Every finding on record at Warren Barr Oak Lawn

Based on observation, interview, and record review, the facility failed to ensure that call lights were consistently within reach of residents (R23, R150, R64) and failed to ensure that wheelchairs were available for residents (R112 & R143) who were assessed to require them for mobility. This affected five residents (R23, R64, R150, R112, and R143) reviewed for accommodation of needs on the total sample of 43. Findings include: 1.On 4/14/26 at 10:05 AM, R23 was observed lying in bed. R23's call light cord was observed clipped to the cord at the wall. Call light was not within reach. On 4/14/26 at 10:30 AM, R150 was observed sitting in wheelchair next to bed. R150's call light cord was observed in-between R150's headboard and mattress and dangling three inches above the floor. Call light was not within reach. On 4/14/26 at 10:12am, R64 was assessed to be alert and oriented to person, place and time, and was observed in bed, with his call light cord wrapped around the hand sanitizer container which was attached to the wall behind R64's bed above his nightstand. R64 said, if he needed assistance, he would pull his call light, but he can't reach it now. V5 CNA (certified nurse aide) said, R64's call light is out of his reach. V5 said, the call light should be within reach for each resident. R64's care plan initiated 3/18/26 documents: keep call lights within reach when in bedroom or bathroom. Minimal data set section C (cognitive pattern) dated 3/19/26 documents a score of thirteen which indicates cognitively intact. Section GG (functional abilities) upper extremity (shoulder, elbow, wrist, hand) is coded as a one which indicates impairment on one side. R23's MDS (minimum data set), dated 1/17/26, notes R23's BIMS (brief interview of mental status) score is 6 out of 15. R23 requires maximum assistance with bed mobility and is dependent for transfers.R23's call light evaluation, dated 1/15/26, notes R23 is alert, oriented x 3 and has no limitations in one or both upper extremity. R23 is able to move upper extremity and is able to press the call light button. R150's MDS, dated [DATE], notes R150's BIMS is 14 out of 15. R150's functional limitation in range of motion notes R150 has impairment in both upper extremities. R150 requires moderate assistance with bed mobility and transfers. R150's call light evaluation, dated 3/27/26, notes R150 is alert and oriented x 3 and is able to move upper extremity and is able to press the call light button. Call light policy dated 10/26/16 documents: It is the policy of this facility to ensure that there is prompt response to the resident's call for assistance. The facility also ensures that the call system is in proper working order. Be sure call light are placed within reach of residents who are able to use it at all times. 2. R112 minimal data set dated [DATE] documents a score of fifteen which documents cognitively intact. Section GG (functional abilities) documents type of wheelchair and/or scooter: manual. On 4/14/26 at 10:46am, R112 who was alert and oriented to person, place time, said, she is supposed to get up on Tuesday and Thursday for two hours but she does not have a wheelchair to sit in. R112 said, staff takes her wheelchair out of her room for other residents. R112 did not have a wheelchair in her room. On 4/14/26 at 10:55am, V6 (cna) said, R112 refused to get up at times. V6 said, the last time she got R112 out of bed was last month. On 4/14/26 at 10:57am, V7 (restorative nurse) said, R112 was supposed to get up to the wheelchair on Tuesday and Thursday. V7 said, R112 does not have a facility issued wheelchair. V7 said, if another resident needs a wheelchair, we will use R112 and give it to another resident. On 4/16/26 at 9:31am, V24 (director of physical therapy) said, R112 get up on certain days but the days R112 is not up out of bed the wheelchair that she used is shared with another residents who has the different get up days. V24 said, we have four wheelchairs in therapy that are different sizes so we can ensure residents are able to transport to therapy. Those four wheelchairs are for therapy only. R143 was admitted on [DATE] with hemiplegia and hemiparesis following nontraumatic intracerebral 03/08/2026 primary hemorrhage affecting right dominant side, pulmonary embolism without acute pulmonale, acute embolism and thrombosis of right peroneal vein, and aphasia following cerebral infarction. R143 brief interview for mental status dated 3/30/26 score 14/15 which indicates cognitively intact. R143's physical therapy notes dated 3/20/26 documents wheelchair used. R143's physician orders dated 3/30/36 documents: physical therapy wheelchair management. On 4/14/26 at 11:49AM, R143 who was alert and oriented at time of interview said she would like to get up out of bed. R143 said they don't always have a wheelchair for her to go in and she has to stay in bed. There was no wheelchair observed in R143 room at time of interview. On 4/14/26 11:51AM, V26 (CNA) said there was no wheelchair in the room for R143 and that is a common problem. It is hard to find wheelchairs for residents and staff have to borrow or look for wheelchairs for residents to get out of bed. On 4/16/26 at 10:12AM, V27(CNA) said resident wheelchairs are hard to come by at the facility. We have more patients than wheelchairs available. We have to go find a wheelchair or borrow one from another patient. We are not always able to get the residents up out of bed because we do not have a wheelchair. This happens at least once a shift. On 4/16/26 at 1027AM, V30 (central supply) said they do not order wheelchairs. On 4/16/26 at 9:20AM, V7 (Restorative nurse) said she does not order wheelchairs. On 4/16/26 at 9:46AM, V2 (DON) said therapy is responsible for ordering wheelchairOn 4/15/26 at 3:00PM, V24 (therapy director) said they have 72 wheelchairs in the facility. V24 said the facility is in need of 20 -30 wheelchairs for all residents to have a wheelchair at this time. Staff will use other resident's wheelchairs to utilize as needed. V24 said they do not order wheelchairs unless it's a custom chair.

Failures at this level required more than one deficient practice statement:A. Based on observations, interviews, and record reviews, the facility failed to follow its infection prevention and control policy, including its COVID-19 policy. Specifically, the facility failed to place a resident with an indwelling medical device on transmission-based precautions upon admission; failed to don appropriate personal protective equipment (PPE) prior to entering an enhanced barrier precautions (EBP) resident room to provide direct care (R6); failed to place a COVID-19 positive resident in appropriate transmission-based (contact/droplet) precautions immediately upon return from the hospital and initiate the required monitoring protocol (R147); and failed to implement contact tracing for residents and staff exposed to a COVID-19 positive resident. These practices affected two residents (R6 & R147) reviewed for infection control practices on the total sample of 43.B. Based on observation, interview, and record review, the facility failed to follow accepted standards of practice for infection control. This included improper transportation of soiled linen, failure to perform appropriate hand hygiene, and failure to ensure Continuous Positive Airway Pressure (CPAP) masks were stored properly for two (R149 and R134) reviewed for infection control standards of practice on the total sample of 43. Findings include: a. 1- R6 was admitted to this facility on 3/14/26 with diagnoses including but not limited to gastrostomy tube. On 4/14/26 at 10:03 AM, there was no signage observed on R6's door or bin with PPE (personal protective equipment) next to R6's room. On 4/14/26 at 11:30 AM, V34 CNA (certified nurse aide) was observed entering a resident's room on enhanced barrier precautions to provide direct resident care. V34 did not follow the EBP signage on the door and don appropriate PPE (personal protective equipment) prior to entering resident's room and providing care. On 4/15/26 at 9:30 AM, there was no signage observed on R6's door or bin with PPE (personal protective equipment) next to R6's room. On 4/16/26 at 10:00 AM, there was no signage observed on R6's door or bin with PPE (personal protective equipment) next to R6's room. On 4/16/26 at 10:15 AM, V27 CNA (certified nurse aide) stated that he was aware R6 was on enhanced barrier precautions (EBP) this morning when he saw the signage on R6's door. On 4/16/26 at 10:20 AM, V28 (agency nurse) stated that she is aware R6 has a gastrostomy tube and is receiving bolus feedings. V28 denied being aware that R6 should be on EBP due to gastrostomy tube. On 4/16/26 at 10:35 AM, there was no signage observed on R6's door. On 4/16/26 at 9:30 AM, V12 IP nurse (infection prevention nurse) denied being aware R6 was admitted to this facility with a gastrostomy tube. V12 stated that R6 should have been placed on EBP upon admission due to having a gastrostomy tube. V12 stated that staff should don gowns and gloves when providing direct resident care to residents on EBP. On 4/17/26 at 8:55 AM, V3 ADON (assistant director of nursing) stated that the nurse is expected to initiate enhanced barrier precautions upon admission of a resident meeting the criteria for EBP, such as indwelling medical devices. R6's POS (physician order sheet) notes an order for gastrostomy bolus feedings after meals and at bedtime daily. R6's ADL (activities of daily living) care plan, initiated 3/16/26, notes R6 has an ADL self care performance deficit and impaired mobility related to limited range of motion, fatigue, activity intolerance, limited mobility, pain, physical inactivity, and cognitive impairment. The facility's infection prevention and control policy, revised 6/30/25, notes enhanced barrier precautions (EBP) is an infection control intervention designed to reduce transmission of multi-drug resistant organisms to others. It involves the use of gloves and gowns during high contact resident care activities for residents with indwelling medical devices. The facility's enhanced barrier precaution policy, revised 9/16/25, notes EBP will be used for any resident in the facility that has an indwelling medical device, such as feeding tube (gastrostomy tube), central line, urinary catheter. High contact resident care activities requiring gown and glove use among residents that trigger EBP use include, but not limited to dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use. 2. On 4/14/26 at 11:30 AM, R147 was observed in his room with his roommate. There was no signage noting contact/droplet isolation on R147's door. There was no isolation cart next to room. R147 was moved to a private room and contact/droplet isolation precautions in the afternoon on 4/14/26. On 4/15/26 at 12:40 PM, V13 CNA (certified nurse aide) stated that on 4/13, R147 was in the physical therapy gym, during exercises R147's blood pressure and oxygen saturation level dropped, R147 was brought back to his room and allowed to rest for a few minutes, upon re-check blood pressure and oxygen saturation level remained low. V13 stated that he was informed this morning, 4/15, that R147 is Covid-19 positive and he was tested. On 4/15/26 at 1:16 PM, V14 (nurse) stated that V15 (nurse) is orienting her. V14 stated that R147 returned from the hospital during her shift on 4/13. V14 denied being made aware prior to now that R147 is Covid-19 positive and that she needs to be tested. On 4/15/26 at 2:30 PM, V5 (agency CNA) stated that she worked Monday evening shift, Tuesday day shift and evening shift. V5 stated that she provided care for R147 on Monday, 4/13, as well as last week. V5 stated that she was looking for R147 yesterday to see what happened to him. V5 stated that she was not informed until yesterday during the evening shift that R147 is Covid-19 positive. V5 denied being tested as of yet. On 4/15/26 at 4:10 PM, V15 (nurse) stated that R147 was transported to the emergency room on 4/13/26 due to oxygen saturation in the 80s. V15 stated that the hospital sent R147 back to the facility without giving her report. V15 denied contacting the hospital for report. V15 stated that R147's elderly family member informed her that R147 was covid-19 negative. V15 acknowledged that she should have contacted the emergency room nurse to confirm that R147 did not have Covid-19 and diagnosis. V15 stated that she was informed today when she came to work that R147 is Covid-19 positive and she was tested. V15 stated that she worked yesterday, 4/14, evening shift and was not made aware of R147's diagnosis at that time. On 4/16/26 at 9:30 AM, V12 IP nurse stated that the discharge paperwork sent back to facility with R147 on 4/13 only noted diagnosis of hypoxia. V12 stated that on 4/14 R147's emergency room record was obtained. When it was reviewed it noted R147 is Covid-19 positive. V12 stated that yesterday afternoon R147 was moved to a private room and placed on contact and droplet isolation. V12 stated that R147's roommate was tested yesterday afternoon; rapid test was negative for Covid-19. V12 stated that the nurse and CNA assigned to R147 on 4/14 evening shift were also rapid tested, both were negative. When questioned if any other residents or staff were tested, V12 responded 'no'. The facility's Covid-19 testing tracker, dated 4/15/26, notes R61, R147's roommate was tested on [DATE], test was negative. No other residents were tested. V2 DON (director of nursing), the evening shift nurse assigned to R147 on 4/14/26, the CNA assigned to R147 on day shift 4/13, and the speech therapist were tested and negative. The physical therapist, occupational therapist, and the residents exposed to R147 in the skilled therapy gym were not tested. The facility's Covid-19 testing tracker presented on 4/17/26 notes physical therapists, the occupational therapist, V5 CNA, and V15 (nurse) were tested on [DATE]. V14 (nurse) was tested on 4/16. R147's emergency room record, dated 4/13/26, was printed on 4/14/26 at 8:26 AM. R147 tested positive for Covid-19 at 4:46 PM and was discharged back to the facility ay 8:50 PM. R147's vital sign documentation, dated 4/13/26 at 2:43 PM, notes blood pressure 120/73, heart rate 103 beats/minute, respirations 18/minute, temperature 97, and oxygen saturation level 87% on oxygen via non-rebreather mask. On 4/14/26 at 3:09 PM, R147's blood pressure was 144/76 and heart rate 103. On 4/15/26, R147's vital signs were documented once noting blood pressure 144/76 and heart rate 103. On 4/16/26 R147's vital signs were documented once, blood pressure 130/72 and heart rate 93. There are no vital signs documented per the facility's Covid policy. R147's POS (physician order sheet), dated 4/14/26 at 4:41 PM, notes an order for Isolation Precaution: Contact/Droplet - Reason for Isolation: R147 is positive for covid all services to be provided in room. Every shift until 04/24/2026 4:41 PM. There is no order found in R147's medical record noting R147 should be monitored every 4 hours for vital signs and signs/symptoms of Covid including oxygen saturation. Residents will be placed on droplet and contact isolation for 10 days from date of onset of symptoms. The facility's Covid-19 guidelines and emergency preparedness plan, revised 10/23/23, notes monitoring of residents: residents who are positive for Covid should be monitored every 4 hours for vital signs and signs/symptoms of Covid including oxygen saturation. b. 1- R149's physician order sheet dated 3/31/26-4/30/26 documents: Continuous Positive Airway Pressure (CPAP): Setting-Titrate minimum of five (5) to maximum of twenty (20) (patient brought own CPAP Machine) at bedtime apply at hour of sleep (HS) and on the morning remove in AM On 4/14/26 at 1:41pm, R149's CPAP mask was observed sitting on his nightstand with any covering/bag. On 4/14/26 at 1:51pm, V10 (nurse) said, R149's CPAP mask was on his nightstand not in a bag. V10 said, the mask should have been placed in a bag after use to prevent cross contamination. V10 said, it is unsanitary to leave the CPAP mask on the nightstand. 2- R134's brief interview for mental status dated 4/3/26 documents a score of fifteen which indicates cognitively intact. Physician order dated 4/2/26 documents: CPAP auto, setting five – ten (5-10) at bedtime on at HS; remove in morning (AM) On 4/14/26 at 10:40am, R134's CPAP mask was observed sitting on her nightstand not in a bag. R134 who was assessed to be alert and oriented to person place and time, said her mask is never put in a bag. On 4/14/26at 10:43am, V11 (nurse) said, R134's CPAP mask was on the nightstand not in a bag. V11 said, it should be in a bag to prevent cross contamination. 3 - On 4/14/26 at 10:45am V4 (agency CNA) was observed removing linen from a bed by the door of a residents room, V4 was not wearing any gloves. V4 exited that room with the bed linen, the linen was not in a bag, V4 was holding the linen against her body. V4 walked down the hall and placed the linen in a blue bag hanging from a cart. V4 said it was okay to transport the linen without a bag. V4 said the linen was not dirty and she knew this because she smelled it. V4 said she was an agency CNA and she did not receive training from the facility on transporting dirty linen, V4 said she did not receive in-service from her agency either. V4 said she did not receive training for infection control. V1 (Administrator) stated it's important that V4 receive training. Facility policy titled infection prevention and controlled dated 7/16/2025 denotes in-part staff and contract workers will be educated about current infection control practices and procedures of the facility at least annually.

