**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility's policies and procedures, staff and resident interviews, the facility failed to protect residents' rights to be free from neglect by failing to follow physician medication orders for 2 (Resident #875 and #775) of 4 residents reviewed. The facility failed to perform and document weekly skin evaluations for 1 (Resident #99) of 3 sampled residents at risk for pressure ulcer to ensure timely identification and treatment of skin alterations. The findings included: Review of the facility policy N-1265 Abuse, Neglect, Exploitation and Misappropriation, documented It is inherent in the nature and dignity of each resident at the center that he or she be afforded basic human rights including the right to be free from abuse, and neglect, mistreatment. Employees of the center are charged with a continuing obligation to treat residents, so they are free from abuse, neglect, and mistreatment.The facility defines neglect as the failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Examples include but are not limited to: Failure to take precautionary measures to protect the health and safety of the resident. Intentional lack of attention to physical needs. Failure to provide services that result in harm to the resident, such as not turning a bedfast resident or leaving a resident in a soiled bed. 1. Review of the clinical record revealed Resident #875 was an alert and oriented [AGE] year old female admitted to the facility on [DATE] at 4:30 p.m. Diagnoses included convulsions, neuropathy, peripheral vascular disease, type 2 diabetes mellitus, hypertension, discitis and osteomyelitis to lumbar spine.Review of Resident #875's physician orders revealed an order to administer Carbamazepine 200 milligrams, 3 tablets at bedtime for seizures.Review of the Medication Administration Record (MAR) lacked documentation the medication was administered on 6/12/25.Review of the facility's provided investigation for neglect revealed documentation that Resident #875 was admitted to the facility on [DATE] around 4:00 p.m. On 6/13/25 it was discovered that the assigned nurse, Licensed practical nurse (LPN) Staff D failed to activate the medication orders that were in the computer system. The failure to activate the medication orders resulted in the pharmacy not being aware of the new admission and the medication orders that needed to be filled and delivered. The nurses on the following shift were able to obtain some of the resident's medications from the facility emergency medication supply. Carbamazepine 200 milligrams give 3 tablets at bedtime for seizures was not available and was not administered on 6/12/25.Review of the Employee Corrective Action Form dated 6/17/25 for LPN Staff D documented On 6/12/25 employee did not activate the medication orders for a new admission. Employee did not obtain signatures for consent forms that are necessary to be able to treat patient. Employee failed to complete the nursing admissions assessments and due to the employee's negligence, the patient did not receive her medications timely. The employee was terminated.The facility did not substantiate the allegation of neglect.On 6/16/25, 3 days after admission, Resident #875 requested to be discharged . On 8/11/25 at 3:25 p.m., in a telephone interview, Resident #875 said, I did not get all of my medications when I arrived there. I did not get my Carbamazepine. I take 3 tablets at bedtime for seizures. I was tearful and afraid. It is so important that I get that. I don't know why they did not have my medicine when I got there. I was only there 3 days, and I was ready to leave day 1. I was upset, I was crying. I did throw a fit because I needed my seizure medication. I had just come from a long hospital stay and I did not want to go back. The facility never told me why they did not have my medication.On 8/12/25 at 8:25 a.m., in an interview the Regional Nurse Consultant (RNC) said Resident #875 did not get the Carbamazepine on 6/12/25 because the nurse did not complete the admission. She said, We did education and the nurse (LPN Staff D) was terminated. On 8/13/2025 at 2:10 p.m., in an interview the Director of Clinical Services (DCS) was asked about the facility's process for ordering medications to ensure new admissions received their ordered medications in a timely manner. The DCS said it should be done within 24 hours. When asked about the timeframe requirement for a nurse to complete the medication orders, he said, It depends on what it is going on throughout the day and how many medications the resident is on. When asked how the pharmacy receives the orders for medications, he said Once they are in the electronic system they are activated immediately. As soon