always compliant, it should be offered at bedtime and naps. NP #338 was unsure where the continuous order for oxygen came from on 11/28/25, but stated it was most likely from a previous hospitalization in November.Review of the facility policy titled Oxygen Administration dated 10/2010, revealed verify that there is a physician order for oxygen administration. Turn on oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of two to three liters per minute.Review of the facility policy titled CPAP/BiPAP Support dated 03/2015, revealed staff was to review medical record and determine his/her baseline oxygen saturation, and respiratory status. Resident should be NPO for at least two hours before using full-face mask. CPAP is used when residents have not responded to other types of oxygen delivery systems.This deficiency represents non-compliance investigated under Complaint Number 2734513.

Based on medical record review, staff and resident interview, and policy review, the facility failed to ensure post fall follow up assessments were completed and care planned fall interventions were implemented. This affected one resident (#52) out of three residents reviewed for falls. The facility census was 101. Review of the medical record revealed Resident #52 was admitted to the facility on [DATE]. Diagnoses included neuroleptic induced Parkinsonism, hemiplegia and hemiparesis following cerebral infarction affecting the right dominate side, bipolar disorder, anxiety disorder, repeated falls, adrenocortical insufficiency, chronic kidney disease stage 3B. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 14. Further review of the MDS revealed Resident #52 was independent with eating, needed set up or clean up assistance with oral hygiene, substantial/maximal assistance with toileting, bathing, partial assistance with upper body dressing, dependent on staff for lower body dressing, footwear application, and substantial assistance with personal hygiene.Review of the care plan dated 07/30/25 revealed Resident #52 was at risk for falls with or without injury related to altered mental status, antidepressant medication, antipsychotic medication, history of falls, unsteady gait, poor safety awareness, noncompliance. Interventions included anticipating and meeting needs, assisting with all transfers, locomotion, and mobility, bag secured to bedside commode to hold wipes within reach, bed placed against wall, and room arranged for ease of transfers to commode, bedside commode, bright colored tape to call light, catheter leg bag as resident allows during day, and non-skid strips between the bed and the commode.Review of the nurse progress notes dated 11/23/25 revealed Resident #52 was found on the floor. Staff assisted resident onto the chair to assess from the fall. Resident #52 was educated on the use of the call light and not ambulating without assistance. Vital signs were stable and the resident denied pain. Resident #52 stated the need to walk and did not want to use the commode. Staff notified the Nurse Practitioner (NP) on call and neurological checks per protocol were started.Review of the neurological checks on 11/23/25 revealed a nurse was to begin checking neurological checks every 15 minutes times one hour, every 30 minutes times two hours, every hour times two hours, and every shift times 72 hours. On 11/23/25 neurological checks were not completed as indicated every 15 minutes. Neurological checks were completed at 1:30 P.M., 1:45 P.M., and 2:10 P.M. Further review of the neurological checks revealed neurological checks were not completed every half hour and were completed on 11/23/25 at 3:00 P.M., 5:00 P.M, 9:00 P.M., and 11:00 P.M.Interview with the Director of Nursing (DON) on 02/09/26 at 2:43 P.M. verified staff had not followed the neurological check protocol on 11/23/25 when Resident #52 was to have checking neurological checks every 15 minutes times one hour, every 30 minutes times two hours, every hour times two hours, and every shift times 72 hours. On 11/23/25 neurological checks were not completed as indicated every 15 minutes. Neurological checks were completed at 1:30 P.M., 1:45 P.M., and 2:10 P.M. The DON further verified the neurological checks were not completed every half hour and were completed on 11/23/25 at 3:00 P.M., 5:00 P.M, 9:00 P.M., and 11:00 P.M.Observation on 02/10/26 at 2:05 P.M. of Resident #52's bedroom revealed there were no skid strips next to Resident #52's bed leading to the bedside commode next to the bed.Interview on 02/10/26 at 2:05 P.M. with Resident #52 revealed the skid strips helped with not slipping while transferring from the bed to the bedside commode and that there were never any skid strips in place after her bedside mat was removed on 01/30/25.Interview with the Director of Rehabilitation (DR) #240 on 02/17/26 at 2:30 P.M. revealed Resident #52 had a bedside mat to prevent injury due to frequent falls; however, the mat became problematic due to the bedside table not being sturdy on the bed mat causing potential falls. DR #240 stated that skid strips should be in front of the bedside commode and directly next to the bed.A follow-up interview with the DON on 02/17/26 at 3:00 P.M. verified there were no skid strips in front of Resident #52's bed or bedside commode.Review of the facility policy titled Neurological Assessment dated 10/2023, revealed routine neurological assessment is conducted to evaluate the resident for small changes over time that may be indicative of neurological injury. Neurological checks were to be conducted as frequently as ordered.This deficiency represents non-compliance investigated under Complaint Number 2722676

Based on medical record review, observation, and resident and staff interview, the facility failed to ensure residents with identified hearing concerns were seen timely by the audiologist. This affected one resident (#82) of three residents reviewed for ancillary services. The facility census was 101. Findings Include:Review of Resident #82's medical record revealed an admission date of 10/24/24. Diagnoses included endometrium cancer, chronic obstructive pulmonary disease, lymphedema, anxiety disorder, osteoarthritis, depression, and unspecified hearing loss.Review of Resident #82's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating Resident #82 was cognitively intact. Resident #82 had moderate difficulty hearing. Resident #82 was on hospice at the time of the review. Review of Resident #82's care plan revised 12/22/25 revealed supports and intervention for risk for pain, self-care deficit, risk for falls, terminal illness and receiving hospice services, risk for changes in mood, refusal of care behaviors, and hearing deficit. Interventions for hearing deficit included getting Resident #82's attention before beginning to speak, have speakers face in the light, face Resident #82 and do not cover mouth when speaking or conversing, if necessary lower speaking tone, move resident to low noise place or remove as much background noise as possible. Review of Resident #82's Ancillary Services Consent form dated 02/03/25 revealed Resident #82 requested an audiological consultation by an audiologist for the purpose of obtaining additional information necessary for the evaluation of the need for, or appropriate type of, medical or surgical treatment of a new hearing deficit or related medical problem. It was noted Resident #82's recent decreased patient responsiveness. Review of the Hospice Agreement Sample from Resident #82's initial hospice provider, as her signed agreement was not available, revealed it was the facility's primary responsibility to provide facility services. It was the facility's responsibility to provide facility services which met the personal care needs and nursing needs which would have been provided by the primary caregiver at home and the facility shall perform facility services at the same level of care provided to each hospice resident before hospice care was elected. The facility was to ensure all facility services were provided and competently and efficiently. Facility services were to meet the standards of care for provided services and shall be in compliance with all applicable law, rules, regulations. Observation on 02/11/26 at 12:18 P.M. Resident #82 was seated in bed with the head of her bed raised. Resident #82 was not able to hear an introduction when spoken to her while standing at the foot of her bed. Resident #82 scrunched her face appearing frustrated and stated she could not hear. She asked who are you. Resident #82 was able to hear if the surveyor stood very close to and the volume was increased.Interview on 02/11/26 at 12:19 P.M. with Resident #82 verified she was not able to hear, did not have hearing aids, and needed staff to come very close to her and shout so she could hear them. Resident #82 stated she would like hearing aids, but she had not seen anyone about her ears since she had been at the facility. Resident #82 stated she knew she needed to have her ears checked before she could get help for her hearing. Interview on 02/12/26 at 7:10 A.M. with the Administrator and the Director of Nursing (DON) verified Resident #82 had not seen the audiologist since she had been at the facility. It was reported Resident #82 was not on the list to be seen when she first was admitted and they switched providers. It was stated Social Services would have additional information.Interview on 02/12/26 at 10:00 A.M. with Licensed Social Worker (LSW) #150 verified Resident #82 had not been seen by the audiologist during her time in the facility. The LSW #150 reported Resident #82 was admitted in October of 2024 and would not sign the consent for ancillary services until February of 2025. At that time the audiologist was scheduled for March 2025 and Resident #82 was not on the list and was not seen. There was then an issue with the provider not having an audiologist in their area. They recently acquired a new provider and they were ironing out the details regarding who would be seen and when. Review of Resident #82's scheduled appointments revealed Resident #82 was scheduled to be seen by the audiologist on 02/18/26 and was scheduled for an ear health appointment with the Nurse Practitioner on 02/23/26.Follow up interview on 02/17/26 at 2:56 P.M. with LSW #150 revealed any long-term resident was offered ancillary services and a consent form requesting/accepting services. This deficiency represents non-compliance investigated under Complaint Number 2724907.