Based on observation, interview and record review the facility failed to ensure residents are not verbally and mentally abused by facility staff. This affected one of three residents (R144) reviewed for staff to resident abuse on the total sample of 43. Findings include:R144 was admitted to the facility on [DATE] with a diagnosis of lumbosacral disc displacement, hyperlipidemia, hypertension and insomnia.R144 Minimum Data Set, dated [DATE] documents brief interview for mental status score was 15/15 which indicates cognitively intact.On 4/15/26 at 1:27PM, Surveyors were walking in the hallway passing R144's room and heard loud arguing. R144's door was open and surveyor observed from the hallway V42 (MDS nurse) and V43(Housekeeping director) standing around R144's bed. V42(MDS nurse) yelled in a stern, loud and dismissive tone I'm done with this and left the room. Surveyors entered R144's room, and R144 was observed in her bed crying with two open bags of her belongings near the foot of the bed. R144 was upset and continuing to cry, said she felt violated because staff were searching for her missing items and throwing her items in a disrespectful way. R144 said V42 found a pair of socks in her belonging and stated are these the items you were missing while holding the socks close to R144's face. R144 felt staff were calling her a liar and being accusatory when speaking with her about her missing items. R144 said V42 just became very disrespectful and yelled she was done with it before exiting the room with no resolution. R144 was still tearful, upset and said she was spoken to like a child. R144 said she just came here for help and she wants to get well. R144 said she cannot walk and just needs to get assistance. R138 who was alert and oriented at time of interview and was in the room at time of incident said staff were yelling and arguing to R144 like she was a child. R138 said that no residents should be talked to or treated in that way. On 4/17/26 at 11:25Am V43(housekeeping director) said she was in R144's room to follow up about a housekeeping issue, V42(MDS nurse) came in the room at that time to follow up with R144 to finish filling out concern report related to missing laundry. V43 said she asked V42 to assist with going through R144's belonging to ensure items were not in her room. R144 gave permission to both staff to go through a bag that was near her bed. The bag had a pair of socks in the bag and we asked if they were the socks which upset R144. R144 and R138 started yelling. V43 was asked if she thought the way V42 spoke to R144 was professional or if she would like her family member spoke to in that way. V43 refused to answer the question. V43 said it was a difficult situation and that they should have left the room earlier.Facility initial abuse report dated 4/15/26 documents: R144 alleges she was mistreated and disrespected by nurse helping her look for her items. R144 feels nurse was calling her a liar because she looked in residents' closet and personal bags for items reported missing.Facility Abuse and retaliation policy revised 1/29/26 documents: it is the policy of the facility to provide professional care ands services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. Abuse is willful infliction of mistreatment, injury, unreasonable confinement, intimidation or punishment. Abuse assumes intent to harm, but inadvertent or careless behavior done deliberately that results in harm may be considered abuse. Verbal abuse includes but not limited to the use of oral, written or gestured language. This definition includes communication that expresses disparaging and derogatory terms to residents within their hearing or seeing distance. Examples, name calling, swearing, yelling, threatening harm, trying to frighten the residents. Mental abuse includes but its not limited to humiliation, harassment punishment, isolation or deprivation to provoke fear of shame.

Based on interviews and record reviews, the facility failed to provide and document sufficient preparation/orientation to one resident to ensure a safe/orderly transfer from the facility to the hospital, failed to obtain a physician order for the transfer, and failed to document the transfer in the resident's medical record. This affected one resident (R130) out of three reviewed for transfer/discharge in a sample of 43. Findings include:On 4/17/26 at 8:55 AM, V3 ADON (assistant director of nursing) stated that the nurse is expected to notify the physician and resident's family of a resident's transfer to the hospital. V3 stated that the nurse is expected to follow up with the emergency room staff and call report to the nurse. V3 stated that the nurse is expected to complete an e-interact form and SBAR (situation, background, assessment, recommendation) for every resident. The nurse should also document the change in condition or reason for transfer to the hospital and the resident's vital signs in the resident's progress notes.R130's POS (physician order sheet), dated 3/9/26, notes an order for a chest x-ray related to lymphedema.There is no order found in R130's medical record to transfer R130 to the hospital for further evaluation and treatment.R130's progress notes, dated 3/9/26 at 5:46 AM, notes a telehealth visit was conducted. It notes R130's primary chief complaint: respiratory: cough. R130 reported cough with thick sputum production and associated sore throat. R130 stated she coughed up a large amount of thick phlegm, which she initially thought might be vomit but appeared consistent with mucus. Cough medication was ordered. The nurse was instructed to monitor for fever, worsening cough, shortness of breath, wheezing, or change in sputum color and notify physician of any change in condition.There is no further documentation found in R130's medical record after the telehealth visit on 3/9 at 5:46 AM.R130's MAR (medication administration record), dated March 2026, R130 did not receive any cough medication on 3/9/26.R130's hospital record, dated 3/9/26, notes R130 presented to the emergency room for evaluation of sore throat, cough, and shortness of breath. R130 developed throat irritation after coughing, worsening to inability to swallow solids for two days. R130 able to drink small amounts of liquids. Covid-19 testing was performed and R130 tested positive. R130 was admitted to the hospital for Covid-19 treatment.

Based on interviews and record reviews, the facility failed to provide the bed hold policy to one resident or representative upon transfer to a local hospital. This affected one of (R130) three reviewed for bed hold in a sample of 43.Findings include:On 4/17/26 at 8:55 AM, V3 ADON (assistant director of nursing) stated that the nurse transferring a resident to the hospital is expected to provide the resident and/or the resident's representative with written information on the duration of the bed-hold policy.R130's medical record does not contain any documentation that R130 or R130's family received written information on bed hold.The facility's bed-hold policy, revised 6/26/25, notes the facility must inform the resident or family members being transferred of the duration of bed hold in writing.

Based on interviews and record reviews, the facility failed to initiate a person-centered care plan for enhanced barrier precautions (EBP) and enteral nutrition for one resident admitted to the facility with a gastrostomy tube and receiving enteral nutrition. This affects one of three (R6) residents reviewed for comprehensive care plan in a sample of 43.Findings include:On 4/14/26 at 10:00 AM, R6 stated that he receives bolus feedings via his gastrostomy tube after meals and at bedtime.R6's POS (physician order sheet) notes an order for enteral nutrition, 360ml (milliliters) bolus feeding after meals and at bedtime daily.On 4/16/26 at 9:30 AM, V12 IP nurse (infection prevention nurse) denied being aware R6 was admitted to this facility with a gastrostomy tube. V12 stated that R6 should have been placed on EBP (enhanced barrier precautions) upon admission due to having a gastrostomy tube. V12 stated that R6 should have a care plan for EBP and gastrostomy tube.On 4/17/26 at 8:55 AM, V3 ADON (assistant director of nursing) stated that the nurse is expected to initiate enhanced barrier precautions upon admission of a resident meeting the criteria for EBP, such as indwelling medical devices.R6's care plan does not note an EBP care plan was initiated.R6's compromised nutritional status care plan, initiated 3/16/26, does not note any interventions related to enteral nutrition.The facility's care plan policy, revised 6/30/25, notes in part the baseline care plan at a minimum should include initial goals based on admission orders, physician orders, and dietary orders. After the comprehensive assessment is completed, the facility will put in place person-centered care plans outlining care for the resident.

Based on observation, interview, and record review, the facility failed to follow its incontinence care policy and failed to ensure that a resident identified as requiring assistance with toileting was assessed and provided incontinence care at least every two hours. This affected one of three residents (R135) reviewed for incontinence care on the total sample of 43. Findings Includes: R135's minimal data set dated [DATE] section C (cognitive pattern) brief interview for mental status documents a score of twelve which indicate moderate cognitive impairment. Section GG (functional ability) documents: lower extremities impairment on both sides. R135 requires substantial maximal assistance rolling left to right and partial/moderate assistance for toilet hygiene. Section H (bladder and bowel) documents urinary continence always incontinent. On 4/14/26 at 11:35am, R135 who was assessed to be alert and oriented to person place and time, said he has not been provided incontinence care since yesterday evening. R135 said, he can smell himself. V8 (restorative aide) and V9 (restorative aide) both said they were recently assigned to R135 because V4 certified nursing assistant left the unit. R135 was observed with a saturated incontinence brief with yellow ammonia smelling urine covering the entire brief. R135's pants, folded bath blanket, sheet and mattress were wet with a multiple dried large irregular shaped ring exceeding the shape of his buttock on the bath blanket. V9 and V8 both said, R135 was soiled and saturated with strong smelling urine. On 4/15/26 at 12:37pm, V4 (certified nursing assistant/cna) said, she was R135 assigned certified nursing assistant. V4 said she did not provide care for R135 before she was pulled from the floor around 11:30am. V4 said, residents are checked and changed every two hours or as needed for incontinence care Incontinence and Perineal Care Policy adopted documents 12/3/15: It is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition. Do rounds at least every 2 hours to check for incontinence during shift.

Based on interview and record review, the facility failed to follow their physician order to ensure compression wraps were applied as prescribed (R78) and failed to ensure the old Scopolamine transdermal patch was removed before applying a new patch (R148). This affected two of three residents (R78 & R148) reviewed for quality of care on the total sample of 43. Findings Include: R78 was diagnosis with Lyphedema. Brief interview for mental status dated 2/26/26 documents a score of fifteen which indicates cognitively intact. Physician order sheet dated 9/28/25 documents: wrap bilateral lower extremities with Compression wraps with Ace bandage at 0600 (6:00am) in the morning apply. On 4/14/26 at 10:36am, R78 who was assessed to be alert and orient to person place and time said, her ace wraps for her legs was not applied today. R78 was observed without her compression ace wraps in place. R78 opened the top of her nightstand dresser drawer, R78's ace wraps were observed in the drawer. R78 said, she was supposed to have her ace wraps applied to decrease the swelling in her legs. On 4/16/26 at 3:39pm, V35 (nurse) said, he normally applies R78's ace wraps in the morning with the assistance of the certified nursing assistant/cna because R78's legs are heavy. V35 said, R78 uses compression wraps to decrease the swelling of her lower extremities because she has Lyphedema. V35 said applying R78's compression wraps have helped decrease the swelling of R78's legs greatly. V35 said on 4/14/26 he was working with an agency cna, cannot recall exactly what happened, if he applied R78's compression wraps or why he charted R78's compression wraps were applied but not observed on R78's legs. On 4/15/26 at 4:51pm, V3 (assistance director of nursing/adon) said, he expects all physician orders to be followed. Physician Order Policy dated 11/10/14 documents: It is the policy of this facility to ensure that all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician's orders. The facility shall ensure to follow physician orders as it is written in the physician order sheet (POS).R148's physician order sheet dated 1/5/26 documents Scopolamine Transdermal Patch seventy-two hours one milligram/ three days-apply one (1) patch transdermally in the morning every three days. On 4/15/26 at 4:51pm, R148 was observed with two Scopolamine Transdermal Patch attached to his body. One patch was observed behind the left ear with 4/15/2026 written on it and another patch on the left posterior upper back with no date written on it. V3 (ADON) said, R148 was supposed to have one patch applied to his body at a time. V3 said the old scopolamine patch was supposed to be removed before the and the new patch applied. V3 said, the scopolamine patch was probably attached to R148's shirt then it attached to R148's back. V3 said, he expects nursing staff to follow physician orders. On 4/16/26 at 3:39pm, V35 (nurse) said, he took off R148's old scopolamine patch from his left ear and applied a new one dated 4/15/26 behind R148's right ear. V35 said he was not aware that R148 had a patch on his upper back. V35 said he did not check R148's back. V35 said R148's patch should have not been applied to his back but behind his ears. Physician Order Policy dated 11/10/14 documents: It is the policy of this facility to ensure that all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician's orders. The facility shall ensure to follow physician orders as it is written in the physician order sheet (POS).

Based on observation, interview and record review the facility failed to follow the ortho physician recommendations to complete physical therapy evaluation and treat, occupational therapy evaluation and treatment, and assist with passive range of motion including pendulum exercises for greater than 30 days for one of three residents (R7) reviewed for physicians' orders regarding therapy and range of motion on the total sample of 43. Findings include: R7 face sheet shows diagnosis of displaced fracture of upper end of right humerus, initial encounter for closed fracture 3/5/26. On 4/14/26 at 11:48am R7 observed alert to person, place, time and situation. R7 observed with a black sling supporting her right arm. R7 said she'd fallen from bed when she was reaching for her phone to call her brother. R7 lifted her arm and R7 was observed with limitation to the shoulder. R7 said her shoulder was not like that before she fell. On 4/16/26 at 11:40am V7 (Restorative Nurse) said R7 had a fall on 3/5/26, R7 was sent out and returned to the facility with a sling on the right upper extremity, R7 was non weight bearing of the right upper extremity. V7 said R7 now has limited range of motion to the right upper extremity. V7 said R7 had full range of motion prior to the fall on 3/5/26. V7 said R7 did not receive physical therapy, passive range of motion (staff to assist) and pendulum exercise as ordered by the ortho physician, order given on 3/16/26. V7 said it was an oversite on her behalf, and she did not see the orders from the ortho doctor for physical therapy, passive range of motion (staff to assist) and pendulum exercises on 3/16/26. V7 said she noticed the orders on 4/13/26. V7 said she carried out the order for passive range of motion on 4/13/26, she began the passive range of motion for R7 on 4/13/26, V7 said she did not conduct an assessment / evaluation of R7 right upper extremity, she just initiated the exercises. V7 said she did not notify the ortho doctor that R7 exercises for passive range of motion, physical therapy and pendulum exercises was not complete. V7 continues to say it was an oversite on her part, she missed it. On 4/18/26 observation completed with V7, V7 assessed R7 right arm/shoulder to have 80 % limited range of motion. V7 said passive range of motion is when the exercise is assisted and pendulum exercise is to reduce pain, improve mobility, prevent stiffness without stretching the joint, and improve circulation without placing stress on the joint. V7 said R7 restorative exercise task dated 3/07/26 - 4/12/26 shows R7 has been receiving active range of motion to the upper and lower extremity, but R7 is not receiving exercises to the right arm/shoulder. V7 said the documentation is not correct and she should have corrected that program orders and updated the care plan. V7 said R7 care plan has not been updated to reflect the changes in R7 restorative program exercises. V7 said she was aware that R7 had a fall in March. On 4/17/26 at 3:31pm V24 (Rehab Director) said any resident that has fallen or is transferred to the hospital should be screened by physical therapy upon returning. V24 said R7 was not screen nor did R7 receive an evaluation or rehab screening on 3/12/26 or 3/16/26. V24 said it was an oversite by the therapy team, and the orders were missed. V24 said she was off duty, but the order should have been carried out. V24 said R7 also went to the hospital and returned a few times, but the screening and evaluations should have been completed. V24 said R7 will be evaluated today by occupation therapy. V24 said she was aware that R7 had a fall in March. On 4/18/26 at 3:44pm V51 (Occupational therapist) said she treated R7 in the past, R7 had full range of motion in her right upper extremity and shoulder prior to the fall on 3/5/26. V51 said she evaluated R7 today and R7 has 75-80-degree limitation in flexion and extension to the right shoulder. V51 said normal limits are 120 degrees for elder adults. A young adult would have 180 full range of motion. V51 said she has to confirm R7 order for non-weight bearing to the right arm/ shoulder. V51 said R7 can receive therapy services although R7 has orders for non-weight bearing. V7 said non-weight bearing does not affect exercises for R7. V51 said physician orders should be followed when given, an evaluation and treatment should be completed within 48 hours of the orders given. V51 said lack of exercise (movement) can contribute to R7 having limitation to the right shoulder. V51 said the plan is to reduce the limitation that R7 has. V51 said exercise improves mobility and stiffness to joints. On 4/17/26 at 1:50pm V2 (Director of Nursing) said it is her expectation that the staff follow physician orders and recommendations. V2 said she was not aware that R7 orders for physical therapy evaluation and treat, occupational therapy evaluation and treat, passive range of motion - staff to assist and pendulum exercise were not carried out on 3/12/26 and 3/16/26, V2 said she was made aware now by the surveyor. V2 was made aware that V7 stated that R7 now has 80% limited range of motion of the right shoulder. V7 reviewed R7 MDS assessment dated [DATE] and stated it shows R7 had full range of motion to upper extremity. R7 MDS dated [DATE] section GG for functional abilities for functional limitation in range of motion shows 0 for no impairment. R7 MDS dated [DATE] section GG for functional abilities for functional limitation in range of motion shows 1 for upper extremity impairment. R7 physician order sheet (POS) shows orders for 3/16/26 at 10:00am, (physician name listed and address) ortho. Occupational therapy evaluate and treat dated 3/12/26, nursing rehab - passive range of motion: PROM to Right shoulder and pendulum exercises, 15 reps/2 sets 6-7 times a week as tolerated dated 4/13/26. Physical therapy: evaluation and treatment dated 3/12/26. R7 ortho consult document dated 3/16/26 shows in-part on 3/5/26, resident fell out of bed and injured her right upper extremity, she was evaluated at the hospital, she reported localized pain without additional pain. Exam- skin intact, swelling and one plus pitting edema throughout right upper extremity, including right hand. Assessment and plan right humerus fracture, initiate pendulum and passive range of motion exercises for the right shoulder. Facility staff to assist with passive range of motion exercises. Orders placed PT and OT to evaluate and treat. R7 care plan with initiated date of 9/19/2023 shows I have ADL care performance deficits and impaired mobility, interventions I would like staff to refer me to physical and/ or occupational therapy as ordered by the physician to evaluate my current condition/status and recommend appropriate interventions to improve my functional status. Facility incident report shows R7 sustain a fall, R7 significant change MDS dated [DATE] shows R7 had a fall with a major injury. During this survey V2, V7, V24 and V51 did not state that R7 refused restorative programing, pendulum exercises, physical therapy or occupational therapy services. Facility did not present documentation that R7 refused these services. R7 MDS section B for behaviors dated 3/14/26 shows 0 for rejection of care- behavior not exhibited. Facility policy titled general care, dated 11/2026 denotes in-part it is the policy to provide care for every resident to meet their needs. Upon admission and readmission, the facility will evaluate the residents for physical and psychosocial needs. Facility policy titled restorative nursing program dated 4/2013 denotes in-part shows it is the policy of this facility to assess for comprehensive nursing and restorative needs upon admission. Appropriate nursing and restorative services consistent to the resident functional needs must be provided. If the assessment shows the resident needs therapy, then therapy should be provided.