as you put in the orders, it's activated and in. Pharmacy gets the notification at that time. When asked to clarify activation, he said, When orders are put in the system, they go into a queue. It shows up as red. The nurse reviews and verifies the orders then hits activate the order which goes to pharmacy. The DCS demonstrated the process of entering, queuing, and activating the orders in the system. The DCS said if the medications are put in by 5:00 p.m., they should be in by midnight. After 5:00 p.m., they pull medications from the facility's emergency medication system. If the medication is not available in the emergency medication system, they notify the physician. He said sometimes they can call it in as stat (immediately) but it still may take a few hours. The DCS said the medications for Resident #875 were entered into the system on 6/12/25 at 10:09 p.m., but they were not activated until 6/13/25 at 6:21 a.m. The Pharmacy can't view or send the medications until the nurse activates them. 2. On 8/11/25 at 9:55 a.m., Resident #775 was observed lying on her left side in bed in her room. The resident's left eye was observed with mild redness and swelling. In an interview, Resident #775 the pain to her eye was better and she could see out of it. The resident said she was now receiving her eye drops. On 8/11/25 at 11:38 a.m., in an interview related to Resident #775's swelling and pain to the left eye, Licensed Practical Nurse (LPN) Staff E said Resident #775 had eye surgery. The physician's ordered eye drops were not administered as ordered before or after the surgery. She said she failed to enter the orders in the system. She said after the surgery, I remember we were busy, and I did not put the orders in. I told the oncoming nurse and she did not do it. LPN Staff E said, We were monitoring her eye. Thank god we got it cleared and she did not lose her vision. On 8/11/25 at 12:22 p.m., in an interview the Registered Nurse Consultant (RNC) said LPN Staff E was a brand-new nurse. She could not figure out where the paperwork for the pre and post-surgical information and orders was.On 8/11/25 at 1:26 p.m., in an interview the DCS said, The first I found out about the whole thing was when the surgeon called and said her left eye was infected.Review of the clinical record for Resident #775 revealed and admission date of 6/23/22. Diagnoses included cerebral ischemia, major depressive disorder, paranoid schizophrenia and muscle wasting.Review of the Brief Interview for Mental Status dated 5/21/25 documented Resident #775 had a score of 12, indicating moderate cognitive impairment.Review of the facility provided incident investigation related to the facility's neglect to administer physician's ordered necessary eye drops before and after eye surgery revealed:On 7/1/25, Resident #775 went out of the facility to the eye doctor. The resident returned with pre-surgical eye drops for cataract surgery. LPN Staff E failed to put the orders into the electronic facility record system. On 7/14/25 the resident had cataract surgery on her left eye and returned to the facility with post-surgical instructions including the eye drops. LPN Staff E was the nurse assigned to the resident post-surgery and failed to place the physician orders into the system. Resident #775 received no pre-surgical or post-surgical care to the left eye. On 7/23/25 the resident had a follow-up appointment with the eye doctor who immediately sent the resident to a retina specialist for an eye infection. On 7/23/25 the eye doctor contacted the facility and spoke with the DCS informing him that the operative eye was inflamed and showed signs of infection. The DCS investigated the matter and discovered the eye drops ordered by the physician had not been transcribed and were not administered. The facility's investigation documented Resident #775 had pain and inflammation in the left eye.On 7/23/25 the facility completed their investigation and verified the allegation of neglect.Review of the physician's ordered eye drops schedule revealed:Week 1: Starting day of surgery:Moxifloxacin (antibiotic) every hour while awake until bedtimeKetorolac (non-steroidal anti-inflammatory) 3 times daily.Prednisolone (steroid) 4 times daily. Week 2:Prednisolone 3 times daily.Ketorolac 3 times daily.Week 3:Ketorolac 3 times daily.Prednisolone 2 times daily.Week 4:Ketorolac 3 times dailyPrednisolone 1 time daily.Review of the post cataract surgery instructions revealed to, Take it easy for one week. Avoid lifting heavy objects or anything more than 10 lbs. Avoid bending over with your head below the level of your waist. Avoid any exercise or sexual activities. Strenuous types of activities can cause elevated pressure in the eye, which might