Based on observation, medical record review, review of wound care provider documentation, review of hospital documentation, staff interview, family interview, nurse practitioner interview, review of the National Pressure Injury Advisory Panel 2025 guidelines, and review of facility policies, the facility failed to provide a timely assessment, ongoing monitoring, and interventions to prevent the development of a pressure ulcer for Resident #05, who was known to have arterial and venous insufficiency, and who was identified at risk for pressure ulcers. This resulted in Immediate Jeopardy and serious physical harm, injuries, and/or negative health outcome on 09/07/25 when Resident #05 was found with an unstageable pressure ulcer to the right malleolus (ankle) underneath an ankle monitoring device. The unstageable pressure ulcer was not accurately assessed, and no interventions were initiated. On 09/08/25 the wound was assessed as an unstageable pressure ulcer and an intervention for wound treatment was to elevate the extremity. There were no interventions documented regarding the frequency of monitoring Resident #05's skin under the ankle monitor and no documentation that the ankle monitor had been removed. There was no documentation of an investigation regarding Resident 05's unstageable pressure ulcer to determine causative factors of the wound development or need to change pressure reduction interventions. Furthermore, Resident #05's nutritional status was not reassessed with the change in condition. Resident #05's wound began deteriorating on 09/25/25 with signs of infection. Wound Nurse Practitioner (WNP) #700 ordered offloading heel boots, a wound culture, and a vascular consult. There was no documentation of the offloading heel boots being implemented. The resident's wound culture was not obtained until 10/06/25. On 10/05/25 the resident began experiencing a decline in condition and laboratory testing was ordered. The laboratory was unable to obtain vascular access, and the resident refused a second attempt. On 10/06/25 the resident was ordered intravenous fluids which were not administered. Additionally, the vascular consult was not obtained prior to the resident discharging per family request to the hospital on [DATE]. On 10/06/25, Resident #05 was admitted to the hospital and diagnosed with a wound infection, septic arthritis of the right ankle, osteomyelitis of the fibula due to Staphylococcus aureus, and was hypoglycemic with an extremely low blood sugar of 26 milligrams per deciliter (mg/dL) and required 15 grams of oral glucose. Resident #05 also required intravenous antibiotics, wound debridement, and negative pressure wound therapy (wound vac). Resident #05 was diagnosed with moderate to severe stenosis of the right lower extremity and an above the right knee amputation was performed on 10/17/25. This affected one (#05) of four residents reviewed for pressure ulcers. The facility identified 10 residents with pressure ulcers. The facility census was 83.On 12/03/25 at 4:31 P.M., the Administrator, the Director of Nursing (DON), and the Assistant Director of Nursing (ADON) #114 were notified that the Immediate Jeopardy began on 09/07/25 at approximately 10:30 A.M. when Resident #05 was found with an unstageable pressure ulcer to the right ankle from an ankle monitoring device with no documented interventions regarding the skin monitoring under the ankle monitor and no documentation the ankle monitor had been removed. Also, there was no documentation in the medical record of an immediate wound assessment and no investigation of the causative factors of the wound development or the need to change pressure reduction interventions. Furthermore, Resident #05's nutritional status was not reassessed with the change in condition. Resident #05's wound began deteriorating on 09/25/25 with signs of infection. WNP #700 ordered offloading heel boots, a wound culture, and a vascular consult. There was no documentation in the medical record that the offloading heel boot intervention was implemented, and the resident's wound culture was not obtained until 10/06/25. On 10/05/25 the resident began experiencing a decline in condition and laboratory testing was ordered. The laboratory was unable to obtain vascular access, and the resident refused a second attempt. On 10/06/25 the resident was ordered intravenous fluids which were not administered, and the provider was not notified of the intravenous fluids not being administered. Additionally, the vascular consult was not obtained prior to the resident discharging, per family request, to the hospital on [DATE]. On 10/06/25 the resident was admitted to the hospital and diagnosed with a wound infection, septic arthritis of the right ankle, osteomyelitis of the fibula due to Staphylococcus aureus and was hypoglycemic with an extremely low blood sugar of 26 milligrams per deciliter (mg/dL) requiring 15 grams of oral glucose. The resident required intravenous antibiotics, wound debridement, and negative pressure wound therapy (wound vac). Resident #05 was diagnosed with moderate to severe stenosis of the right lower extremity and an above the right knee amputation was performed on 10/17/25.The Immediate Jeopardy was removed on 12/05/25 after the facility implemented the following corrective actions:- On 12/03/25, the Administrator immediately notified Physician #600, the Interim Medical Director.- On 12/03/25, Unit Manager Licensed Practical Nurse (UMLPN) #108 conducted a thorough assessment on Resident #05 with no adverse effects noted.- On 12/03/25, the following immediate actions were implemented for Resident #05: - Registered Dietitian (RD) #100 completed a nutritional reassessment for Resident #05. RD #100 reviewed and updated the nutritional interventions by adding an additional nutritional supplement with all meals. - The DON and UMLPN #108 reviewed Resident #05's wound care regimen to ensure the regimen was updated per current physician orders. - The UMLPN #108 reviewed and evaluated Resident #05's medical devices (heel boot) for proper fit and skin protection measures. - The DON implemented for Resident #05 an enhanced turning and repositioning schedule with documentation every two hours. - The DON and ADON #114 reviewed Resident #05's pressure redistribution surfaces as indicated by the current risk assessment. - The DON reviewed Resident #05's current skin care plan. - The ADON #114 reviewed the Certified Nursing Assistant's charting documentation tasks to ensure accuracy.- On 12/03/25, the DON/designee conducted audits for all residents to identify those at risk for pressure ulcer development, with particular focus on residents with ankle monitoring devices or other medical devices in contact with skin. Each identified at risk resident received immediate reassessment of current interventions and implementation of enhanced monitoring protocols. The DON identified one current resident (#51) with an ankle monitoring device and implemented skin monitoring checks each shift. - On 12/03/25, the DON/designee identified 33 residents (#62, #29, #74, #79, #41, #77, #52, #85, #86, #26, #31, #05, #56, #18, #60, #11, #35, #02, #10, #53, #25, #72, #14, #13, #83, #64, #67, #27, #32, #80, #75, #57, #19) with medical devices. The DON/designee implemented enhanced orders for skin monitoring each shift. - On 12/03/25, the DON/designee identified 10 residents (#29, #56, #17, #54, #05, #30, #14, #52, #46, #60) with existing pressure ulcers or a history of pressure ulcers and implemented enhanced skin monitoring orders for nurses to complete visual skin checks on shower/bath day along with a daily comprehensive skin evaluation.- On 12/03/25, the DON/designee identified 14 residents (#05, #07, #12, #13, #14, #15, #16, #20, #22, #25, #31, #52, #55, #75) with vascular insufficiency or other circulatory conditions and implemented enhanced monitoring orders for nurses to complete visual skin checks on shower/bed bath day.- On 12/03/25, the DON/designee identified 34 residents (#01, #05, #12, #13, #14, #16, #17, #18, #19, #21, #22, #25, #28, #30, #32, #36, #38, #39, #41, #46, #49, #50, #52, #55, #56, #57, #61, #63, #67, #69, #70, #74, #77, #80) at moderate to high risk of skin breakdown and implemented enhanced monitoring orders for nurses to complete visual skin checks on shower/bed bath day.- On 12/03/25, the DON, the Administrator, and ADON #114 conducted a root cause analysis identifying contributing factors including: - People: Insufficient knowledge of ankle monitoring skin monitoring protocols - Process: Lack of standardized skin inspection procedures for medical devices - Environment: Insufficient communication systems for reporting skin changes - Methods: Absence of structured investigation process for new pressure ulcers- On 12/03/25, the DON/designee started education will all nurses and certified nursing assistants on pressure ulcer prevention, medical device skin safety to ensure the skin under a device is monitored, skin and wound assessment and documentation training with emphasis on timely reporting. Nurses were also re-educated on implementation of physician orders. Education to be completed by 12/05/25.- On 12/03/25, the Administrator and ADON #114 reeducated RD #100 on the position job description and the importance of reassessing residents with skin integrity changes.- On 12/03/25, the DON/designee implemented enhanced monitoring orders for nurses to complete visual skin checks on all residents on their shower/bed bath day. All new admissions will be evaluated to determine if they qualify for this classification. - On 12/03/25, the DON/designee implemented a standardized pressure ulcer investigation form and process. - On 12/03/25, the DON/designee implemented weekly wound care rounds with wound team participation.- On 12/03/25, the Administrator and the Quality Assurance Team (MD #600, UMLPN #102, UMLPN #108, ADON #114) reviewed policies on medical devices with skin integrity, lab procedures and policies, and clinical documentation.- On 12/03/25, the Administrator and Medical Director (MD) #600 implemented new best practices on A Guide to Device Skin Inspection, effective 12/04/25.- On 12/03/25, the DON reviewed the new admission checklist. The DON updated the checklist to include obtaining physician orders for skin monitoring for new admissions with medical devices. The new admission checklist was implemented and put into effect on 12/05/25. - On 12/04/25, the Administrator notified MD #602 of Immediate Jeopardy. - On 12/04/25, UMLPN #108 conducted a thorough skin assessment on Resident #51 with no adverse effects noted. - On 12/04/25, the Administrator reeducated UMLPN #102 on job duties, manager role, chart review, wound care, accurate order entry, complete investigation, and follow through on all job duties.- On 12/04/25 at 1:30 P.M., the facility held an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting with the Administrator, Infection Preventionist/ADON #114, UMLPN #108, UMLPN #102, and Medical Director (MD) #600. - On 12/04/25, the Administrator and MD #600 reviewed policies for laboratory procedures, and policies for clinical documentation. The reviewed policies were acceptable with no changes needed.- On 12/04/25, RD #100 reviewed all residents with skin integrity changes for nutritional intervention needs. - On 12/04/25, the Administrator/designee educated all staff on new best practices A Guide to Device Skin Inspection. Education was completed on 12/08/25. - On 12/04/25, the Administrator/Designee educated all nurses on laboratory communication and documentation. Education was completed on 12/08/25. - On 12/04/25, the DON/designee conducted a review of all residents with medical devices for skin integrity documentation. Ongoing monitoring will occur daily for five days, then five residents weekly for four weeks, then two residents monthly for two months with a completion date of 03/2026.- On 12/04/25, Unit Managers/designee performed an audit of physician order implementation timeframes on all residents with new orders or order changes. Audits will continue daily for five days, then audit five residents weekly for four weeks, then audit two residents monthly for two months with a completion dated 03/2026.- Starting 12/08/25, the DON/designee will audit random resident medical records to ensure pressure ulcer prevention interventions and skin assessments are in place as ordered. Audits by the DON/designee will continue with five random resident medical records per week for one month, then two random resident records per week for two months with a completion date on 03/31/26.- Starting 12/08/25, the DON/designee will conduct weekly audits on wound dressing changes to ensure timely treatments on five random residents for four weeks, then for five random residents monthly for two months with a completion date of 03/31/26. - Beginning 12/2025, all systemic changes would be reviewed monthly for three months by the Quality Assurance (QA) Team. The DON/designee would report monitoring plan results to the QAPI committee monthly. The QAPI committee would monitor on an ongoing basis until sustained compliance was achieved with quarterly reviews to assess effectiveness and make necessary adjustment to the monitoring plan frequency on demonstrated compliance rates. - Interviews conducted on 12/08/25 from 7:53 A.M. through 8:05 A.M. with Licensed Practical Nurse (LPN) #116, LPN #122, LPN #103, Certified Nursing Assistant (CNA) #202 and CNA #204 revealed the staff had received education on monitoring skin each shift for residents with medical devices. The staff also received education on laboratory communication and procedures, clinical documentation, pressure ulcer prevention, completing wound assessments and wound treatments per physician orders. - On 12/08/25, review of staff education revealed 41 of 43 nurses had received education on laboratory policies and procedures. Interview with the Administrator at the time of the review revealed staff who were not educated would not be scheduled to work until the education was completed. - On 12/08/25, review of staff education revealed 77 of 83 nurses and nursing assistants had completed education on pressure ulcer prevention, medical device skin safety, skin and wound assessments, implementation of physician orders, reporting, and clinical documentation. Interview with the Administrator at the time of the review revealed staff who were not yet educated would not be scheduled until the education had been completed. Although the Immediate Jeopardy was removed on 12/05/25, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure ongoing compliance.Review of the medical record for Resident #05 revealed an admission date of 06/14/23. Diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus, Alzheimer's disease, dementia, hypertension, repeated falls, anemia, peripheral vascular disease. Updated diagnoses dated 10/21/25 included orthopedic aftercare following surgical amputation, methicillin susceptible staphylococcus aureus infection, occlusion and stenosis of carotid artery, and unstageable pressure ulcer of sacral region, acquired absence of right leg above knee, and protein calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #05 had severe cognitive impairment. The resident had no unhealed pressure ulcers but was at risk for developing pressure ulcers/injuries. Resident #05 used a wheelchair and could not ambulate, required the substantial/maximal assistance of staff for toileting, bathing, bed mobility, and transfers. Review of the plan of care initiated 06/16/23 revealed the resident had a potential for an alteration in skin integrity related to immobility, multiple sclerosis, incontinence, and a history of left hip arthroplasty. Interventions included keeping linens clean, dry, wrinkle free, and free of foreign matter, offload heels as tolerated, a pressure reduction mattress to the bed, turn and reposition as needed, and use pillows/pad to support/position as appropriate. Further review of the care plan revealed the resident had impaired cognitive function, wandered, and was an elopement risk due to impaired safety awareness. Interventions included an ankle monitor to the left leg. Staff were to document wandering behaviors and were to check the function of the ankle monitor daily and the placement every shift. The care plan had no interventions to monitor the skin under the ankle monitor. On 09/08/25 the plan of care was revised as the resident had an unstageable pressure ulcer to the right malleolus and was at risk for further breakdown and/or slow healing, and delayed healing due to decreased mobility. Interventions included administering treatments per physician orders, a pressure relieving device for heels, enhanced barrier precautions during high-contact resident care activities, and wound consults as indicated. The resident was also at risk for hyperglycemic/hypoglycemic reactions, abnormal lab values, and diabetic ulcers related to diabetes mellitus and peripheral vascular disease. Interventions included for staff to monitor and report signs and symptoms of hypoglycemia/hyperglycemia and administer medication per physician orders. Further review of the care plan revealed there was no care plan in place for edema or any interventions for the use of compression stockings. Review of Resident #05's physician orders revealed an order dated 01/25/24 for a dietary consult/evaluation as needed. A physician order dated 02/23/24 revealed staff were to check the ankle monitoring device function daily and the placement of ankle monitoring device to the left ankle every shift. Review of a physician order dated 02/23/24 revealed a second order to check placement of the ankle monitoring device each shift and to check function daily. The second order did not specify the location of the ankle monitoring device and did not include anything about monitoring the resident's skin under the ankle monitoring device. Both physician orders for the ankle monitoring device were discontinued on 10/08/25. Review of a physician order dated 05/13/24 revealed an order for blood sugar monitoring daily in the morning. Review of a physician order dated 06/24/24 revealed Resident #05 was ordered knee high compression stockings, staff were to apply in the morning and then remove at bedtime for lower extremity edema, as tolerated. The order for the compression stockings was discontinued on 10/08/25. Review of a quarterly nutritional risk review assessment dated [DATE] at 2:49 P.M. revealed Resident #05 had intact skin, fed self at meals with set up provided, and had variable meal intakes between 51 percent to 75 percent of most meals. The resident was on a controlled carbohydrate regular texture diet with thin liquids, received a nutritional supplement once daily at breakfast and consumed 100 percent of all supplements served. Further review of the nutrition assessments and progress notes revealed no further nutritional assessments were completed until 10/26/25.Review of a shower/bed bath sheet dated 09/03/25 revealed Resident #05 had no apparent skin issues. Review of a shower/bed bath sheet dated 09/07/25 revealed the resident had an open area on the right ankle. Review of an incident report dated 09/07/25 at 10:30 A.M., revealed while the resident was getting a bed bath, support staff noticed Resident #05 had a wound/pressure ulcer on the right ankle. The wound was noted as closed with dry flaky skin covering the wound. The wound was assessed, cleansed, and bandaged. The right foot was then elevated on a pillow. The resident was noted to be wearing an ankle monitor (electronic wander-prevention bracelet) to the right leg. Further review of the progress notes and skin evaluations for 09/07/25 revealed no documentation of a wound assessment or of wound measurements. Review of the physician orders and Treatment Administration Record (TAR) revealed no wound care orders were initiated or administered. Further review of the medical record revealed no notifications of the wound were made to the family or physician. Review of a skin and wound evaluation dated 09/08/25 at 10:42 A.M. revealed Resident #05 had a new in-house acquired unstageable pressure ulcer on the right malleolus found on 09/07/25. The wound measured 2.4 centimeters (cm) in length, 2.1 cm in width, with an undeterminable depth due to a wound bed with 90 percent slough and 10 percent granulation tissue. No odor was noted. The wound had attached edges with serous exudate with amount noted as none. The surrounding wound tissue was intact, dry/flaky, and normal in color and temperature. There was no edema. The wound was noted as healable. An antimicrobial dressing with a foam secondary dressing were noted. The wound was to be cleansed, and honey gel applied to the wound bed and covered with a dry dressing. Wound dressing changes were to be completed daily. The resident was to follow up with the wound nurse practitioner. The physician and family were notified. There was no documentation of notification to the dietitian.A physician order dated 09/08/25 revealed the resident was ordered enhanced barrier precautions for high contact resident care, including wound care. Further review of the physician orders dated 09/08/25 revealed an order to cleanse the unstageable pressure wound with wound cleanser, pat dry, apply honey gel to the wound base and cover with dry dressing, change daily and as needed every evening shift. The order was discontinued on 09/11/25. Review of a nurses note dated 09/08/25 at 12:20 P.M. revealed the interdisciplinary team (IDT) met and reviewed the new pressure ulcer documentation. The nursing assistant was bathing resident when an area of dry skin fell off from the right malleolus revealing a dark moist center. The nurse was alerted, examined the resident's wound, placed a dressing on the wound and elevated the resident's foot on a pillow. The physician was notified with new treatment orders obtained. The resident's family was notified. A new intervention was added to apply a heel boot. The resident would be seen by the wound provider on the next visit. Review of a physician progress note dated 09/08/25 at 4:08 P.M., revealed Resident #05 had a new pressure ulcer to the right ankle but the wound was not examined by the physician. The physician assistant noted the resident would follow up with in-house wound care. Review of a wound provider initial visit progress report dated 09/11/25 revealed Resident #05 had an acute pressure ulceration of the right malleolus. The provider noted previous treatments had included off-loading and elevation. The goal was to facilitate complete closure of the resident's acute wound. Due to numerous comorbidities, the aim was also to prevent the progression of the wound, prevent infection, as well as prevent hospitalization. The wound was noted as unstageable due to slough/eschar. The wound measured 2.1 cm in length by 1.9 cm in width, and depth was indeterminable. The wound had 100 percent necrotic tissue with moderate serosanguineous exudate. The wound was noted as small and full thickness with well-defined wound edges. Other related factors were noted as the resident's age, hypertension, nutrition status, and limited mobility. Wound debridement was completed. The practitioner ordered to cleanse the wound with wound cleanser, pat dry with gauze, apply skin prep to the peri-wound (skin surrounding the wound), apply medical grade honey to the wound bed only, then cover with calcium alginate (cut to size) and then apply a dry dressing three times per week and as needed if loose or soiled. The provider noted an offloading heel boot was recommended, along with turning and repositioning. Review of a wound provider progress report dated 09/18/25 revealed the wound was unchanged with 100 percent necrotic tissue. The wound measured 2.3 cm in length, 2.6 cm in width, with an undetermined depth with light serosanguineous drainage. Wound debridement was completed. The wound provider made no changes to the wound treatment orders and continued to recommend an offloading heel boot. Review of a wound provider progress report dated 09/25/25 revealed the resident's wound was deteriorating. The wound measured 3.5 cm in length and 3.0 cm in width with an undetermined depth. The wound was 100 percent necrotic tissue with moderate serosanguineous drainage. The wound provider ordered a wound culture and a vascular consultation. The wound provider continued to recommend heel boots. New physician wound care orders included to cleanse wound with Dakins solution, rinse with wound cleanser, and pat dry with gauze, apply skin prep to the peri-wound, Santyl (nickel thick, applied to wound from edge to edge), cover with silver alginate (cut to size) and apply dry dressing three times per week and as needed if loose or soiled.Review of a nurse progress note dated 09/26/25 at 12:10 P.M. revealed Resident #05's family was notified of an order for a vascular consult. The family agreed and would call back with dates available to attend the appointment. Review of a nurse's progress note dated 09/30/25 at 3:00 P.M. revealed the resident's family provided dates of availability for the vascular appointment. The vascular provider's office was contacted, and a message was left. A call was placed to the laboratory to check on the wound culture results. The laboratory noted the testing could not be completed as the specimen was not labeled. The nurse practitioner was notified with a new order for a new specimen to be obtained and sent out as soon as possible. Review of a physician order dated 09/30/25 revealed an order for a vascular consult for the right ankle wound and increased pain in the right leg. Review of a wound provider progress report dated 10/02/25 revealed Resident #05's wound continued to deteriorate. The wound measured 5.3 cm in length, 6.5 cm in width, with an undeterminable depth. The wound was 100 percent necrotic tissue with moderate serosanguineous drainage. The wound was debrided. The provider noted awaiting wound culture results and the date of the vascular appointment. The provider noted the resident continued to keep the right leg pulled up and in a lateral position. The provider continued to recommend off-loading heel boots. No changes were made to the wound treatment orders. Review of a nurse's note dated 10/05/25 at 2:16 P.M. revealed the resident had a decrease in appetite and fluids were encouraged during rounding. Resident #05 had muscle tremors on the left side along with an elevated heart rate of 122 beats per minute (normal heart rate 60 to 80 beats per minute). The on-call physician was notified, and new orders were received for an electrocardiogram (EKG), a right ankle x-ray, and laboratory testing including a complete blood count, a complete metabolic panel, an erythrocyte sedimentation rate, C-Reactive protein, and lactate. Review of a radiology report dated 10/05/25 and electronically signed at 7:11 P.M. revealed an x-ray of Resident #05's right ankle was completed due to ankle pain. The radiology report noted the study quality was limited by inappropriate technique which reduced sensitivity for subtle fracture, malalignment, and small joint effusion. Further review of the findings revealed no acute fracture or dislocation, no focal soft tissue swelling, no soft tissue gas, or foreign body identified.Review of a nurse's note dated 10/05/25 at 10:27 P.M. revealed the x-ray and EKG results were reviewed with the on-call physician with no new orders received. Staff continued to encourage fluids and the resident had no distress at this time. Review of a nurse's note dated 10/06/25 at 5:55 A.M. revealed the laboratory staff were unable to draw labs on the first poke and the resident refused the second poke. The lab stated they would redraw tomorrow. Review of a nurse practitioner progress note dated 10/06/25 at 7:00 A.M. revealed Resident #05 had a right ankle wound, pain, tachycardia, and poor intake. The resident was seen as a follow up related to staff reports of a continued decline, poor appetite, tachycardia, an ankle wound, and pain. A wound culture was resent to the laboratory. Heart rate continues at 113 beats per minute today. The resident was noted with an order for metoprolol twice a day, but the medication was withheld due to low blood pressures. The resident refused repeat laboratory orders so far. The nurse practitioner noted that depending on the conversation with the family about the resident's poor appetite and ankle status, may order fluids via hypodermoclysis (subcutaneous or under the skin). Review of a nurse's note dated 10/06/25 at 10:27 A.M. revealed a call was placed to the vascular provider who then requested a fax of the resident's information. An attempt was made twice to fax the requested information, and a message was left to obtain a different fax number. There was no documentation of any attempts to contact the vascular provider between 10/01/25 and 10/05/25. Review of a nurse's note dated 10/06/25 at 12:00 P.M. revealed the resident's family was updated on the orders for the EKG and the x-ray. The family was notified that the resident had refused labs this morning. The resident's family was informed that the nurse practitioner was most likely going to order intravenous fluids. The family was also updated about the pending vascular consult and notified the nurse had made several attempts to get the appointment scheduled. Review of a nurse's note dated 10/06/25 at 1:10 P.M. revealed the vascular provider had provided another fax number and the referral information was faxed again. The nurse practitioner gave a verbal order to start intravenous therapy 0.9 percent normal saline at 50 milliliters (ml) per hour. The resident agreed to the treatment. Review of a physician order dated 10/06/25 revealed an order for a protein supplement, 30 milliliters by mouth twice daily to aid in wound healing. Review of a late entry nurse's note incorrectly dated for 10/07/25 at 7:30 P.M. revealed the resident was sent to the emergency room and the family was updated. Review of a laboratory report dated 10/10/25 revealed Resident #05's wound culture was collected on 10/06/25 at 1:00 A.M. and received at the lab at 7:08 A.M. The results were verified on 10/10/25 at 8:44 A.M. with the residents' wound testing positive for methicillin-resistant staphylococcus aureus (MRSA).Review of the progress notes and TAR dated 08/01/25 through 10/05/25 revealed no documentation the resident had refused her compression stockings or of the physician being notified of compression stocking refusals. Review of the TAR dated 09/01/25 through 10/06/25 revealed the nurses had documented completing checks for the left ankle monitor placement and function every shift except during the dayshift on 09/14/25 and 09/18/25. The nurses also documented the completion of checks for ankle monitor placement each shift and function daily except during the dayshift on 09/14/25 and 09/18/25. The TAR did not list the location of the ankle monitor. Further review of the TAR revealed no documentation of the intervention for the heel boots being implemented or completed. Wound treatments for the right malleolus were completed per physician orders. Review of the nurse's notes, physician orders, and Medication Administration Record (MAR) for 10/06/25 revealed no documentation the resident had received the intravenous fluids per physician order. There was also no documentation the physician was notified the intravenous fluids had not been administered. Additional review of the MAR revealed the resident was not administered the protein supplement prior to discharge to the hospital on [DATE].Review of hospital documentation dated 10/06/25 through 10/18/25 revealed Resident #05 arrived at the emergency department on 10/06/25 at 8:16 P.M. with hypoglycemia, with an extremely low blood sugar of 26 milligrams[TRUNCATED]