Based on observation, interview and record review, the facility failed to follow their intravenous therapy policy by failing to ensure one resident's Peripherally Inserted Central Catheter (PICC) dressing was changed every 7 days. This affects one of one residents (R121) reviewed for intravenous therapy on the total sample of 43. Findings include:R121 was admitted to the facility on [DATE] with diagnosis polyneuropathy, infection and inflammatory reaction due to internal left knee prothesis and anemia.On 4/14/26 at 11:40AM, R121 was in his room up to wheelchair. R121 had a t-shirt on and observed Peripherally Inserted Central Catheter to his right upper arm. There was a clear dressing over the insertion site that was rolled up around the outer edges around the entire dressing. There was a date of 3/19/26 on the dressing. R121 said no one has touched his Peripherally Inserted Central Catheter (PICC) Line site for a while and wasn't sure why It was there. On 4/14/26 at 12:13PM, V2 (Director of nursing, DON) said PICC line dressing are changed every 7 days by the assigned nurse to prevent infections. PICC Line should be discontinued once medication is completed. Site should be flushed before and after medication use. V2 was asked to check R121 with surveyor. V2 confirmed date on PICC dressing was 3/19/26. V2 confirmed there were no active orders for R121 PICC line and unsure why orders were discontinued or why the PICC site was not monitored or removed.R121'a current physician order sheet did not document any orders for R121s PICC line. Review of all discontinued orders documents on 3/13/26 orders for central/PICC line dressing change every 7 days and as needed; flush Iv line with 5 ML of normal saline before and after medication administration.R121's medication administration record did not document any care to R121's Peripherally Inserted Central Catheter (PICC) site.Facility policy intravenous therapy revised 6/30/25 documents: it is the facility policy to ensure that intravenous policy and procedures are compliant to federal standard of care. All midline catheter dressing are to be done every 7 days while following procedures for central line. The extremity circumference will be measured weekly. All central line dressing (PICC) will be changed every 7 days and as needed. Additionally, for PICC line, the length of the external catheter and circumference will be measured weekly to monitor movement and edema.

Based on observation, interview, and record review, the facility failed to ensure that an opened insulin vial was properly labeled with the date opened and/or expiration date, in accordance with medication storage policy. This affected one of one resident (R61) reviewed for medication storage on the total sample of 43. Findings Includes: R61 was diagnosed with type two Diabetes Mellitus with Diabetic Autonomic (Poly) Neuropathy. Physician order sheet dated 4/2026 documents: Insulin Lispro Injection Solution 100unit/ milliliter On [DATE] at 10:51AM, during medication cart audit with V45 (nurse), R61 lispro insulin vial was open and not dated. V45 (nurse) confirmed there was no open date or expiration date on the insulin bag or vial. On [DATE] at 12:22pm, V2 (director of nursing) said, when insulin is open she expects nursing to write and open and expired date on the insulin so that it is used it not used after twenty-eight or thirty days. V2 said, she does not have an insulin policy and uses the medication storage and labeling policy. Medication Storage, Labeling and Disposal Policy dated [DATE] documents: It is the facility policy to comply with federal regulation in storage, labeling and disposal of medication.

Based on interview and record review, the facility failed to follow doctor orders to order a stat lab draw for one resident(R142) for one of one reviewed for lab services on the total sample of 43. Findings include:R142 was admitted to the facility on [DATE] with a diagnosis of alcoholic polyneuropathy, cirrhosis of liver, and hyponatremia.On 4/15/26 at 4:14PM, V15 (nurse) said upon starting her shift on 4/14/26 V25(unit manager) informed her that R142 had orders for stat blood work due to change in condition. V15 said V25 put in order for lab orders. V25 called around 5 or 6 to see if lab had come yet and added more orders. V15 said the family called and said they did not want to wait anymore for lab services and called 911 from their home. R142 was transferred to the hospital.On 4/16/26 at 11:40PM, V25(unit manager) said she put in stat orders for the R142's blood work per doctors orders. V25 said she informed V15(nurse) about the orders. V25 said later that evening the family said they did not want to wait anymore and called 911 to send the residents to the hospital for lab work. On 4/16/26 at 9:46AM, V2 (DON) said stat labs are done within 4 hours contact and staff should contact the physician if not done in time frame and document in the progress notes.On 4/16/26 at 12: 32PM V33 (lab technician) said they received order for R142 on 4/15/26 at 4:22pm. V33 said it was not put in as a stat. There were no calls placed to the lab about it being or stat or about the order. Stat labs are to be done within four hours and should be called in by the facility as well when a stat order is placed. On 4/16/26 at 12:05PM, V46 (physician) said he ordered stat labs for R142 due to change in condition. V46 said he would expect stat labs to be done within 4- 8 hours and his orders to be followed. V46 was unable to recall if anyone informed him the labs were not done within 4 hours.R142's physician order for lab orders dated 4/14/26 do not indicate a stat order for comprehensive metabolic panel and urine osmolality/sodium.R142's progress note dated 4/14/26 at 10:00PM documents: Received call from R142's responsible party that she is tired of waiting for the stat lab to be drawn and she called 911 to pick up the resident and take to local hospital.R142's hospital record dated 4/14/26 documents arrival time at 10:30PM.Facility stat specimen and priority testing policy undated documents: stat tests should be resulted within four hours of notification.

Based on record review and interviews, the facility failed to ensure contracted diagnostic services were provided within 24 hours, as required under the terms of its contractual agreement, for one resident with a history of pulmonary embolism and acute embolism. This affected one of one resident (R143) reviewed for diagnostic services on the total sample of 43. Findings include:R143 was admitted on [DATE] with hemiplegia and hemiparesis following nontraumatic intracerebral 03/08/2026 primary hemorrhage affecting right dominant side, pulmonary embolism without acute pulmonale, acute embolism and thrombosis of right peroneal vein, and aphasia following cerebral infarction. R143's progress notes dated 4/13/26 at 4:31 PM (16:31) documents: R143 endorses pain to left lower extremity and swelling noted. V40(MD) made aware and ordered doppler of left lower extremity. R143's physician order dated 4/13/2026 4:34PM (16:34) documents left duplex scan, veins, extremity, unilateral/limited study. On 4/15/2026 at 10:30 AM, V2 (director of nursing, DON) said they did not know about time frames from diagnostic order to testing performance of diagnostic services for R143. V2 will check the policy. V2 could not find the policy. V2 said the doppler had still not been performed at time of interview.On 4/15/26 at 2:11PM, V20(diagnostic services technician) said they received the order on 4/13/26. V20 said services should be performed within 24 hours but they have been busy with orders. V20 said they sent a technician today to perform service.On 4/17/26 at 3:16 Pm, V40 (MD) said he would expect the diagnostic testing to be done within 24 hours. V40 was not notified order for left duplex scan, veins, extremity, unilateral/limited study was not performed within 24 hours.R143 radiology results report dated 4/15/26 at 6:12PM (18:12 ) findings show left great saphenous vein (GSV) is non-compressible suggestive of superficial venous thrombosis.Facility contract with (Diagnostic Service Provider) with an effective date of 8/1/24 documents under Duties and obligations of Provider: Provider shall provide Services within 24 business hours or schedule a time for service. R143's progress notes did not document any notification to the doctor or attempts made to diagnostic services about R143 doppler orders.

Based on the interview and record review, the facility failed to follow its fall occurrence policy by not conducting a post-fall investigation to determine the reasonable cause of the fall and reviewing the fall care plan with new interventions. This applies to one of three residents (R2) reviewed for falls in a sample of 14.The findings include:R2 was a [AGE] year-old male admitted on [DATE] with an admitting diagnosis including dementia, hemiplegia, hemiparesis, heart failure, and urinary tract infection (UTI).A review of the fall log and nursing progress notes documented that the two falls occurred to R2 on 10/30/25 and 11/7/25.On 12/24/25 at 12:25 PM, V2 (Director of Nursing/Fall coordinator) stated, I am the one investigating after a resident fall and then revising the fall care plan with new interventions. I don't have the post-fall investigation completed for R2 for the falls on 10/30 and 11/7. I know I am supposed to investigate and update the fall care plan with new interventions based on the root cause of the fall.A review of R2's fall care plan indicates any revisions with new interventions to prevent further falls following the falls on 10/30/25 and 11/7/25.A review of the facility presented the Fall Occurrence policy reviewed on 6/30/25 document:5. The fall coordinator will review the incident report and may conduct his/her own fall investigation to determine the reasonable cause of the fall8. The fall coordinator will add the interventions to the resident's care plan.

Based on interviews and record reviews, the facility failed to follow physician orders to ensure as needed pain medication (oxycodone) was administered to one resident as prescribed. This affected one of three residents (R1) reviewed for pain management. This failure resulted in R1 being admitted to this facility on 9/24/25 and requested narcotic pain medication, rated pain as 6 out of 10, but was informed by nurse R1's medication was not available until the next morning.Findings include:On 9/30/25 at 10:55 AM, R1 stated that R1 was admitted to this facility on Wednesday, 9/24/25. R1 stated that she asked for oxycodone (pain medication) and was informed that her medications had not been delivered yet. R1 stated that R1's oxycodone was delivered (on 9/25/25), and she received a dose around 9:00 AM.On 9/30/25 at 1:50 PM, V2 DON (director of nursing) stated that the nurse is expected to sign out medications on the controlled substance sheet and MAR (medication administration record) when a narcotic (oxycodone) is being administered. V2 stated that the medications are to be removed at time of administration. V2 stated that if the hospital sends a prescription for narcotic medication with the resident upon admission, the nurse can call the pharmacy to get emergency authorization, fax the prescription to the pharmacy, and obtain an authorization code to get into the facility's convenience box to remove medication. V2 stated that the nurse has to get an authorization code every time the nurse wants to give a controlled substance until that medication is delivered. V2 stated that the pharmacy delivers medications to the facility twice daily, once in the morning and once in the afternoon.11/14/25 at 1:38 PM, V13 (pharmacist) stated that 29 tablets of oxycodone were delivered to the facility for R1 on 9/25/25 at 7:00 AM. V13 stated that no access codes were given to any nurse for oxycodone on 9/24 or 9/25.On 11/14/25 at 4:54 PM, V11 RN (agency registered nurse) stated that V11 worked 9/24/25 3:00 PM-11:00 PM and was assigned to provide care for R1. V11 stated that R1 requested a dose of oxycodone for pain 6 out of 10. V11 stated that V11 informed R1 that R1's oxycodone (narcotic) medication was not available and offered R1 acetaminophen instead. V11 stated that V11 did not access the convenience box to see if oxycodone was available to administer to R1.On 11/17/25 at 1:46 PM, V12 NP (nurse practitioner) stated that the nurse is expected to assess the resident for pain every shift and when pain medication is requested. V12 stated that nurse is expected to reassess the resident's pain level post medication administration for its effectiveness. V12 stated that the nurse is expected to check the facility's convenience box for the narcotic medication if the medication has not been delivered yet. V12 stated that the nurse is expected to notify the physician if the pain medication is not available and request an alternative medication. R1's medical record notes the following:9/24/25 at 1:13 PM, R1 admitted to the facility. R1 denies pain.9/24 at 10:02 PM, V11 RN noted as needed pain medication (oxycodone) is not available at this time. R1 refused acetaminophen for pain stating it causes gastrointestinal discomfort.9/25 at 9:00 AM, one tablet of oxycodone was signed out on R1's controlled substance sheet. Administration was not documented in R1's MAR (medication administration record).The controlled drug administration record notes oxycodone 5mg tablets 1-2 tablets every three hours as needed for pain control. 29 tablets of oxycodone were received in the facility on 9/25/25 at 7:00 AM. It also notes that the first dose of oxycodone was signed out 9/25 at 9:00 AM. R1's MAR, dated September 2025, notes the first dose of oxycodone was administered on 9/25/25 at 4:04 PM.V12 NP initial visit, dated 9/25/25, notes R1 status post right hip arthroplasty on 9/19/25. R1 noted pain with movement of leg. Pain management with oxycodone. R1's pain care plan, initiated 9/25/25, notes R1 has pain related to status post hip surgery. Interventions identified include but not limited to R1 will report to the nurse complaints of any pain or requests for pain treatment; R1 would like the nurse to review and monitor R1's pain level.R1's hospital medical records, dated 9/24/25, notes a prescription for oxycodone 5mg tablets, take 1-2 tablets by mouth every three hours as needed. Indication: acute post operative pain.The facility's pain policy, revised7/29/25, notes if available in the convenience box, the pain medication ordered will be administered. After the administration of as needed pain medication, the resident will be reassessed for the effectiveness of the pain medication.