cause problems during the first week after the surgery. No dirt or water in your eye for one week. The only substance that should get in your operated eye are the prescribed eye drops, or eyewash included in your post-op kit.Review of the surgical physician progress note dated 7/23/25 revealed Resident #775 had, Severe inflammation vs (versus) endophthalmitis (infection) left eye. The physician referred Resident #775 to the retina specialist for follow up/potential injection for lack of response to treatment and ordered: Prednisolone 1% one drop every hour.Moxifloxacin 0.3% one drop 4 times a day.Review of the Retina specialist progress note dated 7/25/25 revealed to continue Moxifloxacin 4 times a day and decrease Prednisolone from every 1 hour to every 2 hours while awake.On 8/13/25 at 11:16 a.m., in a telephone interview the ophthalmic surgeon's Surgical Technician said on 7/23/25 when the resident was seen for her follow up they became aware she did not receive any pre-op- or post op eye drops. The surgical technician said, The outcome could have been blindness, she could have gone blind, not just have an eye infection.On 8/13/25 at 1:15 p.m., in a telephone interview the ophthalmic surgeon said, I gave very clear written and verbal instruction for both pre-op and post op for cataract surgery. They did not administer any eye drops to her. When I saw her at the post-op follow up on 7/23/25 her eye looked terrible. It was inflamed, red. I immediately sent her to the retina specialist, I was that concerned. The patient could have gone blind, that is the outcome that could have occurred. I have been doing cataract surgery since 2016 and generally 1/50,000 will lose the vision in the operative eye. In my career, I have had 2 and she would have been number 3. It is that serious that they receive the eye drops. We did everything. We sent the scripts electronically to the pharmacy. The eye drops should have started the morning of her surgery. The surgery was at 2:00 p.m., so they had all day to start the drops. The instructions were clear and easy to follow. It was important not to get the left eye wet, not to lift anything, not to rub the eye and to administer the eye drops as ordered.3. Review of the facility policy WC-100, Clinical Guideline Skin and Wound with an effective date of 4/1/17 revealed, to provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated to promote skin health, healing and decrease worsening of or prevention of pressure injury. On admission or readmission, the resident skin will be evaluated for base line skin condition and documented in the resident record. Licensed nurse to document presence of skin impairment or new skin impairment when observed and weekly until resolved. Licensed Nurse to complete skin evaluation weekly and prior to transfer/discharge and document in the medical record. Licensed nurse to report changes in skin integrity to the physician or practitioner and resident or responsible party and documents in the medical record.On 8/11/25 at 10:12 a.m., Resident #99 was observed lying in bed on her left side. In an interview the resident said the nurse had just finished changing the dressings on her wounds. The resident said she was in pain from the wound care and had requested a pain pill. Resident #99 said she requires help to turn in bed.Review of the facility provided weekly wound reports for pressure injury revealed documentation on 2/21/25 Resident #99 had a facility acquired pressure ulcer to the sacrum that measured 3.5 centimeters (cm) in length by 3.5 cm in width.Review of the Wound Care Physician (WCP) progress note dated 2/27/25 revealed Resident #99 had an unstageable pressure ulcer to the sacrum measuring 3.5 centimeters (cm) length by 3.5 cm width. The WCP ordered to cleanse with normal saline, apply Santyl (debridement ointment) and cover with a dry dressing daily.Review of the facility provided incident investigation for Resident #99's facility acquired pressure ulcer revealed on 2/21/25 a nurse reported an open area over Resident #99's sacrum. The Director of Clinical Services (DCS) assessed the wound and it was deemed unstageable. The incident investigation documented the 2 Certified Nursing Assistants (CNAs) who took care of Resident #99 on 2/15/25 said the resident had redness over the area and on 2/17/25 the area opened a little. Tissue injury may have been present under the skin but was not noted until it opened. The investigation noted on 9/19/24 the wound care physician identified a deep tissue injury to Resident #99's sacral area that healed. At some point between 12/17/24 and 2/21/25 the deep tissue injury re-developed and later became a pressure ulcer. The resident has several co-morbidities and healing of any wound