Based on review of the medical record, review of bowel records, staff interview, and policy review, the facility failed to ensure bowel movements were accurately documented and failed to ensure the bowel protocol was followed when a resident was without a bowel movement for greater than three days. Additionally, the facility failed to timely complete a bowel assessment for a resident with a known history of constipation who had no documented bowel movements for six days. This affected one (#74) of three residents reviewed for bowel and bladder. The facility census was 83. Review of the medical record for Resident #74 revealed an admission date of 02/17/22. Diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease, type two diabetes mellitus, chronic kidney disease, and osteoarthritis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was always incontinent of bowel and frequently incontinent of bladder. The resident was dependent on staff for all activities of daily living. Review of the care plan revealed the resident was at risk for constipation due to decreased mobility, and frequent pain medication use. Interventions included administering medications per physician orders, monitoring for medication side effect and reporting changes and complications of constipation. Review of the physician orders for Resident #74 revealed an order dated 05/06/25 for Dulcolax suppository ten milligrams daily, an order dated 10/11/25 for Linzess, 72 micrograms daily for chronic constipation, and an order for Metamucil, two capsules daily for chronic constipation. Further review of the physician orders revealed orders dated 06/11/25 for sennoside-docusate tablet 8.6-50 mg tablet three times per day, and orders dated 06/11/25 for Miralax 17 grams four times a day for constipation, and an order dated 05/05/25 for a mineral oil enema as needed up to twice weekly for constipation.Review of the Medication Administration Record (MAR) dated 11/01/25 through 11/20/25 revealed the scheduled routine bowel medications had been administered per physician orders. the resident refused the Dulcolax suppository ten times, refused the sennoside-docusate four times, and refused the Miralax 46 times. The as needed mineral oil enema was never administered. Review of the bowel task documentation completed by the Certified Nursing Assistants dated 11/15/25 through 11/20/25 revealed the resident had no bowel movements from 11/15/25 through 11/20/25. Review of the progress notes dated 11/15/25 through 11/20/25 revealed there was no documentation the physician was notified of the resident not having a bowel movement. There was no documentation the resident was assessed for bowel sounds prior to 11/20/25. There was no documentation the resident was provided with additional interventions or medications to assist with bowel movements. There was no documentation the resident had been educated regarding refusals of bowel medications. Review of a nurse's note dated 11/20/25 at 11:49 A.M. revealed the resident had a declinein condition with increased pain in his bottom, drooling, and greenish phlegm. The nurse practitioner was notified.Review of a nurses note dated 11/20/25 at 1:13 P.M. revealed the resident was evaluated by the nurse practitioner with new orders for STAT labs. The resident was agreeable with the treatment plan. The resident's representative called 911 and the resident was sent to the hospital. Review of the bowel alert report dated 11/15/25 through 11/20/25 revealed Resident #74 had triggered an alert for no bowel movement on 11/16/25, 11/17/25, 11/18/25, 11/19/25, and 11/20/25. Review of the hospital documentation dated 11/20/25 through 11/25/25, provided by the facility, revealed no documentation the resident had a bowel blockage. The resident was admitted to the hospital with diagnoses including acute respiratory failure and pneumonia.Interview on 11/25/25 at 11:52 A.M., Licensed Practical Nurse (LPN) #103 revealed the facility tracked resident bowel movements. LPN #103 revealed a resident would be added the no bowel movement list after three days. LPN #103 revealed Resident #74 had received a lot of bowel medications. LPN #103 revealed if a resident had not had a bowel movement in three days then the nurse practitioner would be notified. LPN #103 revealed Resident #74 has had several x-rays in the past to check for blockages. Interview on 11/25/25 at 12:00 P.M., LPN #122 revealed Resident #74 was not feeling well and the nurse practitioner had ordered some laboratory testing which the resident was agreeable with. LPN #122 revealed she had went to lunch and when she returned another nurse had stated the resident was not looking good. LPN #122 revealed she had went to notify the nurse practitioner but the resident's family member had requested the resident be sent to the hospital. LPN #122 revealed there was no time to assess the resident as the nurse practitioner was already in the room and then emergency medical services had arrived. LPN #122 revealed the unit managers provided a bowel list each morning and the nurse practitioner was notified if the resident had no bowel movement in three days. LPN #122 revealed she was not aware if the resident was on the no bowel movement list prior to discharging to the hospital. Further interview on 11/25/25 at 1:53 P.M. LPN #122 revealed she now recalled a nursing assistant had informed her on 11/18/25 that the resident had diarrhea but LPN #122 had not asked the aide the amount or consistency. LPN #122 was aware it was possible to have diarrhea with a bowel blockage. LPN #122 verified she had not assessed the resident, had not listened for bowel sounds, and had not reviewed the bowel movement charting. LPN #122 further revealed Assistant Director of Nursing (ADON) #114 had asked her today when the resident's last bowel movement was because there was no record of it. LPN #122 revealed she made a late entry progress note in the medical record today. Interview on 11/25/25 at 1:44 P.M., Unit Manager Licensed Practical Nurse (UMLPN) #102 revealed a dashboard in the electronic medical records provided an alert for resident's with no bowel movements after 72 hours. UMLPN #102 revealed after 72 hours the physician should be notified. UMLPN #102 had reviewed the resident's bowel charting and nurse's notes. UMLPN #102 then verified there was no documentation Resident #74 had a bowel movement from 11/15/25 through 11/20/25 and no documentation the physician had been notified. UMLPN #102 could not recall if the resident had alerted for no bowel movements. UMLPN #102 was asked to provide documentation of the no bowel movement report. UMLPN #102 revealed she was not sure if that could be provided but would look into it. Interview on 11/25/25 at 2:33 P.M., Nurse Practitioner (NP) #109 revealed Resident #74 had a history of constipation and diarrhea. NP #109 revealed staff normally notified her if a resident had not had a bowel movement in three or four days. NP #109 revealed staff may have told her in passing of Resident #74 not having a bowel movement and she had just not made a documented note of it. NP #109 revealed the resident was non-compliant with his many bowel medications and saw a gastrointestinal (GI) physician. NP #109 revealed Resident #74 complained more about diarrhea then constipation. NP #109 revealed the resident was not feeling well on 11/20/25 and she had ordered labs for the resident. NP #109 revealed the resident wanted to remain in the facility, but the resident's representative wanted the resident sent out and called emergency medical services. NP #109 revealed she had assessed the resident prior to transport to the hospital. NP #109 also revealed she had assessed the resident's bowel sounds which were present in all four quadrants. Interview on 12/01/25 at 11:06 A.M., LPN #116 revealed the nursing assistants charted the resident's bowel movements and the unit manager would provide a daily list of residents without a bowel movement for three days. LPN #116 revealed after three days the physician would be notified for new orders but the nurses could use the facility's standing orders in the binder. Review of the facility policy Bowel Management Protocol, dated 02/15/25, revealed the facility would ensure residents were free from complications secondary to constipation. This would be accomplished through adequate assessment, tracking, and treatment as indicated. A normal bowel pattern was once daily up to once every three days. Further review of the policy revealed to provide medications per physician orders, encourage activity as allowed and tolerated, and encourage fluid intake as allowed and tolerated. Prune juice may be given daily. The Certified Nursing Assistants would document each shift the number the number of bowel movements and size of bowel movements on the resident flow record. The nurse would medication as ordered by the physician or obtain a physician's order for residents on the bowel care list including a suppository, milk of magnesia or lactulose. The nurse would follow up on those residents on the bowel care list for results and documentation should include size and consistency of the bowel movement.