Based on observation, interview, and record review, the facility failed to recognize an acute change in condition for a resident. This failure applied to one (R5) of three residents reviewed for nursing care and resulted in a delay in care for R5 who was hospitalized for respiratory failure. Findings include: R5 is [AGE] years old and admitted to the facility on [DATE] and has diagnoses that include hydrocephalus, g-tube placement, communication deficit weakness and lack of coordination. Minimum data set (6/28/24) indicates R5 to have severe cognitive impairment and unable to make needs known to staff. The assessment data also includes that R5 is incontinent of bowel and bladder and totally dependent on staff for turning, repositioning and all other activities of daily living. On 7/15/24 at 12:51PM R5 was in the facility, observed by the Surveyor to be in bed, and appearing to be in respiratory distress. R5 was visibly and audibly gasping for air and respirations were counted at 47 breaths per minute. At 12:55PM V7 Registered Nurse said that R5 has been breathing like that all morning. It's baseline. V7 said that vital signs were taken about 15 minutes prior and documented as: blood Pressure 111/44, Temperature 97.4F, Pulse 100 beats per minute, Respirations 24 breaths per minute and Oxygen 94% on room air. At 12:58PM V7 and V8 LPN (licensed practical nurse) went to the bedside of R5 at request of the Surveyor. V8 was orienting with V7 on this day and while at the bedside, V7 and V8 agreed that R5's presentation and assessment was unchanged since earlier that morning around 9AM. Surveyor requested an immediate set of vital signs which V7 and V8 obtained. The pulse oximeter measured a pulse of 110 beats per minute and an oxygen saturation fluctuating between 80% and 97% on room air. V9 Registered Nurse entered the room at 1:07PM physically assessed R5 and agreed that R5's presentation was normal for their baseline, and that R5 periodically gets like this. At 1:08PM V7 was asked for a respiration count and said it was 28 breaths per minute. V7 said that a normal respiration count should be between 12 and 25 breaths per minute. Surveyor requested to count again together out loud, and the result was 40 breaths per minute. V7 left the room to call the medical provider for further orders. At 1:33PM, R5 was observed in bed, condition unchanged. V7 said that the provider was notified that R5 has a rate of 40 respirations and did not give any further orders. At 1:58PM V2 Director of Nursing said that a respiration rate of 40 would not be considered normal, however co-morbidities should be considered overall. V2 said, that R5's family refused hospice services upon recommendation and R5 remained full code at the moment, meaning that all measures should be taken to sustain life. V2 went to personally assess R5 and follow up with V7. Emergency Paramedics were observed on site in the facility at 2:30PM. V7 said that they called 911 due to R5 experiencing a further increase of breathing and decreased blood pressure to 89/50. R5 was transferred via Fire Department to the hospital emergency room and admitted to the neurological intensive care unit for respiratory failure and treated for sepsis. The medical group representing R5's physician and Nurse Practitioner refused an opportunity to interview R5's providers during this investigation. The facility provided Notification for Change of Condition policy revised 6/6/24 which states in part: Policy Statement: The facility will provide care to residents and provide notification of resident change in status. Procedures 1. The facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is: b. A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); c. A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or d. A decision to transfer or discharge the resident from the facility as specified in S483.15 (c ) (1) (ii) as in the continued presence of the resident poses a threat to the safety and health of the resident and other individuals in the facility. Per federal definition S483.1 0(g)(14 ), a need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences (e.g., an adverse drug reaction), or commence a new form of treatment to deal with a problem (e.g., the use of any medical procedure, or therapy that has not been used on that resident before). Per federal guidance under S483.10(g)(14), physician also need to be notified if resident experiences symptoms such as chest pain, loss of consciousness, or other signs or symptoms of heart attack or stroke.

Based on interview and record review, the facility failed to implement turning and repositioning to prevent the development of new pressure injuries and complete treatment orders. This failure affected two residents (R4 and R5) who were at high risk of developing pressure ulcers and resulted in R4 and R5 developing deep tissue injuries to the sacrum. Findings include: R4 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that included Protein-calorie Malnutrition, Heart failure, and metabolic encephalopathy. According to Skin Evaluation Assessment of 3/13/24, R4 was assessed to have one pressure ulcer of the right heel. Minimum Data Set (3/25/24) indicated R4 was cognitively impaired, incontinent of bowel and bladder and dependent on staff for turning, repositioning and toileting. R4 used a manual wheelchair, to which they were dependent on staff to transfer and maneuvers. R4 was able to feed self with set-up assistance from the staff. The mobility task for R4 was reviewed for March 2024. Turning and bed mobility were not documented night shift 3/17 and morning shift 3/18. According to nursing progress notes on 3/18 at 3:30PM, an open wound [was] noticed to the sacrum A significant change was noted on 3/19/24 and R4 was assessed to have a sacral deep tissue injury measuring 7cm (centimeters) length by 10cm width. The wound nurse practitioner assessed and treated R4 on 3/19 and orders were placed to cleanse with normal saline and apply bordered foam every three days. The Treatment Administration Record of March 2024 did not contain any signatures that this treatment was completed 3/22, 3/25 or 3/28. R4 was discharged from the facility on 4/1/24. R5 is [AGE] years old and admitted to the facility on [DATE] and has diagnoses that include hydrocephalus, g-tube placement, communication deficit weakness and lack of coordination. Minimum data set (6/28/24) indicates R5 to have severe cognitive impairment and unable to make needs known to staff. The assessment data also includes that R5 is incontinent of bowel and bladder and totally dependent on staff for turning, repositioning and all other activities of daily living. According to Skin Evaluation (6/22/24) R5 admitted to the facility with staple to a surgical scalp laceration and without any pressure ulcers. During assessment by the nurse practitioner on 7/10/24, R5 was noted with a sacral deep tissue injury (pressure wound) measuring 5cm length and 6.5cm width. Orders were placed to cleanse with normal saline and apply medical grade honey and silver alginate (for debridement) and secure with a hydrocolloid bandage every other day and as needed. Review of the Treatment Administration Record July 2024 indicated that this treatment was not signed as completed 7/14/24. On 7/15/24 R5 was in the facility, observed by the Surveyor to be in bed, and appearing to be in respiratory distress. Facility staff was notified, and R5 was transferred to the hospital emergency room and admitted to the neurological intensive care unit due to respiratory failure. A care plan for skin integrity was initiated 6/21/24 and included an intervention to check skin every shift and report abnormalities to the nurse. A skin observation report was requested from the facility and not provided. On 7/16/24 at 3:24PM V13 Wound Care Nurse was interviewed and said, the wound care team was alerted to R5's sacral wound after the nurse placed a wound consult. The nurses and CNA's are responsible for checking skin of high risk residents every shift and during incontinence care. R5 was high risk due to immobility, use of g-tube and general unresponsive presentation. Because of this, we ordered R5 to be on an alternating pressure relieving mattress to assist with prevention of skin breakdown, however it does not replace the need for turning, repositioning and routine skin care. By the time the wound care team assessed the sacral wound, it was a deep tissue injury with leathery eschar (dead tissue). V13 was unable to determine for certain how long the wound had developed but said that it was likely a full thickness wound under the dead tissues. V13 was not able to recall any information regarding R4's admission to the facility. Facility Policy Skin Care Regimen and Treatment Formulary revised 1/24/24 states in part: It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate treatment for residents with skin breakdown. Procedures 1. Charge nurses must document in the Electronic Health Record any skin breakdown upon assessment and identification. Furthermore, treatment must be obtained from the patient's physician. 2. Routine daily wound care treatment/ dressing change is administered by the wound care nurse or designee daily unless otherwise indicated by the patient's attending physician. a) Pressure Injuries/ Vascular Wounds (Stasis/ Arterial/ Diabetic) b) Surgical Wounds c) Other Skin Conditions 4. TAR [Treatment Administration Record] Nursing Documentation includes: a) Routine wound care completed by wound care nurse or designee. b) Ostomy care completed by the wound care nurse or designated nurse. 5. Refer any skin breakdown to the skin care team and physician including wound physician/NP (nurse pracitioner) for further review and management as indicated. 6. Residents who are not able to turn and reposition themselves will be turned and repositioned at least every 2 hours unless otherwise specified by the physician.

Based on interview and record review, the facility failed to provide timely incontinence care assistance for one of three residents (R8) reviewed for incontinence care. Findings include: R8 is [AGE] years old and admitted to the facility with diagnosis that include peritonitis, difficulty walking, shingles, COPD and heart failure. R8 was also experiencing a infection of the bowels that causes frequent loose stools. Minimum Data Set 7/10/24 noted that R8 lacks any cognitive impairment, is incontinent of bowel, has an indwelling urinary catheter and requires physical assistance from staff for activities of daily living. On 7/18/24 at 10:17AM R8 was observed in bed, alert and coherent. The call light was activated, and V11 Unit Nurse Manager was observed donning an isolation gown. V11 went in to address R8, turn the light out and left. R8 requested incontinence care. At 10:25AM, R8 was interviewed and said, that the nurse came in and said that the CNA (Certified Nursing Assistant) was busy and that they would come as soon as they were done. R8 said that the staff doesn't always come timely, and due to the bowel issue, R8 needs frequent incontinence care and needs help from staff to remain clean due to inability to move independently. R8 said, you can call, and they won't answer, or they will take their time. R8 said that after a few days of admission, R8 requested to be moved closer to the nurse's station in hopes that they would be accessible to quicker help. R8 says when they don't answer the call light, R8 calls out into the hallway, but is often ignored. R8 said, since you [Surveyor}] are in the building, they will come right away. R8 pressed the call light at 10:34AM. Shortly after, V11 returned to the room, deactivated the call light, and R8 asked again to be changed. V11 firstly said that the CNA should be coming shortly. Surveyor asked if nurses were able to provide incontinence care. V11 said, yes nurses are trained to provide incontinence care, and then said they would come back to the room with supplies to provide care for R8. Surveyor left the room at 10:45AM and R8 continued to wait for staff to assist. Progress notes and census dated 7/10/24 noted that R8 requested a room change. R8 was moved from one room to another, where the nurse's station is visible from the room. Care Plan initiated 7/3/24 notes that R8 is incontinent of bowel and has an indwelling urinary catheter, however, does not incorporate associated interventions related to bowel incontinence. On 7/22/24 at 1:00PM V12 Infection Preventionist said that they have been working in the facility since November 2023 and it was noticed that the facility had increased trends related to urinary tract infections. V12 said, that once this was noted, V12 conducted an in-service with all of the nursing staff to ensure that proper procedures were conducted related to perineal cleaning and since, the incidents of residents developing urinary infections has decreased. We prevent UTIs from occurring by ensuring residents receive timely and proper incontinence care and increasing fluids. Facility Policy Incontinent and Perineal are revised 6/6/24 states in part: Policy Statement: It is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition.

Based on interview and record review, the facility failed to offer Influenza and Pneumococcal immunization as required for four of five residents (R25, R,27, R73 and R265) reviewed for immunization in a sample of 20 residents. Findings include: On 4/4/24 at 11:45am, and V2 (Director of Nursing) and V22 (Infection Retentionist) both stated, all immunization given or refused should be documented. V22 stated that, she is responsible for checking that residents' s immunization are up to date once admitted into the facility. During record review on 4/4/2024 at 1:00 PM, R25, R27, R73 and R265' s immunization records did not indicate that these residents received or refused the Pneumococcal vaccine. R27's immunization record had no documentation to indicate that she received or refused the influenza vaccination. Facility policy reviewed 12/12/23 reads: Pneumococcal Vaccination. Policy statement: It is the policy of the facility to offer and administer Pneumococcal vaccination to each resident as recommended by CDC's Advisory Committee on Immunization Practices (ACIP), unless otherwise contraindicated or the resident or responsible party has refused the vaccine. Procedure. 4. Pneumococcal vaccination will be offered upon admission if recommended by ACIP. All current residents recommended by ACIP to received Pneumococcal vaccine shall received vaccination unless otherwise medically contraindicated or refused. 6. All administration and refusals will be documented. Facility policy reviewed: 8/8/2023 reads: Influenza Vaccination Policy statement: It is the policy of the facility to annually offer and administer vaccination against influenza to each resident unless otherwise medically contraindicated or the resident or responsible party has refused the vaccination. Procedure. 4. All current residents shall be offered vaccination during flu season unless otherwise medically contraindicated or the resident or responsible party refuses. All refusal will be documented.

Based on observation, interview and record review the facility failed to ensure that the urine collection bag was covered for two of two residents (R261, R264) reviewed for resident's rights in a sample of 20. Findings include: 1. On 04/02/2024 at 7:22AM during unit rounds, R261 was observed lying on bed with urine collection bag placed on the side of the bed that is facing the hallway, uncovered. R261's door was also observed wide open. R261's room is a 2-bed room and has a roommate. On 04/02/2024 at 10:48AM during observation with V10 (Registered Nurse), R261 was observed sitting on his wheelchair with urine collection bag uncovered. On 04/02/2024 at 10:48AM during interview with V10, V10 stated that R261's urine collection bag should be covered. On 04/04/2024 at 9:29AM during interview with V2 (Director of Nursing), V2 stated that all urine collection bags should be covered to maintain resident's dignity. Review of R261's Order Summary Report dated 04/04/2024 indicated admitted on 03/29/2024 and diagnoses of not limited to chronic kidney disease, stage3, and retention of urine. 2. On 04/02/2024 at 7:48AM during unit rounds, R264 was observed lying on bed with urine collection bag placed on the side of the bed, uncovered. R264's room is a 2-bed room and has a roommate. On 04/02/2024 at 10:52AM during observation with V12 (Licensed Practical Nurse), R264 was again observed lying on bed with urine collection bag placed on the side of the bed, uncovered. On 04/02/2024 at 10:52AM during interview with V12, V12 stated that R264's urine collection bag should be covered for privacy. On 04/04/2024 at 9:29AM during interview with V2 (Director of Nursing), V2 stated that all urine collection bags should be covered to maintain resident's dignity. Review of R264's Order Summary Report dated 04/04/2024 indicated admitted [DATE], diagnoses of not limited to benign prostatic hyperplasia with lower urinary tract symptoms and retention of urine, order for indwelling catheter with order date of 03/29/2024. Review of facility's policy entitled Privacy and Dignity revised 7/28/2023 indicated the following: Policy Statement: It is the facility's policy to ensure the resident's privacy and dignity is respected by the staff at all times. Procedures: 4. Urine bags will be covered with the use of privacy bags.