is compromised by her diagnoses of peripheral vascular disease, Raynaud's disease and CREST syndrome (autoimmune disease that causes the skin and connective tissues to harden and tighten).The facility's investigation noted that Resident #99 returned to the facility on [DATE]. The hospital form 3008 noted that the resident had no wound over the sacrum. There was no record of a facility admission skin assessment or subsequent skin assessments. These should have been done weekly per facility policy.The summary of relevant resident record review noted that review of the Treatment Administration Record revealed two nurses documented that they performed skin assessments when in fact they were not done.The facility verified the allegation of neglect and documented, The two nurses involved did not perform the weekly skin assessment and is dereliction of duty. Furthermore, they documented on the Treatment Administration Record that the skin assessment were done but they did not do them. There is no record of skin assessments.On 8/11/25, Review of the clinical record for Resident #99 revealed an admission date of 7/26/24. Diagnoses included peripheral vascular disease, protein calorie malnutrition, left below knee amputation, major depressive disorder and current cigarette smoker.Review of Minimum Data Set (MDS) assessments revealed on 12/17/24 Resident #99 had an unplanned discharge to an acute care hospital. Resident #99 returned to the facility on [DATE].Review of the Quarterly MDS assessment with a target date of 12/29/24 revealed Resident #99's cognitive skills for decision making were intact with a Brief Interview for Mental Status score of 15. The MDS noted the resident was at risk of developing pressure ulcers and had no unhealed pressure ulcer. Resident #99 was always incontinent of bladder or bowel.Review of the Treatment Administration Record (TAR) for January 2025 and February 2025 revealed Licensed Practical Nurse (LPN) Staff B documented she completed the weekly skin sweeps on 1/6/25, 1/12/25, 1/19/25, 1/28/25, 2/2/25 and 2/16/25.LPN Staff A documented she completed the weekly skin sweeps on 2/9/25 and 2/23/25.On 8/12/25 at 12:00 p.m., in an interview LPN Staff A confirmed on 2/2/25 and 2/16/25 she signed the Treatment Administration Record (TAR) verifying she completed the weekly skin evaluation but she did not do them. LPN Staff A said she could not remember why she did not do the skin evaluation on 2/2/25 and 2/16/25. She said she must have been busy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility's policies and procedures, staff and resident interviews, the facility failed to ensure staff consistently performed weekly skin evaluations for 1 (Resident #99) of 3 residents reviewed for early identification and treatment of pressure ulcers. The findings included:Review of the facility provided weekly wound reports for pressure injury revealed documentation on 2/21/25 Resident #99 had a facility acquired pressure ulcer to the sacrum that measured 3.5 centimeters (cm) in length by 3.5 cm in width.On 8/7/25 the weekly wound report noted Resident #99 had a facility acquired stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) on the sacrum measuring 2 cm x's 1.8 cm with 0.8 cm depth. A left hip facility acquired stage 4 pressure ulcer identified on 5/22/25 measured 2.5 cm x's 2.5 cm with 1.5 cm depth.Review of the facility provided incident investigation for Resident #99's facility acquired pressure ulcer revealed on 2/21/25 a nurse reported an open area over Resident #99's sacrum. The Director of Clinical Services (DCS) assessed the wound, and it was deemed unstageable. The incident investigation documented the 2 Certified Nursing Assistants (CNAs) who took care of Resident #99 on 2/15/25 said the resident had redness over the area and on 2/17/25 the area opened a little. Tissue injury may have been present under the skin but was not noted until it opened. The investigation noted on 9/19/24 the wound care physician identified a deep tissue injury to Resident #99's sacral area that healed. At some point between 12/17/24 and 2/21/25 the deep tissue injury re-developed and later became a pressure ulcer. The resident has several co-morbidities and healing of any wound is compromised by her diagnoses of peripheral vascular disease, Raynaud's disease and CREST syndrome (autoimmune disease that causes the skin and connective tissues to harden and tighten).The facility's investigation noted that Resident #99 returned to the facility on [DATE]. The hospital form 3008 noted that the resident had no wound over the sacrum. There was no record of a facility admission skin assessment or subsequent skin assessments. These should have been done weekly per facility policy.The