Based on observation, review of the medical record, staff interview, and policy review, the facility failed to ensure enhanced barrier precautions were maintained during wound care. This affected one (#05) of four residents reviewed for wound care. The facility identified 29 residents with enhanced barrier precautions. The facility census was 83. Review of the medical record for Resident #05 revealed an admission date of 06/14/23. Diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus, Alzheimer's disease with late onset, dementia, hypertension, repeated falls, anemia, peripheral vascular disease, orthopedic aftercare following surgical amputation, Methicillin susceptible staphylococcus aureus infection, occlusion and stenosis of carotid artery, and unstageable pressure ulcer of sacral region, acquired absence of right leg above knee, and protein calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #05 had severe cognitive impairment. The resident was at risk for developing pressure ulcers/injuries. The resident used a wheelchair and could not ambulate. The resident required the substantial/maximal assistance of staff for toileting, bathing, bed mobility, and transfers. Review of a physician order dated 10/21/25 revealed the resident was ordered enhanced barrier precautions for high contact resident care including wound care.Review of a nurse ' s note dated 10/21/25 at 2:00 P.M. revealed Resident #05 had returned from the hospital on [DATE] and a second skin check was completed. The resident had an above the knee amputation of the right leg with the incision well approximated with 16 sutures. The resident had an unstageable pressure ulcer to the coccyx, and unstageable pressure ulcer to the left heel, a deep tissue injury of the left lateral foot and left malleolus. Observation on 11/25/25 at 2:00 P.M. of Resident #05 revealed a sign outside the resident ' s door indicating the resident required enhanced barrier precautions (gown and gloves) when providing high contact care. Licensed Practical Nurse (LPN) #103 and the Unit Manager Licensed Practical Nurse (UMLPN) #102 provided wound care treatment for the resident ' s unstageable sacral wound per physician orders. LPN #103 and UMLPN #102 had not donned a gown prior to providing wound care for the resident. The uniform tops of both LPN #103 and UMLPN #102 touched the resident while turning and repositioning the resident during wound care. Interview on 11/25/25 at 2:16 P.M., LPN #103 and UMLPN #102 verified the resident required enhanced barrier precautions during wound care. LPN #103 and UMLPN #102 verified they had not worn gowns while providing wound care for the resident. Review of the facility policy Enhanced Barrier Precautions, revised 03/2024, revealed enhanced barrier precautions (EBPs) were utilized to reduce the transmission of multidrug-resistant organisms (MDROs) to residents. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities including wound care.

Based on review of the medical record, staff interview, and policy review, the facility failed to ensure resident representatives and physicians were notified of changes in condition. This affected one (#05) of three residents reviewed for changes in condition. The facility census was 83. Review of the medical record for Resident #05 revealed an admission date of 06/14/23. Diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus, Alzheimer's disease with late onset, dementia, hypertension, repeated falls, anemia, peripheral vascular disease, orthopedic aftercare following surgical amputation, Methicillin susceptible staphylococcus aureus infection, occlusion and stenosis of carotid artery, and unstageable pressure ulcer of sacral region, acquired absence of right leg above knee, and protein calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #05 had severe cognitive impairment. The resident had no unhealed pressure ulcers. The resident was at risk for developing pressure ulcers/injuries. The resident used a wheelchair and could not ambulate. The resident required the substantial/maximal assistance of staff for toileting, bathing, bed mobility, and transfers. The resident required set-up assistance for eating. The resident had no significant weight loss.Review of a nurse's note dated 10/05/25 at 2:16 P.M. revealed the resident had a decrease in appetite and fluids were encouraged during rounding. Resident #05 had muscle tremors on the left side along with an elevated heart rate of 122 beats per minute. The on-call physician was notified, and new orders were received for an electrocardiogram (EKG), an x-ray, and laboratory testing including a complete blood count, a complete metabolic panel, an erythrocyte sedimentation rate, C-Reactive protein, and lactate. Review of a physician order dated 10/05/25 revealed an order for an EKG and x-ray of the right ankle.Review of a radiology report dated 10/05/25 and electronically signed at 7:11 P.M. revealed an x-ray of Resident #05's right ankle was completed due to ankle pain. The radiology report noted the study quality was limited by inappropriate technique which reduced sensitivity for subtle fracture, malalignment, and small joint effusion. Further review of the findings revealed no acute fracture or dislocation, no focal soft tissue swelling, soft tissue gas, or foreign body identified.Review of a nurse's note dated 10/06/25 at 12:00 P.M. revealed the resident's family was updated on the orders for the EKG and the x-ray. The family was notified that the resident had refused labs this morning. The resident's family was informed that the nurse practitioner was most likely going to order intravenous fluids. The family was notified about the pending vascular consult and notified the nurse had made several attempts to get the appointment scheduled. Review of a nurse's note dated 10/06/25 at 1:10 P.M. revealed the vascular provider had provided another fax number and the referral information was faxed again. The nurse practitioner gave a verbal order to start intravenous therapy 0.9 percent normal saline at 50 milliliters (ml) per hour. The resident agreed to the treatment. Review of the nurses notes from 10/05/25 through 10/07/25 revealed no documentation the resident's representative was notified of the x-ray results of the right ankle.Review of the nurse's notes, physician orders, and medication administration record (MAR) for 10/06/25 revealed no documentation the resident had received the intravenous fluids per physician orders. There was also no documentation the physician was notified the intravenous fluids had not been administered. Interview on 12/03/25 at 9:07 A.M., Unit Manager Licensed Practical Nurse (UMLPN) #102 verified there was no documentation Resident #05's representative had been notified of the x-ray results for the right ankle. UMLPN #102 verified there was no documentation the IV had been administered per physician orders. Further interview with UMLPN #102 revealed she was unable to obtain IV access. UMLPN #102 verified there was no documentation of the unsuccessful attempt to initiate the IV and no documentation the physician was notified.Review of the policy Change in a Resident' Condition or Status, revised 02/2021, revealed the facility would promptly notify the attending physician of a need to alter the resident's medical treatment. This deficiency represents non-compliance investigated under Complaint Number 2677336.

Based on observation, review of the medical record, staff interview, resident interview, family interview, and policy review revealed the facility failed to ensure medical documentation was complete and accurate. This affected two (#5, #51) of three residents reviewed for clinical documentation and had the potential to affect all residents. The facility census was 83. 1. Review of the medical record for Resident #05 revealed an admission date of 06/14/23. Diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus, Alzheimer's disease with late onset, dementia, hypertension, repeated falls, anemia, peripheral vascular disease, orthopedic aftercare following surgical amputation, Methicillin susceptible staphylococcus aureus infection, occlusion and stenosis of carotid artery, and unstageable pressure ulcer of sacral region, acquired absence of right leg above knee, and protein calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #05 had severe cognitive impairment. The resident required the substantial/maximal assistance of staff for toileting, bathing, bed mobility, and transfers. Review of the plan of care initiated 06/16/23 revealed the resident had impaired cognitive function, wandered, and was an elopement risk due to impaired safety awareness. Interventions included an ankle monitor to the left leg. Staff were to document wandering behavior and were to check function of ankle monitor daily and placement every shift. Further review of the care plan revealed there was no care plan in place for edema or interventions for compression stockings. Review of a physician order dated 02/23/24 revealed to check the ankle monitoring device function daily and placement of ankle monitoring device to the left ankle every shift. Review of a physician order dated 02/23/24 revealed a second order to check placement of the ankle monitoring device each shift and check function daily with no specified location of the device. The orders for the ankle monitoring device were discontinued on 10/08/25. Review of a physician order dated 06/24/24 revealed the resident was ordered knee high compression stockings, staff were to apply in the morning and then remove at bedtime for lower extremity edema, as tolerated. The order for the compression stockings was discontinued on 10/08/25.Review of an incident report dated 09/07/25 at 10:30 A.M. revealed the resident was found with a wound to the right ankle. Further review of the incident report revealed the resident's ankle monitor was on the right leg. Review of the progress notes and Treatment Administration Record (TAR) dated 08/01/25 through 10/05/25 revealed no documentation the resident had refused the compression stockings. Staff documented daily the compression stockings were applied in the morning and removed at bedtime. Further review of the TAR revealed staff were documenting the ankle monitor to the left leg was checked for placement and function every shift. There was no documentation the ankle monitor had been moved to the right leg. Review of a late entry nurse's note dated 10/07/25 at 7:30 P.M. revealed the resident was transported to the hospital. Review of the hospital documentation dated 10/06/25 revealed the resident was admitted to the hospital on [DATE] around 8:16 P.M. Interview on 12/01/25 at 2:30 P.M., Unit Manager Licensed Practical Nurse (UMLPN) #102 revealed Resident #05 no longer wore an ankle monitor. UMLPN #102 revealed the resident used to wear an ankle monitor on the right leg. UMLPN #102 reviewed the resident's medical record and verified the resident had two separate physician orders for documenting function and placement of the ankle monitor. The first order noted no location of the ankle monitor, and the second order noted the ankle monitor on the left ankle. UMLPN #102 verified staff had documented completing both orders. UMLPN #102 revealed staff should have checked both ankles and then clarified the order and the correct location of the ankle monitor. Further interview on 12/01/25 at 3:52 P.M., UMLPN #102 revealed she could not say with 100 percent certainty if Resident #05's ankle monitor was on the right leg. Additional interview with UMLPN #102 revealed the nurse's note dated 10/07/25 stating the resident was admitted to the hospital had been documented on the incorrect date on 10/07/25. UMLPN #102 verified the resident was transferred to the hospital on [DATE].Interview on 12/01/25 at 4:52 P.M., LPN #116 revealed being notified on 09/07/25 by Certified Nursing Assistant (CNA) #130 of a wound found on Resident #05's right ankle. LPN #116 revealed a risk assessment had been completed noting the ankle monitor was on the right ankle. LPN #116 revealed moving the ankle monitor up higher on the resident's right leg. LPN #116 revealed he was only aware of the ankle monitor being in place on the right ankle. LPN #116 revealed he was unaware there were two separate physician orders for monitoring placement and function of the ankle monitor with one noting the left ankle and the other with no specified location.Interview on 12/02/25 at 8:07 A.M., Certified Nursing Assistant (CNA) #130 revealed Resident #05 had a wound to the right ankle and the resident's ankle monitor would rest in the area of the wound. CNA #130 revealed Resident #05 was supposed to wear compression stockings but would refuse to wear them most of the time saying, they hurt her legs. CNA #130 revealed she tried to make sure the ankle monitor was over the resident's socks or compression stockings.Interview on 12/03/25 at 8:14 A.M., with Resident #05's Family Member (FM) #98 revealed the resident had the ankle monitor device on her right ankle for over a year with nothing underneath of it. FM #98 revealed the device was plastic and rubbed and irritated the resident's skin. FM #98 revealed she had asked staff to remove the ankle monitor. FM #98 revealed the Administrator stated, we cannot remove it. FM #98 revealed when the resident got the sore on her right ankle she had asked the staff again to remove the ankle monitor as the staff had to lift of the ankle bracelet to attend to the sore. FM #98 revealed one day she visited the resident and staff had moved the ankle monitor to the left ankle. FM #98 revealed she had never seen the resident wearing compression stockings and was unaware the resident had required compression stockings. FM #98 revealed the resident wore non-skid socks.Interview on 12/03/25 at 8:56 A.M., LPN #119 revealed Resident #05 had sometimes refused compression stockings. LPN #119 believed Resident #05's ankle monitor had been on the right ankle but was not 100 percent certain.Interview on 12/08/25 at 8:09 A.M., the DON verified Resident #05 had not liked wearing the compression stockings and would refuse. Interview on 12/08/25 at 10:33 A.M., the Administrator revealed the facility had no documentation the resident had been refusing her compression stockings. The Administrator revealed staff had been educated on documenting resident refusals and the accuracy of their documentation.2. Review of the medical record for Resident #51 revealed an admission date of 06/21/22. Diagnoses included dementia, type two diabetes mellitus, chronic obstructive pulmonary disease, and heart failure. Review of the quarterly Minimum Data Set (MDS) assessment completed 09/16/25 revealed the resident had moderate cognitive impairment. The resident was independent for bed mobility. The resident was at risk for pressure ulcers.Review of the care plan initiated 11/13/24 revealed the resident wandered aimlessly and was an elopement risk related to impaired safety awareness. Interventions included for placement of an ankle monitoring device to the right ankle. Staff were to check placement every shift and monitor functioning status per facility protocol. Review of the physician orders dated 11/13/24 revealed for staff to check placement and function for the ankle monitor every shift to the right ankle. Review of the Treatment Administration Record (TAR) from 11/01/25 through 11/30/25 revealed staff had documented completing ankle monitoring checks for placement and function every shift except on day shift on 11/08/25, 11/12/25, 11/13/25, and 11/18/25. Licensed Practical Nurse (LPN) #140 had documented the ankle monitoring function and placement checks were completed during the day shift on 11/07/25, 11/11/25, 11/16/25, 11/17/25, 11/21/25, 11/28/25, 11/29/25, and 11/30/25.Observation and concurrent interview on 12/02/25 at 9:03 A.M., LPN #140 revealed Resident #51 was the only current resident with an ankle monitor. LPN #140 revealed she would check and make sure the ankle monitor was not too tight. LPN #140 revealed Resident #51's ankle monitor would alarm if the resident's family took the resident out of the unit. LPN #140 revealed she had worked in the facility for about a year. LPN #140 revealed she was unaware of any device used to check the function of an ankle monitor. LPN #140 looked for a device to check function at the nurse's station and found the device in a bottom drawer. LPN #140 verified she had been documenting she had checked the function and placement of the resident's ankle monitor when in fact she had not known how. LPN #140 could not get the device monitor to turn on. LPN #140 then consulted with UMLPN #108 who then opened the battery compartment on the device revealing no batteries were present. UMLPN #108 then left the unit to find batteries. Further observation revealed UMLPN #108 replaced the battery and instructed LPN #140 on how to use the device monitor to check the function of the ankle monitor. LPN #140 then checked Resident #51's ankle monitoring sensor for function and placement. Review of the facility policy Charting and Documentation, revised 07/2017 revealed all services provided to the resident, progress toward care plan goals, and changes in condition shall be documented in the resident's medical record. Documentation in the medical record would be objective, complete, and accurate.