Based on observation, interview, and record review, the facility failed to ensure that nursing staff had the required competencies when transcribing physician orders for newly admitted residents to ensure that care is being provided as ordered and to meet the needs of the residents; they also failed to ensure that standards of nursing practice were being followed during the administration of medication. This failure applied to three of three (R73, R103, and R504) residents reviewed for nursing services and resulted in (R73) receiving medication that was not ordered; (R103) not having a BiPap machine upon admission, that R103 was required to wear due to history of sleep apnea and respiratory failure; and (R504) did not receive medication that were needed for the prevention of blood clots upon admission to the facility. Findings include: R103 was a [AGE] year-old male initially admitted to the facility on [DATE] and expired on [DATE]. His medical diagnoses include but are not limited to the following: respiratory failure, sleep apnea, severe protein calorie malnutrition, muscle wasting, altered mental status, history of falling, hyperlipidemia, heart failure, dementia, depression, and absence of lung, HTN, and COPD. Transition of care report from (facility) state in part but not limited to the following: Reason for hospitalization : fall, altered mental status, acute respiratory failure, and COPD. 4 liters of oxygen. Per hospital discharge records dated [DATE] state in part but not limited to the following: BiPap QHS per pulmonary recommendations Settings: ,d+[DATE], 50% FiO2. Venous blood gas improved with BiPap. Fast track report: Oxygen: 3 liters, has a BiPap from home and will bring. Physician Order Sheet dated [DATE] at 2:04 PM states in part but not limited to the following: BiPap; Oxygen 4 liters per minute; Settings: ,d+[DATE], set rate 12 breathing 25; FiO2 40% with tidal volumes 448 every evening and night shift and as needed for sleep apnea while sleeping. On [DATE] at 12:50 PM, V2 (Director of Nursing) was interviewed regarding R103's BiPap machine and orders. V2 states admissions were notified at some point from the hospital liaison that R103 needed a BiPap. At this point, admissions did order a BiPap for R103, however when the resident arrived to the facility, we did not see an order on the discharge records for the BiPap, so the BiPap was not set for R103. R103 did not receive the BiPap on [DATE]. I know that the unit manager was made aware that R103needed a BiPap the following day on [DATE] and this is how the order was obtained. I am not sure if the BiPap was one from home or the one admissions had ordered for him. I am unsure of who set the BiPap machine up for R103. On [DATE] at 1:30 PM, V35 (Unit Manager) was interviewed regarding R103's care while at the facility. V35 states on [DATE] she spoke with V27 (Family Member) about concerns V27 had about R103's care. V27 told me at this time that R103 was previously found unresponsive and needs a BiPap when he sleeps. V27 satated she came to the facility and saw R103 sleeping without the BiPap. V27 was concerned this would happen again. I ensured her we were able to care for R103. This was the first time we were made aware that R103 required a BiPap while sleeping. After this conversation, I looked into the situation and found that R103 did not have an order for the BiPap in place. I contacted the doctor, confirmed the order, and obtained a written order. I talked with the nurses on his unit to ensure he is wearing the BiPap at all times while R103 is sleeping. I am unsure of where the BiPap came from, if it was brought in by the family or it was one that we had ordered for the resident. On [DATE] at 12:10 PM, V29 (Registered Nurse) was interviewed about R103's admission to the facility. V29 says she was the admitting nurse for R103 and believes he was admitted around 3:00 PM on [DATE]. We are made aware of new admission orders and status by both the hospital discharge records and by the hospital nurse's report. I remember he came in via transport with oxygen. I also received report from the hospital nurse that he was on oxygen. I did not get report from the hospital nurse that he was using a BiPap nor was it in his hospital discharge orders. Typically, if a resident is on a BiPap the hospital nurse will report to us the settings of the BiPap or the settings will be on the discharge paperwork. I did not have any interaction with his family when he admitted , he came by himself. Asked V29 how the admission orders are reviewed after the admitting nurse puts them in, in which V29 said two nurses verify the orders upon admission, the next day the unit manager would review the admission records. From there the physician typically shows up the following day to verify the orders, notes, and to see the resident. V29 says I have been disciplined in the past for transcribing medications incorrectly. Per facility One-On-One Inservice Record, V29 (Registered Nurse) was disciplined on [DATE], [DATE], [DATE], and [DATE] for medication reconciliation and medication/treatment guidelines. 44570 Findings include: R504 was an [AGE] year-old male admitted to the facility [DATE] with diagnoses that included cerebral infarction and hypertension. Immediately prior to transfer, R504 underwent a surgical laminectomy of the spine after sustaining a fall in the home. According to the Minimum Data Set assessment dated [DATE], R504 was assessed to be totally dependent on staff for all activities of daily living, requiring extensive 2-person assistance with bed mobility, turning and toileting. R504 mobilized with a wheelchair and was not ambulatory. According to nursing progress note dated [DATE] at approximately 1:00AM, R504 was assessed by nursing staff to have multiple episodes of yellow emesis at start of the shift. During emesis R504 was observed to have fixed stare. Nurse assessed vital signs: Blood Pressure: ,d+[DATE] Heart Rate: 89 and blood glucose: 299. The nurse on duty called 911 for transport to the nearest hospital. According to hospital records dated [DATE], several hours after arriving to the Emergency Department, R504 received life resuscitation measures and expired. Death Certificate dated [DATE] lists cause of death: Cardiopulmonary Arrest and Massive Pulmonary Embolism. On [DATE] at 10:06AM V2 Director of Nursing said, we were made aware that R504 went to the hospital and passed away. When the hospital called, they asked for a medication list and the unit manager grabbed the chart and reconciled the notes. That is when she found that there was a discrepancy with how the admission medication orders were transcribed. It is possible that this could have contributed to blood clot development, and I began an investigation based off of this concern. The medication, Heparin was missed (upon admission to the facility) and was not documented on the Physicians Order Sheet. R504 did not receive Heparin at any time while in the facility. The nurse that transcribed the orders was from an agency and was asked not to return after this incident. On [DATE] at 9:58AM, V30 Medical Director and primary physician of R504 said, when patients come from the hospital, we are supposed to follow all the hospital orders. I was told by the facility that the nurses have a system in place where they call the physician and go over the medication list, and then another nurse will verify that all the medications have been ordered in the system correctly according to the discharge medication list. I round at the facility, and I also will review the hospital discharge orders when I do the initial visit. I don't know how an error could have occurred with these systems in place. Heparin is used to help prevent blood clots, such as DVT (deep vein thrombosis) and pulmonary embolism. Heparin is used to help prevent blood clots of all kinds, particularly in high-risk patients. It is possible that without the Heparin being given as ordered, a patient who is at risk of developing blood clots has a higher chance of developing them if they are unable to walk or move on their own. V30's Physician progress note dated [DATE] indicated that R504 was assessed, and all hospital records were reviewed. Hospital discharge forms and Physician Order sheet reviewed for [DATE]. Hospital discharge medication list included Heparin 5,000 units to be given every 8 hours which was not transcribed to the Physician Order Sheet at the time of admission to the facility. There is no record of R504 receiving this medication while in the facility at any time. Physician progress note dated [DATE] documented that R504 was at risk for developing DVT (deep vein thrombosis). Facility policy titled, Admission, long-term care (Revised [DATE]) includes: Ensure that a complete list of the medications the resident was taking at home is documented in the resident's medical record. Compare this list with the resident's current medications. Reconcile and document any discrepancies in the resident's medical record to reduce the risk of transition-related adverse drug events. R73 is a [AGE] year-old male admitted to the facility [DATE] with diagnoses that include End Stage Renal Disease, Diabetes, Hypertension and Spinal Stenosis. R73 is alert and oriented as assessed on [DATE], with a BIMS (Brief Interview of Mental Status) score of 14 (cognitively intact). On [DATE] V6 (RN) wrote a progress note at 4:07PM that stated, Resident accidentally taken the wrong medication family aware and MD will continually monitor resident for side effect and reaction. Facility Witness statement for the incident of [DATE] states that V6 (RN) pulled medications for R73 and the roommate and entered the room with both medication cups in hand. When she set the medication in front of R73, he ingested one pill and then stated that the medications in the cup were not his meds. V6 took the remaining medicine from R73 and gave him the other prepared medications. Prior to going into the room, the medications were labeled with the resident's names. V6 (RN) could not be reached for interview during this investigation. Review of V6's Employee file reviewed and found to contain Employee Warning Notices that indicated V6 had received written notice of three additional medication administration related incidents since being hired in the facility in 2018. On [DATE] at 10:06AM V2 Director of Nursing said, I am aware that there have been multiple medication administration errors since I've been the Director of Nursing. Medication administration errors are avoidable by utilizing the 5 rights. When an incident like this occurs, the nurses are provided education in the form of an in-service that emphasizes the Rights of Medication Administration, such as right medication, right dose, right patient, right time, and right route. I was not aware that V6 (RN) had a history of documented medication errors or incidents. R73 did not require any hospitalization after the incident, and the physician was called with no further orders but to monitor for any reactions. Facility policy titled, Medication and Treatment Administration Guidelines, Long-Term Care (no revision date) includes: Medications are administered in accordance with the following rights of medication administration or per state specific standards: Right patient, right medication, right dose, right route, right time (including duration of therapy, right documentation, right of patient to refuse, right clinical indication).

Based on interview and record review, the facility failed to accurately transcribe hospital discharge orders to ensure that a newly admitted resident received all medications needed for treatment and failed to prevent a medication administration error. These failures affected two residents (R504 and R73) reviewed for medication administration and resulted in one resident (R73) receiving medication that was not ordered and resulted in (R504) not receiving medication for the prevention of blood clots upon admission to the facility and then being emergently transferred to the hospital and subsequently expiring. Findings include: R504 was an [AGE] year old male admitted to the facility [DATE] with diagnoses that included cerebral infarction and hypertension. Immediately prior to transfer, R504 underwent a surgical laminectomy of the spine after sustaining a fall in the home. According to the Minimum Data Set assessment dated [DATE], R504 was assessed to be totally dependent on staff for all activities of daily living, requiring extensive 2 person assistance with bed mobility, turning and toileting. R504 mobilized with a wheelchair and was not ambulatory. According to nursing progress note dated [DATE] at approximately 1:00AM, R504 was assessed by nursing staff to have multiple episodes of yellow emesis at start of the shift. During emesis R504 was observed to have fixed stare. Nurse assessed vital signs: Blood Pressure: ,d+[DATE] Heart Rate: 89 and blood glucose: 299. The nurse on duty called 911 for transport to the nearest hospital. According to hospital records dated [DATE], several hours after arriving to the Emergency Department, R504 received life resuscitation measures and expired. Death Certificate dated [DATE] lists cause of death: Cardiopulmonary Arrest and Massive Pulmonary Embolism. On [DATE] at 10:06AM V2 Director of Nursing said, we were made aware that R504 went to the hospital and passed away. When the hospital called, they asked for a medication list and the unit manager grabbed the chart and reconciled the notes. That is when she found that there was a discrepancy with how the admission medication orders were transcribed. It is possible that this could have contributed to blood clot development and I began an investigation based off of this concern. The medication, Heparin was missed (upon admission to the facility) and was not documented on the Physicians Order Sheet. R504 did not receive Heparin at any time while in the facility. The nurse that transcribed the orders was from an agency and was asked not to return after this incident. On [DATE] at 9:58AM, V30 Medical Director and primary physician of R504 said, when patients come from the hospital, we are supposed to follow all the hospital orders. I was told by the facility that the nurses have a system in place where they call the physician and go over the medication list, and then another nurse will verify that all the medications have been ordered in the system correctly according to the discharge medication list. I round at the facility, and I also will review the hospital discharge orders when I do the initial visit. I don't know how an error could have occurred with these systems in place. Heparin is used to help prevent blood clots, such as DVT (deep vein thrombosis) and pulmonary embolism. Heparin is used to help prevent blood clots of all kinds, particularly in high risk patients. It is possible that without the Heparin being given as ordered, a patient who is at risk of developing blood clots has a higher chance of developing them if they are unable to walk or move on their own. V30's Physician progress note dated [DATE] indicated that R504 was assessed, and all hospital records were reviewed. Hospital discharge forms and Physician Order sheet reviewed for [DATE]. Hospital discharge medication list included Heparin 5,000 units to be given every 8 hours which was not transcribed to the Physician Order Sheet at the time of admission to the facility. There is no record of R504 receiving this medication while in the facility at any time. Physician progress note dated [DATE] documented that R504 was at risk for developing DVT (deep vein thrombosis). Facility policy titled, Admission, long-term care (Revised [DATE]) includes: Ensure that a complete list of the medications the resident was taking at home is documented in the resident's medical record. Compare this list with the resident's current medications. Reconcile and document any discrepancies in the resident's medical record to reduce the risk of transition-related adverse drug events. R73 is a [AGE] year old male admitted to the facility [DATE] with diagnoses that include End Stage Renal Disease, Diabetes, Hypertension and Spinal Stenosis. R73 is alert and oriented as assessed on [DATE], with a BIMS (Brief Interview of Mental Status) score of 14 (cognitively intact). On [DATE] V6 (RN) wrote a progress note at 4:07PM that stated, Resident accidentally taken the wrong medication family aware and MD will continually monitor resident for side effect and reaction. Facility Witness statement for the incident of [DATE] states that V6 (RN) pulled medications for R73 and the roommate, and entered the room with both medication cups in hand. When she set the medication in front of R73, he ingested one pill and then stated that the medications in the cup were not his meds. V6 took the remaining medicine from R73 and gave him the other prepared medications. Prior to going into the room, the medications were labeled with the resident's names. V6 (RN) could not be reached for interview during this investigation. Review of V6's Employee file reviewed and found to contain Employee Warning Notices that indicated V6 had received written notice of three additional medication administration related incidents since being hired in the facility in 2018. On [DATE] at 10:06AM V2 Director of Nursing said, I am aware that there have been multiple medication administration errors since I've been the Director of Nursing. Medication administration errors are avoidable by utilizing the 5 rights. When an incident like this occurs, the nurses are provided education in the form of an in-service that emphasizes the Rights of Medication Administration, such as right medication, right dose, right patient, right time and right route. I was not aware that V6 (RN) had a history of documented medication errors or incidents. R73 did not require any hospitalization after the incident, and the physician was called with no further orders but to monitor for any reactions. Facility policy titled, Medication and Treatment Administration Guidelines, Long-Term Care (no revision date) includes: Medications are administered in accordance with the following rights of medication administration or per state specific standards: Right patient, right medication, right dose, right route, right time (including duration of therapy, right documentation, right of patient to refuse, right clinical indication).

Based on interviews and records reviewed the facility failed to document a dependent resident's (R1) skin condition when initially observed or reported. This failure affected 1 or 3 residents reviewed for pressure ulcer prevention. This failure resulted in R1 developing an unstageable pressure ulcer to R1's sacrum. Findings include: R1 is [AGE] years old with diagnosis including but not limited to Metabolic Encephalopathy, Dysphagia, Urinary Tract Infections, Reduced Mobility, and Altered Mental Status. R1 admitted to the facility on [DATE] and discharged to home on 11/2/22. On 11/16/22 at 10:06 AM V7, Unit Manager Registered Nurse, stated R1 stayed in bed and was not active. V7 stated R1 was dependent on staff. V7 stated skin checks are done daily if a resident has wounds and weekly if the skin is clear. On 11/16/22 at 10:57AM V5, Director of Nursing, said the nurses do skin checks weekly or daily. V5 said we don't keep the skin sheets, they are not part of the medical record. V5 said the skin checks will be charted in the electronic treatment administration record (ETAR). V5 reviewed R1's ETAR and saw with the surveyor no skin checks are documented. At 12:03 PM V5 said she has no additional body audits to support that R1's skin was checked before the development of R1's pressure ulcer. At 2:45 PM V5 said the purpose of nurse documentation is for communication. V5 said I would expect a description of the alteration, if a resident had a new skin alteration, to be found in the nurses' notes. On 11/16/22 at 1:08PM V11, Certified Nursing Assistant, said she gave R1 a bed bath, when she worked on 10/31/22. V11 said after a resident receives a shower, we complete a shower sheet and the nurse will sign it. V11 said when we give a bed bath, we don't complete a shower sheet. V11 said I never saw a skin problem with R1. On 11/16/22 at 2:09PM V10, Wound Nurse Practitioner, said on 11/1/22 I was told to see R1 for a skin alteration. V10 said R1 had comorbidities that contribute to skin breakdown including limited mobility, Hypertension, Diabetes, and history of a stroke. V10 said skin checks would be a beneficial intervention. V10 said if the nurse knew of a skin alteration the nurse should have written a note. V10 said a note would have been beneficial to know what kind of wound the resident had or the progression of the wound from when it was first seen to the current time. On 11/16/22 at 2:32 PM V15, Nurse, said when a wound is reported to me, I let the wound care team know and call the doctor. V15 said for a skin impairment I make a progress note. V15 said the purpose of documenting a wound is so the facility has documentation of the skin condition. V15 was unable to recall R1's wound or why she obtained the treatment order on 10/30/22 for R1's intergluteal crease. On 11/17/22 at 10:00 AM V19, Nurse, said if she signed off a treatment on eTAR for R1, then she provided the ordered treatment. V19 was unable to remember what R1's skin or alteration looked like. R1's Braden Scale assessment dated [DATE] notes R1 is at risk for pressure ulcers, with a score of 15. R1's care plan initiated on 9/27/22 states R1 is at risk for alteration in skin integrity related to Diabetes, Urinary Tract Infection, Hypertension, Impaired Mobility, and Cerebral Vascular Accident. The goal for R1 is to decrease/minimize skin breakdown risks. Review of R1's Order Recap Report notes an order dated 10/30/22 to cleanse intergluteal crease and cover with dry dressing daily. R1's Progress Notes reviewed 10/26/22 to 11/1/22 do not have documentation related to physician order for intergluteal crease dressing. There is no skin assessment documented for R1's intergluteal crease on the day the order was received. Review of R1's Order Recap Report notes the order for the intergluteal crease was ended on 11/1/22. A new order dated 11/1/22 states Sacrum: cleanse, apply Thera-Honey and cover with dry dressing. A Medical practitioner Wound Progress Note written by V10 on 11/1/22 documents R1 needs assistance with bed mobility. Acute unstageable pressure ulcer noted to sacrum. A Skin and Wound Evaluation written by V18, Registered Nurse, documents on 11/1/22 R1 has an unstageable pressure alteration. The alteration has slough and or eschar present. The alteration is in house acquired. The alteration is 5.1 cm in length and 8.0 cm in width. It is documented noted 30% purple discoloration. [A picture of R1's wound is attached to this evaluation.] R1's Functional Status assessment dated [DATE] notes R1 requires extensive assistance with bed mobility. Skin Conditions assessment dated [DATE] notes R1 has no pressure ulcers but is at risk. R1's Functional Status assessment dated [DATE] notes R1 requires extensive assistance with bed mobility. Skin Conditions assessment dated [DATE] notes R1 has an unstageable pressure ulcer. The facility provided a document revised on 8/19/22 titled Change in Status, Identifying and Communicating, Long-Term Care. Documentation states identifying and communicating change in resident's status includes other assessment findings in the appropriate areas in the medical record, nursing interventions, and resident response. The facility provided a document titled Skin Management Guidelines dated 3/2022 which documents, in part: Skin alterations and pressure injuries are evaluated and documented by the nurse. Body audits are completed by the nurse daily for patients with pressure ulcers and documented on the eTAR; new findings are documented in a progress note. By the nurse weekly for patients without pressure injuries and documented on the eTAR; new findings are documented in a progress note. By the nursing assistant during baths/showers, and if indicated during routine daily care and documented on the Skin Worksheet. The Skin Worksheet is used by the nursing assistant to document skin observations. The worksheet is completed at least twice per week with the patient's bath/shower. Completed worksheets are given to the nurse for validation and action planning as indicated. In the event a patient experiences a new pressure injury, complete Braden Scale, PUSH Tool, and Skin Progress Note.