summary of relevant resident record review noted that review of the Treatment Administration Record revealed two nurses documented that they performed skin assessments when in fact they were not done.The facility verified the allegation of neglect and documented, The two nurses involved did not perform the weekly skin assessment and is dereliction of duty. Furthermore, they documented on the Treatment Administration Record that the skin assessment was done but they did not do them. There is no record of skin assessments.On 8/11/25, Review of the clinical record for Resident #99 revealed an admission date of 7/26/24. Diagnoses included peripheral vascular disease, protein calorie malnutrition, left below knee amputation, major depressive disorder and current cigarette smoker.Review of Minimum Data Set (MDS) assessments revealed on 12/17/24 Resident #99 had an unplanned discharge to an acute care hospital. Resident #99 returned to the facility on [DATE].Review of the Quarterly MDS assessment with a target date of 12/29/24 revealed Resident #99's cognitive skills for decision making were intact with a Brief Interview for Mental Status score of 15. The MDS noted the resident was at risk of developing pressure ulcers and had no unhealed pressure ulcer. Resident #99 was always incontinent of bladder or bowel.Review of the Treatment Administration Record (TAR) for January 2025 and February 2025 revealed Licensed Practical Nurse (LPN) Staff B documented she completed the weekly skin sweeps on 1/6/25, 1/12/25, 1/19/25, 1/28/25, 2/2/25 and 2/16/25.LPN Staff A documented she completed the weekly skin sweeps on 2/9/25 and 2/23/25.Review of the Wound Care Physician (WCP) progress note dated 2/27/25 revealed Resident #99 had an unstageable pressure ulcer to the sacrum (Pressure ulcer's tissues are obscured such that the depth of soft tissue damage cannot be observed) measuring 3.5 centimeters (cm) length by 3.5 cm width. The WCP ordered to cleanse with normal saline, apply Santyl (ointment to remove dead tissue) and cover with a dry dressing daily.On 8/11/25 at 10:12 a.m., Resident #99 was observed lying in bed on her left side. In an interview the resident said the nurse had just finished changing the dressings on her wounds. The resident said she was in pain from the wound care and had requested a pain pill. The resident rated her pain a 9 out of 10 (severe pain). Resident #99 said she requires help to turn in bed.On 8/11/25 at 10:23 a.m., in an interview with Registered Nurse (RN) Staff H said she was doing the wound care today. She said she was not the wound care nurse but when there was an extra person on the assignment, someone does the wound care. The RN Staff H said Resident #99 had 3 wounds. The sacrum and the left hip were treated with Moist Dakins solution (broad spectrum antiseptic) and dry sterile dressing daily and as needed. The Left hip was infected, and the resident was receiving the antibiotic Bactrim. RN Staff H said the resident was not able to turn completely in bed, she requires 2 people to assist her.On 8/12/25 at 9:10 a.m., observation of wound care with Resident #99, with her consent. Unit Manager LPN Staff F provided wound care and CNA Director of Patient Services Staff G assisted with positioning the resident. The left hip wound was yellow with slough (dead tissue), and tan drainage, a moderate amount. The Sacral wound was approximately the size of a deck of cards, black with an open area at 6:00 O'clock. The treatment was Dakins soaked gauze and dry dressing for all the wounds. The Unit Manager said the wound care is completed daily but she often does not let the wound care physician look at the wounds and she refuses treatments at times. The Unit Manager said the resident likes to sit outside and smoke most of the day.On 8/12/25 at 10:16 a.m., in a telephone interview with the Wound Care Physician he said the resident refused care and is non-compliant. We recommended a low air loss mattress, and she refused it. She is non-compliant and a smoker. There is a low chance for the sacral wound to heal. I visit once a week it is on and off with her. She does not always allow me to see her, and she is alert and oriented. She is very stubborn, and she refused the air mattress and said it was too hard. She does not comply with turning and repositioning. The left hip is showing signs of infection, and she is on antibiotics for that.On 8/12/25 at 12:00 p.m., in an interview LPN Staff A confirmed on 2/2/25 and 2/16/25 she signed the Treatment Administration Record (TAR) verifying she completed the weekly skin evaluation but she did not do them. LPN Staff A said she could not remember why she did not do the skin evaluation on 2/2/25 and 2/16/25. She said she must have been busy.