Based on observation, review of the medical record, resident interview, staff interview, and policy review. The facility failed to ensure surgical wound care was completed per physician orders. This affected one resident (#43) of three residents reviewed for wound care. The facility identified five residents with surgical wounds. The facility census was 83. Review of the medical record for Resident #43 revealed an admission date of 09/10/25 and a readmission date of 10/23/25. Diagnoses included pneumonia, anxiety, and surgical aftercare following surgery of the digestive system.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of the physician orders dated 11/18/25 revealed the resident had a surgical wound to the right upper quadrant mid abdomen. The orders were to cleanse the wound with wound cleanser, pat dry, apply skin prep to the skin surrounding the wound, apply the antibacterial dressing and foam, change three times per week on Tuesdays, Thursdays, and Saturdays, and as needed. Review of the nurses' notes from 11/21/25 through 11/25/25 revealed no documentation the resident had refused wound care. Review of the Treatment Administration Record (TAR) dated 11/01/25 through 11/25/25 revealed the wound care treatment to the abdomen had been documented as completed on 11/22/25. Interview on 11/25/25 at 1:25 P.M., Resident #43 revealed the facility had not completed the wound care to her surgical wound since the previous week. Resident #43 revealed she had asked the nurse to change the dressing on Saturday 11/22/25 but the nurse never returned to complete the dressing change. Resident #43 also revealed she had to request every week for dressing for her PICC (Peripherally Inserted Central Catheter) line to be changed or it would not have gotten done.Observation on 11/25/25 at 1:25 P.M. of Resident #43's abdominal wound dressing revealed the dressing was dated 11/20/25. Interview on 11/25/25 at 1:36 P.M., the Assistant Director of Nursing (ADON) #114 verified the wound dressing was dated 11/20/25 and the wound treatment had not been completed on 11/22/25 as documented. ADON #114 revealed she would find someone to change the wound dressing. Review of the facility policy Wound Care, revised 10/2010, revealed wound care would be provided per physician orders and the dated and time the wound care was given would be documented in the medical record. This deficiency represents non-compliance investigated under Complaint Number 2677336.

Based on observation, medical record review, review of wound center documentation, staff interview, and review of a facility clinical protocol, the facility failed to provide timely assessment, monitoring, and interventions to prevent the development of a pressure ulcer. Actual harm occurred when Resident #56, who was assessed at moderate risk for pressure ulcer development, had care plan interventions for skin checks each shift with no documented evidence of the skin checks completed. Subsequently, the resident was discovered with a unstageable pressure ulcer (obscured full-thickness skin and tissue loss) to the left lateral heel and no ongoing assessments were completed to determine causative factors of the wound development or need to change pressure reduction interventions. Resident #56's wound required surgical debridement and ongoing treatment applications as a result. This affected one (#56) of two residents reviewed for pressure ulcers. The census was 81. Findings include: Review of the medical record revealed Resident #56 admitted to the facility on [DATE] with the diagnoses including, a stage four sacral pressure ulcer (full-thickness skin and tissue loss), atrial fibrillation, congestive heart failure, type II diabetes mellitus, tracheostomy, history of hemorrhage from a tracheostomy stoma, gastrostomy, colostomy, cerebral infarction, chronic respiratory failure, anemia, anxiety disorder, major depressive disorder, and a chronic non-pressure right lower leg ulcer. Review of the Minimum Data Set (MDS) assessments dated 01/22/25 and 04/03/25 revealed Resident #56 had intact cognition, was able to make needs known, was not assessed with any refusal of care, and had no range of motion impairments to bilateral upper and lower extremities. Resident #56 was dependent on staff for the completion of activities of daily living, utilized a motorized wheelchair independently, was incontinent of bladder, received nutrition via feeding tube, was assessed at risk for pressure ulcer development with one stage four pressure ulcer present on admission and three venous and arterial ulcers, and received antianxiety, antidepressant, anticoagulant, diuretic, and opioid medications. Review of a nursing plan of care dated 03/13/24 revealed the care plan was initiated due to Resident #56's potential for alteration in skin integrity related to immobility, diabetes mellitus type II, congestive heart failure, depression, and contractures. Interventions included to administer treatments as ordered and monitor effectiveness, apply moisturizing lotion as needed to dry skin, offload heels as tolerated, turn and reposition as needed, and use pillows/pads to support/position as appropriate. Additional interventions were implemented on 08/28/24 to include pressure redistribution mattress to the bed, heel lift suspension boots to be worn to bilateral feet at all times as tolerated and to be removed for bathing/hygiene and every shift skin checks. Review of a nursing plan of care dated 04/04/24 revealed the care plan was developed to address Resident #56's alteration in skin integrity related to a stage four pressure ulcer to the coccyx. Interventions included the application of a low air loss pressure redistribution mattress to bed and refer to a wound treatment specialist as needed. Review of Resident #56's physician order dated 11/23/24 revealed an order was initiated to off load heels while in bed as tolerated every shift for skin breakdown prevention. Review of a nursing plan of care dated 01/02/25 revealed the care plan was implemented to address Resident #56's venous stasis ulcer to the left foot and left first toe and indicated the resident was at risk for further breakdown and/or slow, delayed healing related to cardiovascular disease, decreased mobility, impaired circulation, and incontinence of bowel and bladder. Interventions included treatment as ordered and wound consultation as indicated. Review of assessments for predicting pressure sore risk dated 01/22/25 and 04/02/25 revealed Resident #56 was at moderate risk for pressure sore development. Review of Resident #56's treatment order dated 01/16/25 revealed treatment to the resident's vascular wounds to the left foot, great toe (hallux) to include for staff to cleanse with normal saline, pat dry, paint the wound bed with betadine and leave open to air daily and as needed. An order was implemented on 01/23/25 for the vascular wound to the top (dorsum) of the left foot and included to cleanse with normal saline, pat dry, and apply skin prep daily and as needed. An order was implemented on 01/30/25 for treatment of the vascular wound to the right lower extremity, anterior and posterior, to cleanse with normal saline, pat dry, apply adaptic, wrap the leg with an unna boot (compression dressing), abdominal dressing (ABD), wrap with Kerlix and change three times weekly and as needed. Additionally, on 01/30/25 the resident's coccyx wound was ordered a treatment to cleanse with normal saline, pat dry, apply hydrogel and packing strip to the wound bed, and cover with foam dressing three times weekly and as needed. Review of a nursing plan of care dated 02/10/25 revealed the care plan was initiated to address Resident #56's risk for pressure ulcers and other skin problems such as skin tears, bruising, bleeding, abrasions, rashes, and excoriation related to debility, immobility, and peripheral vascular disease. Interventions included to monitor skin daily with routine care. Further review of Resident #56's medical record revealed no documentation indicating the resident's skin was being assessed every shift as described in the nursing plans of care dated 03/13/24 and 02/10/25. Review of a skin and wound evaluation dated 02/12/25 noted, on the same date, Resident #56 was discovered with an intact pink or red blister to the left lateral heel that was in-house acquired measuring 0.7 centimeters (cm) long by (x) 1.0 cm wide. Additional care interventions included heel suspension/protection device, incontinence management, and a mattress with a pump. Further review revealed the notes documented a new wound to the left lateral heel had the appearance of a loose blister. Resident #56 had heel boots on and the nurse practitioner was notified. There was no documentation contained in the medical record which revealed the potential origin of the wound or additional mechanical interventions to promote healing. Review of Resident #56's physician treatment orders dated 02/12/25 revealed a treatment for wound care to the left lateral heel blister area. The order was to cleanse with normal saline, pat dry, apply foam dressing, and change every other day and as needed. Review of skin and wound evaluation dated 02/13/25 revealed Resident #56's left lateral heel wound measured 1.5 cm long x 1.3 cm wide x undetermined depth with a light amount of serosanguineous exudate (a fluid that contains both serum (clear, watery liquid) and blood cells). The wound seen by the wound nurse practitioner. Review of Resident #56's wound treatment orders revealed the orders were modified on 02/13/25 to include wound care to the left lateral heel blister area to include cleanse with normal saline, pat dry, apply skin prep, and cover with a foam dressing to be change three times a week and and as needed on day shift every Tuesday, Thursday, and Saturday. Review of wound specialist documentation dated 02/20/25 assessed Resident #56's left medial heel wound as a stage three acute pressure ulceration (full-thickness skin loss) that measured 1.4 cm long x 1.0 cm wide x 0.1 cm deep. The acute ulceration was debrided by sharp methods and devitalized tissue was removed to the level of healthy bleeding tissue which included biofilm and slough. The debridement area extended down to the level of soft tissue. All surrounding periwound hyperkeratotic skin was also removed. The post-debridement measurements of the left heel wound was 1.4 cm long x 1.0 cm wide x 0.2 cm deep. Review of out-patient wound center discharge instructions dated 05/06/25 assessed Resident #56's wound to the left heel as a stage three pressure wound. The wound measured 2.2 cm long x 2.0 cm wide x 0.1 cm deep with serosanguinous drainage. Review of a skin and wound evaluation dated 05/08/25 revealed Resident #56's left lateral heel blister was in-house acquired and developed on 02/12/25. The measurements were 1.1 cm long x 2.0 cm wide, no depth and a moderate amount of serosanguineous drainage present. Interventions included a heel suspension/protection device, incontinence management, and a mattress with a pump. Further review revealed the wound was improving with recommendation to keep heels elevated. Review of Resident #56's physician order on 05/08/25 noted the wound dressing to the left lateral heel was changed to include for staff to cleanse with antibacterial soap and water, rinse well, apply silver alginate to the wound, and cover with silicone border foam dressing. The treatment was to be changed daily and as ordered. Observation on 05/13/25 at 12:53 P.M. with Unit Manager Licensed Practical Nurse (LPN) #474 noted Resident #56 was in bed with an air mattress and bilateral heel protector boots in place. LPN #474 applied a prescribed treatment to Resident #56 stage four coccyx wound and proceeded to remove the left heel protector boot. Resident #56's left lower extremity was noted with a flexible-type tape wrapped around the ankle and upper foot. LPN #474 removed the tape and a padded dressing was observed to the heel. LPN #474 removed the dressing which resulted in a small to moderate amount of serosanguineous drainage. LPN #474 proceeded to cleanse the wound with a four inch long by four inch wide gauze and antibacterial soap and water, which resulted in a moderate amount of bleeding. LPN #474 then placed silver alginate to the wound and covered with a silicone border foam dressing. Interview on 05/14/25 at 1:55 P.M., with Unit Manager LPN #474, during review of the medical record, stated Resident #56 had heel protector boots in place at time of the left lateral heel pressure ulcer discovery and no further evaluation had occurred to determine the origin of the wound. Unit Manager LPN #474 verified there were no additional mechanical interventions implemented to prevent further deterioration or promote healing of the left lateral heel pressure ulcer. Unit Manager LPN #474 also confirmed there was no documented evidence to indicate Resident #56's heel protectors were removed each shift to assess skin integrity. On 05/15/25 at 10:20 A.M. interview with the Director of Nursing (DON), during review of Resident #56's medical record, confirmed no documentation contained in the medical record indicated Resident #56's skin under the offloading boots was assessed each shift as indicated in the nursing plan of care to monitor for pressure ulcer development. In addition, Resident #56 was assessed at moderate risk and not high risk for pressure ulcer development in spite of being admitted with a stage four pressure ulcer to the coccyx and vascular skin breakdown to the lower extremities. Review of facility pressure ulcers/skin breakdown clinical protocol, revised April 2018, revealed monitoring will include physician guidance of the care plan, especially when wounds are not healing or new wounds develop despite existing interventions.

Based on medical record review, staff interview, and review of the dialysis contract, the facility failed to ensure effective communication took place between the facility and the dialysis center. This affected one (#34) of one residents reviewed for dialysis. The facility census was 81. Findings include: Review of the medical record revealed Resident #34 was admitted to the facility on [DATE]. Diagnoses included end-stage renal disease, heart failure, type II diabetes mellitus, hypertension, and dependence on renal dialysis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was cognitively intact. The resident was assessed to receive dialysis. Review of Resident #34's active physician orders for May 2025 identified an order for dialysis on Mondays, Wednesdays, and Fridays. Review of Resident #34's dialysis communication forms for 03/01/25 through 05/08/25 revealed each form had three sections. The first section was to be completed by nursing staff prior to dialysis treatments, the second section was to be completed by the dialysis center during treatments, and the third section was to be completed by nursing staff upon the resident's return from dialysis. Further review revealed dialysis communication forms dated 03/03/25, 03/05/25, 03/07/25, 03/10/25, 03/19/25, 04/11/25, 04/23/25, and 05/07/25 had the first and third sections completed by the facility, but did not have the second section completed by the dialysis center. Review of the electronic and paper medical records for Resident #34 revealed there was no evidence the dialysis center was contacted on the aforementioned dates in attempt to have the form completed or to inquire about the status of the resident while at dialysis. Interview on 05/14/25 at 1:03 P.M. with the Director of Nursing (DON) verified the dialysis center had not completed their portion Resident #34's communication forms and there was no evidence facility staff attempted to communicate with the dialysis center on each occurrence. Review of the dialysis contract, dated 05/01/25, revealed the facility would ensure there was documented evidence of collaboration of care and communication between the nursing facility and end-stage renal disease dialysis unit.