Based on interviews and record reviews this facility failed to consistently and accurately assess, monitor, and implement interventions such as: adequate weight monitoring, cardiology consultation, medication for the signs and symptoms of [CONDITION(S)] for 1 of 3 residents reviewed for [CONDITION(S)] and nursing assessment. This failure resulted in in R1 not receiving medications to treat CHF or having laboratory testing to monitor the disease progression, and having significant weight gain unmonitored. On [DATE], R1 suffered a [CONDITION(S)] at this facility and expired at the hospital. Findings include: On [DATE] at 1:10pm, V6 (attending physician) stated that V6 was managing R1's cardiac condition since it was difficult for R1 to get to outside appointments. V6 stated that V6 will order a BNP (B-type natriuretic peptide-test to monitor a person's heart failure) blood test if there is any change in a resident's condition, such as: [CONDITION(S)] (swelling) or shortness of breath to determine if the resident's heart failure is worsening. V6 stated that V6 would expect the nurse to notify him of any changes in R1's medical condition, weight, or vital signs. V6 did not recall if R1 was receiving medications specific to treat CHF, such as ACE inhibitor (Angiotensin Coverting Enzyme) or ARB medications (Angiotensin Receptor Blockers). On [DATE] at 11:50am, V2 DON (interim director of nursing) stated that the CNAs (certified nurse aides) will obtain resident weights and document results in the resident's electronic medical record. V2 stated that the dietitian is responsible for monitoring if there are any weight discrepancies. On [DATE] at 12:15pm, V8 (social services) stated that the nurse is responsible for scheduling outside physician appointments for residents. V8 stated that the nurse documents in the resident's electronic medical record name of physician being seen, date, time, transportation arrangements. Review of R1's medical record notes R1 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R1's POS (physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There is no documentation found noting R1 had an appointment to have AICD checked during R1's stay at this facility to ensure it was functioning appropriately. Review of R1's POS (physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . V13 managed R1's cardiac care while in hospital [DATE]-[DATE]. V13 (cardiologist) was unavailable for interview during this survey. Review of R1's cardiac care plan related to CHF, initiated [DATE], notes to obtain weights as needed, report significant changes. Review of R1's weight documentation notes: On [DATE], R1's weight was 159.2 pounds -- 1.6 pound increase in one month; 8% increase in 3 months; 13.6% increase 6 months. On [DATE], R1's weight was 157.6 pounds -- 6.9% increase in one month; 9.89% increase in 3 months. On [DATE], R1's weight was 147.4 pounds -- 5 pound increase in one month. On [DATE], R1's weight was 142.4 pounds. On [DATE], R1's weight was 142 pounds. On [DATE], R1's weight was 142.8 pounds. On [DATE], R1's weight was 140.1 pounds. There is no documentation found in R1's medical record noting R1's physician was notified of significant weight changes. There is also no documentation noting R1 was re-weighed to verify the accuracy of the results obtained. Review of R1's medical record, dated [DATE], notes an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R1's MAR (medication administration record), dated [DATE], does not note R1 received the diuretic medication on [DATE] at 8:00am. There is also no documentation noting staff were applying compression stockings to R1's lower extremities as prescribed. On [DATE], the nurse practitioner noted R1 with chronic bilateral lower extremity [CONDITION(S)]. There is no documentation noting R1's chronic bilateral lower extremity [CONDITION(S)] was addressed and interventions implemented prior to [DATE]. Review of R1's medical record does not note R1 had BNP level checked during R1's entire stay at this facility. R1's BNP result was 3,022 (normal range is less than or equal to 450) while in hospital [DATE]-[DATE]. Review of R1's nutrition documentation notes: On ,d+[DATE], Monthly weight 147.4 pounds, gain of 5 pounds past month, 9 pound increase from ,d+[DATE] to current. Significant weight loss identified at 6 month interval. No added salt diet provided with stable intake. Continue present management as weight loss has subsided with gain trend. On ,d+[DATE], Monthly weight 157.6 pounds. Weight identifies a gain of 6.9% past month, 13.9% at 6 months. R1 continues with liberalized no added salt diet appropriate for age, stable intake at provided meals. Weight gain does not appear a medical concern. On ,d+[DATE], Monthly weight 159.2 pounds, 1.6 pound increase past month with significant gain at ,d+[DATE] months of 8% and 13.6% respectively. Orders continue no added salt diet. No [CONDITION(S)] reported [DATE] per MD note. On [DATE], R1 displays weight gain, R2 has good intake, history of chronic bilateral lower extremity [CONDITION(S)]. Receives diuretic which can cause fluid weight reduction. Continue present management. Review of R1's hospital medical record, dated [DATE]-[DATE], notes R1 with Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The heart is not pumping all of the oxygen-rich blood the body needs). On [DATE] approximately 1:20 PM, R1 was unresponsive. A code blue was called. 911 called, CPR continued. R1 ws transferred to a stretcher and sent out to hospital. Review of R1's death certificate, dated [DATE], notes cause of R1's death: [CONDITION(S)]. Review of this facility's weight management guidelines, revised ,d+[DATE], notes when accurately measured, weight is a primary screening and monitoring indicator. The degree of weight change has direct correlations with impact on health status. Review of this facility's weight measurement policy, dated ,d+[DATE], notes to compare weight to previous weight. If there is a discrepancy, weigh the resident again. Discrepancies are considered to be 5 pounds if resident is over 100 pounds. Validation of weights should be done as soon as discrepancy is noted or by end of shift. Validated weights are entered into the electronic health record by the end of shift. Significant weight change is defined as 5% in 30 days, 7.5% in 90 days, and 10% in 180 days. Notify the physician and responsible party. Per the American Heart Association guidelines 2022, a weakened or stiffened heart muscle pumps less blood to the body with each beat. As a result, fluid backs up into the lungs and throughout the body. Heart failure most often causes swelling ([CONDITION(S)]) indicating the body is retaining extra fluid. Swelling can be in the hands, abdomen, ankles, legs, and feet. Fatigue occurs when the body doesn't get enough oxygen-rich blood. People may feel more tired or have less energy than usual, even at rest. BNP level greater than 900 could mean one's heart function is unstable.

Based on observation, interview and record review, the facility failed to demonstrate interventions were implemented for a resident to prevent an infection and worsening of facility acquired unstageable pressure ulcer and failed to address a resident's pain during a pressure ulcer treatment. This applies to one of three residents (R1) reviewed for pressure ulcers in a sample of three. R1 was hospitalization for infection of left heel unstageable pressure ulcer on 7/28/16. Findings include: R1 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. R1's admission clinical notes dated 3/7/16 read that R1 was admitted to the facility with skin intact, no open areas. R1's clinical notes dated 4/1/16 read New onset of skin breakdown. Left distal heel plantar unstageable pressure ulcer measuring 4.0 cm x 3.5 cm. R1's clinical notes read that R1's facility acquired left heel unstageable pressure ulcer was debrided on 5/6/16, 5/12/16 and 7/27/16. R1's clinical notes dated 7/28/16 at 20:01 read R1 transferred to local hospital per Z2 (Physician) [DIAGNOSES REDACTED]. R1 returned to the nursing home on 8/1/16 on intravenous antibiotic medications. On 8/3/16 at 12 noon, Z3 (Infection Disease Physician) stated that R1 is currently on antibiotics. R1's lab report of left heel wound culture dated 7/22/16 reads Heavy growth Staphylococcus aureus. R1's POS (Physician order [REDACTED]. On 8/3/16 at 8am, E5 (Wound Nurse) was observed changing R1's pressure ulcer dressing to R1's left heel facility acquired unstageable pressure ulcer. E4 (Licensed Practical Nurse) assisted E5 with R1's pressure ulcer dressing change. E5 touched R1's left leg to reposition for dressing change and R1 yelled Ouch, ouch. E5 removed R1's dressing to her left heel and R1 yelled Ouch, ouch. E5 asked R1 Are you in pain? R1 stated Yes. E5 continued with the dressing change. R1 yelled Stop it. E5 stated I will wipe one more time. E5 was cleansing R1's wound with saline and a gauze. E4 stated We will put a clean dressing on. R1 stated I don't want it to hurt. At 8:25am, R1 still stated It hurts. E5 applied the clean dressing and put on R1's boot. As E5 put on R1's boot after the dressing change, R1 stated Ouch, ouch. After R1's dressing change was completed, surveyor asked E5 if R1 is always in pain. E5 stated R1 is most of the time like that. At 8:45am, E6 (Licensed Practical Nurse) stated that she gave R1 pain medication 15 minutes prior to the dressing change. E6 stated R1 is in pain whenever someone touches her left leg even with the medication. On 8/3/16 at 12 noon, Z3 (infectious disease doctor) stated, R1 does have a bone infection since R1's pressure ulcer is down to the bone. Z3 stated that R1 is in pain. R1's clinical notes dated 8/3/16 day shift notes R1's pain as 0. R1's MAR (Medication Administration Record) dated 8/3/16 at 7:46am reads that R1 received [MEDICATION NAME] tablet 5-325 mg ([MEDICATION NAME]-[MEDICATION NAME]) 1 tablet. R1's care plan for pain dated 3/9/16 reads R1 will express that pain management is within acceptable limits. On 8/3/16 at 12:45pm, Z2 (Attending Physician) stated usually the facility contacts him if pain medication needs to be changed. There is no documentation Z2 was contacted for increased pain medication since R1 returned from hospital on [DATE]. The facility failed to provide pain relief for R1 on 8/3/16 from 8am to 8:30am during R1's pressure ulcer dressing change to R1's left heel. The facility's skin practice guide dated 2013 reads Initial plan of care - promoting the prevention of pressure ulcer development, promoting the healing of pressure ulcers that are present and prevention of infection of the wound to the extent possible. The facility failed to demonstrate how R1's pressure ulcer development was avoidable and failed to prevent the infection of R1's left heel unstageable pressure ulcer. The facility's pain practice guide dated 2011 reads For patients with acute pain, the primary goal might be to relieve the pain as quickly as possible. Interventions need to address prevention, anticipation and treatment.

Based on interview and record review the facility failed to accurately transcribe and administer a resident's ordered medication and failed to identify a medication that a resident received was [MEDICAL CONDITION] medication instead of the ordered renal anti-rejection medication for 42 days. This applies to 2 of 2 renal transplant residents (R1, R10) out of eight residents reviewed for medication administration in a sample of 10. This failure resulted in R1 being hospitalized and treated for [REDACTED]. Findings Include: R1's Physician order [REDACTED]. R1's progress note dated 3/29/16 indicated R1 was sent to a local hospital. R1's progress notes dated 3/31/16 indicated R1 was readmitted to the facility. R1's hospital discharge medication list dated 3/31/16 includes an order for [REDACTED]. R1's Medication Review Report dated 4/1/16 did not include an order for [REDACTED]. R1's Medication Review Report dated 4/1/16 includes an order for [REDACTED]. R1's April and May 2016 Medication Administration Records indicates that R1 received [MEDICATION NAME] capsules 25 mg (two capsules) at 9:00 am and [MEDICATION NAME] 25 mg capsules (three capsules) at 9:00 pm everyday from 4/1/16 to 5/12/16. The facility's proof of delivery dated 4/1/16 - 5/19/16 indicated [MEDICATION NAME] was delivered to the facility for R1. The facility's incident report dated 5/13/16 indicated R1 received medication [MEDICATION NAME] 50 mg in the morning and 75 mg in the evening, instead of receiving prescribed [MEDICATION NAME] 50 mg in the morning and 75 mg in the evening. R1's incident report indicates that the root cause of the medication error was attributed to an incorrect transcription from the hospital's discharge medication to the electronic medication administration record. R1's progress note dated 5/12/16 at 6:00 pm indicates in part: E2, director of nursing (DON) received a call from Medical Doctor (no name) reporting R1 received [MEDICATION NAME] versus [MEDICATION NAME]. R1's progress note indicates that [MEDICATION NAME] would be discontinued and [MEDICATION NAME] will be initiated. R1's progress note also indicates R1 was on [MEDICATION NAME] at original admission and upon return from the hospital [MEDICATION NAME] was entered. R1's progress note dated 5/12/16 at 9:32 pm indicated R1 did not return from the nephrology clinic appointment and was being admitted to the hospital with [REDACTED]. R1's Pharmacy Consultant Medication Regimen Review documented by Z4 (Consultant pharmacist) on 4/19/16 with no irregularities found. R1's Medication Review Report dated 4/1/16 was signed and dated on 5/7/16 indicating the medication was reviewed. R1's hospital medical records dated 5/12/16 - 5/15/16 indicated R1 was admitted to the hospital due to leukopenia and receiving the wrong medication. R1's medical records indicate that R1 was admitted to the hospital secondary to medication error and is being treated for [REDACTED]. R1's laboratory urine culture dated 5/7/16 indicates that R1's urine was positive for Escherichia coli. R1's laboratory [MEDICATION NAME] level dated 5/10/16 includes a level less than 10ng/ml with a therapeutic range of 100 - 400 ng/ml. On 5/19/16 at 10:10 am E5 Licensed Practical Nurse (LPN) when asked what the process is to transcribe medication for a new admission or re-admission E5 stated that the orders are verified with the Physician and entered into the computer to pharmacy. E5 stated that she verified R1's orders with R1's Physician but does not recall what happened when she transcribed R1's medication upon re-admission. When asked what the medications [MEDICATION NAME] and [MEDICATION NAME] are used for E5 stated that she was not aware of the purpose of the medication. On 5/19/16 at 8:28 am E2 Director of Nursing (DON) stated she cannot attest to whether R1 received [MEDICATION NAME] while in the facility. E2 stated that when R1's readmission papers were reviewed [MEDICATION NAME] was ordered. E2 stated that when there are new medication orders each medication is verified with the Physician, entered into the computer and confirmed. On 5/19/16 at 8:44 am E11 Unit Manager Registered Nurse (RN) stated that R1 received [MEDICATION NAME] while in the facility. E11 stated that R1's hospital discharge order was to receive [MEDICATION NAME]. E11 stated that when there are new medication orders each medication is verified with the Physician, entered into the computer and confirmed. E11 stated that R1's medication order for [MEDICATION NAME] was entered incorrectly. On 5/19/16 at 8:51 am Z2 (R1's Physician) stated that it is the expectation that the facility carry out the hospital orders after the orders are verified. Z2 stated that [MEDICATION NAME] should have been given to R1. Z2 stated that [MEDICATION NAME] can lower the immune system and that R1 was admitted to the hospital for monitoring of any adverse effects after receiving the [MEDICATION NAME] instead of the [MEDICATION NAME]. On 5/19/16 at 12:24 pm Z4 (Consultant Pharmacist) stated that during a medication review the resident ' s current medication is viewed through the computerized system and checked for dosing, duplication and resident side effects. Z4 stated that the medication is reviewed through the Medication Administration Record [REDACTED]. Z4 stated that there were no irregularities found on 4/19/16 when R1's medication was reviewed. Z4 stated that there were no concerns with R1's order for [MEDICATION NAME] because the medication is an immunosuppressant and R1 has a history of renal transplant. On 5/23/16 at 11:24 am Z4 (Consultant Pharmacist) stated that [MEDICATION NAME] is an immunosuppressant and a medication used [MEDICAL CONDITION] patients. Z4 could not confirm a history [MEDICAL CONDITION] in R1. Z4 stated that [MEDICATION NAME] should be used with caution when given to patients with [MEDICAL CONDITION] because the medication may cause renal toxicity. On 5/23/16 at 4:15 pm Z3 Neurologist stated that R1 had a routine visit on 5/12/16 at the Nephrology transplant clinic when it was noted that R1 was receiving [MEDICATION NAME], a [MEDICAL CONDITION] agent instead of the prescribed medication [MEDICATION NAME]. Z3 stated that R1 was admitted to the hospital on [DATE] to monitor for further bone marrow suppression, including decrease in white blood cells, hemoglobin and platelets. Z3 stated that [MEDICATION NAME] is medication used for patients [MEDICAL CONDITION], lupus and [MEDICAL CONDITION] arthritis. Z3 stated that [MEDICATION NAME] causes bone marrow suppression and is not usually prescribed as a transplant anti-rejection medication. Z3 stated that during R1's hospital stay R1's white blood cell count dropped to 1.4K/uL and the hemoglobin dropped to 7.7 g/dl requiring R1 to receive a transfusion of two units of packed red blood cells. Z3 stated that any long term effects of the [MEDICATION NAME] remains to be seen but R10 can potentially reject the transplanted kidney and there is always the risk of [MEDICAL CONDITION]. Z3 stated that bladder infections and blood in the urine are also side effects of the use of [MEDICATION NAME]. The manufacturers insert for [MEDICATION NAME] indications and usage includes malignant disease: malignant [MEDICAL CONDITION], [DIAGNOSES REDACTED], [MEDICAL CONDITION]'s, and neuro[DIAGNOSES REDACTED], [MEDICAL CONDITION] of the ovary and breast [MEDICAL CONDITION]. The manufacturer's insert under warning and precautions includes urinary tract and renal toxicity. The adverse reactions include [MEDICAL CONDITION], renal impairment and [MEDICAL CONDITION] toxic. R10's records indicate that R10 was admitted to the facility on [DATE]. R10's order summary [DIAGNOSES REDACTED]. R10 ' s hospital discharge orders (undated) include an order for [REDACTED]. R10's March 2016 Medication Administration Record [REDACTED]. R10's March 2016 MAR indicated [REDACTED]. E13 stated that an incident report was done and the resident, family and physician were notified. R10's incident report dated 5/23/16 (error occurred 3/18/16 - 3/21/16) indicates that a medication error occurred when R10's order of [MEDICATION NAME] 1 mg (4 capsules twice a day) was reconciled as [MEDICATION NAME] 1 mg (1 capsules twice a day). The facility's requirement and guidelines for clinical record content dated 2015 indicates that the nurse is responsible for the accuracy of transcription and signs and dates the orders as noted.