Based on observation, medical record review, staff interview, and policy review, the facility failed to provide adequate staff assistance and implement fall interventions during care to prevent falls. This affected one (#19) of two residents reviewed for falls. The facility census was 81. Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 02/26/24 with diagnoses of congestive heart failure, anxiety, and dementia, repeated falls. Resident #19 was under hospice care. Review of the modified quarterly Minimum Data Set (MDS) assessment, dated 10/31/24, revealed Resident #19 was dependent for toileting and required substantial/maximal assistance for bed mobility. Further review revealed Resident #19 did not have any falls since the previous assessment. Review of the current care plan, initiated 02/26/24, revealed Resident #19 was at risk for falls due to impaired balance, impaired mobility, and incontinence. Further review of the care plan revealed Resident #19 had an activities of daily life (ADL) self-care deficit related to impaired balance and limited mobility. An intervention was added on 04/01/24 and revealed Resident #19 required extensive assistance of two staff members for bed mobility, including rolling from left to right. Review of the quarterly fall review document, dated 10/31/24, revealed Resident #19 was at high risk for falls. Review of the nursing progress note dated 01/30/25 revealed Resident #19 had a witnessed fall while receiving care. Resident #19 received a skin tear to his left elbow that was cleaned with normal saline and dressed with bordered gauze. No additional injuries were noted during the nursing assessment after the fall. Review of the interdisciplinary progress note dated 01/31/25 revealed Resident #19 reported rolling off the bed during incontinence care. An intervention for two staff assistance for bed mobility was implemented. Review of the facility's fall investigation revealed a statement by Certified Nurse Assistant (CNA) #530 indicating Resident #19 turned to the left and CNA #530 provided care and got linens in place. Resident #19 then rolled to the right and kept rolling onto the floor. Interview on 05/12/25 at 3:47 P.M. with Resident #19 revealed he fell approximately four months ago when he rolled off the bed while staff was changing him. Resident #19 stated he sustained a skin tear but did not have any broken bones and was not taken to the hospital. Interview on 05/13/25 at approximately 3:15 P.M. with CNA #530 revealed she was providing incontinence care for Resident #19 at the time of his fall on 01/30/25. CNA #530 stated she had often previously provided incontinence care to Resident #19 and the resident was able to roll himself over in bed independently. CNA #530 stated she was walking around the foot of the bed while Resident #19 rolled himself over and rolled off the bed on 01/30/25. Interview on 05/14/25 at 9:32 A.M. with the Director of Nursing (DON), during concurrent review of Resident #19's medical record, confirmed Resident #19's MDS assessment dated [DATE] revealed the resident required substantial/maximal assistance for bed mobility. The DON stated substantial/maximal assistance meant staff would provide hands-on assistance as needed, and ensure the resident rolled toward the staff while he/she stood at the edge of the side of the bed. Review of the policy, Activities of Daily Living (ADL), Supporting, revised April 2025, defined substantial/maximal assistance - if the helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2. Review of the comprehensive annual MDS assessment, dated 01/31/25, revealed Resident #19 had impaired cognition and was dependent for toileting, and required substantial/maximal assistance for bed mobility. Further review revealed Resident #19 had one fall with a non-major injury since the previous assessment. Review of the fall risk observation (assessment) document, completed 01/30/25, revealed Resident #19 was at high risk for falls. Review of the current care plan, initiated 02/26/24, revealed Resident #19 was at risk for falls due to impaired balance, impaired mobility, and incontinence. An intervention added on 01/31/25 revealed Resident #19 required two staff assistance for bed mobility. Further review of the care plan revealed Resident #19 had an ADL self-care deficit related to impaired balance and limited mobility. Review of an intervention added 01/31/25 revealed resident #19 required extensive assistance of two people for bed mobility, including rolling to left and right. An intervention added 05/12/25 revealed Resident #19 required assistance of two people for toileting. Observation on 05/12/25 at 3:51 P.M. revealed Resident #19's call light was on. Concurrent interview with Resident #19 revealed he needed to be changed. Observation on 05/12/25 at 3:56 P.M. revealed CNA #495 entered Resident #19's room alone and closed the door. Observation on 05/12/25 at approximately 4:02 P.M. revealed CNA #495 exited Resident #19's room with a bag of soiled items. Interview on 05/12/25 at 4:04 P.M. with CNA #495 confirmed she provided incontinence care to Resident #19 by herself. CNA #495 stated Resident #19 could roll himself over in bed and CNA #495 was not aware Resident #19 required two staff to be present during incontinence care. Interview on 05/12/25 at 4:11 P.M. with Licensed Practical Nurse Unit Manager (LPN UM) #475, during concurrent review of Resident #19's care plan, confirmed two staff members should assist Resident #19 while he received incontinence care. Review of the policy titled, Falls - Clinical Protocol, revised March 2018, revealed the facility will identify pertinent interventions to try to prevent subsequent falls.

Based on observation, medical record review, and staff interview, the facility failed to ensure call lights were within reach for one (#43) of four residents reviewed for call light accessibility. The census was 81. Findings include: Review of the medical record for Resident #43 revealed an admission date of 06/14/24. Diagnoses included venous insufficiency, multiple sclerosis, and osteoporosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 was cognitively intact, dependent for toileting, showering/bathing, upper body dressing, lower body dressing, and required substantial/maximal assistance for personal hygiene. Observation on 05/12/25 at 10:26 A.M. revealed the call light laying on the floor beside Resident #43's bed. Interview with Certified Nurse Aide (CNA) #449 on 05/12/25 at 10:47 A.M. verified Resident #43's call light was lying on the floor out of the resident's reach. Observation on 05/12/25 at 10:48 A.M. revealed CNA #492 attached the call light to Resident #43's bed sheet near her right arm. Resident #43 attempted to grab the call light and could not reach it. Interview with CNA #492 on 05/12/25 at 10:58 A.M. verified she placed the call light on the bed sheet in an area that Resident #43 could not reach.

Based on observation, medical record review, resident interview, and staff interview, the facility failed to maintain a clean environment. This affected two (6 and #49) of four residents reviewed for physical environment. The facility census was 81. Findings include: 1. Review of the medical record for Resident #6 revealed an admission date of 04/14/25. Diagnoses included acute kidney failure, asthma, hypertensive heart and chronic kidney disease, type II diabetes, and anxiety. Review of the admission Minimum Data Set (MDS) assessment completed on 04/21/25 revealed Resident #6 was cognitively intact. Observation on 05/12/25 at 9:45 A.M. of Resident #6's room revealed a cup with popcorn coming out of it all over the floor. Observation and interview on 05/12/25 at 1:43 P.M. of Resident #6's room revealed the popcorn remained on the floor. Resident #6 stated the popcorn on the floor bothered her and she would like it to be cleaned up. Interview with Licensed Practical Nurse (LPN) Manager #475 on 05/12/25 at 1:52 P.M. verified the popcorn on the floor in Resident #6's room. 2. Review of the medical record for Resident #49 revealed an admission date of 09/04/21. Diagnoses include hypertensive chronic kidney disease, iron deficiency anemia secondary to blood loss, anxiety, major depressive disorder, and weakness. Review of the quarterly MDS assessment dated [DATE] revealed Resident #49 was cognitively intact. Observation on 05/12/25 at 12:04 P.M. revealed the floor in Resident #49's room was sticky. Observation on 05/12/25 at 1:46 P.M. revealed bloody tissues, a mustard packet, a cotton swab, and pieces of pretzels on the floor. The floor in Resident #49's room remained sticky. Concurrent interview with Resident #49 stated it bothered him that his guests would see the trash on the floor and feel the stickiness. Interview with LPN Manager #475 on 05/12/25 at 1:54 P.M. verified the trash on Resident #49's floor and verified the floor was also sticky.

Based on medical record review, staff interview, and policy review, the facility failed to ensure residents who received psychotropic medications were monitored for behaviors, adverse effects, and efficacy. This affected one (#24) of five residents reviewed for psychotropic medications. The facility census was 81. Findings include: Review of the medical record revealed Resident #24 was admitted to the facility on [DATE]. Diagnoses included anxiety, depression, and hypertension. Review of the plan of care dated 03/24/25 revealed Resident #24 received antidepressant medication. Interventions included monitoring and documenting side effects and effectiveness. Review of the plan of care dated 03/24/25 revealed Resident #24 received antianxiety medication. Interventions included monitoring and documenting side effects and effectiveness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 was cognitively intact. The resident received antianxiety and antidepressant medication. Review of Resident #24's active physician orders for May 2025 identified an order for desvenlafaxine (antidepressant medication) extended-release oral tablet with instructions for one tablet by mouth one time per day for depression; and an order for buspirone (antianxiety medication) oral tablet with instructions for one tablet by mouth three times per day for anxiety. Review of Resident #24's medication administration records (MARs) for March, April, and May 2025 revealed the resident received buspirone three times per day from 03/06/25 through 04/06/25, 04/08/25 through 04/21/25, 04/23/25 through 04/27/25, and 05/01/25 through 05/11/25. In addition, the resident received desvenlafaxine daily from 03/06/25 through 04/21/25, 04/23/25 through 04/27/25, and 05/02/25 through 05/11/25. Review of the medical record revealed no evidence Resident #24 was monitored for behaviors between 03/06/25 through 04/03/25. In addition, there was no evidence the resident was ever monitored for efficacy and adverse consequences related to antidepressant and antianxiety medication. Interview on 05/15/25 at 11:14 A.M. with the Administrator verified Resident #24 received psychotropic medication and there was no evidence of monitoring for efficacy and adverse consequences. The Administrator also verified there was no evidence of monitoring for behaviors unit 04/03/25. Review of the facility policy titled, Psychotropic Medication Use, revised February 2025, revealed residents who received psychotropic medications would be monitored for adverse consequences. Review of the facility policy titled, Behavioral Assessment, Intervention, and Monitoring, revised February 2025, revealed if psychotropic medications were used to treat behavioral symptoms, the interdisciplinary team would monitor side effects and adverse consequences related to psychotropic medications.

Based on observation, medical record review, and staff interview, the facility failed to provide ongoing assistance and coordination, with resident involvement, in developing discharge goals and plans for discharge. This affected one (#62) of one residents reviewed for discharges in a facility census of 81. Findings include: Review of the medical record revealed Resident #62 admitted to the facility on [DATE] with diagnoses including atrial fibrillation, venous insufficiency, segmental and somatic dysfunction of the lower extremity, major depressive disorder, hypertension, dysphagia, and right artificial hip joint. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was assessed with intact cognition, utilized a wheelchair for mobility, was independent with activities of daily living, was occasionally incontinent of bladder and was continent of bowel, and assessed at risk for pressure ulcer development with no skin breakdown. Review of Resident #62's social service admission assessment dated [DATE] revealed a documented discharge goal to return home. Review of Resident #62's interdisciplinary discharge planning update document dated 11/14/23 noted Resident #62 goal to return home. Review of the medical record revealed a nursing plan of care dated 02/02/24 which documented Resident #62 was anticipated to remain as permanent resident. Review of a social service quarterly assessment dated [DATE] noted Resident #62 planned to return to the community and listed an address. Review of Resident #62's physical therapy Discharge summary dated [DATE] noted the resident's discharge destination as long-term care setting due to his highest practical level achieved. Discharge recommendations included an assistive device for safe functional mobility and elevated toilet seat/three in one commode. The prognosis to maintain current level of function was determined as excellent with consistent staff support. There were no further instructions to staff documented and no documentation contained in the medical record included Resident #62 was informed long-term placement was recommended. On 05/13/25 at 10:04 A.M. interview with Resident #62, during observation, noted the resident in bed and alert. Resident #62 stated 06/01/25 was the last day he could return to his apartment and wanted to return home. Resident #62 stated he was never informed he was going to remain in the facility long-term and had limited contact with social services related to discharge planning. On 05/13/25 at 2:57 P.M. interview with Licensed Social Worker (LSW) #425 revealed, when assuming role of LSW in April 2024, she was told Resident #62 was staying in the facility under long-term care. Approximately two weeks prior (the end April 2025), LSW #425 was informed by Resident #62 he wanted to transition to the community and the resident had an apartment being held since admission to the facility. LSW #425 proceeded to refer Resident #62 to therapy services and confirmed the medical record lacked documentation indicating Resident #62 was involved or updated regarding potential discharge from the facility. Observation and interview on 05/14/25 at 12:15 P.M. noted Resident #62 independently seated in a wheelchair in his bathroom completing activities of daily living independently. The resident was dressed and groomed, and stated he was preparing for a therapy session and working to get stronger before discharge from facility.

Based on medical record review, review of the hospital medical records, staff and resident interview, review of a text message correspondence, and policy review, the facility failed to ensure a resident was free from an avoidable fall during incontinence care. This resulted in Actual Harm when Resident #26 fell out of bed and sustained a right leg fracture during incontinence care, when staff used improper techniques and had not utilized the assessed number of staff for bed mobility. This affected one resident (#26) out of three residents reviewed for accidents. The facility census was 92. Findings Include: Review of the medical record revealed Resident #26 was admitted to the facility on [DATE]. Diagnoses included [CONDITION(S)], neuromuscular dysfunction of bladder, unspecified open wound right ankle, Charcot's joint right ankle/foot, type II diabetes, [CONDITION(S)], obesity, [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #26 was cognitively intact. He required two person, extensive physical assistance for bed mobility. Review of the plan of care dated 10/12/20 revealed Resident #26 had a self care deficit. Interventions included assist with daily hygiene, grooming, dressing, oral care, and eating as needed. There was nothing specified about the extent of physical assistance that was needed for bed mobility and/or incontinence care. Resident #26 was at risk for falls and interventions included encourage to transfer and change positions slowly and provide assistance to transfer and ambulate as needed. An updated intervention dated 05/29/22 was two plus person assistance for bed mobility. Review of the progress notes dated 05/29/22 at approximately 7:15 A.M., revealed State tested Nursing Aide (STNA) #101 was performing incontinence care by herself for Resident #26. The note was not specific to the process in which STNA #101 had completed the care, however confirmed the care was done independently. During the process of changing Resident #26's brief, he rolled out of bed, landing on his right side. Resident #26 was sent to the hospital for a full evaluation, which included scans and x-rays of his body. Review of the hospital records dated 05/29/22 revealed a right nondisplaced oblique fracture proximal tibial diaphysis and one nondisplaced transverse fracture proximal fibulae shaft with marked osteopenia. Interview with Resident #26 on 07/02/22 at approximately 12:25 P.M., confirmed he fell from his bed when the aide was changing his brief. He said there was only one aide performing the task. Resident #26 said the aide rolled him toward his window, which was away from the staff person, and he fell because he had not realized how close to the edge of the bed he was. He said it was determined his right leg was fractured because of the fall. Interview with Licensed Practical Nurse (LPN) #102 on 07/02/22 at approximately 12:40 P.M., revealed she typically does not complete incontinence care with any residents by herself; the aides would take the lead and if the aide asked for assistance, she would help. LPN #102 said during care the resident should be rolled toward the staff person if they were completing the task independently. If there were two people, one staff person would be on each side of the resident's bed. Interview with STNA #101 on 07/02/22 at 2:21 P.M., confirmed she performed incontinence care and a brief change with Resident #26 by herself. She said she used the information on the kardex and thought it specified to use one person for bed mobility. She said she rolled Resident #26 away from her, toward his wall when she changed his brief. She said the proper procedure she would usually roll the person toward her, but if the person was larger and she could not reach to roll the resident toward her, she would roll them away or ask for a second staff person to help. STNA #101 would not answer why she had not asked for assistance on the day of the incident. She verified she rolled Resident #26 away from her, took his dirty brief off, and he started to fall as she was going to place the new brief on him. A text message correspondence with the Director of Nursing (DON) on 07/05/22 from 7:31 A.M. to 8:16 A.M. confirmed the kardex for Resident #26 was the same as his care plan at the time of the fall; stating the resident should be transferred with assistance as needed. There was nothing that specified bed mobility and/or how many staff should be utilized when performing bed mobility and/or incontinence care. Review of the facility policy titled Bed Positioning, dated February 2019 revealed the procedure for turning a resident from back lying to side lying includes the following: verify transfer assist needed per kardex, obtain additional assistance and needed equipment as indicated, move the person to the edge of the bed on the farthest side from you so that when they are turned, they are in the middle of the bed, position the lower extremity farthest away over the lower extremity closest to you if the resident is able, cross the resident's arms over the chest if resident is able, reach across the resident and place one hand on the resident's shoulder and the other hand on the resident's hip, gently roll the resident towards you, and support the resident's back with appropriate positioning devices. This deficiency substantiates Complaint Number OH 524