Based on record review and interview, the facility neglected to assess, monitor and notify the physician of a resident identified as having labored breathing. This failure applies to one of three residents (R1) reviewed for respiratory care services in a sample of 8. This failure resulted in a delayment of treatment and services and emergency care for labored breathing. R1 was found not breathing without vital signs. R1 expired at the facility. Findings include: R1 ' s Admission Record Report indicated current admitted was [DATE] and [DIAGNOSES REDACTED]. R1 expired [DATE] in the facility. Advance Directives noted in R1's record indicated Full Code status. R1 ' s electronic Progress note dated [DATE] timed 16:30 (4:30pm) E13 (Nurse) documented " (R1) was received in bed non verbal with labored breathing, (oxygen) flowing well at 3L/NC (Liters per Nasal Cannula) sat(Saturation) 96%. " At 19:46 (7:46pm) E13 documented " went in to administer nebulizer treatment as ordered, prior to tx (treatment) (R1) was receiving O2 (Oxygen) flowing 3L (liter)/NC (Nasal Cannula), with sat @ 96%, returned to reassess observed (R1) not breathing unable to obtain vital signs immediately initiated CPR (Cardio [MEDICAL CONDITION] Resuscitation) and code blue, placed call to 911, local paramedics arrived staff continued with CPR, paramedics assessed (R1) and stated (R1) was DOA (Dead on Arrival). " R1 ' s medical record did not show that from 16:30 pm thru 19:46 pm that the doctor was notified of the labored breathing, that R1 was assessed associated with the labored breathing and that R1 was monitored in association with knowledge of R1's labored breathing. [DATE] at 3:00pm, when E13 was asked about the delay in treatment and why the physician was not notified of R1 ' s change in condition on [DATE] at 4:30pm, E13 stated " I started passing my medications and then come back to (R1) around 5:30pm. (R1) had scheduled order for Nebulizer treatment which I administer to (R1) at about 5:30pm. I did not call the doctor at 4:30pm, I did not take (R1) ' s Vital Signs. " E13 was unable to provide documentation of vital signs or assessment done. E13 stated R1 having labored breathing is not something new and that is not a change in condition. On [DATE] at 3:50pm review of R1 ' s medical record care plan did not have any individualized plan of care addressing labored breathing problem. On [DATE] at 12:40pm, Z1 (Physician) stated in part that R1 has multiple medical problems that includes Pericardial Effusion with emergency surgery done and chest tube was inserted to drain the fluids from the lungs. Z1 further stated (R1) needed long term care at the time of stay at the facility. Z1 further stated " If they have told me (R1) was having labored breathing I would have sent (R1) to emergency room . The Nebulizer treatment order was for congestion. " Z1 further stated in part that R1 should have been sent to the local hospital emergency room for the complaint of labored breathing. On [DATE] at 10:45am, Z1 was interviewed again. Z1 stated in part that (R1) is " full code " if they have called me I would have sent (R1) to the hospital. Z1 further stated " even if they did not call me (R1) should have been sent to the hospital for labored breathing. " On [DATE] at 10:02am, E17 (Respiratory Therapist) stated in part that it is important during assessment of residents with respiratory problems including Labored breathing to know what the vital signs are, what the rate of respiration is and whether the resident is congested by listening to the lungs sounds these are very important information ' s to determine the stability of the resident. On [DATE] at 12:41pm, Z3(Nurse Practitioner) stated in part that labored breathing is never a normal breathing whenever a resident is noted with abnormal breathing it is expected for the nurse to assess the resident, start oxygen if not already in use and call the doctor, the nurse practitioner or the respiratory therapist because we all work together as a team in health care field. The facility procedure guidelines dated 2011 from out of state university stating " this Interact version 3.0 tool is the procedure we (Referring to the facility) follow, we don ' t have any policy for nursing assessment of resident with respiratory distress. " This facility policy and procedure titled Change of Condition documented in part that the Physician and the Nurse practitioner should be immediately notified of any symptom, sign of apparent discomfort " A Marked Change i.e. (that is) more severe in relation to usual symptoms and signs, or Unrelieved by measures already prescribed. The policy further indicated that Vital signs should be reported unless these values are stable and known by the primary clinician. This procedure was not followed. On [DATE] at 2:00pm, E18 (Care Plan Coordinator) stated so far looking at (R1) ' s care plan I did not see anything for labored breathing care planned. R1 ' s care plan did not address the problem of labored breathing. E18 further stated " there is at times when a chronic problem is singled out but it could be incorporated in the intervention of other focuses like tube feeding and under [MEDICAL CONDITION]. " R1 ' s care plan for [MEDICAL CONDITION] with goals that include but not limited to R1 will exhibit no acute cardiac distress such as c/o (complain of ) chest pain, cyanosis, SOB (Shortness of Breath) etc (and so on) listed under interventions to " obtain vital signs as indicated; report changes to physician. " This plan of care was not followed. On [DATE] at 11:36am, E1 (administrator) stated in part that although the staff did not document the appropriate nursing assessment and care rendered to R1 properly she believed good care was rendered. Facilities policy related to neglect states the following,"Neglect means the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." The policy also indicates the following," the facility must develop and implement written policies and procedures that prohibit mistreatment, neglect and abuse of residents and misappropriation of resident property."

Based on Record review and interview, the facility failed to ensure, that the physician was notified, that nursing respiratory assessment was initiated and that continued monitoring associated with labored breathing was implemented . This failure applies to one of three residents (R1) reviewed for respiratory care services in a sample of 8. This failure resulted in a delayment of treatment and services and emergency care for labored breathing. R1 was found not breathing without vital signs. R1 expired at the facility. Findings include: R1 ' s Admission Record Report indicated that current admitted was [DATE] and [DIAGNOSES REDACTED]. R1 expired [DATE] in the facility. R1 ' s electronic Progress note dated [DATE] timed 16:30 (4:30pm) E13 (Nurse) documented " (R1) was received in bed non verbal with labored breathing, (oxygen) flowing well at 3L/NC (Liters per Nasal Cannula) sat(Saturation) 96%. " At 19:46 (7:46pm) E13 documented " went in to administer nebulizer treatment as ordered, prior to tx (treatment) (R1) was receiving O2 (Oxygen) flowing 3L (liter)/NC (Nasal Cannula), with sat @ 96%, returned to reassess observed (R1) not breathing unable to obtain vital signs immediately initiated CPR (Cardio [MEDICAL CONDITION] Resuscitation) and code blue, placed call to 911, local paramedics arrived staff continued with CPR, paramedics assessed (R1) and stated (R1) was DOA (Dead on Arrival). " R1 ' s medical record did not show that from 16:30 pm thru 19:46 pm that the doctor was notified of the labored breathing, that R1 was assessed associated with the labored breathing and that R1 was monitored in association with knowledge of R1's labored breathing. [DATE] at 3:00pm, when E13 was asked about the delay in treatment and why the physician was not notified of R1 ' s change in condition on [DATE] at 4:30pm, E13 stated " I started passing my medications and then come back to (R1) around 5:30pm. (R1) had scheduled order for Nebulizer treatment which I administer to (R1) at about 5:30pm. I did not call the doctor at 4:30pm, I did not take (R1) ' s Vital Signs. " E13 was unable to provide documentation of vital signs or assessment done. E13 stated R1 having labored breathing is not something new and that is not a change in condition. On [DATE] at 3:50pm review of R1 ' s medical record care plan did not have any individualized plan of care addressing labored breathing problem. On [DATE] at 12:40pm, Z1 (Physician) stated in part that R1 has multiple medical problems that includes Pericardial Effusion with emergency surgery done and chest tube was inserted to drain the fluids from the lungs. Z1 further stated (R1) needed long term care at the time of stay at the facility. Z1 further stated " If they have told me (R1) was having labored breathing I would have sent (R1) to emergency room . The Nebulizer treatment order was for congestion. " Z1 further stated in part that R1 should have been sent to the local hospital emergency room for the complaint of labored breathing. On [DATE] at 10:45am, Z1 was interviewed again. Z1 stated in part that (R1) is " full code " if they have called me I would have sent (R1) to the hospital. Z1 further stated " even if they did not call me (R1) should have been sent to the hospital for labored breathing. " On [DATE] at 10:02am, E17 (Respiratory Therapist) stated in part that it is important during assessment of residents with respiratory problems including Labored breathing to know what the vital signs are, what the rate of respiration is and whether the resident is congested by listening to the lungs sounds these are very important information ' s to determine the stability of the resident. On [DATE] at 12:41pm, Z3(Nurse Practitioner) stated in part that labored breathing is never a normal breathing whenever a resident is noted with abnormal breathing it is expected for the nurse to assess the resident, start oxygen if not already in use and call the doctor, the nurse practitioner or the respiratory therapist because we all work together as a team in health care field. The facility procedure guidelines dated 2011 from out of state university stating " this Interact version 3.0 tool is the procedure we (Referring to the facility) follow, we don ' t have any policy for nursing assessment of resident with respiratory distress. " This facility policy and procedure titled Change of Condition documented in part that the Physician and the Nurse practitioner should be immediately notified of any symptom, sign of apparent discomfort " A Marked Change i.e. (that is) more severe in relation to usual symptoms and signs, or Unrelieved by measures already prescribed. The policy further indicated that Vital signs should be reported unless these values are stable and known by the primary clinician. This procedure was not followed. On [DATE] at 2:00pm, E18 (Care Plan Coordinator) stated so far looking at (R1) ' s care plan I did not see anything for labored breathing care planned. R1 ' s care plan did not address the problem of labored breathing. E18 further stated " there is at times when a chronic problem is singled out but it could be incorporated in the intervention of other focuses like tube feeding and under [MEDICAL CONDITION]. " R1 ' s care plan for [MEDICAL CONDITION] with goals that include but not limited to R1 will exhibit no acute cardiac distress such as c/o (complain of ) chest pain, cyanosis, SOB (Shortness of Breath) etc (and so on) listed under interventions to " obtain vital signs as indicated; report changes to physician. " This plan of care was not followed. On [DATE] at 11:36am, E1 (administrator) stated in part that although the staff did not document the appropriate nursing assessment and care rendered to R1 properly she believed good care was rendered.

Based on observation, interview, and record review, the facility failed to follow their policy for turning residents during incontinence care to prevent falls for 2 of 3 residents (R1, R3) reviewed for falls in the sample of 3. This failure resulted in R1 rolling out of bed, hitting her head on the windowsill, and falling to the floor. R1 sustained a laceration to the head requiring 3 staples and trauma to the head causing bleeding on the brain. Findings include: On 5/6/14 at 8:15am, R1 was sitting up in a chair in the hospital room. R1 has 3 staples to the left side of her head, 2-3 centimeters above the left ear and dark purple bruising to the following areas: center of the forehead, and the left neck, shoulder, upper arm, breast, side, abdomen, hip, buttocks, and back of the thigh. R1's right shoulder is swollen and misshapen with an obvious deformity. R1 stated that in the morning of 5/2/14, a nurse aide was changing her incontinent brief. As R1 was turned to the left side, the aide was on the right side. The aide pulled the brief out from under her, causing R1 to roll off the left side of the bed, hit her head on the windowsill, and fall to the floor. Only one aide changed her that morning. On 5/6/14 at 2:45pm, R3 was in bed receiving skin care by E11(Nurse Aide). E11 pushed and turned R3 toward the left side, while remaining on the right side of the bed, the opposite side. R3's head and left shoulder rolled off the bed and R3 grabbed with her right hand to brace herself on the windowsill. R3 was able to brace herself and allowed E11 to continue cleaning her. Hospital records document the following: 5/2/14 Neurosurgeon Consult R1 sustained a traumatic subarachnoid hemorrhage; Physician Note 5/2/14 "significant bruising and swelling to the left shoulder; emergency room Documentation 5/2/14 laceration 3 centimeters in length to the left side of scalp, closed with 3 staples; [DIAGNOSES REDACTED]. On 5/7/14 at 10:10am, E7(Nurse Aide) stated she was the only one in the room changing R1 on 5/2/14. At that time, while on the left side of the bed, E7 turned R1 toward the right, cleaned her, and rolled the wet incontinent brief and linen under R1. E7 instructed R1 to turn back to the center of the bed, but R1 was closer to the left side of the bed. E7 went back around the bed to the right side and asked R1 to turn to the left. R1 turned slightly, E7 placed her hand on R1's hip area, and pulled the brief and linen out from under R1. R1 fell off the left side of the bed. On 5/7/14 at 10:40am, by phone interview, Z1(Physician) stated that R1 is alert and oriented. Z1 spoke with R1 about what happened. Z1 stated R1 is oriented and reliable, her version of the fall is very detailed and consistent. Z1 stated R1 sustained a laceration to the left side of her head which required staples, a very large collection of blood to the left shoulder which required a blood transfusion, and a small area of bleeding on the brain from trauma. Z1 stated the facility should have followed their policy to prevent R1's fall. On 5/7/14 at 12:05pm, E1(Director of Nursing) stated if there is only one caregiver, the resident is turned toward the caregiver, not away from them. Incontinence Care Policy - Assist to side lying position by turning towards caregiver, unless more than one caregiver present.

Based on observation, interview and record review the facility failed to provide a diet consistent with resident needs, feeding assistance and monitor meal intake in order to maintain nutritional status for 1 of 3 residents (R7) reviewed for weight loss in the sample of 27. This failure resulted in R7's weight decreasing from 91.2 pounds to 69.1 pounds in 4 weeks. Findings include: Admitting Record documents R7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. MDS 3/2/13 documents R7 needs limited assistance with 1 person assist to eat. Speech Therapy Orders 2/7/13 document R7 will be treated for [REDACTED]. On 7/3/13 at 3:15pm E21(Speech Therapist) stated that R7 needed verbal cues to remind her to eat and drink. R7 did not have chewing or swallowing problems, treatment was due to decreased cognition and awareness, "(R7) had to be reminded to eat and drink, but (R7) would spit out solid food." Record review documents R7 admission weight on 2/2/13 is 82 pounds (lb), a mechanical soft diet is ordered plus oral supplements. R7 has an order for [REDACTED]. There is no weight until 3/14/13, when R7 weighed 69.1 lb. Intake Task documentation shows R7's meal intake in February 2013 is 25-50%, and decreases to 0-25% in March 2013. The meal and intake documentation for February and March 2013 is not complete. The meal intake is not documented for approximately 1/3 of each month. There is no documentation of oral intake in the progress notes. On 7/2/13 at 12:45pm E2(Director of Nursing) stated intake of meals and fluids should be charted every shift to monitor how much residents are eating and drinking. Nutrition Assessment 2/21/13 addresses a weight gain. The next nutritional assessment is on 3/21/13, after the significant weight loss from 91.2 lb to 69.1 lb. Speech Therapy Evaluation 2/7/13 documents severe cognitive impairment, requires cues and reminders to eat. Concern Form 2/12/13 documents R7 lost her upper dentures. Email communication 3 weeks later on 3/1/13 documents the first time the facility attempted to contact the dentist for replacement dentures. On 7/2/13 at 2:45pm Z11 (Nurse Practitioner) stated that if he knew about the decrease in appetite, he would have ordered more frequent weights, change the consistency of the diet sooner due to resident needs or lack of upper dentures, or increase the protein or supplements sooner. The diet was changed on 3/19/13 to a nourishing liquid diet and R7 started to gain weight. R7's weight increased to 79.2 on 3/28/13, an increase of 10 lb in 2 weeks; and stabilized at 80.8 lb on 4/8/13 on the new nourishing liquid diet. 3/21/13 Nutritional Assessment documents R7 refusing solid foods and R7 is placed in the dining room for meals. On 7/1/13, at 3:45pm E4(Dietitian) stated R7 did not like to eat solid foods. On 7/3/13, at 3:15pm E21(Speech Therapist) stated R7 would spit out solid food. E21 never conducted a therapy session during a meal. There are no Nutrition Notes between 2/21/13 and 3/15/13 to address R7's decreased oral intake of liquids and solids, and no new interventions were implemented. On 7/2/13 at 2:20pm Z10(Physician) stated that the weekly weights should have been done as ordered. If R7 wasn't eating solid food, the diet should have been changed sooner. The IV fluids were ordered for dehydration, not nutrition. R7 should have been monitored more closely due to her risk factors for weight loss, dehydration, decreased cognition, decrease in oral intake, a pressure sore and previous episode of diarrhea. Since R7 gained and maintained weight, the weight loss could have been prevented. Weight Management Practice Guide System for Obtaining Height and Weight documents "weight is one of the most important points of objective data used in evaluating nutritional and clinical status." It also documents "current standards of practice (CMS State Operations Manual Appendix PP) recommend weighing the resident on admission or readmission, weekly for the first four weeks after admission, and at least monthly thereafter to help identify and document trends such as insidious weight loss. Weighing may also be pertinent if there is a significant change in condition, food intake has declined and persisted (for more than a week)."

A. Based on record review and interview, the facility failed to take into account major risk factors present for 1 resident (R3) in determining the overall risk of developing pressure ulcers out of 7 residents reviewed for pressure ulcers. The facility also failed to follow its' protocol for assessment and monitoring the skin of R3 who was deemed at low risk for pressure ulcer development. These failures resulted in R3 being assessed as low risk for development of pressure ulcers rather than at high or moderate risk. R3 was treated with a lower level of interventions and monitoring of skin by less skilled staff than if at high risk.. These failures to accurately assess and monitor R3's skin integrity resulted in R3 developing deep tissue injuries to bilateral heels 2 weeks after admission to the facility. Findings include: R3 is an [AGE] year old female admitted to the facility on [DATE]. R3's initial admission assessment, dated 8/22/11, assesses R3 to be at low risk for Pressure ulcer development based on a Braden score of 16 (low risk 15-18). This same admission assessment indicates that R3 has an altered mental status, requires assistance for bed mobility and toileting, has slightly limited sensory perception, slightly limited activity and mobility, occasional moist skin and has a potential problem with friction and sheer due to her requirement for assistance with bed mobility and feeble independent movement. This 8/22/11 assessment indicates that R3's skin was intact upon admission. R3 was noted to have 2 bruises on admission. R3's [DIAGNOSES REDACTED]. R3's care plan for functional mobility imitated on 8/23/11 reflects that R3 was unable to move independently. R3's cognitive loss care plan, initiated 8/27/11 reflects that R3 has decreased orientation and safety awareness, as well as short term memory impairment secondary to [MEDICAL CONDITION]. R3 has a care plan initiated 8/29/11 for altered nutrition, secondary to R3 receiving a therapeutic diet due to her diabetes and potential for fluid shifts secondary to noted [MEDICAL CONDITION]. R3 required a modified diet per speech therapy according to this care plan. Page 4 of the facility's Skin Practice Guide states, "If a patient is at low or moderate risk and other major risk factors are present, e.g., advanced age, poor dietary or protein intake, diastolic pressure below 60, hemodynamically unstable, advance to the next level of risk." R3 had advanced age, liver [MEDICAL CONDITION], impaired mental status, impaired mobility, occasional incontinence, diabetes mellitus, and altered nutrition, but was still assessed at low risk.. On 2/16/11 at 11:45 am, E1 (Interim Administrator) stated that a resident at low risk, with no skin alteration, will have skin checks done twice a week, documented on shower sheets..According to the facility's Skin Practice Guide, page 12 states that these routine skin observations are conducted by nursing assistants during the resident's bath or shower, with the CNA(certified nursing assistant) submitting results to the nurse. Residents at high risk or very high risk will have skin checks weekly by a licensed nurse, documented in the TAR (treatment administration record). On 2/16/11 at 2:30 pm, E1 stated that she has not located any skin/shower sheets for R3 from her admission on 8/22/11 up to the date of 9/6/11, when her heel wounds were discovered. Review of R3's medical record including TARs reflects no evidence of ongoing skin assessment/monitoring from her admission of 8/22/11 through 9/6/11, when bilateral heel wounds were noted.. On 1/26/12 at 11:00 am, E3 (wound coordinator) stated that high risk residents are care-planned as such, and get interventions including a low air loss mattress and protective boots, even if they have no breakdown. Residents at high risk will be repositioned every 2 hours. For low risk residents, those residents get repositioned every 4 hours, or as needed. They make sure the low risk residents have wheel chair cushions and barrier ointment applied. According to E3, residents at moderate risk are considered at high risk, and they will still get a low air loss mattress and protective boots unless they refuse. They may use pillows in place of the boots for comfort. E3 also stated that all of their mattresses are pressure-relieving, but there are special mattresses that are pressure-reducing, which are only used when certain criteria are met. Wound care notes for R3 dated 9/6/11 (untimed) reflect that a DTI (deep tissue injury) was noted to R3's right heel measuring 2cm by 2cm, and another to the left heel, measuring 2.5 by .5 cm. The skin was described as intact, with [MEDICAL CONDITION] noted of the lower legs. This note also reflects that protective boots were applied and a low air loss mattress was ordered. R3's physician's orders [REDACTED]. On 1/26/11 at 12:20 pm, E3 stated that a deep tissue injury, along with a pressure ulcer is due to pressure. It is a purplish discoloration of the skin over a bony prominence but with intact skin, so you can't tell what's going on underneath. A DTI may or may not open up. R3's initial skin care plan for skin was initiated 8/22/11, and indicates that R3 is at risk for altered skin integrity related to limited mobility; it does not address all of her other risk factors, such as impaired circulation secondary to diabetes mellitis. The interventions are vague and generic interventions that would be used for any resident: ie, encourage and assist as needed for repositioning frequently. It does not specify how frequently or how this is to be measured or monitored. Encourage consumption of all foods high in protein and encourage fluids. It does not indicate how this will be measured/monitored. Use pillows/positioning devices as needed. Again, it does not indicate how this will be measured and monitored, or how frequently this is to be done. Barrier cream to peri area as needed; this is vague and generic and does not state when specifically barrier cream is to be used. Observe skin condition with ADL (activities of daily living)care daily and report abnormalities. This leaves checking of R3's skin to CNAs rather than to licensed nursing staff. This information regarding a resident at low risk for developing pressure ulcers actually developing a DTI in the facility was discussed with E3 on 1/26/11 at 12:50 pm. E3 was unable to give any explanation as to why R3 developed these DTIs. This same information was presented to the facility management (E1, E2-DON, Z1- Clinical Services; Z2-Regional Director) during the daily status meeting on 1/26/12 at 4:30 pm. Pressure ulcer development was discussed in subsequent daily status meetings on 2/14/12 and 2/15/12 at 4:30 pm. No facility staff ever provided an explanation of why R3 developed DTIs while in the facility. No documentation was provided or found in the medical record indicating that these DTIs were unavoidable. B. Based on record review and interview, the facility failed to perform skin checks/implement interventions as ordered for 2 residents (R8, R4) at risk for pressure ulcer development out of 7 residents reviewed for pressure ulcers. The facility also failed to maintain accurate assessment records relating to admission assessment of wounds for 2 resident (R8, R7 ) out of 7 residents sampled for pressure ulcers. 1. R8 was re-admitted to the facility on [DATE] with a Braden score of 14, indicating R8 was at moderate risk for developing pressure ulcers. The Patient Admission/Re-admission screen dated 10/25/11 which is the Admission Nursing Assessment and contains R8's Braden score, indicates the following findings under the skin section: a black, round area on R8's posterior left thigh; long toenails bilaterally, upper back with scratches, multiple puncture sites, multiple bumps and scratches and left abdomen discoloration. There is no documentation in this admission assessment of any breakdown on R8's buttocks/sacral area. Admission Nursing note dated 10/25/11 at 7:50 pm reflects that R8 was readmitted from the hospital and that fall precautions were in place. This admission note makes no mention of any skin breakdown/open areas on R8's skin.. Wound care notes from 10/26/11 (untimed) indicates R8 readmitted and seen by wound care. This note written 10/26/11 describes a Stage 2 pressure ulcer to R8's coccyx measuring 1 by 1 cm with no drainage. R8's POS (physician order [REDACTED]. On 2/14/12 at 3:15 pm, E3 (wound coordinator), after reviewing the wound note of 10/26/11, stated that she believed R8 was readmitted from the hospital with this Stage 2 wound. E3 explained that the admission nurse does the first assessment, and that is a staff nurse who is not to stage any wound or make any Diagnosis: [REDACTED]. Within 24 hours, a new admission is seen by someone from the wound care team , who is able to stage wounds and confirm appropriate treatment orders. She reviewed the admission nursing assessment containing the Braden score and agreed that this assessment and picture depicting skin alteration did not document a Stage 2 wound on R8's coccyx. She also agreed this wound was not mentioned in the nursing admission note. E3 reviewed the hospital transfer form and notes that their description of R8's sacrum is that R8 had blanchable redness on the sacrum. November TAR (Treatment Administration Record) reflects skin checks not done daily; specifically, skin checks not documented as being done on 11/5/11, 11/6/11, 11/11/11. 11/12/11 and 11/16/11 (R8 was transferred to the hospital on [DATE]). This same TAR also reflects that R8's dressing change was not done on the days ordered between 11/8/11 to 11/13/11. This TAR shows a dressing change on Monday, 11/7/11, and Sunday, 11/13/11, with 6 days in between dressing changes. R8's POS of 10/26/11 orders daily skin checks. E3 reviewed R8's November 2011 TAR and on 2/14/11 at 3:15 pm, agreed that some skin checks were missed. She also stated that while R8's dressing change was performed twice in the week between 11/8 and 11/13, she agreed that the dressing change did not occur on Monday and Friday as ordered, which would only allow 4 days in between dressing change, rather than 5. 2 R4 was admitted to the facility on [DATE] with an admission Braden score of 14, indicating that R4 was at moderate risk for pressure ulcer development per her 9/23/11 admission nursing assessment. This same assessment documents that R4 was admitted with redness of the coccyx. Initial wound care note dated 9/25/11 also states that R4 was admitted with a healed Stage 2 ulcer on her buttocks This note reflects that R4 is at risk for skin breakdown due to skin integrity, and documents that daily skin checks were ordered. Telephone order sheets dated 9/25/11 confirm the order for daily skin checks. November 2011 TAR for R4 reflects that daily skin checks for November were not done as ordered; specifically, skin checks were not conducted on 11/5, 11/6, 11/10, 11/13, 11/14, 11/17, 11/19 and 11/24. 3. R7's re-admission assessment dated [DATE] reflects a Braden score of 12, indicating R7 was at high risk for pressure ulcer development. R7's re-admission assessment also reflects that R7 had a skin tear on his coccyx measuring 1 cm by .5 cm. A wound care note dated 10/25/11 (untimed) reflects a stage 2 pressure ulcer to the sacrum measuring 2 cm by 2 cm. On 2/14/12 at 3:15 pm, E3 stated she believed the Stage 2 was the same area the admission nurse referred to as a skin tear. E3 stated that the admission nurse is not to stage a wound or make a diagnosis, but only to describe what she sees. Review of POS for R7 does not reflect any treatment orders obtained for R7 for the sacral wound until 10/25/11.

Based on record review and interview, the facility failed to develop interventions, and supervise 1 of 10 sampled residents(R 1) with a history of falls, to minimize the risks for recurring falls and injuries. This failure resulted in 4 fall occurrences, including a fractured Right Hip. Findings Include: R 1 is a [AGE] year old admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Admission assessment review indicate that R 1 is determined to be cognitively impaired, poor mobility, dependent with all ADL's(Activities Of Daily Living), and a fall risk due to fall history, unsteady gait, psychotropic medication use and underlying health conditions that may predispose the resident to falls. Careplan review indicates that an initial fall careplan was written on 3-12-11. The careplan indicates that the identified factors from the admission assessment are not documented in the problem area of the careplan and that there are are no documented interventions/approaches. The careplan only states"At Risk For Falls Due To Weakness." Review of facility incident reports indicated that R 1 was involved in 4 fall related incidents: 1. 3-14-11 at 12:45 am, R 1 was found on the floor on the left side of the body, at the foot of the bed. R 1 was taken to the local hospital. R 1 sustained a fractured Right Hip. R 1 returned to the facility on [DATE]. 2. 3-22-11 at 8:30pm, R 1 was found kneeling on the floor next to the bed. 3. 3-26-11 at 8:29 am, R 1 was found in the hallway, attempted to get out of the wheelchair and fell on to the floor. 4. 3-26-11 at 10:40 am, a CNA(Certified Nursing Assistant) was trying to transfer R 1 back into the chair after standing, R 1 backed up slipped, hit his head on the footboard of the bed. This incident resulted in R 1 going out again to the hospital. Further review of the fall careplan does not show any additions or revised interventions associated with each fall occurrence. Interview with E 1(Administrator) on 6-23-11 at 11:00 am stated that the careplan was not updated related to the falls but the nurses did implement interventions. Interview with E 3(Assistant Director Of Nursing) on 6-23-11 at 11:30 am stated that the fall careplan should have been documented with the identified problems, goals, and interventions. Interview with E 2(Director Of Nursing) on 6-23-11 at 11:45 am stated that she was aware of R 1 history of falls and that the careplan was not complete as it should have been. Nurses note review indicate that R 1 was consistently agitated, confused, and resistant to care. There are no documented interventions identified to address the specific contributing factors associated with the falls. Review of the facility fall policy states " If upon completion of the nursing admission evaluation, the patient is found to be at risk for falls or has a history of falls, an initial plan of care is developed and individualized interventions are initiated." This was not done.