Based on medical record review, staff interview, and review of facility incident reports the facility failed to develop and implement fall interventions based on resident risk factors. This resulted in Actual Harm when Resident #01 sustained a distal femur fracture after a fall. This affected one resident (#01) of three residents reviewed for falls. In addition, the facility failed to complete fall investigations to identify and analyze resident risk factors. This affected three residents (#01, #02 and #03) of three residents reviewed for falls. The facility census was 88. Findings include: Review of the medical record revealed Resident #01 was admitted on [DATE], readmitted on [DATE], and discharged on [DATE]. Diagnoses included partial intestinal obstruction, difficulty walking, acute kidney failure, muscle wasting and atrophy, unspecified dementia, and type II diabetes. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #01 was cognitively intact, required extensive two-person assistance with bed mobility and extensive one-person assistance with dressing and toilet use. Transfers and ambulation were identified as not having occurred during the seven day look back period of the MDS. Additionally, Resident #01 was frequently incontinent of bowel and bladder. Review of the plan of care initiated 09/30/21 revealed Resident #01 was at risk for falls due to weakness. Interventions included bed in the low position, reinforce the need to call for assistance, and therapy evaluation and treatment per orders. Additional review of the plan of care revealed a fall intervention was created on 01/04/22 to offer Resident #01 to use the restroom before laying down. Review of the Admission/Re-Admission Evaluation dated 10/21/21 revealed Resident #01 was at risk for falls. Identified risk factors included incontinence, foot problems, and Resident #01 worried about falling or felt unsteady when walking. Review of a progress note dated 10/22/21 at 2:09 P.M. revealed Resident #01 was found sitting on the floor, next to the bedside, with her legs straight out in front of her. Resident #01 stated she fell coming back from the bathroom. No injury was noted and the resident was reminded to use her call light. Review of a progress note dated 11/18/21 at 3:15 A.M. revealed Resident #01 was found lying on her back, on the floor, along the bed. No injury was noted and Resident #01 stated she thought she was going to the bathroom. The resident was incontinent of urine at the time. Review of a progress note dated 12/31/21 at 10:41 P.M. revealed Resident #01 was found on the floor next to the bed. Resident #01 stated she was trying to use the restroom. Review of a progress note dated 01/02/22 at 6:55 A.M. revealed Resident #01 was yelling out from her room and was found on the floor next to her bed. Resident #01 had removed her clothes, was incontinent of urine, and complained of right knee and thigh pain. The physician ordered x-rays. Review of a nurse practitioner note dated 01/02/22 at 12:00 P.M. revealed Resident #01 was found that morning on the floor next to her bed. Resident #01 had removed her clothing because she was incontinent of urine. X-rays showed a fracture of the right distal femur (area of leg just above the knee). Resident #01 was sent to the emergency department for further evaluation. Review of a radiology report dated 01/02/22 revealed views of the right knee showed Resident #01 had a fracture of the distal femur with soft tissue swelling. Interview on 02/14/22 at 11:35 A.M. with the Director of Nursing (DON) revealed fall interventions would be included on the resident's Kardex (overview of resident care needs). The DON confirmed information on the Kardex was pulled from the plan of care and if the intervention was not in the plan of care, it would not be on the Kardex. The DON verified Resident #01's plan of care was updated on 01/04/22, two days after her fall resulting in a fractured distal femur, to offer Resident #01 to go to the bathroom before laying down. The DON stated she had verbally communicated that intervention to nursing staff on 01/01/22 but the DON verified there was no evidence this intervention was implemented or relayed to all the nursing staff. The DON verified each of Resident #01's falls involved bathroom use or episodes of incontinence and the Resident's plan of care did not include any interventions related to bathroom use or incontinence to decrease her fall risk until after Resident #01 sustained a distal femur fracture on 01/02/22. Interview on 02/14/22 at 12:15 P.M. with the Director of Rehabilitation (DOR) #208 revealed Resident #01 required moderate one person assistance with any type of sit to stand positioning and was unsteady on her feet. Additionally, speech therapy (ST) had assessed Resident #01's ability to function safely due to cognitive deficits to be less than 50% of the time. 2. Review of the medical record revealed Resident #01 was admitted on [DATE], readmitted on [DATE], and discharged on [DATE]. Diagnoses included partial intestinal obstruction, difficulty walking, acute kidney failure, muscle wasting and atrophy, unspecified dementia, and type II diabetes. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #01 was cognitively intact, required extensive two-person assistance with bed mobility and extensive one-person assistance with dressing and toilet use. Transfers and ambulation were identified as not having occurred during the seven day look back period of the MDS. Additionally, Resident #01 was frequently incontinent of bowel and bladder. Review of the plan of care initiated 09/30/21 revealed Resident #01 was at risk for falls due to weakness. Interventions included bed in low position, reinforce need to call for assistance, and therapy evaluation and treatment per orders. Additional review of the plan of care revealed a fall intervention was created on 01/04/22 to offer Resident #01 to use the restroom before laying down. Review of the Admission/Re-Admission Evaluation dated 10/21/21 revealed Resident #01 was at risk for falls. Identified risk factors included incontinence, foot problems, and Resident #01 worried about falling or felt unsteady when walking. Review of progress notes from 09/30/21 through 01/02/22 revealed Resident #01 had falls on 10/22/21, 11/18/21, 12/31/21, and 01/02/22. Review of facility incident reports dated 10/22/21, 11/18/21, 12/31/21, and 01/02/22 confirmed Resident #01's falls. The incident reports had no documented fall investigations. 3. Review of the medical record for Resident #02 revealed an admitted [DATE] and a readmitted [DATE]. Diagnoses included pneumonia, type II diabetes, [CONDITION(S)] ([CONDITION(S)]), muscle wasting and atrophy, difficulty walking, unspecified dementia, heart failure, weakness, and hypertension. Review of the Quarterly MDS dated [DATE] revealed Resident #02 was moderately cognitively impaired and required extensive one person assistance with transfers, bed mobility, dressing, toilet use, and was frequently incontinent of bowel and bladder. Review of the plan of care initiated 12/03/21 revealed Resident #02 was at risk for falls due to weakness, previous falls, and [CONDITION(S)]. Interventions included administer medications as ordered, bed in low position, encourage to transfer and change positions slowly, have commonly used articles within easy reach, offer to use the restroom before laying down, assist to transfer and ambulate as needed, reinforce need to call for assistance, reinforce wheelchair safety as needed such as locking brakes, and visual reminder to use call light. Review of the Admission/Re-Admission Evaluation dated 12/02/21 revealed Resident #02 was at risk for falls. Risk factors included problems with her heart rate and incontinence. Review of progress notes dated 01/08/22 through 02/12/22 revealed Resident #02 had falls on 01/08/22, 01/25/22, 01/29/22, and 01/30/22. Review of facility incident reports confirmed Resident #02's falls. The incident reports had no documented fall investigations. 4. Review of the medical record revealed Resident #03 was admitted on [DATE]. Diagnoses included displaced fracture of right tibia, type II diabetes, muscle wasting and atrophy, repeated falls, and hypertension. Review of the Admission MDS dated [DATE] revealed Resident #03 was cognitively intact and required extensive assistance with bed mobility, transfers, and toilet use and had a history of falls. Review of the plan of care dated 11/05/21 revealed Resident #03 was at risk for falls due to impaired balance, poor coordination, unsteady gait, fracture, recent falls. Interventions included administer medications as ordered, encourage to transfer and change positions slowly, and keep commonly used articles within easy reach. Review of the Admission/Re-Admission Evaluation dated 11/05/21 revealed Resident #03 had no fall risks. Review of progress notes from 01/01/22 through 02/12/22 revealed Resident #03 had a fall on 02/11/22. Review of the facility incident report confirmed Resident #03's fall on 02/11/22. The incident report had no documented fall investigation. Interview on 02/14/22 at 11:35 A.M. with the Director of Nursing (DON) revealed the facility completed incident reports on each fall and the falls were discussed at a daily team meeting, but the facility did not complete fall investigations to assist with determining needed interventions. The DON verified there was no evidence a fall investigation was completed for each of the falls sustained by Residents #01, #02, and #03. This deficiency substantiates Complaint Number OH 759.

Based on medical record review, staff interview, policy review and review of information from the American Diabetes Association, the facility failed to monitor a diabetic resident (#107) who was experiencing [DIAGNOSES REDACTED] (low blood sugar). This resulted in actual harm when Resident #107 was not monitored according to physician orders related to [DIAGNOSES REDACTED], subsequently suffered a fall, and was hospitalized for [REDACTED].#107) out of two residents reviewed for hospitalization . The facility identified 28 residents with a [DIAGNOSES REDACTED]. Findings include: Review of medical record for Resident #107 revealed she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the admission plan of care revealed Resident #107 had a focus area that she was on insulin related to diabetes. The goal was to be free of insulin side effects. Interventions included to monitor blood sugar and laboratory results as ordered by physician and to monitor for signs and symptoms of [DIAGNOSES REDACTED]. Report to the physician as indicated. Review of the physician orders revealed upon admission on 09/17/18 Resident #107 had an order for [REDACTED]. Another insulin order dated 09/19/18 was for Humalog insulin, inject subcutaneously as per sliding scale. The sliding scale indicated if the resident's blood sugar is: 151 to 200 inject two units; 201 to 250 inject four units; 251 to 300 inject six units; 301 to 350 inject eight units; 351 to 400 inject 10 units, before meals and at bedtime. Review of the physician orders revealed other diabetic orders included: 1. If resident's blood sugar (BS) is less than 60 (and the resident is alert) give milk, orange or apple juice. Call the physician, recheck the BS in 15 minutes and chart as needed. If resident's BS is less than 50 (and the resident is alert) give one or two insta-glucose gels orally and call the physician. Monitor BS until within acceptable range (greater than 70) and chart. 2. [MEDICATION NAME] HypoKit Solution one milligram (mg), inject one mg intramuscularly (IM) as needed for [DIAGNOSES REDACTED] related to diabetes. If resident's BS is less than 60 (and the resident is not alert) give one mg IM. Call the physician. Recheck BS in 15 minutes and chart AND if BS less than 50 (and the resident is not alert) give one mg IM. Call the physician. Monitor BS until it is within acceptable range of greater than 70 and chart, ordered on [DATE]. Review of the nurse progress notes dated 09/19/18 revealed at 3:53 P.M. Resident #107 was alert and her skin was warm and dry. She was given two peanut butter and jelly sandwiches with two oranges. The nurse will recheck her BS a while after she was done eating. At 5:16 P.M. the physician was notified Resident #107's BS was 51, that she was fed and her blood sugar was rechecked and was 73. Resident #107 was asymptomatic, and no new orders were received. At 7:59 P.M. Resident #107 was too lethargic to eat. One tube of glucose was given by mouth. At 8:08 P.M. Resident #107's scheduled 70/30 insulin was held for her BS of 47. At 9:01 P.M. Resident #107 was observed on the floor beside her bed. She had no injuries noted. She was assisted back into bed by three staff. Resident #107 was very lethargic, her lungs had rales throughout. Her blood sugar was 32. Glucogen was given IM at her left thigh. Resident #107 was diaphoretic. At 9:03 P.M. the physician was called, informed of her fall without injuries and informed of her blood sugar of 47 which was treated with oral glucose. The physician was informed that her blood sugar was rechecked and found to be 32 for which she was treated with IM glucogen, that her lungs had rales throughout and Resident #107 was diaphoretic and very lethargic. The physician ordered for transport obtained to the emergency room . All of the notes were signed by Registered Nurse (RN) #663. Further review of the electronic medical record revealed the following documented BS readings for Resident #107: 09/19/18 at 8:04 A.M. BS reading of 130; 09/19/18 at 11:28 A.M. BS reading of 169; 09/19/18 at 3:53 P.M. BS reading of 51; 09/19/18 at 5:05 P.M. BS reading of 73; 09/19/18 at 8:08 P.M. BS reading of 47; 09/19/18 at 9:16 P.M. BS reading of 32; 09/19/18 at 9:43 P.M. BS reading of 82. Review of the Acute Care Transfer form dated 09/19/18 at 9:17 P.M. revealed Resident #107 had an unplanned transfer to an acute care hospital for blood sugar of 32, lungs with rales throughout and a fall from her bed. Resident #107 was lethargic at the time of the transfer. Further review of the nurses notes revealed on 09/19/18 at 9:51 P.M. a second dose of IM glucogen was given per the physician order. Signed by RN #663. At 9:52 P.M. Resident #107 was transported to ER per squad (EMS.) Signed by RN #663. On 09/20/18 at 6:28 A.M. the note revealed Resident #107 was being admitted to the hospital for [DIAGNOSES REDACTED]. Review of the hospital records for Resident #107 dated 09/19/18 to 09/20/18 revealed she was seen in the emergency room for [DIAGNOSES REDACTED]. Her blood sugar was as low as 27 at 1:56 A.M. on 09/20/18. She was admitted to the hospital for further monitoring and evaluation of her [DIAGNOSES REDACTED]. Interview with Director of Nursing (DON) on 12/06/18 at 8:08 A.M. she verified Resident #107 experienced [DIAGNOSES REDACTED] on 09/19/18 at supper time and at bedtime accuchecks. The DON verified RN #663 did not follow the physician orders to check/recheck Resident #107's blood sugars every fifteen minutes and/or until her blood sugar was greater than 70. The DON verified per the progress notes, Resident #107 was left unattended during her two hypoglycemic events. The DON verified Resident #107 was hypoglycemic at 7:59 P.M. with a BS of 47 and was not rechecked until she was found on the floor in her room at 9:15 P.M. with a blood sugar of 32, a time-frame of one hour and fifteen minutes. The DON verified when Resident #107 was on the floor in her room she was to lethargic to take anything by mouth and required the administration of two doses of glucogen via injection and that Resident #107 was transported to the emergency room (ER) for evaluation and treatment of [REDACTED].#107 was admitted to the hospital and did not return to the facility. Interview by phone on 12/06/18 at 9:09 AM with RN #663 she verified she had previously worked at the facility. RN #663 denied remembering Resident #107. RN #663 denied remembering any hypoglycemic event or sending Resident #107 to the ER for [DIAGNOSES REDACTED]. Interview with Licensed Practical Nurse (LPN) #450 on 12/06/18 at 8:32 A.M. verified for a resident with [DIAGNOSES REDACTED] she would recheck the BS often and per the physician order. She stated she would keep a close eye on the resident. Interview with RN #460 on 12/06/18 at 8:41 A.M. verified low blood sugars should be rechecked per physician orders and recheck in 15 minutes. RN #460 stated she would continue to monitor low blood sugars every 15-20 minutes until the resident was stable. Interview with RN, Unit Manager (UN) #290 on 12/06/18 at 3:45 P.M. verified there was a facility policy to monitor residents during a hypoglycemic event which included to follow physician orders and repeat finger stick as ordered per physician, usually every 15 minutes during a hypoglycemic event. For a resident is symptomatic or severely hypoglycemic, to not leave the resident unattended and monitor the blood sugar levels every ten minutes until with acceptable range. Review of the facility policy titled [DIAGNOSES REDACTED]: Treatment dated 12/2009 revealed the purpose was to describe treatment to increase blood sugar as soon as possible. For BS less than 60 and the resident is asymptomatic, follow physician orders at provide treatment such as milk, orange or apple juice or glucose orally. Repeat finger stick as ordered per physician usually every 15 minutes. For blood sugar less than 50 and resident is symptomatic or severely hypoglycemic, repeat the finger stick. Monitor vital signs every five to 15 minutes until stable. Do not leave the resident unattended. Monitor the blood sugar levels every 10 minutes until with acceptable range. Review of information from the American Diabetes Association revealed a normal blood glucose range is between 70 and 99.

Based on medical record review, staff interviews, and review of facility policies, the facility failed to ensure accurate medication reconciliation upon a resident's admission, resulting in significant medication errors involving the resident's [MEDICAL CONDITION] medications. This resulted in actual harm when Resident #10 did not receive her [MEDICAL CONDITION] medications as ordered by the neurologist and began having breakthrough [MEDICAL CONDITION] activity, resulting in hospitalization . This affected one (Resident #10) of three residents reviewed for medication reconciliation. The facility census was 103. Findings include: Review of Resident #10's medical record revealed she was admitted to the facility on [DATE]. Medical [DIAGNOSES REDACTED]. Review of the resident's admission Minimum Data Set (MDS) assessment revealed the resident had no impairment in cognition and no rejection of care. Review of the resident's admission history and physical from the hospital dated 03/17/18 revealed the resident was taking [MEDICATION NAME] ([MEDICATION NAME] acid) 750 milligrams (mg) three times daily (tid), Onfi 10 mg twice daily, [MEDICATION NAME] 200 mg twice a day (bid), and [MEDICATION NAME] 1000 mg bid to treat her [MEDICAL CONDITION] upon her admission to the hospital. Review of the nursing admission note dated 03/31/18 at 7:41 P.M. revealed Registered Nurse (RN) #53 called the physician and informed him of the resident's admission and medications were verified. Review of the resident's admission orders [REDACTED]. The orders were signed by Certified Nurse Practitioner (CNP) #80 on 04/03/18. Review of the resident's hospital discharge summary dated 03/31/18 revealed a fax date of 04/01/18 at 4:19 P.M., which revealed the resident had been hospitalized from [DATE] through 03/31/18 for breakthrough [MEDICAL CONDITION], urinary tract infection, dysphagia, vitamin K deficiency, [MEDICAL CONDITION], and elevated ammonia. It was documented the hospital neurologist made changes to the resident's [MEDICAL CONDITION] medications during the hospitalization as the [MEDICATION NAME] was found to be interacting with the resident's platelets. Her elevated ammonia level was documented as likely due to the [MEDICATION NAME] and therefore it was discontinued. Her discharge [MEDICAL CONDITION] medications included Onfi 10 mg bid, [MEDICATION NAME] 200 mg bid, [MEDICATION NAME] 1500 mg bid, and [MEDICATION NAME] 25 mg daily for one week, then starting 04/07/18 increase to 25 mg twice daily. The documentation explained the physician added [MEDICATION NAME], although they were aware [MEDICATION NAME] caused the resident to experience dizziness. It was documented they were currently limited with treatment options for the resident and this was the best option for her. Review of the resident's facility admission history and physical completed on 04/01/18 by CNP #80 revealed the resident presented to the hospital as a transfer from a different skilled nursing facility due to reported prolonged period of unresponsiveness and staring while at the skilled nursing facility with concerns for possible [MEDICAL CONDITION]. CNP #80 documented to continue the present medication regimen. Review of the resident's laboratory results revealed an ammonia level of 40 (normal 11-51 umol/L) on 04/04/18. On 04/05/18, the resident's ammonia level had increased to 59. On 04/16/18, the resident had an ammonia level of 53. Review of the nursing notes revealed the resident began experiencing [MEDICAL CONDITION] activity at the facility on 04/05/18. She continued to have further [MEDICAL CONDITION] activity on 04/06/18, 04/07/18, 04/09/18, 04/10/18, 04/11/18, 04/12/18, 04/13/18, two episodes on 04/14/18, two episodes on 04/15/18, 04/16/18, two episodes on 04/18/18, and 04/20/18. Review of the physician's orders [REDACTED]. The resident's [MEDICATION NAME] dosage was increased to 1,250 mg twice daily, she remained on the original doses of Onfi, [MEDICATION NAME], and [MEDICATION NAME], and was never placed on [MEDICATION NAME]. Continued review of the resident's medical record revealed [REDACTED]. She was sent to the emergency room during the appointment when she experienced [MEDICAL CONDITION] activity and was admitted to the hospital. Review of the resident's hospital history and physical dated 04/20/18 revealed the resident presented to the emergency room from the neurologist's office with chief complaint of breakthrough [MEDICAL CONDITION]/staring spells. The resident was residing at the skilled nursing facility for the last three weeks. She was discharged at the end of (MONTH) (YEAR) from the hospital neurology service on [MEDICATION NAME] 200 mg bid, [MEDICATION NAME] 1500 mg bid, [MEDICATION NAME] 25 mg daily, and Onfi 10 mg bid. The resident was doing well for a few days, but started having staring episodes [MEDICATION NAME] five to twenty minutes, and lately multiple episodes daily. After confirmation, it was determined the resident was on [MEDICATION NAME] 200 mg bid, [MEDICATION NAME] 1250 mg bid, Onfi 10 mg bid, and [MEDICATION NAME] (which she was weaned off at the last hospitalization due to hyperammonemia, somnolence and nonalcoholic [MEDICAL CONDITION] (NASH). She presented with an increased ammonia level of 38 (normal 11-35 umol/L). The resident's [DIAGNOSES REDACTED]. She would be weaned back off the [MEDICATION NAME]. [MEDICATION NAME] 25 mg once daily would be restarted. [MEDICATION NAME] dosage would be corrected to 1500 mg bid. The resident was discharged home on[DATE]. Interview with Registered Nurse (RN) #53 on 05/08/18 at 4:50 P.M. revealed she had not received the resident's hospital discharge summary which contained the discharge orders when she admitted the resident on 03/31/18. She stated she only had the hospital admission history and physical which was dated 03/17/18 and verified that was where she obtained the orders for the admission to the nursing facility. She verified she did not call the hospital to request the resident's discharge summary or orders and gave the physcian the incorrect orders for verification upon the residents admission. Interview with CNP #80 on 05/10/18 at 10:05 A.M. verified she signed Resident #10's admission orders [REDACTED]. CNP #80 verified she should have reviewed the discharge summary prior to signing the admission orders [REDACTED]. She also verified the discharge recommendation for [MEDICATION NAME] were not followed. Review of a facility policy titled admitted d 12/09 revealed the purpose was to prepare for and admit a resident to center in a manner that reduced anxieties/fears and obtains necessary clinical information. Procedures included notify physician of admission and obtain or verify orders. Review of a facility policy titled Medication Reconciliation dated 11/16 revealed medication reconciliation was a process for creating a complete and accurate list of a patient's current medications at admission and with each transition of care to ensure medication safety. Medication reconciliation included prescription medications, over-the-counter medications, herbal/naturopathic, vitamins, supplements, home remedies. Medication reconciliation required communication and collaboration between health care providers along the continuum of care. Medication reconciliation assisted in the identification of therapeutic duplications, high risk/problem prone medications due to potential risks or drug/drug interactions. At admission: Review medication list obtained from referral source (hospital, other SNF, assisted living facility, independent living facility, home list). Identify medications that were discontinued at the time of transfer to the skilled nursing facility. Identify medications that patient reports to have been taking prior to admission from referring facility. Review discrepancies with admitting attending physician for disposition and reconciliation; document others in the patient's clinical record. This deficiency substantiates Complaint Number OH 597.

Based on surveyor observations, medical record review, resident and staff interviews and review of facility policy, it was determined the facility failed to assess and provide physician ordered preventative skin treatments for one resident (#14). This resulted in actual harm when Resident #14 developed two unstageable pressure ulcers to the left foot. This affected one (#14) of three residents reviewed for skin integrity and the care of pressure ulcers of a total of seven residents currently identified with pressure ulcers. The facility census was 117. Findings include: Review of Resident #14's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident required the extensive assist of two persons for activities of daily living. The resident was assessed to be at risk for the development of pressure ulcers and had two Stage II pressure ulcers and one surgical wound. The assessment also indicated the resident had pressure relieving devices in his chair and bed and was on a turn and repositioning schedule. Review of the resident's current wound grid tracking forms revealed the resident had no skin impairments to the heels. Review of the Resident #14's monthly physician's orders [REDACTED]. The order also directs staff to complete a head to toe assessment daily checking all of the resident's bony prominences. Resident #14's at risk for alteration in skin integrity care plan, dated 05/11/11, related to left hip decubitus, [MEDICAL CONDITIONS] bladder, supra pubic catheter, incontinence, impaired mobility, on-going brown skin patches to bilateral thighs, lower extremities and posterior thighs and bilateral feet, bilateral finger tips red and right buttock pressure ulcer was reviewed. The care plan noted a goal for the skin to remain intact, free from further [DIAGNOSES REDACTED], breakdown, excoriation, or bruising until next review. Interventions included to administer preventive treatment as ordered by the physician, apply moisturizers to skin as needed and barrier cream to perineal area as needed, chair cushion, encourage and assist to reposition as needed based upon resident's needs, notify the physician and significant other of any change in skin condition, provide education to family/resident, provide preventative skin care routinely and as needed and use pillows/positioning devices as needed. On 06/22/11 at 8:18 A.M., Resident #14 was observed resting in bed. There was a low air loss mattress in place. The resident's feet were observed lying directly on the bed with a pinkish drainage noted on the sheet by the left foot area. There were no pillows under the resident's legs to elevate his heels or feet off of the bed. On 06/22/11 at 9:21 A.M., during a dressing change of the left hip wound, the resident's left lateral heel was observed to have a dark scab with an open area seeping. The left lateral small toe was also observed to have a scabbed area. Review of Registered Nurse (RN) #60's, the facility's wound nurse, progress note dated 06/22/11 revealed Resident #14's left heel had new skin breakdown. The area was a suspected pressure area after 06/20/11. The fifth lateral toe also had a scabbed area with no inflammation. Interview with RN #60 on 06/22/11 at 10:00 A.M., verified she was unaware of the pressure areas to Resident #14's left heel and toe until 06/22/11. RN #60 measured the areas. The left heel area was identified as an unstageable pressure ulcer that measured 1.0 centimeter (cm) by 2.0 cm with an undetermined depth. The left little toe measured 0.5 cm in diameter with a dark scab and an undetermined depth. Observation of Resident #14, with the Director of Nursing (DON) present, on 06/22/11 at 10:05 A.M. revealed the resident lying in bed with his lower legs up on a pillow but his heels were resting directly on the bed. The DON verified that even with the pillows in place, the resident's heels were not elevated off the bed. The DON also verified staff was to apply a physician ordered skin prep to the resident's heels at 6:00 A.M. and 9:00 P.M. and that the 3:00 P.M. to 11:00 P.M. shift was to complete a head to toe assessment daily. Interview with Resident #14 at 10:20 A.M. revealed he had complaints of left foot tenderness but thought it was from the shoes he wore out to his doctor's appointment on Monday, 06/20/11. The resident stated he was not repositioned the whole time he was out of the facility. He also indicated that when he wears shoes, they hurt his feet. Interview with the Certified Nurse Practitioner (CNP) #12 on 06/22/11 at 10:55 A.M. verified the areas to Resident #14's left foot have not been present for a long time. CNP #12 stated the resident told her that he went out to a doctor's appointment on Monday and that he had worn shoes and was not repositioned while he was there. CNP #12 indicated the resident has legs tremors and his feet lay outward. By Monday night, 06/20/11, CNP #12 believed the areas were probably red and pinpoint but then increased over time to where it is today. Further review of the medical record, specifically the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. In addition, there was no documented evidence of the resident's skin condition, specifically his feet, from 06/20/11 until 06/22/11 when the two unstageable pressure areas were identified. Telephone interview with Licensed Practical Nurse (LPN) #70 on 06/23/11 at 9:40 A.M. revealed Resident #14 requested Tylenol at 3:00 A.M. on 06/21/11, Tuesday morning, for generalized pain. She stated she just turned on the resident's bathroom light, not the main room lights, so she did not wake up the roommate. LPN #70 indicated Resident #14 told her she could apply the skin prep on his heels. LPN #70 stated his heels appeared the normal reddish, purple color. LPN #70 verified the resident has foot drop and that his feet rest directly on the bed. Interview with LPN #71 on 06/23/11 at 9:46 A.M. verified she worked 06/21/11 on the second shift. She verified she did not complete a head to toe assessment on Resident #14 and did not apply the physician ordered skin prep because the resident was up in the chair the whole shift. Review of the facility's skin policy dated July 2008 revealed residents with pressure ulcers have a head to toe skin evaluation completed daily by the licensed nurse to identify additional skin changes.